​Summaries of the Integrated Care Innovators

Far West Local Health District – Staying Healthy Program

In Far West NSW the Local Health District is working with a number of local partners to develop a better connected model of care to support 25 – 55 year olds in Broken Hill. The approach focuses on supporting people with risk factors for chronic conditions to make lifestyle changes that will maintain or improve their health.

The Staying Healthy Program is an early intervention program focused on engaging with people living in the Broken Hill.  The program targets 20-55 year olds that are at risk of developing a chronic disease through current lifestyle choices such as drinking alcohol at harmful levels, smoking, inactivity and poor dietary choices.

By working with health providers, services and consumers to improve the community’s health literacy and capacity to make informed choices, the program aims to contribute to improved health outcomes in Far West NSW.  To achieve this aim the program is addressing the high proportion of people who are disengaged in their health and the healthcare system of the local community.

Hunter New England Local Health District – Care in the Last Year of Life

As people approach and reach the end of their life their patterns of health service utilisation change with increasing general practice visits, emergency department presentations and hospital visits.  Negotiating complex health, aged and social care systems can be challenging. The Care in The Last Year of Life Program has started a big conversation with local clinicians and the community about end of life care in the Hunter region.

The initiative aims to improve communication between people in the last year of life, their families/carers and the clinicians and services providing care. It supports and encourages people to talk about and document their wishes; whilst assisting clinicians to more closely align treatment choices with the person’s expressed needs and goals of care as they approach end of life.

Hunter New England Local Health District – Mehi Integrated Care Program

Moree District Hospital Antenatal Outreach Program provides antenatal services to women in two isolated rural communities of Collarenebri and Mungindi. This innovative service is funded by the Rural Doctors Network as part of the Medical Outreach Indigenous Chronic Disease Program.

The Mehi Integrated Care Project allows Indigenous and Non-Indigenous women to access comprehensive antenatal care particularly for Indigenous women. It allows patient centred care on country, to remain closer to home, family, and community and receive timely referrals to specialised perinatal services.

Illawarra Shoalhaven Local Health District – Geriatrician in the Practice

The Geriatrician in the Practice program is supporting General Practitioners (GPs) and Practice Nurses in the Shoalhaven region increase their skillset in assessing, diagnosing and managing dementia.

The ‘Geriatrician in the Practice’ initiative involves a Geriatrician and Dementia/Delirium Clinical Nurse Consultant accompanying the GP and Practice Nurse in their rooms and providing a joint, integrated GP and specialist appointment. that It is more easily accessible for patients, and in an environment they are familiar with and comfortable in. The initiative has been implemented in the Shoalhaven region of the Illawarra Shoalhaven Local Health District. The initiative expands similar physician-based models and applies it to geriatrics, with focus particularly around dementia assessment, diagnosis and management.

Justice and Forensic Mental Health Network – Custody to Community Program

The Custody to Community Integrated Care Program aims to identify people most at risk of long term health conditions, mental illness, drug and alcohol misuse and cognitive impairment, and reintegrate them into community based healthcare upon release from custody.

The Program aims to reduce numbers of newly released individuals presenting to acute community based health services for medication and unscheduled appointments, thus reducing the impact of this vulnerable population on the acute care sector and better integrating them back to community and primary care. Importance is placed on health care through support offered to attend health services during the initial four week post-release period.

A specific Mental Health model of care is also in development to undertake appropriate screening before release, and ensuring supports are in place post-release.

Mid North Coast Local Health District – Nambucca Valley Integrated Care 

A large number of unnecessary hospital presentations and frustration with local health services reporting frustrated with a lack of connection between services in the Nambucca Valley have has led to a pressing need for a more integrated approach to how health care is delivered in the region.

The Nambucca Valley Integrated Care Initiative (NVICI) is collaboration between Mid North Coast Local Health District, various community care providers and the local council within the Nambucca Valley. The collaborative is focused on the needs of each individual in the region and employs a philosophy of a ‘no wrong door’ approach to accessing health and social care in the region.

A major focus is on changing the culture of service providers and the community in how services are communicated, accessed, provided and evaluated. This includes strategies to shift the demonstrated pattern of sometimes inappropriate and expensive Emergency Department usage to more appropriate primary health care in the community.

Murrumbidgee Local Health District -– Chronic/Complex Disease Healthcare: Engaged with all Stakeholders and Services (CHESS)

Working with a range of partners locally Murrumbidgee Local Health District is assisting people to better manage their health conditions and avoid hospitalisation. The ‘Chronic/Complex Healthcare: Engaged with all Stakeholders and Services (CHESS)’ integrated care model places the General Practitioner at the core of care coordination for patients with Chronic and Complex Diseases (CCD). The CHESS model will deliver both clinical and social support services, to support patients to stay at home and avoid hospitalisation or exacerbation of their disease.

The focus is to improve the quality of care for patients with CCD through early identification and risk stratification within General Practice and the Primary Health Care sector. Murrumbidgee Local Health District is working alongside other providers, including the local Primary Health Network, Ambulance Service NSW and social service providers Baptist Care and Australian Unity, to better coordinate care.

Nepean Blue Mountains Local Health District – Checkpoint

Nepean Blue Mountains Local Health District have been working with local GPs and service providers to establish Checkpoint - an Integrated and Intensive Care Management service for patients under the age of 70, who have presented to Nepean Hospital’s Emergency Department and/ or other services 20 times or more in a 12 month period.

Clients who utilise hospital services 20 times or more within a 12 month period are likely to have multiple complex and chronic care needs. To meet these needs, closer work with primary care is required alongside the development of models of care that are tailored to individual need. The Checkpoint program has established a flexible Brokerage Fund designed to fast track the purchase of appropriate care services outlined in the Multidisciplinary Care Plan of its patients.

Northern NSW Local Health District - Integrated Care Program for Whole of System Management of Chronic and Complex Conditions

Placing the patient at the centre of their own care and coordinating services around them has seen a culture shift in the Northern region of NSW to think outside of the hospital for people with chronic and complex conditions.

The Northern NSW region is leading an Integrated Care Program (ICP) with pooled resources across the Local Health District, North Coast NSW Primary Health Network, NSW Ambulance, local Aboriginal Medical Services, and General Practitioners.

The ICP is focused on achieving whole of system support for those with selected chronic and complex needs. Founded on the patient-centred health care home model, patients will receive assistance in coordinating care across settings to sure the most appropriate care is delivered in the most appropriate setting. Integrated care in Northern NSW builds on established chronic disease management programs in the District.

Northern Sydney Local Health District – Musculoskeletal Initiative in Primary Care

In partnership with the Sydney North Health Network, Northern Sydney Local Health District aims to build capacity in primary care to deliver musculoskeletal models of care with corresponding hospital based services. Three models of care will be delivered as part of the program: Osteoporosis Re-fracture Prevention; Spinal (Back and Neck) Pain Pathway; and Osteoarthritis Chronic Care Program.

The program aims to provide patients with a better understanding of their condition and treatment options, improve their quality of life, better engage with care providers, and better comply with health care plans.

Building on the success already achieved in the hospital setting with similar models of care, general practice will skilled up to have a better understanding of care providers appropriate for musculoskeletal conditions, and increasingly use chronic care tools and related Medicare Benefit Schedule items better, including use of practice nurses for care plans and health coaching for the conditions the initiative is addressing.  

St Vincent’s Health Network – Psychogeriatric Services on Screen (SOS)

St Vincent’s Hospital Network is delivering Psychogeriatric Services on Screen (SOS) which is used by clinicians form multidisciplinary backgrounds to obtain web-based clinician-to-clinician advice, support, case conferencing, supervision and education with the aim of building their capacity to manage their patients with psychogeriatric problems.

Psychogeriatric SOS involves the St Vincent’s Hospital Psychogeriatric team providing their expertise via web conferencing to rural and remote clinicians who need assistance in managing older people with mental health problems, mental illness and dementia. The model is focused on the provision of services in the community, to prevent and avoid hospital presentation and admission. The success of the model relies on shared care with General Practitioners and other primary care clinicians, and on the St Vincent’s Hospital multidisciplinary team providing a flexible, timely response to their needs for assistance with assessing and managing the mental health needs of older patients.

South Eastern Sydney Local Health District – Multilevel Specialist Care

South Eastern Sydney Local Health District has worked closely with the local Primary Health Network, private providers and Macquarie University to develop a specialist integrated healthcare clinic in Miranda with a particular focus on improving skin cancer and wound care health outcomes for people in the district.  

An innovative partnership between the South Eastern Sydney Local Health District, private dermatology provider Ramsey, the Central and Eastern Sydney Primary Health Network, and Macquarie University has seen the development of a new, innovative model of multilevel integrated care - the Integrated Specialist Healthcare Clinic (ISHC). The ISHC model is patient centric and focuses on delivering timely assessment and treatment to patients. 

Southern NSW Local Health District – Innovation and Integration

A model which is responsive to the needs of aged chronic and complex clients in the southern NSW region of Eurobodalla is being developed in partnership with a number of agencies, not only within but outside of health.

The Southern NSW Local Health District Innovation and Integration project aims to develop partnerships with health care providers outside the District to develop innovative and integrated health care in the district for clients at risk of hospital admission.

The partnership is developing an integrated ‘rapid response’ model of care that will be able to respond to people who require urgent intervention in order to stay healthier at home.  The pilot population and initial focus of the initiative will be aged chronic and complex clients in the Eurobodalla region. This model will then be transferred to vulnerable families and other groups of patients across the District.

South Western Sydney Local Health District – Wollondilly Health Alliance

In a growing region of south west Sydney, an innovative partnership is tackling the most pressing health needs of the population by promoting local services and healthy lifestyles. The Wollondilly Health Alliance (WHA) was formed to identify and address health care access issues in Wollondilly Shire. The Wollondilly Health Alliance is a partnership between General Practitioners, Wollondilly Shire Council, South Western Sydney Primary Health Network, South Western Sydney Local Health District & and Non-Government Organisations.

The aim of the WHA is to proactively address the ongoing health issues facing the Wollondilly community, and work towards creating a better serviced and healthier Wollondilly community.

Sydney Children’s Hospitals Network – Kids Guided Personalised Services (GPS)

The Sydney Children's Hospitals Network Kids GPS Integrated Care project supports families who are caring for children with complex and chronic conditions by developing shared care models that bring together local health services with the tertiary hospitals.

The focus is comprehensive system change and transformation, partnering with local health districts, General Practitioners and Community Services to help families feel connected to their local health services. Eligibility for the service is defined both by the medical complexity of the child’s condition, and the psycho-social complexity of the child’s family and environment, with the use of prioritisation tools reflecting the inequity experienced by vulnerable populations.

The goal is to reduce the impact of these conditions on the family’s life, and to reduce the increasing dependence on the Sydney Children's Hospitals Network for all their health care needs. For families, this will mean more hospital-free days and less time off work and school, and for clinicians it will mean more time and resources to spend with the children whose condition today requires tertiary knowledge and experience.

Sydney Local Health District – Healthy Homes and Neighbourhoods

Families and their children with complex needs and health issues in inner city suburbs of Sydney can now access a broad range of services through one-point of contact.

Sydney Local Health District has established a cross-agency integrated care program to move vulnerable families with children from exclusion to inclusion; and from dependency to independence. This initiative is called Healthy Homes and Neighbourhoods (HHAN). The program includes nurse and social work led care coordination components, where care is wrapped around families and the needs of both adult and child family members are considered. Vulnerable families are identified when adults or children come in contact with medical, health, education or community service providers. Care coordinators are working with a number of health and social care partners to ensure the family's health, parenting and education needs are met, they are connected to their local community, and services and supports are in place for the future.

All the needs of identified families are in scope for the intervention, including housing, employment, income support and legal advice. Geospatial mapping was used to identify clusters of extreme family disadvantage, where additional community projects are being implemented. The suburbs where this is occurring are Redfern, Waterloo and Riverwood.

Sydney Local Health District – Living Well, Living Longer

People living with mental illness are on average more likely to experience and die early from physical health conditions, such as cardiovascular disease. The Living Well, Living Longer initiative integrates the physical needs of mental health consumers with health screening and lifestyle activities so that clients can reach their personal and health goals.

The Living Well, Living Longer initiative brings together primary care, mental health and specialist services to improve the physical health care provided to people living with severe mental illness. The initiative addresses the complex health needs of people living with mental illness who are known to have a lower life expectancy, but have less likelihood of being screened and treated for physical health problems than the general population.

Strong consumer and carer engagement is key to the successful delivery of the program, as is the role of the Peer Support Worker to link consumers with a range of health and lifestyle services.

Page Updated: Monday 25 July 2016
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