In NSW, Integrated Care involves the provision of seamless, effective, and efficient care that reflects the whole of a person's health needs. The NSW Integrated Care program achieves this by employing state-wide strategies that both foster communication and connectivity between primary, hospital and community health care providers and provide better access to community-based services closer to home.
NSW Integrated Care has eight key initiatives focused on achieving the strategic priorities. The initiatives are:
Planned Care for Better Health (PCBH) identifies patients at risk of hospitalisation early and strengthens the care provided to them. It aims to improve the patient's experience of care and keep patients healthier over the long term. It is focused on the needs of people who are at risk of hospitalisation in the next twelve months by providing care coordination, care navigation and/or health coaching to improve their experience and outcomes.
There are a variety of targeted services offered to patients specific to their LHD to meet their healthcare needs. The PCBH Risk of Hospitalisation (ROH) algorithm presents a meaningful prediction of a patient's unplanned hospitalisation in the next 12 months in the form of a numerical value. It is based on an extensive list of demographic and socioeconomic factors as well as hospitalisation and medical history. PCBH is currently being implemented across all NSW LHDs.
Emergency Department to Community (EDC) provides tailored intensive case management and specialist care to clients in the community, improving their health and reducing the need for hospitalisation. It is a comprehensive care initiative supporting patients under the age of seventy who have been identified as frequent Emergency Department (ED) presenters with complex chronic health and social care needs. Key to the identification of suitable patients for this initiative is the EDC algorithm, which will be built into the Patient Flow Portal (PFP) in 2022. The EDC algorithm considers ED admission history from the last four years, existing chronic conditions, and several demographic and social determinants.
The Secondary Triage (ST) process aims to improve the residents' experience by providing care within their Residential Aged Care Facility (RACF); as well as reducing ambulance transfers to EDs for residents with low acuity needs. All low priority calls to Ambulance are triaged by a Clinical Review Officer (CRO). Based on agreed criteria, the call is transferred to the My Emergency Doctor (MED) line for assessment and management, staffed by Fellows of the Australasian College for Emergency Medicine Specialists (FACEMs). Working together, they plan the appropriate clinical management and link the patient to the GP or a community-based service at the local hospital.
The Alternate Referral Pathways project is an expansion of secondary triage in line with the NSW Ambulance (NSWA) implementation of the Virtual Care Clinical Call Centre (VCCC). NSWA VCCC will be a comprehensive and integrated in-house virtual triaging service and address the needs of low acuity calls to NSWA by supporting them to alternate pathway to care to ensure the right care, in the right place, at the right time.
Residential Aged Care (RAC) promotes partnerships between NSW Health and RACFS to better manage the needs of residents in their care. It aims to improve the skills of RACF staff to better identify the health needs of their residents and to avoid unwarranted ambulance callouts, ED presentations and hospital admissions. Training, early identification, escalation pathways and clear standard operating procedures are key for implementation. RAC ties in specifically with the 'Aging Well and Aged Care' focus within the Australian National Long-Term Health Plan. Additional funding will support an expansions of Commonwealth-funded aged care places, an extension of home care packages and an increased investment in rural aged care.
Paediatric Network (PN) upskills local health services staff using telehealth and virtual care services, enabling access to specialist paediatric care, for children with complex needs, closer to home. It is particularly focused on regional and rural areas to reduce the patient/carer travel burden and ensure quality care and consultations close to the patient's family.
Vulnerable Families (VF) provides care coordination for families who require health and social care support from multiple agencies, improving access to better-coordinated care and fostering a nurturing environment for families. It is a health-oriented community support initiative for parents or carers with complex health and social needs and their children.
Specialist Outreach to Primary Care (SOPC) builds the capability of GPs to provide patients with specialist assessment and care in the community. GPs are linked with medical specialists to enhance their ability to assess and manage a variety of conditions such as early-onset dementia, heart disease and diabetes to meet the needs of their patients and the community.