Integrated care involves the provision of seamless, effective and efficient care that reflects the whole of a person’s health needs. This includes state-wide strategies coordinating better communication and connectivity between health care providers in primary care, community, and hospital settings, and providing better access to community-based services closer to home.
The Integrated Care Implementation team have six key initiatives focused on achieving the strategic priorities. The initiatives are:
Planned Care for Better Health (PCBH)
Planned Care for Better Health identifies patients at risk of hospitalisation early and strengthens the care provided for them, to improve their experience of receiving care and to keep them healthier over the long term.
ED to Community
ED to Community provides tailored intensive case management and specialist care to clients in the community, improving their health and reducing the need for hospitalisation.
Specialist Outreach to Primary Care
Specialist Outreach to Primary Care (SOFC) 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.
Residential Aged Care (RAC)
Residential Aged Care promotes partnerships between NSW health and RAC facilities to better manage the needs of residents in their care. The aged care staff are trained in early identification and management including appropriate escalation pathways through the provision of clear standard operating procedures.
Vulnerable Families provides care coordination for families who require health and social care support from multiple agencies. Access to better coordinated care ensures families’ health and social care needs are met, enabling parents/carers to provide a safe and nurturing environment for their children.
Paediatric Network upskills local health services staff using telehealth and other virtual care services, enabling access to specialist paediatric care, for children with complex needs, closer to home.