Integrated care is a key strategic priority for NSW Health. Substantial investment is made annually to integrate services and systems and improve experience and outcomes for patients, their families and carers.
Models of care that incorporate elements of integrated care are dynamic, constantly evolving and continuously improving to better meet patient needs.

Monitoring and evaluating these dynamic models, along with the various methods and approaches to delivering integrated care across NSW, is, an agile process that is key to identifying which activities provide the right care, in the right place, to the right people.
Monitoring and evaluation of Integrated Care is used to:
  • provide insights into the effectiveness of integrated care programs and interventions,
  • inform decision-making,
  • determine whether a specific program or intervention is meeting its objectives.
  • Integrated care captures several data and information points to aid with monitoring improvement and progress over time.

Internal data collection platforms

Integrated Care Outcomes Database

Patient enrolment data drawn from NSW Integrated Care initiatives are captured in the Patient Flow Portal. Three times a year this data is extracted, and linked to other NSW Health data sources, de-identified and uploaded onto the Integrated Care Outcomes Database (ICOD).

ICOD enables the tracking of activity of patients that have been enrolled in an integrated care initiative such as:

  1. Demographics of enrolled patients,
  2. Trends in enrolments for local initiatives,
  3. Performance against key indicators including:
    • Emergency department visits,
    • Hospital admissions,
    • Average length of stay,
    • Readmission rates,
    • Potentially preventable hospitalisations.

Patient Flow Portal  

The Patient Flow Portal (PFP) provides access to a suite of modules that can be used by NSW Integrated Care staff and Local Health District (LHD) executives to monitor and manage integrated care initiatives. The main modules used to monitor Integrated care initiatives are the Integrated Care Module and the Integrated Care Patient List Views.
The Integrated Care module is a state-wide, standardised system for capturing data on enrolment of patients into integrated care initiatives through the phases of identification, selection, enrolment, intervention, and review. It allows monitoring and tracking through the integrated care process and provides an enriched data source that can support comprehensive reporting.

Health Information Exchange  

Health Information Exchange (HIE) is the electronic movement of health related information among organisations according to nationally recognised health standards. The goal of facilitating access is to retrieve clinical data provided by physicians, nurses, pharmacists, other health care providers and patients. The HIE holds the Admitted Patient Data Collection (APDC), Emergency Department Data Collection (EDDC), and the NSW Registry of Births, Deaths, and Marriages (RBDM) data.

Enterprise Data Warehouse for Analysis, Reporting and Decision Support (EDWARD)

The Enterprise Data Warehouse for Analysis Reporting and Decision Support (EDWARD) is a new comprehensive data collection that services the wide range of analytics tools used system wide, and aids in the development of new analytics applications. EDWARD has all Non-Admitted Patient (NAP) data. 


External data collection platforms 

Centre for Health Research Linkage

The Centre for Health Record Linkage (CHeReL) links multiple sources of data and maintains a record linkage system that protects privacy. Record linkage brings together information that relates to the same individual, family, place or event from various sources. This makes it possible to create longitudinal sequences of health events. Combined, these individual stories create a larger story about the health of people in NSW. Information from both the HIE and EDWARD are linked to integrated care patients by CHeReL. 


Bureau of Health Information Healthcare Observer

The Bureau of Health Information (BHI) collects data on patient experience and the performance of various hospitals and clinics. Data from patients who have given consent for their results to be shared will be sent to CHeReL. Data that is currently being collected by BHI includes Patient Experience surveys. 


Health Outcomes and Patient Experience (HOPE) System

The new Patient Reported Measures (PRMs) IT system, HOPE supports the routine collection, measurement of data and timely reporting of PRM outcomes to clinicians. HOPE systems will be implemented across Districts, trialled by the Leading Better Value Care and Integrated Care initiatives. The data collected through HOPE will complement the range of existing NSW Health PRMs collections, including the Patient Survey run by BHI.

It is an ethically approved program that securely links encoded data from general practices to other health data in NSW, including hospital and emergency department, with privacy of patients securely maintained.

Current as at: Wednesday 17 March 2021
Contact page owner: System Performance Support