Introduction:
The implementation of integrated healthcare will have significant implications for the workforce. This presentation will articulate the drivers, challenges, and areas of focus as it pertains to the workforce so as to enable the successful implementation of integrated models of care.

Methods:
The information presented within has been yielded from PwC research, stakeholder consultations, and consulting engagements in the context of transforming organisations and their people to successfully deliver integrated care through patient-centric multidisciplinary teams.

Drivers of workforce challenges:
• An ageing workforce will see a high volume of retirements over the next 5-10 years, with significant impacts on General Practice, Psychiatry and Anesthetics.
• There is an acute shortage forecasted for nurses, including an expected shortage of 130,000 workers by 2030.
• The ability to establish and foster collaborative relationships and partnerships to drive integrated models of care will be inhibited by workforce shortages, downward pressure on budgets, complex chronic illnesses, and increasing service demand.
• Increasing the size of the clinical workforce will create a corresponding demand for non-clinical support roles.
• The introduction of technology such as robotics, AI and genomics will drive the need for associated skills within the existing workforce while increasing the need for new roles such as engineering and data scientists.
• The sub-specialisation of healthcare professionals has been steadily increasing. However, integrated care delivery will require organisations to evolve behaviours from a siloed and single organ mindset to one that is collaborative and outcome-focused.

Discussion:
Key workforce interventions are listed below.
• Partner with education providers, as well as leverage immigration, to address projected skill gaps and drive up supply, particularly in rural and remote areas.
• Drive collaborative and integrated models of care with adjacent sectors, including aged care and disability, so as to leverage talent pools and mitigate talent attraction risks.
• Roles will be augmented to focus on managing patients outside the hospital, including remote monitoring, case management, and preventative care with consideration given to the interplay between clinical services.
• Engage with emerging technology, leveraging connectivity to drive integration while assessing the corresponding impacts on workforce roles and capabilities.
• Develop a competitive labour market, led by a compelling Employee Value Proposition and a purpose-driven future mission to attract, develop and retain talent.
• Establish flexible resourcing models that allow providers to scale to meet changing demand, while considering agile models of practice and partnerships.
• Support the requisite behavioral change to shift towards truly integrated ways of working with a focus on employee wellbeing to mitigate risks of burnout.

Conclusions:
The healthcare sector will need to assess the current and future impacts of rapid and diverse change on providers to develop early and proactive strategies to transition the workforce towards the delivery of integrated care, ultimately leading to enhanced patient outcomes.

Limitations:
This research is reflective of the experiences of PwC employees and clients, though has not been empirically tested. Further studies could involve collaborations between industry and academia to identify theory-enhanced, better-practice recommendations.

In North West Queensland, an estimated 400 people are affected with chronic kidney disease (CKD). Geography and transient staffing has made efforts towards primary and secondary prevention challenging. It is well known that CKD patients need extra support and strategies to increase engagement with renal services to prevent rapid progression to end stage renal disease. Disconnected care and disconnection from communities has led to people with CKD being disengaged with the service.
Client feedback has highlighted the need for culturally safe service delivery in a trusted setting, or “Renal Hub” integrating all kidney related services. This is being achieved by streamlining the model of care to ensure continuity of care for all people affected by CKD, stages one to five. This involves integrating primary care for CKD with the renal dialysis unit, creating one big team; fostering a working environment with shared vision and accountability for all renal patients. Renal dialysis and CKD nursing staff can upskill each other through knowledge sharing and skill building, to allow staff a wider scope of practice whilst increasing capacity for patient management on all stages of renal impairment. This model of care will optimise nursing staff coverage for all areas of renal care, which is often a challenge in rural and remote areas.
This model cultivates a collaborative approach between clients, communities, primary health providers, diabetes service, Aboriginal health workers, allied health and all stakeholders in improving patient outcomes. A unified effort in preventing, treating and managing CKD and ESRD demonstrates the health service’s commitment to integrated care and to advance kidney health in North West Queensland.

Introduction:
Alcohol-related liver disease (ALD) is a leading cause of advanced liver failure worldwide and is associated with a high mortality. Complete alcohol abstinence is the hallmark of medical treatment. The only effective treatment option for non-responders with advanced disease is liver transplantation with excellent long term outcomes in carefully selected patients. Relapse to harmful alcohol use post-transplant can occur and is associated with increased mortality. Thorough patient assessment, monitoring for and addressing relapse risk represent significant clinical challenges. Treatment of comorbid Alcohol Use Disorder (AUD) is complex and requires active patient participation and behaviour modification, which is complicated by the severity of the underlying medical condition. An integrated clinic was established at Royal Prince Alfred Hospital to address these issues.

Timeline of Practice change
A consult liaison psychiatry service was integrated into the Australian National Liver Transplant Unit in 1986. The Drug Health Service was involved from 1998. Research conducted in 2013 demonstrated striking reluctance in pre-transplant patients to accept AUD diagnosis and treatment.1. An integrated clinic was established in 2018. The clinic is led by a hepatologist with transplant and addiction experience and is comprised of an alcohol counsellor with occupational therapy experience, a psychiatrist and an addiction specialist. 94 patients have been referred and followed to date (Figure 1).


Aim and Theory of change
ALD patients referred for transplant are reluctant to attend traditional AUD treatment due to associated stigma and prioritisation of competing medical care. Expressing risk of relapse to AUD as negligible may facilitate selection for transplantation but may paradoxically compromise treatment for this disorder. Patients also report ongoing psychological stress and poor health-related quality of life post transplantation which increases relapse risk. This is compounded further by unresolved childhood trauma, affect dysregulation and limited social supports.

An integrated clinic allows for coordinated treatment which embodies the principles of involved disciplines, minimising contradictory approaches and development of a patient-centred treatment plan. Interventions include coordination of medical and psychiatric reviews, biomarker monitoring, psychoeducation, motivational interviewing, relapse prevention, trauma-informed care and wellbeing groups and individual counselling focusing on quality of life and function.


Figure 1: Integrated clinic pathway

Targeted population
· Patients with advanced ALD referred for transplantation

Stakeholders
· Australian National Liver Transplantation Unit
· Drug Health Services
· Consult liaison psychiatry

Highlights
· Integration of relapse prevention into routine medical pre and post-transplant care
· Highly specialised team

Outcomes
· Extending criteria for transplantation
· Prevention, early identification and treatment of relapse
· Increased uptake of counselling by patients

Comments on sustainability
Funding was allocated for a hepatologist and alcohol counsellor within DHS/ANLTU.

Transferability and Conclusions. A significant shift in clinical practice led to an integrated model of care tailored to the biopsychosocial needs and capabilities of ALD patients. This model could be replicated with other medical disorders where self-management is required.

Reference
1. Heyes,C.M, Schofield, T, Gribble,R, Day, CA and Haber, PS. Reluctance to Accept Alcohol Treatment by Alcoholic Liver Disease Transplant Patients: A Qualitative Study. Transplant Direct, 2016; 2 (10): e104. DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5068203/

In 2017-18 the Department of Health and Human Services (DHHS) commenced the Victorian Integrated Care Model (VICM), a three-year trial aiming to reduce avoidable hospitalisations and fragmentation in care, particularly for patients with complex and chronic conditions.

The suite of activities being implemented as part of the VICM include:
• Improving electronic information sharing of common patients to help support integrated care delivery
• Building a shared understanding of patient needs between the primary and hospital workforces and building trust between providers
• Developing online resources to increase workforce capability and capacity
• Convening Integrated Care Communities of Practice events to facilitate networking and relationship building
• Use of linked data to identify patterns of service utilisation across primary and acute care services to inform future planning
• Industry transition support to enable coordinated approaches to care across organisational boundaries.

The VICM’s overall objective is to support better integration of care between health services and GPs for shared patients with complex and chronic conditions. Phase one of VICM has focused on establishing joint governance between key stakeholders, laying the foundation for joint planning and governance between the PHNs and the hospital providers so that in the future, services are designed and delivered across the continuum for common client cohorts. The initiative builds on the Commonwealth’s Health Care Homes reform in primary care currently being trialled in the south eastern Melbourne region.

Partners include DHHS, South Eastern Melbourne Primary Health Network (SEMPHN), Alfred Health, Monash Health, Peninsula Health, local GPs (including Health Care Home sites), and the Australian Disease Management Association (ADMA).

The VICM is being implemented over three-years, from 2017-18 to 2019-20 and key highlights include:
• Enhancements to functionality of health services’ electronic referral (eReferral) solutions, adding notification capabilities to alert GPs when their patients present to the Emergency Departments (ED) and of scheduled outpatient appointments.
• Integrated Care Communities of Practice events, open to all health and social providers in the south eastern Melbourne region, to reinforce the importance of integrated care.
• Online training resources will be accessible online to educate and train the workforce on the principles of integrated care.
• Hospital process redesign to ensure all patients that present to EDs have the correct GP listed in the Patient Administration Systems and discharge summaries are sent to the correct GP.

Sustainability plans will provide a footprint for future scaling at health services state-wide, expanding beyond the south eastern Melbourne region, for key features such as Communities of Practice events, eReferral, data linkage and service redesign activities.

Phase one of the VICM trial has prioritised establishing joint governance and relationship building between the PHN, GPs and health services, an important step in the collaboration process. The VICM trial ends on 30 June 2020 and DHHS will use findings from the trial to develop an evidence base for future investment, focusing on sharing best-practice and understanding the factors to successful implementation, before expanding reforms beyond the south eastern Melbourne region.

Introduction: It is a priority in Australia to address the increasing prevalence of overweight and obesity among children. While present guidelines suggest the involvement of dental practitioners in addressing childhood overweight and obesity, there is a lack of evidence regarding their role and how this is best implemented in practice. Two comprehensive reviews were conducted to:
1. Determine the role of dental practitioners in addressing childhood overweight and obesity
2. Identify effective guideline implementation strategies that would facilitate role expansion in the dental setting

Methods: A scoping review and a systematic review were undertaken involving extensive searches across multiple databases including Scopus, CINAHL, Medline, PsycINFO, Embase, Cochrane and Google Scholar. To address the study objectives, customised search strategies were developed for each database, using combinations of Boolean operators, truncations and Medical Subject Headings. Studies included in the scoping review explored weight interventions for children in the dental setting, while the systematic review sought studies which evaluated the effectiveness of guideline implementation strategies in the dental setting.

Results: Eleven studies were included in the scoping review, which identified a clear role for dental practitioners in addressing overweight and obesity among children. However, empirical research was scarce, with only three studies evaluating existing interventions, of which two found improvements in children’s dietary and physical activity behaviours. In addition, two other studies found that parents would be accepting of such interventions if they were implemented. The systematic review identified 16 studies regarding guideline implementation strategies, which reported audit and feedback, reminders, education, patient-mediated interventions, pay for performance and multifaceted interventions as effective. However, when compared to other settings, research highlighted pay for performance might be superior in the dental setting.

Conclusion: Current evidence suggests a clear role for dental professionals in addressing childhood overweight and obesity and highlights potential implementation strategies that could effectively facilitate role expansion.

Lessons learned: Evidence from the scoping review suggests that dental practitioners have a role to play in addressing overweight and obesity among children. In addition, findings from the systematic review highlight effective implementation strategies for dental practitioners, which can serve to inform future adoption of clinical guidelines in this sector. However, as no studies explored the use of implementation strategies for childhood overweight and obesity guidelines in the dental setting, further research is required to determine if implementation strategies can be effectively used to facilitate the adoption of such guidelines by dental practitioners.

Limitations: The transferability of findings from the scoping review might be limited as all but two included studies were from either Canada or the United States. In addition, data from included studies in the systematic review were of variable quality and had high heterogeneity, thus meta-analysis could not be conducted.

Suggestions for future research: The findings highlighted a need for empirical research that evaluates the effectiveness of dental practitioners in performing weight and height screening, and counselling interventions. Future research should focus on high quality empirical evidence that combines childhood overweight and obesity interventions in the dental setting with effective guideline implementation strategies.