1. Introduction
Integrated care is a major NSW Health strategic priority and a key enabler of value-based healthcare. The NSW Ministry of Health provides funding to 15 Local Health Districts (LHD) and three Specialty Health Networks (SHN) to support local health partnerships to implement innovative, evidence-based and locally led models of Integrated Care.

NSW Health defines value based on the Quadruple Aim of population health outcomes, cost efficiency of the system and the experience of receiving and providing care. To assist with statewide evaluation of Integrated Care with respect to the Quadruple Aim, the NSW Ministry of Health developed two surveys targeted to Integrated Care patients and providers, respectively.


2. Description of policy context and objective
Capturing the patient perspective and measuring what matters to patients is fundamental to a patient-centred health system. The provider experience is also crucial to optimise the delivery of healthcare and patient outcomes.

The Integrated Care Patient Survey was developed by the Ministry in partnership with the Bureau of Health Information. The survey underwent cognitive testing to ensure it was relevant and understandable to patients. The 60-question survey is believed to be the first to combine Patient-Reported Experience Measures, Patient-Reported Outcome Measures using the PROMIS-10 tool, and the Patient Activation Measure (PAM). The survey captures patient experience with respect to care coordination, care plans, respect, empowerment and discharge planning. The PAM captures patients’ self-efficacy, knowledge and confidence to manage their health.

The Integrated Care Provider Survey comprises 28 questions capturing providers’ understanding, satisfaction, teamwork, care coordination, communication, workload and resources.

3. Targeted population
The provider survey has been emailed to more than 1,000 providers across the acute, primary and social care sectors, involved in the care of Integrated Care patients.

The Integrated Care Patient Survey has been posted to more than 20,000 Integrated Care patients in NSW. Patients who received a similar survey in the previous six months and those no longer enrolled in Integrated Care initiatives were excluded. Where consent is provided, the patient survey data will be linked with hospital data collections.


4. Highlights
Aggregated results of both surveys will be fed back to the system. The results will help inform management and quality improvement of Integrated Care at a local level, and inform strategic planning of the statewide strategy. The surveys allow comparison of the effectiveness of Integrated Care initiatives which are theoretically similar, but target varied patient cohorts.

5. Comments on transferability
These surveys are used to evaluate provider and patient experience of Integrated Care at a statewide level. They may have utility in similar jurisdictions, to evaluate the impact of varied, locally led models across a large area.

6. Conclusions
Preliminary results and response rates of the surveys will be presented. Results of these surveys will yield useful information for LHDs/SHNs and the Ministry to monitor the impact and outcomes of investments in Integrated Care.

A collaborative approach in Community Health is essential for clients to achieve their optimal health and wellbeing goals. At North Richmond Community Health (NRCH) the Dietetics, Diabetes and Oral Health Services have collaborated to establish an integrated referral and service system.

NRCH supports a diverse population of the community including 4,000 residents from the Richmond Public Housing Estate, located in close proximity to the health service. As an organisation, NRCH is committed to working with refugees, asylum seekers, newly-arrived migrants, people of different cultural and linguistic backgrounds, people who inject drugs and people of all socio-economic backgrounds.
Initially the need for an integrated service had been identified by key staff in the Dental, Diabetes and Dietetics team due to the complexity of referral pathways, difficulty with information sharing due to different information technology platforms and the diverse needs of the community accessing the service. The dietetics team had also identified that there were less referrals to the service for the 65 years age and above age group. Recent research has identified that up to 35% of this age group are at risk of malnutrition. As a result of this identified need a Dental, Diabetes and Dietetics Collaboration was established at NRCH in February 2019 with membership from key staff and management at NRCH.

The Collaboration focussed on creating better flow of clients between dental, diabetes and dietetic departments. A preventative health model and work flow was developed to capture clients who have or are at risk of chronic disease or have or are at risk of oral health issues was developed. The health model and work flow is in the implementation phase.

A number of key documents were used to inform the process of developing these processes. The Joint Position Statement on Oral Health and Nutrition, October 2015, between Dietitian’s Association of Australia and Dental Health Services Victoria and the Role of Credentialled Diabetes Educators and Accredited Practising Dietitians in the Delivery of Diabetes Self Management and Nutrition Services for People with Diabetes, December 2008, Australian Diabetes Educators Association and Dietitian’s Association of Australia.

Collaboration within health organisations is essential in the development of systems to support integrated services to achieve health and wellbeing. NRCH continues to support the development and implementation of systems and resources to link services for the community.

Introduction

Coordinated healthcare is achieved through ongoing relationships between patients and providers, the timely transfer of relevant patient information between different care providers, and the cooperation between these providers to provide connected healthcare. This research examines patient-reported experiences of information continuity between general practitioners (GPs) and other providers such as specialists, hospitals (including emergency departments) and allied health professionals.

Methods

Using the 2016 Survey of Health Care (SHC), we assessed patient-reported experiences with health professionals and the health system, including whether their usual GP had an understanding of the patient’s healthcare history, whether their usual GP seemed informed about specialist or hospital care or whether their test results were available at the time of their appointment. These responses analysed were from a representative sample of the 8.8 million Australians aged 45 and over who had seen a GP in the previous 12 months.

Results

Of patients who:
- Were admitted to hospital, 14% reported that their GP was not informed of their follow-up needs.
- Required services after their admission, 20% reported that arrangements were not made by the hospital.
- Visited an emergency department, 23% reported inadequate information sharing back to their GP.
Patients with no usual GP were 2–3 times as likely to report poor sharing of information as those with a usual GP.
Compared with patients in Major cities, patients in Remote/Very remote areas were more likely to report that their usual GP or place of care was not informed after their most recent visit to a specialist (10% and 19%, respectively).

Discussion

Having a usual GP increases the likelihood of better information sharing across providers and settings, especially when compared with patients who have a usual place of care only. Patients living in Remote/Very remote areas who consistently experience worse information sharing are also less likely to have usual GP. The results are important for people with complex conditions who are more likely transition between care systems and receive fragmented care.

Conclusion

Many patients reported inadequate information sharing between doctors and healthcare settings, and there were significant disparities in the amount of information sharing based on location, age, settings involved and whether or not the patient had a usual GP.

Lessons learned

While the survey looked at both usual GP and usual place of care, the results showed that the former had a much bigger impact on information transfer than that latter.

Limitations

About 124,000 people were selected for the survey. The response rate was 29% (35,495).The scope of the SHC was people aged 45 and over who had at least one GP visit in the 12 months between November 2014 and November 2015. About 5.5% of people in that age group in the 30 June 2016 estimated resident population did not see a GP in the 2015–16 financial year.

Suggestions for future research

Future research will link the survey results to Medicare Benefits Schedule and Pharmaceutical Benefits Scheme, hospital and ED datasets to enable insights into use of services and health outcomes.