Introduction

Against a backdrop of strong population growth for our region, an ageing population, potential healthcare workforce shortages and greater numbers of hospitalisations and GP visits over the next 15 years, Northern Sydney Primary Health Network (NSPHN) have been concentrating on innovative and sustainable solutions that shift the focus of care out of the hospitals and supporting the role of primary health.

Practice Change and Aim

To build capacity in general practice and improve patient outcomes, NSPHN commissioned a ‘Social Work Service to Support GPs’. These services aim to provide support for patients to stay well and in their own homes, including better support around psychosocial, health, social and welfare needs, in order to reduce the likelihood of admission or readmission to hospital.

Targeted population and stakeholders

The social work service provides timely and flexible access to holistic, practical support to ensure the social determinants of good health are identified and managed to improve outcomes for patient’s chronic and complex health conditions. It aims to reduce the workload for primary care health professionals in supporting non-health needs of patients.

Timeline/ Highlights

The social work service was commissioned in July 2016, it has been referred to by over 300 individual GPs and has worked with over 1000 patients. Access to other services or organisations have included Community Transport, Department of Housing, Centrelink, The Guardianship Tribunal and Sydney Home Nursing etc.

Sustainability

The GP Social Work program enhances the relationship between the GP, patient and the services by providing a psychosocial assessment and providing a quick, short term, solution focussed prioritisation of client goals and expectations.

Transferability

The service model allows transfer to other metropolitan locations.


Conclusions (comprising key findings)

The modality of service is flexible according to consumer’s needs, such as home visits, coffee shops, GP surgeries, this ensures that it a patient centred model. Through effective data collection of the types of multiple services required by a patient with chronic disease, the program highlights the extent of social needs in the management of patient’s chronic disease.


Discussions

The needs of people who are referred to the social work services are highly complex and frequently demand multiple providers and funders collaborating, this need has been described as increasing. In the longer term, both health providers and patients have developed a better understanding of the available health, social and welfare supports, but there continues to be a need of stronger working relationships between community, primary and tertiary care professionals.


Lessons learned

Investment in planning, stakeholder engagement, co-design, monitoring and evaluation is essential to successful commissioning of services and initiatives. Closing the communication gap between GPs and services are imperative. Referral forms need to be refined to ensure optimal information is gathered so that the patient can be triaged more effectively. Waiting times to access services or packages through My Aged Care or the National Disability Services can be time consuming and have the potential impact patient outcomes.

Introduction
Healthy Homes and Neighbourhoods (HHAN) delivers whole of family care coordination to families in communities of disadvantage in Sydney, Australia. The model of care coordination delivered is contextually-bound, and tailored to the unique characteristics of the local community. Services are delivered from place-based hubs.

Evaluation work completed to date indicates that HHAN contributes to better outcomes and experience of care for enrolled patients. However, the outputs and optimal dosage of care that leads to these positive outcomes is poorly understood. Hence the research question to be addressed is: what is the optimal HHAN care coordination model(s) and what contributes to their effectiveness?

Theory/Methods
A mixed methods approach was used. Thirty medical records of patients enrolled in HHAN were reviewed to describe the patient journey, including records from two place-based hubs and one community health centre. Interviews were conducted with core staff involved in the delivery of HHAN. Staff were asked about their role, what and how they deliver services, and what actions lead to positive outcomes for enrolled families.

Results
Patients receiving care from the community health centre received more service events/month than those receiving care from place-based hubs. However, place-based hubs had more face-to-face contact with care coordinators.

Themes were identified from interview data. A similar episode of care with set steps/structures was evident across all sites, implemented by all clinicians, despite there being some variation in delivery across the team. Participants identified "polite persistence" and focus on the development of relationships as crucial to success with patients. Unpredictable, crisis-driven workflow was identified as a barrier to success, as well as differing levels of patient readiness for care.

Discussion
This study provides more detailed information about a model of health and social care coordination that has emerged in Sydney. Whilst the model across sites was perceived to be delivered differently, a set structure with assessment, goal setting, consultation, planning and review was evident. This informs the development of a mechanism for governance and monitoring of patient throughput and caseload planning within this team. It may also inform scaling of the model to other regions.

Conclusion
This study contributes knowledge to the gap in published literature regarding the practicalities of implementing a model of health and social care coordination, and the definition of such models. Findings may inform activities that improve the quality of services provided by this team by creating a benchmark or guideline for care coordination services. This may improve access to the service for more families.

Lessons learned
This study contributes to the paucity of literature about models of care coordination for vulnerable families and forms the beginning of a framework of a model of care coordination for this service.

Limitations
Data collected from medical records was existing clinical information, with definitions defined for the purposes of patient activity reporting. Data that was important to the research question may not have been collected.

Suggestions for future research
Further research linking patient experience and outcome data to activity data will enhance the knowledge gained through this study.

Introduction
The New South Wales (NSW) health system faces challenges in the coming decades as the effects of a changing population place pressures on the delivery of health care.
Integrated Care is a crucial step to delivering care that is patient-centred and of value to the population. The NSW Integrated Care Strategy was launched in 2014. Local health partnerships were supported to implement innovative, locally led models which trialled new ways of working to address the needs of communities across NSW. Detailed monitoring and evaluation informed the next steps of the strategy.

Description of policy context and objective
The NSW Health Strategic Framework for Integrating Care was developed in 2018. The Framework articulates a clear vision for integrating care in NSW across the life course. Principles, enablers and expected outcomes are outlined in the Framework, and these are demonstrated in two major implementation activities: scaling effective initiatives across NSW; and collaborative commissioning with providers, organisations and settings in the community.

Scaling effective initiatives
Six Integrated Care initiatives have been selected for scaling across NSW. Each focuses on a cohort of the community, rather than a specific disease, and aims to manage health and social needs in primary and community care where possible and appropriate.
The NSW Ministry of Health provides funding to Local Health Districts (LHD) to implement scaled initiatives in partnership with primary and social care services. LHDs enrol patients on a state-wide Integrated Care Patient Flow Portal which enables continuity of care across NSW and monitoring and evaluation of the strategy with aggregated and linked data.

Collaborative commissioning
Collaborative commissioning promotes the development of partnerships between Primary Health Networks (supported by the Commonwealth Government) and LHDs (NSW Government). Partnerships develop care pathways for patient groups identified through a comprehensive population needs assessment. These pathways reflect the need for better coordination between primary and secondary health services, as well as other service providers that contribute to the social determinants of health. Collaborative commissioning incentivises local autonomy and accountability for delivering patient-centred, outcome-focused and value-driven care in the community.

Targeted population
Integrated Care in NSW focuses on improving outcomes for vulnerable people and at-risk populations across the lifecycle.

Highlights
Integrated Care in NSW strives for whole-of-person care where care is wrapped around the individual rather than focusing on a pathway to address a specific disease. We recognise the need to create linkages between NSW service clusters, state and federal government agencies, and non-government providers. Providing these linkages takes the burden of coordination off the patient so they have a seamless experience that meets their needs.

Comments on transferability
This state-wide approach to integrating care has been informed by monitoring and evaluation of previous strategies implemented in NSW. Lessons learned throughout implementation may be transferrable to other states in Australia, or similar regions internationally.

Conclusion
Integrated Care in NSW has evolved over time, in response to the needs of the population, new evidence and continuous monitoring and evaluation. Improved outcomes have already been demonstrated across the Quadruple Aim of healthcare delivery.

Authors: Mr Ben Ross-Edwards, Ms Kristen James and Mr Peter Wood
Background: As the burden of chronic and complex conditions on individuals, communities and populations increases exponentially around the world, Wide Bay Hospital and Health Service (WBHHS) faces significant local challenges. Compared with the Queensland average, the Wide Bay has higher rates of unemployment, socioeconomic disadvantage, and mental health illness. Moreover, the health demographic profile shows higher than the Queensland average of adults with obesity, diabetes, asthma, arthritis and heart disease, with 24% of the population over the age of 65 years of age and ~7.5% experiencing profound or severe disability. It is not surprising that within this context, WBHHS has among the highest rate of potentially preventable hospitalisations (PPHs) in Queensland.
A review of WBHHS chronic disease management demonstrated that the patient experienced considerable gaps and barriers to achieving quality care and outcomes. The patient journey was uncoordinated, disease-focused, siloed into service-delivery and provider-centred models, there was duplication of capabilities, and limited information sharing. The result was a complex and fragmented service delivery and care provision, with little alternative to the Emergency Department for patients requiring urgent (not emergency) assessment and care.
Practice change: Evidence from New South Wales Health indicates that Integrated Care Models are successful in addressing complex and chronic illness management. WBHHS considered the aspirations of such a model could be incorporated to address the local requirements. WBHHS has established a multisectoral and multidisciplinary strategy to govern the management of chronic and complex conditions in Wide Bay. The primary tenet of the strategy is hospital avoidance. The Integrated Care Model is a high value, patient-centred model which uses the quadruple aims of improving patient experience, better health outcomes, lower cost and improved clinician job satisfaction. Through an integrated multi-disciplinary workforce, the model promotes realignment of roles and functions within existing resources. Service is coordinated fore-fronted patient care intervention and diversion throughout the patient health care journey from prehospital, (in collaboration with Queensland Ambulance Service), through the Emergency Department, followed through in-patient care, to a wrap-around in-home monitoring and early intervention service at home.
Objectives: • Coordinating care around patients, family and carers rather than patients trying to coordinate care around systems. • Improving the patient journey through seamless connection between models of care, leveraging both government and non-government, inpatient and community service providers to maximise capacity and capability, keeping patients well and at home. • Integration of holistic biopsychosocial assessment and care provision addressing the determinants of health. • Improving access and equity in the right care, in the right place, at the right time. Including rapid access for GPs and Ambulance services to give an alternate pathways to emergency departments • Reducing preventable hospital presentations and admissions through diversion, ambulatory clinics specialising in chronic and complex care and social prescription. Conclusion: The WBHHS Integrated Care Model is taking a lead role in Queensland, implementing early intervention strategies and social prescription within the health care journey of patients with chronic and complex needs. Placing their health and welfare at the forefront of care and treatment.

1. Introduction
This presentation proposes health reform policy changes (developed with consumer input) to enable an integrated approach for the management of patients with chronic multi-morbidities to address these problems. An innovative feature of this new proposed approach is it better develops and defines the role of consultant physician expertise which has hitherto either been overlooked in previous models of health care integration (e.g. Health Care Homes) or underutilised. Another innovative feature is the call for use of better integrated funding sources.

2. Policy context and objective
The next five-year national health agreement (NHA) asks Commonwealth and state governments to ‘integrate systems and services to improve health outcomes for Australians’. The present system, based on the fee for service system (for GPs and other private healthcare practitioners) and activity-based funding of public hospitals, leads to patients with multi-morbidities accessing services from multiple providers in different locations on an episodic basis. Patients may not be referred to the right services, there can be unnecessary and wasteful repetition of services (for example, imaging and pathology); prescribing related issues; and conflicting advice from different providers.

Policy needs to support:
• The more effective provision of substructure for specialists to diagnose, treat, co-manage care for these patients, collaborating with GPs;
• Connecting mechanisms for specialists to work in community-based ambulatory settings.
• The availability of suitable facilities in the community for patients with chronic, complex and multiple healthcare needs.

3. Targeted population
A Model of Chronic Care Management is proposed for patients known to incur high system costs due to cardio-vascular related multi-morbidities.

4. Highlights
The Model provides more opportunities for specialists to collaborate with GPs in an ambulatory care setting, managing such patients and preventing chronic disease exacerbations with other members of a multidisciplinary team which may include specialist nurses and allied health practitioners. This could occur in accessible community settings or through ‘virtual’ collaborations.

One key change should be strengthening the linkages between Commonwealth-funded Primary Health Networks (PHNs) and State Government local health and hospital networks, to enable jointly planned and localised regional healthcare. Another highlight is that participating clinicians would be compensated under a non-fee for service basis (specifically through a salary rather than on an episodic fee basis).

5. Comments on transferability
The model can be adapted to address other types of multi-morbidities, such as in geriatric care or CALD groups. The model creates long-term roles for specialist physicians, nurses and allied health practitioners.
6. Conclusions
Models of care should be patient-centred, inclusive of multiple providers and settings, and better support the prevention of exacerbations of chronic disease.
Health policy reform must allow for better configurations of universal care service funding processes for integrated primary care teams, with fewer restrictions on site of service delivery. Integrating consultant physician expertise, trained in complex chronic care would improve the timely access to care for those who would most benefit.