Introduction
South Western Sydney covers a diverse region with pockets of rural communities, unprecedented growth areas, significant socio-economic disadvantage and large populations of culturally and linguistically diverse communities. The region will face significant demographic, health, social and financial challenges over the next few years due to rapid population growth and infrastructure development.

Health Alliances aim to develop effective solutions to coordinate efforts and direct limited resources through place-based partnerships and cross-sector collaboration, to reduce the burden of chronic disease, lead disease prevention initiatives and tackle inequity.

Wollondilly Health Alliance (formed in 2014) and Fairfield City Health Alliance (formed in 2018) are made up of three key partners representing all levels of government; South Western Sydney Local Health District, South Western Sydney Primary Health Network, and Local Council.

Targeted population and stakeholders
In addition to key partners, local representatives from primary care, government agencies and non-government organisations has enabled Health Alliances to leverage knowledge, expertise and resources to develop innovative solutions to improve community health outcomes.
Solutions are tailored to the local area and identified by a health needs assessment based on community demographics, social determinants of health and local health service provision.

The Wollondilly Health Alliance’s strategies and programs include: home-based telemonitoring, video consultations, a mobile community information service, an outdoor gym, a community garden, Aboriginal community engagement through arts, and village café.

The Fairfield City Health Alliance’s strategies and programs include bilingual diabetes self-management program, mental health literacy training for Arabic community and spiritual leaders, and development of an integrated model for gambling harm screening and referral.

Highlights
- Telemonitoring program has reduced Emergency Department presentations and hospital admissions, and demonstrate self-reported improved quality of life, increased confidence to manage health and self-care, and reduced reliance on hospital services.
- Dilly Wanderer (mobile bus information service) has increased knowledge of preventive health, improved health literacy, and increased social connectedness.
- Healthy Towns projects demonstrate self-reported improvements in fruit and vegetables consumptions, participation in physical activity, and improved skills.
- External grant awarded to develop an integrated model for gambling harm screening and referral in primary care and community service settings.
- Under the Western Sydney City Deal, eight local councils, two LHDs and two PHNs, committed in principle to develop the ‘Western Sydney City Deal Health Alliance’.

Sustainability
Partner investment in Health Alliances include a mix of co-funded and in-kind investment. Shared resourcing arrangements or external funding contributions are in place for the implementation of specific programs.

Discussion
Evaluation of Health Alliance programs are predominantly qualitative via surveys. A quantitative evaluation is being planned, due for completion in December 2019.

The successful implementation of Health Alliances have been enabled by a framework based on:
- shared health priority areas prioritised by partners
- an agreed governance structure and strong leadership
- a formal Memorandum of Understanding between key partners
- secretariat and project management support from project officers
- financial and in-kind support from partners.

Integrated Care is a well-established knowledge domain in healthcare systems but with a multiplicity of definitions and conceptualisations. Kodner and Spreeuwenberg summarised Integrated Care expansively as “... a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors ... [to] ... enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex problems cutting across multiple services, providers and settings”.

The World Health Organization calls Integrated Care "a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency.” The Nuffield Trust and the National Health Service in the United Kingdom provide somewhat similar definitions that focus more on the goals of Integrated Care rather than the means of achieving said goals. In 2009, Armitage et al counted some 175 definitions and concepts in Integrated Care, which Kodner in the same year described as “an imprecise hodgepodge”. Since then, there have been many more definitions, models and frameworks (collectively “models”), not least of which is the popular Rainbow Model by Valentijn.

All models are attempts at succinctly capturing the essence of complex realities, differently and differentially experienced by participants, with a view to providing a common language for engagement and communication. Models represent the underlying reality and thus mediate across minds and contexts.

The benefit of a model depends on how closely it represents the underlying reality for useful decision-making. Current models inevitably perceive the world through their own lenses and are, in themselves, not the reality, so the choice of model may significantly influence conversations on Integrated Care. The sheer number of models make a complex knowledge domain even more challenging.

A "Unified Theory of Integrated Care" that brings together disparate models onto a common architecture could go a long way to improving our common understanding and communications in Integrated Care.

The Business Model Canvas (Osterwalder, Pigneur, Smith et al) is a design tool that helps entrepreneurs conceptualise, develop, test and enhance their businesses, especially novel startups attempting to disrupt current value delivery processes. In brief, each canvas captures how products and services meet value propositions for their clientele through defined relationships and channels, and how resources and partners are sustainably and profitably engaged to create these products and services.

This presentation collates common definitions, frameworks and models of Integrated Care and maps them onto a common business model canvas, demonstrating their different perspectives and emphases, illustrating their parallels and differences, and enabling a more transparent display of the systems and processes that underlay Integrated Care. If the past models are each separate windows into the house of Integrated Care, this exercise breaks down the intervening walls to open the interior of the home for hopefully greater understanding and insight.

1. Introduction

High-value integrated care is a priority for health system reform in Australia; however, there is a paucity of research informing strategies to achieve this in practice. Factors preventing integration, particularly at organisational, functional and systemic levels, are poorly understood. The aim of this research was to identify key barriers in current practice in order to inform planning and implementation of future integrated care initiatives.

2. Theory/Methods

The Australian Centre for Health Service Innovation (AusHSI) completed a state-wide evaluation of 23 integrated care initiatives implemented across Queensland during 2016-2019. Qualitative data was collected via a combination of semi-structured individual interviews and focus groups designed to explore factors that facilitated or impeded successful implementation of the integrated care initiatives, and factors relating to sustainability, scalability and generalisability. Interviews were audio-recorded, transcribed, and coded using the Consolidated Framework for Implementation Research to inform detailed identification of barriers and facilitators of implementation. The six dimensions of the Rainbow Model of Integrated Care informed additional analysis of the data to synthesise the salient obstacles to integrated care.

3. Results

162 stakeholders across 13 Health and Hospital Service districts in Queensland participated, representing: Hospital and Health Services; Primary Health Networks; primary care practices; allied health services; and various non-government organisations. Stakeholders included steering committee members, executive sponsors, clinicians, project managers, administrative officers, and external partners. Analysis identified key factors under broad interrelated themes: funding; digitisation; data evaluation; disciplinary boundaries; administration and governance. Higher-level organisational, functional and systemic factors significantly constrained the possibilities for integration at clinical and professional levels. Initiatives had made progress overcoming some clinical, professional and organisational barriers; however, functional and systemic barriers remained significant obstacles to integrated care.

4. Discussion

A notable concern raised by these findings is that segmented and incongruent funding models across care sectors in Australia are contributing to competing organisational interests and values. This study highlights the potential for system level reforms to alleviate challenges through: new Medicare item numbers; other regulatory mechanisms or incentives to support GP engagement in integrated care initiatives; and opportunities for shared digital solutions to improve integrated patient-centred care, efficient service coordination, and meaningful service evaluation.

5. Conclusions

Inter-organisational partnerships are substantially constrained in the level of genuine integration they can achieve within existing structures and funding models. Strategic leadership, strong individual inter-professional relationships, and transparent inter-organisational negotiations are likely to enhance the success of future integrated care initiatives.

6. Lessons Learned

This research informs priorities for strategic operational change across all sectors of the health system in the pursuit of high-value integrated care. An integrated approach to future funding and service models is critical. Implementation of appropriate digital solutions to facilitate clinical and service integration remains an urgent priority.

7. Limitations

These findings may not be generalised to dissimilar societies or healthcare systems.

8. Future Research

Evaluating care integration frameworks that can successfully overcome organisational, functional and systemic barriers is a priority for future research.

Health Hub Morayfield was predicated on the concept of integrated person centred care. The large scale private commercial development converted an ex-Bunnings warehouse into a major health hub in a poor socio-economic suburb.
The development brought much needed quality health services into an area that had struggled to recruit health professionals and health service businesses.
The theory of change was that to bring health service providers into the area there needed to be a defined point of difference to encourage people to work in the area. The concept was not about collocation of services but true collaboration with the person at the heart of service delivery.
Morayfield was the targeted population and the key stakeholders were the range of service providers, both private for profit and not for profit organisations.
The General Practice services commenced in December 2017, however the preparatory work for collaborative governance and application of the IPCC framework began several months before this.
The strategic planning for the collaborative service venture was developed directly from the key strategies identified in the IPCC framework, with an additional concept included which relates to viability and sustainability. The engagement strategy included tenants and stakeholders as well as community members and groups who are now forming a volunteer group to support the work of the hub. The Health Hub at Morayfield sees an average of 5000 people per week accessing the General Practice.
An additional conceptual pillar was added to the WHO framework which focused on viability and sustainability. This concept was critical to include given the need for each business to be successful as part of small to medium size business modelling as well as for surety of service provision for the community that needed access to a range of services
The concepts of integrated person-centred care including, relationship with a known primary provider and ease of access to supporting diagnostic and therapeutic services are replicable. The engagement of the community in both consultation for the development and in becoming part of the infrastructure support for the community members who access the Health Hub is also transferable.
The application of the IPCC framework in collaboration with the range of service providers in the Health Hub proved effective in keeping a clear focus for service development and implementation. The advent of the Health Hub at Morayfield heralds the potential of medium to large scale primary care services leading change in collaboration with a range of service providers to improve health and wellbeing in communities through thoughtful planning and real life integration to meet defined community need.
The concept on this scale is not without its problems including the funding models for services with little incentive for Government to redirect funding into the primary sector.
The importance of effective planning, bringing together people with genuine engagement, enshrining of values and a vision for service provision and true engagement with the community.
A framework developed for National Level policy development can be applied at a local level.