Delivering an integrated system of care in Western NSW, Australia
Delivering an integrated system of care in Western NSW, Australia Conference Paper
14th National Rural Health Conference: A World of Rural Health
- Author(s): Robinson, L
- Secondary Author(s): Coleman, Leanne
- Published: 2017
- Publisher: National Rural Health Alliance
Abstract: Introduction: Western NSW (WNSW) is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes. A strategy to transform current services into a patient centred, coherent system of care is well into its third year with WNSW Local Health District (LHD) leading the way as a NSW Health Integrated Care Demonstrator Site. A range of district-wide and locality-based integrated care initiatives are being implemented to better connect providers to improve health outcomes for the region. Methods: The WNSW Integrated Care Strategy is being implemented using a collaborative partnership approach between the LHD, the Western Primary Health Network, and Bila Muuji Aboriginal Health Services. The vision of the strategy is: To transform existing services into an integrated WNSW system of care that is tailored to the needs of our rural and remote communities, and improves access to care and health outcomes, with particular focus on closing the Aboriginal health gap. A key element of the strategy was the establishment of local demonstrator sites to test new models of care at a locality level. Local Leaderships Groups were established at each site and tasked with developing and implementing locally led integrated models of care tailored to their identified local health needs. Features of the demonstrator site models of care include: GP-led multi-disciplinary team based care standardised risk stratification process to target identified cohorts comprehensive assessment to address medical and social care needs shared care planning health and social care coordination multi-disciplinary case conferencing. Results: Over two and a half years the strategy has: established a Health Intelligence Unit providing a ‘one-stop-shop’ for health care data, analysis, advice and support established nine local demonstrator sites focusing on chronic disease management, the first 2000 days of life and dementia. strengthened the connection between care providers in a locality appointed local Health and Social Care Coordinators based in primary care development of risk stratification criteria introduced primary care based multidisciplinary case conferencing. Early analysis of the enrolled cohort is indicating an improved health journey, improved health outcomes and a reduction in acute care utilisation Discussion: A key objective of the strategy was to develop sustainable models of care that are easily and rapidly transferable to other sites and localities. We consider the learnings from our experience in transforming our local health system transferable to other contexts, with suitable tailoring to local funding, delivery and accountability environments.
- Urls: http://www.ruralhealth.org.au/14nrhc/sites/default/files/Robinson%2C%20Louise_A10.pdf Available from, http://www.ruralhealth.org.au/14nrhc/program/concurrent-speakers Download site
- Publisher Location: Cairns