It Pays to be Well Connected - Delivering an integrated system of care in Western New South Wales, Australia

摘要

Introduction : Western NSW 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 4th year. A range of locality-based initiatives are being implemented to better connect health and social care providers to improve health outcomes for the region. Methods : The Western NSW Integrated Care Strategy (Strategy) is being implemented using a collaborative partnership approach between the LHD, the Western Primary Health Network, and Bila Muuji Aboriginal Health Service. The vision for the Strategy: To transform existing services into an integrated Western NSW 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 integrated models of care at a locality level. Features of the models include: Primary care led team based care Risk stratification Comprehensive assessment Shared care planning Health and social care coordination Multi-disciplinary case conferencing in primary care Results : Over 4 years the Strategy has: Enrolled 1500 people across 12 local demonstrator sites focusing on chronic disease management, the first 2000 days of life and Aboriginal Health. Strengthened the connection between care providers to provide team based care Appointed local Health and Social Care Coordinators Introduced primary care based multidisciplinary case conferencing Established a change team to enable rapid transfer of integrated models across the region Evaluation of the Strategy is indicating an improved health journey, improved health outcomes and a reduction in acute care utilisation. Discussion : We consider the learnings from our experience transferable to other environments, with suitable local tailoring.