Integrated Care across Health District Boundaries

摘要

The Healthy Homes and Neighbourhoods (HHAN) Program provides long term care coordination to families with complex health and social needs, in the Sydney Local Health District (SLHD). Referral during the antenatal period is the preferred pathway, aiming to ensure complex families have support for themselves and their child, commencing in the period prior to birth. Previous geospatial mapping has identified two areas of clustered disadvantage within SLHD. Following identification of reduced attendance at one of two SLHD antenatal clinics, a HHAN care coordinator established communications with two hospitals in adjoining health districts to discover patterns of attendance for “out of area” pregnant women. Reasons for attendance at these “out of area” antenatal clinics is uncertain at this stage, but Local Government has identified gaps in public transport to the secondary SLHD hospital. Further research into cross boundary hospital attendance will be undertaken. By attending the adjacent Local Health District’s psychosocial meetings, HHAN aims to identify and engage with vulnerable women and their families, living with SLHD, but attending “out of area” health services. Engagement with adjoining health districts helps to integrate health and social care services beyond our local health district borders, which is vital for families living within previously identified areas of disadvantage. This initiative targeted pregnant women, and their families, with complex health and social needs residing in SLHD who were utilising antenatal health services outside SLHD boundaries. Engagement with health and social care providers across local health district boundaries is essential as HHAN aims to ensure vulnerable women and their families are not “falling through the cracks”. This presentation will focus on the initial collaboration between nurses/midwives and social workers, based in bordering health districts with the common aim of providing client focused support. Attendance at adjacent health district psychosocial meeting commenced in July 2017, following a period of discussion between health districts to acknowledge the identified gap in SLHD antenatal attendance and recognition of cross boundary health utilisation. Ongoing collaboration is planned to allow for seamless referral into the HHAN program and other health and social care services. Inter-Health District Care Coordination is a developing area within Australian public health. This Sydney-based, high-risk, antenatal pathway demonstrates to health care providers and their consumers that flexible support is possible across health boundaries. Interdisciplinary, cross health district collaboration is an essential current and future pathway to improve outcomes in the most vulnerable members of our population. The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. This inter-health district liaison is enhancing communication and planning across health borders. Challenging and supporting health and social care partners to think and act outside their geographical boundaries is essential for ongoing change in these sectors, as we put the consumer and their complex lives at the forefront of our care. Whilst change is challenging, collaboration between health service providers is one step towards providing timely, integrated supportive care for vulnerable families.