Improving integrated services for patients with chronic and/or complex conditions

A part of the Australian Better Health Initiative (ABHI) to help primary care providers streamline coordination of care for patients with chronic and/or complex conditions such as diabetes, respiratory and cardiovascular diseases across the lifespan.

Overview of the policy context

In February 2006, the Council of Australian Governments (COAG) announced a four-year, national program called the Australian Better Health Initiative (ABHI) to strengthen the health system’s focus on promoting good health and reducing the burden of chronic diseases like diabetes, respiratory and cardiovascular disease. As a COAG 2006-2010 initiative, the Australian Government has committed $250m, with States and Territories matching this.

The Australian Government has provided $9 million over four years (2006/07 - 2009/10) through the NSW Divisions of general practice network to improve integration of state and commonwealth funded health services. There are 13 Integration Project being run in NSW by a number and consortia of Divisions.

There are five priority areas identified under ABHI:

1. Promoting Healthy Lifestyles

2. Supporting Early Detection of Lifestyle risk factors and chronic disease

3. Supporting lifestyle and risk factor modification

4. Encouraging active patient self management

5. Improving integration and coordination of care

The fifth priority area under ABHI is focused on improving integration so that people with chronic and/or complex conditions can receive more flexible and innovative support. Both the NSW Government and Australian Commonwealth Government have dedicated funding to this component of ABHI.

The primary care integration focus brings together various aspects of the healthcare system so that hospitals, ambulatory care, primary health care and care in the community have clear funding, role delineation, paths of engagement and transition and are able to continually improve their use of both the workforce and technology.

Why do we need integration programs for chronic and/or complex conditions?

Integration of care is particularly important in the context of better managing patients with chronic and/or complex conditions who often receive care from multiple providers, funded by different jurisdictions, across different settings. For these patients in particular, care can often be fragmented. An essential requirement of integrated care is to establish collaborative relationships between different primary care service providers. This program helps to either establish or strengthen vital communication channels between the public, private and non-government organisations working within the primary health care sector.

The goals that define the (ABHI) Primary Care Integration Programs are essentially about:

1. Functional relationships between health care service providers;

2. best practice arrangements for co-ordinating clinical pathways; and

3. better use of systems to navigate and support co-ordination of care.

How are integrated care projects being delivered through the Divisions?

Divisions have appointed regional integration coordinators to work as non-clinical change agents to support better chronic disease management. Each Division has identified local priority areas and are working with key stakeholders to meet the above goals, including their local general practices, Area Health Services, private allied health providers and non government organisations.

Hyper-links to Divisions involved in innovative integration projects:

Integrated care projects - success stories

Successful integration projects have been characterised by the following key steps:

1. Assessing local service gaps;

2. implementing local strategies to change systems of service; and

3. care coordination in partnership with their local public, private and non-government services.

GP NSW is keen to share the integration approaches across the Divisions network. The following stories demonstrate the process of partnerships and some of the outcomes and lessons learnt so far. We hope these case studies will give you an idea of some of the important work that Divisions and their partners are doing under this program.

WentWest: Integrating Hospital, General Practice and Community Health: an initiative in association with Sydney West Area Health Service
Sutherland Division: a partnership working with the hospital to improve discharge processes in aged care in Sutherland
Hunter Rural Consortia: a partnership between Hunter New England Health and four Divisions of General practice to address the gaps in the system
Northern Rivers Division: establishing a patient held shared electronic health record
Mid North Coast: strengthening approaches to chronic disease using a model of chronic disease collaboratives

Useful chronic disease resources for Divisions

Other useful links:

GP NSW support for Integration Projects in NSW

An essential requirement of integrated care is to establish collaborative relationships between the different primary care service providers. This Program will help to either establish or strengthen communication channels and information sharing between the public and privately funded primary care sectors so that patients receive more streamlined care.

GP NSW has a state based integration coordinator who works closely with the Divisions to offer the following support:

Work with NSW Health in planning and development of chronic disease initiatives
Support Divisions to collaborate and work in partnership with Area Health Services and local community health teams
Provide information, resources and training on chronic disease initiatives and help divisions identify opportunities for improved linkages in state and commonwealth programs
Provide resources to Divisions related to Chronic disease initiatives
Ensure Divisions are aware and up to date with Commonwealth and State initiatives supporting health promotion, disease prevention and better chronic disease management

For information or support with this initiative please contact Jerry Bacich GP NSW (ABHI) Primary Care Integration Coordinator on ph: (02) 9239 2966 or by email at jerrybacich@gpnsw.com.au

Where to from here?

The Primary Care Integration Program ceases on 30 June 2010. Over the next six months GP NSW will be conducting a state-wide evaluation of the ABHI Primary Care Inetgration Program and recommendations on the future sustainability of the Divisions projects will be determined after June 2010.