NSW Health Integrated Care
Delivering truly integrated care is one of three strategic directions in the NSW State Health Plan: Towards 2021. Due to an ageing population and a growing number of people with chronic or complex health conditions, people’s health needs are changing and demands on the health system are increasing. NSW Health is responding to these challenges by investing in new, innovative models of integrated care, and transforming the health system to routinely deliver person-centred, seamless, efficient and effective care, particularly for people with complex, long-term conditions.
What is integrated care?
Integrated care entails the provision of seamless, effective and efficient care that reflects the whole of a person’s health needs: from prevention through to end of life, across both physical and mental health, and in partnership with the individual, their carers and family. It necessitates greater focus on a person’s needs; better communication and connectivity between healthcare providers in primary care, community and hospital settings; and better access to community-based services close to home.
Who benefits from integrated care?
Integrated care can benefit anyone with health needs, but it is particularly important for people with complex and long-term conditions. It helps them manage their own health, keeping them healthy, independent and out of hospital for as long as possible. This includes people with chronic conditions, frail and elderly people, people with disability, and those at the end of life.
NSW Integrated Care Strategy
To transform the NSW healthcare system, the NSW Government has committed $180 million over 6 years to implement innovative, locally-led models of integrated care across the state. This Integrated Care Strategy is being implemented across three closely-related areas:
- three Integrated Care Demonstrator sites
- 17 Innovator initiatives
- four statewide enablers.
The objectives of the NSW Integrated Care Strategy are to transform delivery of care, improve health outcomes for patients, and reduce costs due to inappropriate and fragmented care, across hospital and primary care services. This is achieved by:
- focusing on organising care to meet the needs of targeted patients and their carers
- designing better-connected models of healthcare
- improving the flow of information between hospitals, specialists, community and primary care healthcare providers
- developing new ways to work across state government agencies and with Commonwealth-funded programs, to deliver better outcomes for identified communities
- providing greater access to out-of-hospital community-based care.
The following outcomes will demonstrate this strategy is achieving these objectives.
- Patients will report that they can more easily navigate the health system.
- The patient experience will improve, as will health outcomes.
- Waiting times will decrease for patients as they navigate the system.
- The number of patients who can be cared for in the community will increase.
- Avoidable hospitalizations will decrease; frequency of hospital admissions and emergency department attendance will also decrease.
- Sharing of clinical information will improve.
- Unnecessary duplication of pathology and radiology tests will decrease.
The NSW Government has allocated funding to three Integrated Care Demonstrators, to develop and implement system-wide approaches for integrating care at a local level. Learn more about these Demonstrators:
A Planning and Innovation Fund was established to support discrete and innovative integrated care initiatives run by local health districts and specialty health networks, along with their partner organizations. Seventeen initiatives were originally funded from across all local health districts and specialty health networks. The initiatives represent a wide range of themes, patient groups, geographical areas and partnership models.
Enabling integrated care statewide
A key focus of the NSW Integrated Care Strategy is to deliver technology that connects different information technology systems and data across NSW. The strategy advocates for greater use of innovative technology to deliver improved patient experiences and outcomes, and better health service delivery for clinicians. The following measures are being taken:
- Statewide enablers, including the rollout of HealtheNet, are being developed.
- The strategy is working with the Agency for Clinical Innovation to pilot patient reported measures. A statewide approach for active, shared care collaboration is being developed, including support for proof-of-concept technology.
- Technology is being investigated to track integrated care patients and cohorts, and potentially care activities, for patient identification, monitoring and evaluation purposes and improved outcomes.
Integrated care for people with chronic conditions
Evaluation of the former Chronic Disease Management Program led to a redesigned model for coordination and integration of care for eligible patients with chronic conditions. Now under development, this Integrated Care for People with Chronic Conditions (ICPCC) model will align with the NSW Integrated Care Strategy's work.
The ICPCC model's aims, like those of the NSW Integrated Care Strategy, are to improve health outcomes for people with chronic conditions, including the following.
- More patients who can be cared for in the community receiving their care there. This will reduce avoidable hospitalisations, frequency of hospital admissions and emergency department attendance, and length of stay in hospital.
- Greater access to out-of-hospital, community-based care will be provided.
- Patient-reported health outcome and experience measureswill improve.
The IPCC's target cohort is people with one or more chronic conditions who are:
- at risk of hospitalisation in the next 15 months
- likely to benefit from one or more of the integrated care Interventions.
The redesign of the ICPCC is ongoing.
Primary care focus
The NSW Integrated Care Strategy puts greater emphasis on developing and enhancing strong relationships between state health services and primary care.
Primary care plays a vital role in initiating and maintaining community relationships with patients and families. It also provides a valuable alternative to hospital and specialist care. Demand on healthcare services is growing as chronic diseases become more prevalent. There is greater focus on comprehensive and coordinated care involving a wide range of health professionals. The need for information sharing between general practitioners and health services is greater than ever.
As part of the $180 million investment in the NSW Integrated Care Strategy, the NSW Ministry of Health is supporting locally-led local health districts and specialty health networks. This support aims to progress collaborative working relationships with primary care providers, including general practitioners. The care given by these providers is vital to help people with chronic and complex conditions stay healthy and in the community.
This information is provided by the NSW Ministry of Health System Performance Support branch.