Abstract
With an ageing population and a growing number of people living with chronic and complex health conditions, people’s health needs are changing and demands on the health system are increasing. ‘Delivering truly integrated care’ is one of three strategies in the NSW State Health Plan: Towards 2021 which aims to address these challenges. $180M over six years has been invested by the NSW Government to deliver on this strategy.
Following an evaluation of the former NSW Chronic Disease Management (CDM) Program, a redesigned model has been developed which will focus on the delivery of ‘Integrated Care for People with Chronic Conditions’ (ICPCC). This new approach aligns with the NSW Integrated Care Strategy and takes into account emerging Australian Department of Health policy directions.
Once fully implemented, there will be a state-wide model for local delivery of integrated care to patients with chronic conditions who are at risk of a hospitalisation in the next 15 months.
The model includes a number of consistent elements to support equitable access and enable comprehensive evaluation, while also providing local flexibility to ensure that the needs of communities and individual patients can be met.
The ICPCC model strengthens the emphasis on:
- selecting the right people and matching them to the right integrated care intervention;
- the importance of engaging patients and carers and collecting Patient Reported Measures;
- the need for collaborative relationships with PHNs and GPs, and supporting capacity and capability building in primary care; and
- the need for technology to support shared care planning, information sharing and data collection.
Implementation of the ICPCC model is phased during 2016-17. Both the model, and experience to date with the five ‘Early Implementer’ Local Health Districts, will be discussed in this presentation.