Figure 1
Project INTEGRATE Key Dimensions and sub-elements of Integrated Care [5].
Table 1
Enabler activities supporting the population streams.
| Enabler | Description |
|---|---|
| Population health approach | Vulnerable groups were identified by need, disadvantage, and likelihood to be high users of health services in the future. A risk stratification model, informed by a detailed diagnostic assessment, was carried out to identify the three target populations. |
| Outcomes-based commissioning | Outcomes-based commissioning places the emphasis on the achieving the desired outcomes for the service user (rather than the more usual measure of performance by activity). The CCICP tested outcomes-based commissioning in the context of NGO-provided care coordinators for a Central Coast sub-population of vulnerable older people (North Wyong region). |
| Co-design | Co-design, that is the involvement of stakeholders in service design, was used to varying degrees. For example, substantial consultation and workshops were undertaken for both care coordination and shared care planning in the vulnerable older people stream but less so in the chronic and complex stream. In the vulnerable youth and children stream, there was much engagement and dialogue with stakeholders and to a lesser extent with the young people involved. |
| Information sharing tools | A key enabler of integrating care is the ability to share information safely and securely amongst care professionals. A number of projects to improve information sharing, identifying, selecting and enabling a shared care planning system were undertaken. Several options were considered but an IT platform that could deliver all of these needs has not yet been identified. Shared care planning work was deferred in order to prioritise work on other objectives. |
| Multiagency Accelerated Implementation Methodology (AIM) | A lack of workforce change management skills, lack of a common language across partner organisations and professionals, and resistance to change were identified as key barriers to successful program implementation. An evidence review identified that joint training in the use of a consistent framework and change management approach would support effective interagency work and therefore Aim was trialled. AIM is an internationally recognised change management methodology supported by the Agency for Clinical Innovation (ACI) and the Health Education and Training Institute (HETI) for NSW Health staff to practically assist with project implementation. In order to build capacity to deliver collaborative change 97 staff trained in 2016. Importantly, the two-day training sessions were delivered purposefully as cross-sectoral training to groups containing a mix of LHD and partner agency staff, including HNECC PHN, FACS, DEC, NSW Ambulance and the Family Referral Service (the Benevolent Society). Feedback from the training was overwhelmingly positive and further training was delivered in 2017 and planned for 2018. |
| International evidence and experts | Evidence and international experts in integrated care to inform planning, implementation and review of progress have been drawn upon since inception. |
Figure 2
Central Coast Integrated Care Program Overview.
Table 2
Survey results summary.
| Dimension | Responses agreeing with statement of best practice | Strongly agreed/agreed | Neither agreed or disagreed | Disagreed/strongly disagreed | Summary analysis of free text |
|---|---|---|---|---|---|
| Patient-centred care | CCICP contributed to improved achievement in patient-centred care | 82% | 19% |
| |
| Health literacy promotion | 70% | 26% | 4% | ||
| Decision making shared with service user | 59% | 33% | 7% | ||
| Self-care empowerment | 52% | 44% | 4% | ||
| Carer support | 44% | 56% | |||
| Service user feedback on service | 44% | 37% | 19% | ||
| Holistic care planning shared with service user | 41% | 48% | 11% | ||
| Access to own care record | 41% | 37% | 22% | ||
| Clinical integration | CCICP contributed to improved achievement in clinical integration | 82% | 7% | 11% |
|
| Multidisciplinary assessment and care planning | 78% | 7% | 15% | ||
| Coordinators ensure care continuity | 59% | 37% | 4% | ||
| Case management of defined user groups | 59% | 37% | 4% | ||
| Single entry point for multiple services | 59% | 15% | 26% | ||
| Care transition management | 37% | 52% | 11% | ||
| Defined pathways of care | 30% | 59% | 11% | ||
| Volunteers/community actively involved in coordinating care | 15% | 67% | 19% | ||
| Professional integration | CCICP contributed to improved achievement in professional integration | 74% | 11% | 15% |
|
| Shared professional responsibility and accountability | 70% | 26% | 4% | ||
| Multi-disciplinary teams with agreed roles and responsibilities | 67% | 26% | 7% | ||
| Professional commitment to integrated care | 63% | 11% | 15% | ||
| Formal agreements support professional collaboration | 56% | 41% | 4% | ||
| Continuous multi- and inter-professional education | 37% | 56% | 7% | ||
| Organisational integration | CCICP contributed to improved achievement in organisational integration | 74% | 15% | 11% |
|
| Shared performance and outcome measurement | 56% | 33% | 11% | ||
| Collective incentives | 56% | 37% | 7% | ||
| Shared strategic objectives, policies and procedures | 52% | 33% | 15% | ||
| Shared governance and accountability mechanisms | 41% | 56% | 4% | ||
| Systemic integration | CCICP contributed to improved achievement in systemic integration | 67% | 26% | 7% |
|
| Involvement of all stakeholders in design, implementation and evaluation of programs and policies | 44% | 26% | 30% | ||
| Supportive national/regional policies | 37% | 37% | 26% | ||
| Compatible regulatory framework | 33% | 44% | 22% | ||
| Financing and incentives promote integrated care | 33% | 48% | 19% | ||
| System-wide outcome and performance measurement | 30% | 52% | 19% | ||
| Investment in an adequate workforce | 19% | 33% | 48% | ||
| Functional integration | CCICP contributed to improved achievement in functional integration | 44% | 44% | 11% |
|
| Uniform service user identifier | 37% | 26% | 37% | ||
| Support systems for shared decision making | 26% | 41% | 33% | ||
| Effective communication between professionals and service users | 19% | 52% | 30% | ||
| Single care record that can be shared for all care purposes | 15% | 33% | 52% |