The inTouch Integrated Care Framework – Reimagining Integrated Health Service Delivery

Introduction

Globally, integrated care has been adopted as a guiding principle to reduce fragmentation and to make health systems more person-centred [1]. Integration has long been viewed as a solution to fragmentation of care, increased complexity in delivery of care, and poor quality of care [2]. However, integrated care is not a simple, “one size fits all” approach: care means different things to different people [3]. The differences are highlighted by the ongoing debates about what exactly constitutes integrated care [4]. Regardless of the definition of integrated care adopted, there is understanding that it strengthens health services by being flexible, people-centred [5], multi-morbidity focused [6] and deliverable by multi-disciplinary teams [7] across different settings. With a rise in chronic conditions across OECD counties [8], integrated health systems focus on delivering appropriate care, preventing people from being in the acute system unnecessarily. This goal requires integrated care services and processes that include primary care, specialist care, and acute services [910].

In many countries there is an increasing recognition across health and social care providers and commissioners that care needs to focus on supporting people to remain well at all stages of life. Key strategies to achieve this are supporting people to receive care in community settings close to home [11], and developing integrated care systems that encompass health and social services [12], such as housing, welfare and education. We know that attaining integration of services across and within different settings, organisations, and professions enhances value in service delivery and reduces silos [13]. However, achieving a shared vision and common understanding of what integration looks like across multiple services, health and social care professionals, and patients, is a significant challenge [1415]. Furthermore, it can be difficult to ensure the seamless flow of information between service providers across different settings [16], in a timely and contextually sensitive way [17]. The lack of agreement around integration extends to a lack of clarity about how to achieve it, including how more integrated care can be supported and facilitated. If integrated care is to be achieved change is required to promote primary and acute care planning together to break down silos in health service delivery [1418]. That is, a complete paradigm shift so that care planning considers health, welfare and social circumstances in determining health and community services.

Whilst frameworks for integration exist, these tend to concentrate on meeting the needs of targeted groups and populations with defined chronic diseases [19]. Integrated care framework efforts tend to be on integrating care vertically or horizontally but not both [4], with calls for more comprehensive models that address multi-morbidities [20]. In response to this, maturity models and system appraisal frameworks for integrated care have been developed, such as the SCaling IntegRated Care in COntext (SCIROCCO) project that focuses on the facilitating factors and pitfalls of integrated care initiatives in five European regions [21], and the Project INTEGRATE framework to assess people-centred integrated care processes [22] developed using lessons from literature. At a systems level, governments are formulating polices and promoting frameworks to achieve the integration of care, for example the NSW Health Integrated Care Strategic Framework [23]. Other frameworks cover different settings such as: the integrated behavioral health (IBH) Cross-Model Framework aimed at primary care clinics who are trying to use and sustain integrated behavioral health [24]; the ICP OP 10 Step Framework, a framework to implementing integrated care for older persons [25]; and the Navian Hawaii’s Integrated Care Program, separate to their Hospice Care team, working with those who are seeking curative treatment [26]. What is common across these frameworks is that successful integration of health and social care depends on the implementation of initiatives that are locally focused [2728] and secure meaningful engagement of staff, consumers and care providers [2829].

Successful integration of health and social care depends on the implementation of initiatives that are based on local needs and conditions [27]. They have been implemented using a bottom-up approach and secure meaningful engagement of staff, consumers and care providers [2829]. To improve health system efficiency, we require integrated care frameworks that are flexible and adaptable for different community contexts, conditions and settings. Individual patient care needs must be balanced with the broader social and care needs of a community in line with a population or public health perspective [30]. In working towards developing and sustaining effective, safe health care systems, we need to deliver care in the community with access to specialist services that do not require an admission, or readmission, into acute services [31].

Western Sydney Local Health District (WSLHD) initiated and has facilitated the development of the inTouch Program, linking services within its geographic region. inTouch is an integrated care strategy for safe, high quality patient care delivered in the appropriate environment. The inTouch Program provides an innovative approach to integrate services by facilitating cooperation and care navigation between providers across primary, aged, community and acute settings. Using a case study approach, we focus on WSLHD, describing and analysing the inTouch Program and its three current pathways to present the empirically derived inTouch Integrated Care Framework.

The inTouch Program

inTouch Pathways

WSLHD partnered with multiple healthcare providers to develop and deliver three inTouch pathways. External healthcare providers included NSW Ambulance, Western Sydney Primary Health Network (WSPHN), general practitioners (GP), and 65 aged care residential facilities. This Program is delivered in the inTouch operational service that operates through a central point of contact, a call service functioning from 8 am to 8 pm 7 days per week. The phone line is a free number that serves as a single point of access for all three inTouch pathways. The phone line is staffed by a triage clinician supported with a procedure manual and clinical guidelines that inform responses to inquiries. The triage clinician is qualified to provide preliminary advice regarding immediate and follow-up care. Appointments for further care can be organised for services within the District or with GPs.

The three inTouch care pathways are: 1. inTouch COVID Care in the Community [40]; 2. inTouch Residential Aged Care Facilities (RACF) [34]; and, 3. inTouch Planned Care for Better Health (PCBH) [41]. A summary of the three care pathways is discussed and presented below (Table 2), demonstrating that the elements can be adapted across different settings, contexts and conditions.

Table 2

Overview of three care pathways of the inTouch Program.

1. inTouch COVID CARE IN THE COMMUNITY
Lifespan	January 2021 – ongoing
Purpose/aim	Care for COVID-19 patients: not requiring face-to-face clinical care or intervention; and early identification and intervention when deteriorating.
Partners	WSLHD Specialty teams NSW Ambulance NSW Health COVID response
Evaluation/monitoring	NSW Ambulance and WSLHD COVID Monitoring Framework WSLHD inTouch COVID Clinical Governance Framework
Data sources	WSLHD NSW Ambulance NSW Health NSW Police
Actions	COVID-19 patients initial assessment of symptoms, medical and social risk factors – assigned a risk category – Low or High Patients receive follow-up assessment calls based on their risk category; if risk profile changes reclassification of category. inTouch clinicians provide resources and information to support the wellbeing of patients, including how to access additional community services. Patients self-manage COVID-19 symptoms and actions if deteriorating/ improving.
Activity	Data reported January 2021-November 2023: 47,587 patients have received care on pathway, 16,485 cared for directly by WSLHD 31,767 were cared for by Calvary/Medibank under contract with WSLHD using the pathway. Impact: During the peak of the pandemic in 2021 WSLHD inTouch - admission rates were 4.6% compared to 25% NSW, and death rates were 0.04% compared to 1.4% for NSW.
2. inTouch RACF
Lifespan	April 2022 – ongoing
Purpose/aim	Improve aged care residents’ health and wellbeing through person-centred, flexible, timely care
Partners	Aged care residential facilities (n = 65) NSW Ambulance WSLHD Specialty teams Primary Care through WSPHN
Evaluation/monitoring	NSW Health Urgent Care Service Evaluation Framework NSW Ambulance and WSLHD RACF Monitoring Framework Analysis of WSLHD activity & hospital utilisation data sets
Data sources	WSLHD NSW Ambulance
Actions	Pathway provides: Specific referrals process for NSW Ambulance, general practices, and RACFs; Continuous monitoring of the NSW Ambulance Arrivals Board to identify suitable patients; Virtual clinical assessments and triage to identify appropriate ED alternative care plans; SCPs developed in partnership with patient/carers, speciality medical teams, GPs, RACF providers and other community-based services; and, Referrals and care navigation to services delivered in residence, including mobile diagnostics capability for rapid assessment and treatment.
Activity	Data reported April 2022-November 2023: 5,127 referrals received. Access savings include: 1,965 avoided (38%) transfers of residents to EDs. 11% reduction in readmission (based on the usual rate within 28 days). 2% reduction in ED representations (based on the usual rate within 48 hrs). NSW Ambulance savings: 2,692 paramedic hours (based on average of 101m of case cycle time). NSW Patient Transport Service savings: 1,562 return trips to RACFs.
3. inTouch PCBH
Lifespan	July 2022 – ongoing
Purpose/aim	Facilitate and strengthen care for patients identified of being at risk of unplanned hospitalisation within 12 months.
Partners	Primary health network (PHN) WSLHD Specialty Teams Justice Health
Evaluation/monitoring	NSW Health Integrated care Monitoring and Evaluation Framework
Data sources	NSW Health: Integrated Care Outcomes Database (ICOD) Patient Flow portal WSLHD activity and hospital utilisation data sets NSW Health Integrated Care Outcomes Database
Actions	Mutli-disciplinary shared care model: Care Facilitators undertake coordinate care and navigate access to services, and health coaching, General practitioners and acute care specialty teams deliver clinical care.
Activity	Data reported July 2022–November 2023: 8,097 referrals received. Post hospital discharge services delivered include: 5,053 calls to people who are at high-risk of hospitalisation addressing medication management, additional medical (re)tests and/or referral/ follow-up with GP; 840 calls by Aboriginal Health Practitioner to Aboriginal people with chronic conditions; 58 Type 2 Diabetes multidisciplinary case conferences; 1,994 episodes of supportive post discharge transfer of care to GPs and/or self-management support to people with Atrial Fibrillation; 316 referrals for care navigation to inTouch referral support team; and, 136 referrals to COACH program team for lifestyle risk factor modification health coaching.

inTouch Pathway 1 – COVID Care in the Community

inTouch COVID Care in the Community was developed January 2021 in response to the COVID-19 Delta outbreak. inTouch COVID Care in the Community proactively manages and monitors COVID-19 positive patients who do not need face-to-face clinical care and provides early identification and intervention to COVID-19 positive patients who are deteriorating (Figure 1; Table 3).

Figure 1

Table 3

inTouch Pathway 1 – COVID Care in the Community.

ELEMENT	APPLICATION
1. Stakeholder engagement and risk analysis	This pathway reduces unnecessary emergency department and hospital admissions by: identifying and rectifying deterioration early in COVID-19 positive patients; and, supporting patients to self-manage at home.
2. Population and individual care plans	The initial assessment checklist addresses: consent to engage with inTouch; a risk profile evaluation; symptom identification and clinical history; mental wellbeing screening; and, health literacy review. A SCP is established using a template with options to refer to WSLHD services and private primary health and welfare services in the community.
3. Continuum care coordination	Support and care coordination for patients as required, including: clinical care provided by Hospital in the Home (HITH); mental health services; and/or, welfare and social care services.
4. Shared decision making	Adult Short Screening Questionnaire administered to patients to: determine pathway suitability; decision-consent capabilities; identification of risk/ high-risk clinical indicators; and, required education and resources.
5. Knowledge translation and health literacy	Health literacy resourcing: patients given health information and skills education regarding physical, mental, and social health needs.
6. Monitoring, review and adaptation	Ongoing SCP assessment addressing: physical health and COVID-19 symptom assessment; – mental wellbeing screening; consent and health literacy; and, care plan, including services needed and escalation strategy.

inTouch Pathway 2 – Residential Aged Care Facilities (RACF)

The inTouch Residential Aged Care Service (RACS) pathway was established in April 2022. The pathway provides a single encounter of care for ‘primary care type’ low acuity conditions such as falls and wound care of aged care residents to prevent ED presentations and increase a resident’s options of care setting (Figure 2; Table 4).

Figure 2

Table 4

inTouch Pathway 2 – Residential Aged Care Facilities (RACF).

ELEMENT	APPLICATION
1. Stakeholder engagement and risk analysis	The inTouch RACS pathway criteria is people who reside in a aged care facility (n = 65) within the WSLHD geographical boundary. The pathway increases options for the delivery of primary care needs without a resident having to leave their facility. Service stakeholders include GPs, RACF clinicians, NSW Ambulance, Paramedics, and the Virtual Clinical Care Centre (VCCC).
2. Population and individual care plans	The initial assessment checklist addresses: consent to engage with inTouch; a risk profile evaluation; symptom identification and clinical history; mental wellbeing screening; and, health literacy review. A SCP is established using a template with options to refrfer to WSLHD services and private primary health and welfare services in the community.
3. Continuum care coordination	inTouch RACS pathway ongoing care coordination involves determining the service best placed to do so – either inTouch clinician, GP or Primary Centred Medical Home. Within care coordination is the provision of urgent responsive community care alternatives for low acuity conditions.
4. Shared decision making	Shared decision making enabled via: patients and professionals co-design care plan – participate in identifying needs, options and decisions re health and social issues; case conferences and information sharing with acute care, community and primary health services.
5. Knowledge translation and health literacy	Health literacy resourcing: health professionals, carers and patients given health information and skills education regarding physical, mental, and social health needs, and services – acute, primary care and community – to address them.
6. Monitoring, review and adaptation	Ongoing SCP assessment addressing: physical health-illness and symptom assessment; mental wellbeing screening; consent and health literacy; and, care plan, including services needed and escalation strategy. Program level evaluation incorporates monitoring of ED presentation rates and hospital utilisation by individuals from RACF.

inTouch Pathway 3 – InTouch Planned Care for Better Health (PCBH)

The inTouch PCBH service has been operational since July 2022 and was developed using the inTouch elements in response to one of the eight NSW Health NSW Integrated Care Initiatives, Planned Care for Better Health [42] (Figure 3; Table 5). The PCBH pathway improves the patient’s experience of care and keeps patients healthier over the long term to ultimately prevent ED presentations and potentially preventable hospitalisations. Many of these patients will have complex and chronic needs.

Figure 3

Table 5

inTouch Pathway 3 – inTouch Planned Care for Better Health (PCBH).

ELEMENT	APPLICATION
1. Stakeholder engagement and risk analysis	The Risk of Hospitalisation (ROH) algorithm (37) is used plan patient centered interventions. The pathway criteria is patients identified as being at-risk of unplanned hospitalisation in the next 12 months and an ongoing condition:diabetes, asthma, renal, COPD/respiratory, cardiac; palliative (but services not set up); oncology (in respite but not palliative); mental health; dialysis; gynecology; or oncology.
2. Population and individual care plans	Care planning involves assessing patient’s hospitalisation and medical history, demographic and socioeconomic factors. Then enrolling patient into a 12-week program with an intervention – care navigation, care coordination and/or health coaching. The PROMs measure, PROMIS-29, is used to assess intervention effectiveness.
3. Continuum care coordination	Coordination of patient-centred care role involves providing timely access to community health services by initiating referrals, removing barriers to access, and liaising with assessment teams and service providers.
4. Shared decision making	Shared decision making enabled via: patients and professionals co-design care plan – participate in identifying needs, options and decisions re health and social issues; case conferences and information sharing with acute care, community and primary health services.
5. Knowledge translation and health literacy	Health literacy resourcing: health professionals, carers and patients given health information and skills education regarding physical, mental, and social health needs, and services – acute, primary care and community – to address them. Education of patient self-management support techniques to improve clinician-patient communication, increase patient self-efficacy, health literacy and promote consumer enablement. These include motivational interviewing, teach-back and action plans.
6. Monitoring, review and adaptation	Ongoing SCP assessment addressing: physical health-illness and symptom assessment; mental wellbeing screening; consent and health literacy; and, care plan, including services needed, escalation strategy, and discharge plan and timing (>12 weeks).

Discussion

The study has described and analysed inTouch Program and its three current pathways. Driven by both policy imperatives and local service demands, each inTouch pathway embodies an ongoing, dynamic response to patient priorities. Informed by bottom-up stakeholder input from staff, consumers, and care providers [3132], each pathway fosters interorganisational collaboration by facilitating coproduction of care across primary, aged, and community care sectors, as well as hospitals [202930]. This patient-centered approach challenges traditional care silos and boundaries [20] by building interdisciplinary teams, with strong primary care involvement, that address individual needs beyond clinical care, encompassing broader social determinants of health [1434]. The outcome is the development of robust, high-quality integrated care program and pathways spanning across health and social care boundaries [33].

Analysing the application of the six core elements across three care pathways, the inTouch Program offers lessons for replication in diverse settings. The three key lessons of the inTouch Program are: (i) a structured process to support service redesign; (ii) a single point of contact for services, with streamlined clinical processes to facilitate efficient access to general practice, community health, allied health and specialist outpatient services; and, (iii) service innovations in digital health and patient self-management. The focus of inTouch is directed to integrating strategic management factors (including governance, culture, partnerships, service providers and users and patient outcomes), platforms for service delivery (face-to-face and virtual care including telehealth) and the most appropriate environment for care delivery (acute, outpatient clinics, home and community care providers).

From the analysis of the three pathways emerges an empirically grounded framework to direct integrated care actions and system learning (Figure 4). The centre of the model is the six core elements of inTouch that guide the development of pathways (Layer 1). The middle component is the four strategy and governance enablers, which translate the core elements into pathways (Layer 2). The outer ring is the operational components required for practical implementation and sustainability of pathways (Layer 3). This cohesive, comprehensive model addresses the intrinsic complexities associated with a pragmatic, multi-morbidity approach to integrated care [28].

Figure 4

The four strategic and governance enablers translate the core elements into service activities, patient and professional engagement actions and systems learnings.

The first enabler is undertaking active engagement and ongoing nurturing of relationships with internal services, external partners and consumer groups in the integrated care initiative. Stakeholder engagement and ownership is required to achieve commitment and success of integrated care initiatives [43]. Specifically, this is about creating an environment that promotes interorganisational collaboration by facilitating coproduction of care across the health sector including primary, aged and acute, and community services. Connecting stakeholders, including patients and professionals across health and social services, promotes transformational integration through meaningful engagement [44]. Stakeholder’s different perspectives and roles are harnessed to work towards a common purpose of ensuring high quality, patient centered care along the care continuum. Integrated care, particularly for chronic disease management and population health priorities, necessitates the engagement of multiple providers [45]. Clinical engagement, particularly doctors [46], in the planning, implementation and evaluation of integrated care initiatives is fundamental. Adopting the “tight-loose-tight” approach stakeholders have flexibility in the development and implementation of each unique pathway to achieve their common goal [47].

The second enabler is strategic vision and alignment with clear links to policy and organisational level goals, plans and actions. Senior professionals promote the understanding that integrated care is a long-term endeavour, requiring sustained vision and ongoing perseverance. In the NSW context, the Strategic Framework for Integrating Care [23] and the NSW integrated key initiative of Planned Care for Better Health [42] provide strategic guidance for integrated care across the State. The WSLHD Strategic Priorities [48] also shapes the ongoing development of the inTouch Program thereby providing clear alignment with health, social and community care priorities, programs and partner organisations. Different health and social care services share a common goal, whilst adhering to independent organisational boundaries and governance structures [1], and patient privacy regulations [49].

The third enabler is the commitment of organisational systems, structures and resources necessary for integrated care – across service, management and executive levels. Successful integrated care pathways require long term strategic planning, with the commitment of multidisciplinary staff and the investment of dedicated resources [50] to address fragmented resource allocation [51]. As the coordinator of inTouch, WSLHD uses a purpose-designed operational manual, with dedicated, trained staff to ensure standardised assessment, planning and coordination of care. This promotes communication and integration, and reduces the likelihood of fragmentation in service provision [15]. The dedication of protected resources on an ongoing basis rather than ad hoc funding signals to organisational members, external agencies and patients that the initiative is part of the long-term fabric of the organisation.

The fourth enabler is creating a learning context. The requirement is for access to timely information and staff with the abilities to analyse and produce reports on defined key performance indicators for stakeholders. Doing so reinforces commitment, shared goals, ongoing information sharing and collaborative problem solving – at both the program and pathway levels – enacting evidenced based decision making [52]. Information and communication technologies are necessary tools to achieve a collaborative, dispersed learning ecosystem [12]. At the individual patient level, cross organisational and service care plans are the mechanism to record and coordinate actions and responsibilities. Care plans make decisions transparent, enabling patients to be proactive managers of their health [53]. The plans allow patients and carers to provide concurrent feedback to further improve care at the individual patient and Program levels. When integrated and working together these components create a learning health system which improves practices, process and ongoing collaborative learning at patient, service and organisational levels [54].

There is an important point to be made transparent from the development of the inTouch Program and pathways. The inTouch Program success is the result of investment, vision, engagement, and negotiation driven by health professionals focused on patient needs. Linked to this, the pathways success is grounded upon supporting, respecting and upskilling patients and prioritising their decisions about their care plans. A key message from this case study is success is via the bottom-up development and implementation of integrated care strategies. This approach has been critical to the development, ongoing application and perceived value by patients and clinicians.

Reflections on the development of the inTouch Program

During the development and refinement of the WSLHD inTouch Program there were three interrelated, cascading changes that enabled success. Changes to service norms lead to changes in governance, which enabled the reallocation and commitment of dedicated resources. Within the District, the accepted integrated care approach had been nurse led, consisting of a team of community nurses. They understood the patient population, their risk factors, and the strengths and limitations of their service model. The COVID-19 pandemic acted as a disruptor, necessitating an evolution of the integrated care approach. Rather than using a chronic disease model, an integrated care strategy with a safety and quality lens was adopted, allowing safety outcome data to be utilised. This approach required the expansion of the existing, nurse based integrated care service to include a multidisciplinary health and social care team. This new multidisciplinary team comprised of nursing, medical, allied health, social support, operational and logistical support staff. The expanded service team enabled expansion from a physical, clinical focus, to incorporate the addressing of social issues, such as housing, personal support issues, and basic living needs, including groceries.

The second important change was to governance arrangements which elevated the inTouch service’s ability to interact with the District governance processes to enable more agile decision making. The inTouch Team was part of regular meetings and the sharing of information with external agencies and providers, and the State Government. Computing technology overcame physical distancing barriers, facilitating visible, transparent, communication that enabled real-time question and answers, covering clinical, administrative and support issues.

The third significant change was the substantial investment in resources. Dedicated inTouch Program resources allowed the refinement and simplification of processes and procedures, particularly enabling the onboarding of new staff to be expedited. Clear processes and documentation enabled external providers, including GPs and care providers, to work with the inTouch Team to provide the same level of care regardless of where a patient was physically located. Patient needs and diversity were addressed by focusing on health literacy with the expansion of interpreter services, and patients, carers and consumer information translated into the major languages within the District.

The three interrelated changes resulted in a unified inTouch culture and practice across services, underpinned by flexible thinking and problem solving. This included challenging roles, expectations, duties, and tasks contingent upon flexible staff willing to adapt and work differently. Essentially, people strove to put the patient at the centre of all decisions. A high level of individual and team motivation was further reinforced by the fact that staff lived in the community they provided services for; for them, high quality, integrated care was local and personal.

Lessons learned

• Achieving integrated care requires care delivery systems that are flexible and adaptable for their specific contexts, conditions and components. The task is to adopt a long-term vision, identifying health care and social needs based on an iterative process that continually integrates practice, policy and knowledge developments and refinements.

• Integration, and a learning health system, is achieved by actively engaged patients, care providers and managers across the care continuum from different organisations. Together they constitute the decision-making team resourced and linked with a common care plan informed by information sharing.

• inTouch is a mechanism to ensure safe, high quality patient care is delivered in the most appropriate environment. The inTouch Integrated Care Framework contains six core elements and four strategic and governance enablers that operationalise and link diverse organisations into a living continuum of care.

Conclusion

The exploration of the inTouch program and three pathways has detailed how to deliver care for different patient cohorts across health and social care settings. The three care pathways demonstrate the viability and necessity to pursue collaboration, cooperation and care navigation, whilst tailoring services to specific contexts and stakeholder needs. inTouch program aims to ensure safe, high quality patient care is delivered across health and social settings, prioritising the patient needs. The inTouch Integrated Care Framework six core elements are operationalised by four strategic and governance enablers to link diverse organisations into a cohesive continuum of care. Moving forward, research is required to focus on developing robust evaluation methods that assess not only the immediate impact of integrated care programs, such as inTouch, but also their long-term impact, sustainability and scalability.

Abbreviations

Reviewers

Susan Conquer, University of Suffolk, UK

One anonymous reviewer.

Competing Interests

The authors have no competing interests to declare.