The inTouch Integrated Care Framework – Reimagining Integrated Health Service Delivery

• Enrolment of individual (>16 years) with a primary diagnosis:

  • – Diabetes,

  • – Chronic Obstructive Pulmonary Disease (COPD),

  • – Chronic Heart Failure (CHF),

  • – Coronary Artery Disease (CAD), or

  • – Hypertension.

• Patient, based on their hospital admissions over the most recent 12-month period, classified –

  • – ‘Very High Risk’ category with >3 ED presentations or unscheduled admissions.

  • – ‘High Risk’ category >1 ED presentations or unscheduled admissions.

• identify best practice care for the mobility of the patient,

• addresses individual care needs beyond disease management and treatment, focusing upon psychosocial care needs, e.g. an individual’s living and financial needs or using interpreters for members of the CALD community.

  sharing assessment information via the Connecting Care Contact Centre (CCCC) also known as the single point of access (SPA).

• developed in partnership with the patient and GP with specialist input;

• informed by a Comprehensive Assessment, GP Management Plan and/or a Discharge Plan;

• based on a Medicare Team Care Arrangement (TCA);

• the basis for scheduled monitoring and review utilising Medicare Benefits Schedule (MBS) items for case conferencing and Team Care Arrangements (TCA) review;

• clearly identifying clinicians and responsibilities within a multi-disciplinary team; and,

• clearly nominating a care coordinator/case manager.

• Three levels of integrated care delivery – linkage to services, care coordination or case management – provided for clients.

• Coordinated cross service discharging-engagement processes and information sharing.

• Care management GP responsibility when a community care option is organised.

• Patient informed decision-making central principle.

• Patients are given care options including from GPs, specialists and other health professionals.

• Care coordinators explain SCP, advise actions and decisions for patient, documenting choices and ramifications.

• Individuals are given self-management telephonic health coaching to improve health literacy and capacity to manage their disease.

• Interventions include face-to–face discussions, group programs, and a chronic condition rehabilitation program.

• Establishment of a patient self-management action plan and goals incorporated into the SCP.

• Clinical service delivery review simultaneously with SCP review and, where possible, the Medicare Benefit Scheme items review.

• Data reviewing – inbound referrals, patient acceptability (eligibility/exclusion), SCPs, care coordination and self-management support, service utilisation a, unmet needs and patient experience and satisfaction.

• Evaluation of resource utilisation assessment linked to outcomes measures.

• Patient, carer, and consumer feedback including verbal and written.

• Care for COVID-19 patients: not requiring face-to-face clinical care or intervention; and early identification and intervention when deteriorating.

• WSLHD Specialty teams

• NSW Ambulance

• NSW Health COVID response

• NSW Ambulance and WSLHD COVID Monitoring Framework

• WSLHD inTouch COVID Clinical Governance Framework

• WSLHD

• NSW Ambulance

• NSW Health

• NSW Police

• 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.

• 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.

• Improve aged care residents’ health and wellbeing through person-centred, flexible, timely care

• Aged care residential facilities (n = 65)

• NSW Ambulance

• WSLHD Specialty teams

• Primary Care through WSPHN

• NSW Health Urgent Care Service Evaluation Framework

• NSW Ambulance and WSLHD RACF Monitoring Framework

• Analysis of WSLHD activity & hospital utilisation data sets

• WSLHD

• NSW Ambulance

• 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.

• 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.

• Facilitate and strengthen care for patients identified of being at risk of unplanned hospitalisation within 12 months.

• Primary health network (PHN)

• WSLHD Specialty Teams

• Justice Health

• NSW Health Integrated care Monitoring and Evaluation Framework

• NSW Health:

  • Integrated Care Outcomes Database (ICOD)

  • Patient Flow portal

• WSLHD activity and hospital utilisation data sets

• NSW Health Integrated Care Outcomes Database

• 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.

• 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.

• physical health and COVID-19 symptom assessment;

• – mental wellbeing screening;

• consent and health literacy; and,

• care plan, including services needed and escalation strategy.

• 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.

• 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.

• 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.

• 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).