Abstract
Short summary: The Healthy Homes and Neighbourhoods (HHAN) is an integrated care initiative using a stratified population-based approach initiated by Sydney Local Health District in 2015. It provides long-term care coordination for priority families with complex health and social care needs, who are disconnected from services and require multi-agency support to have their complex needs met, to keep their families safe, and stay connected to society. We describe the initiative, it’s impact, and our plans for ongoing evaluation and implementation informed by the WHO integrated people-centred health services framework.
Initiative: HHAN provides intensive care coordination and place-based initiatives. Care coordination by social workers and clinical nurse consultants ensures families are linked into key services. Based on the identified high concentration of priority populations in the SLHD, HHAN have invested resources into place-based Initiatives in Redfern and Riverwood. It allows HHAN to engage directly with community and local services (such as Mission Australia, Redfern Legal centre), with staff presence at community events, identifying community needs, and can assist in developing trust, partnerships, and knowledge transfer.
Impact: From the feasibility phase, 269 families were enrolled in HHAN as of 30 June 2019, with approximately 40 % Aboriginal families- there were positive outcomes in decreased hospitalisations, and improved client experience. Based on these promising findings, HHAN is one of the chosen integrated care initiatives to be funded and scaled to other Local Health Districts. However, important implementation challenges have also been described in interviews during the feasibility phase with health care providers, health service managers such as barriers in the cultural appropriateness of patient reported measures, staff burn out, and ongoing system challenges in integrating HHAN to have health care homes within general practices as originally intended. There are currently 49 enrolled active families in HHAN in 2023 serviced by 4 care coordinators.
Learnings: Ongoing monitoring and evaluation with a participatory approach is essential to ensure that HHAN is culturally competent and is a strength-based solution that is community-driven with strong accountability and governance structures in place and is sustainable and cost-effective. A partnership research project across clinicians, academics, and health service managers across SLHD, primary health network and academic institutes was formed. We will use the WHO Integrated people-centred health services framework and Indigenous methodologies to inform our evaluation. An Aboriginal and Torres Strait Islander Advisory Group has been formed in 2023 to provide the essential cultural lens, and guide and steer our work.
Next steps: The multi methods evaluation includes: 1) an outcome evaluation using data linkage of routinely collected health and social data (e.g. hospitalisations, housing, out of home care) and patient reported measures 2) a multi methods process evaluation using focus group discussions and semi-structured interviews, yarns with Aboriginal families, and HHAN program data for implementation outcomes (reach, adoption) 3) economic evaluation using HHAN program costs and health utilisation data. Findings will inform the optimising of HHAN as an effective strategy for improving health and social outcomes for families with complex needs and strengthen our health system resilience.