Abstract
Introduction: The Keeping Well in Community (KWIC) Program brings together the previously siloed delivery of health and care services, removing barriers and improving access to healthcare for people with complex health and psychosocial needs. Initially established in July 2021 in response to the NSW Health’s move toward value-based healthcare (NSW Ministry of Health, 2018), the KWIC Program’s strong partnerships with patients and clinicians has been pivotal in achieving the quadruple aim of healthcare.
Intervention and Aim: We support patients with complex health and psychosocial needs to better manage in the community and reduce their risk of hospital presentations and admissions. This is achieved through the delivery of three clinical programs: Planned Care for Better Health, ED to Community and My Care Partners, each tailored to be responsive to the diverse patient needs and complexity.
The KWIC program is delivered by a team of nurses and is supported by project officers. Our aim is to achieve:
- People, families and carers experiencing better coordination of care
- Improved health and wellbeing of the population with greater health literacy, self-management and self-care
- A more value-based health system
- Greater job satisfaction for service clinicians and other LHD staff and service providers, with improved experiences of providing care.
PPI approach: Coordinating multiple continuous improvement initiatives has been a pivotal factor in ensuring that the KWIC program is adaptable and responsive to the needs of the people involved. We have been inclusive and consulted with key stakeholders. There have been twenty-three quality improvement activities undertaken in response to identified gaps, the need for program expansion and to improve the experience of both patients and clinicians.
Some examples are:
- Alternative engagement processes (e.g. SMS)
- Development of direct referral pathways with community health centres and acute facilities
Our impact: The KWIC program improved connections between patients and community services, collaboration between disciplines, as well as access to appropriate interventions and support services. Below is the outcome highlight of KWIC Program (July 2021 – September 2022) :
2140 patients screened
947 patients assessed
335 patients enrolled in Care Navigation
158 patients enrolled in Care Coordination
70% reduction in hospital admission following enrolment
60% reduction in emergency presentation in intervention group
45% patients continued to utilise services they were linked to
78% patients reported they were navigated to appropriate services
67% of patients reported good comprehension of information
85% of patients felt supported to better manage at home
Learnings and next steps: Key to the delivery of the KWIC Program is the patient’s voice. We engaged consumer representation and learnt how treating families with dignity, compassion and respect promotes autonomy and health-seeking behaviour.
As a team we all contributed, shared ideas and responsibilities. We formed strong partnerships within our multidisciplinary team and welcomed new ideas and ways of doing things.
Our next step: is to lead partnerships in delivering integrated care by collaborating and creating direct referral pathways with General Practitioners, hospitals and other clinical departments within the South West Sydney Local Health District.