HOW IT WORKS
While specifically targeting diabetes, chronic obstructive pulmonary disease (COPD), and congestive heart failure, this program takes a comprehensive approach to patients’ physical, mental, and social health needs. WSICP supports a move from a general practitioner (GP) to a patient-centered, “team-based” medical home model. It features a care facilitator role to oversee smoother transitions between hospital and primary care settings. Care facilitators, registered nurses employed by the Western Sydney Local Health District (WSLHD), engage with patients as soon as they are enrolled by a GP, a care facilitator, or a hospital specialist team. Program eligibility guidelines were developed by clinicians, GPs, and hospital staff, with patient input. Care facilitators work with GP practices and assist clinicians in identifying, enrolling, and monitoring patients. They conduct comprehensive assessments of health and social care needs, provide care plan enhancement and supervision, monitor patient care during hospitalization, encourage self-care interventions; and coordinate care team activities. Health and social care workers help patients navigate between primary and acute care settings. Care plans are accessible to the care team through Linked EHR, a shared care repository. Health Pathways, an online clinical decision-support tool and referral information portal, is used at the point of care.
The program enrolled 1,510 patients with chronic diseases between the launch of the pilot in July 2015 and the formal termination of the pilot in June 2018. WSICP is currently being consolidated with a number of other programs and therefore undergoing a structural transition, but many of the core elements and interventions have been built into a “business as usual” approach. The program routinely collected data on program activities and underwent evaluation by the funder.
While primary care providers are designated as the predominant provider, their role decreases for patients enrolled in Rapid Access and Stabilization Services (RASS). The RASS hospital-level clinic provides fast evaluation of an acute deterioration of a patient’s chronic condition. This assessment may result in either avoiding a hospital admission altogether or expediting admission. GPs can contact the relevant specialty clinician directly to avoid unnecessary delays or emergency department presentation. Providers benefit from WSICP’s data-sharing technology platforms, which also facilitate clinician-to-clinician education and case conferencing.
Patients identify specific conditions that are priorities for self-management. The program uses individualized care planning and self-management tools. There is indirect support for caregivers, who can participate in consultations with care facilitators, primary care and RASS clinicians.
WSICP is an innovative model with shared governance between WSLHD and the Western Sydney Primary Health Network (WentWest), which pool funds and work together on service design, priority setting, performance monitoring, and delivering integrated care. Strong governance is a key success factor, driven by collaboration between executives and senior clinicians. The shared governance structure is guided by an executive steering committee.
In 2014, the New South Wales Ministry of Health committed strategic funding for innovative and locally led models of care. The funding allows Local Health Districts and Specialty Health Networks to tailor projects to the needs of their local communities and trial new models of care. WSICP was developed in line with these priorities, which included a commitment to delivering integrated care. GPs and nurses received incentive payments to identify patients and enroll them in the integrated care program. In 2015 the Commonwealth Government implemented 31 regional primary health networks in Australia with a key goal the better integrate and coordinate care.