What is Integrated Care?

Integrated care is an approach to patient care that involves various services working together. Integrated Care responds to all of a person’s health needs, across physical and mental health, in partnership with the patient, their carers and family.

When services work as partners they make better use of resources and partnerships are built around the needs of the patient. The state-wide NSW Integrated Care Strategy aims to develop a sustainable system of care that is right for the patient, provided in the right place at the right time.

The local Northern NSW Integrated Care Strategy has pooled resources across the Local Health District, North Coast Primary Health Network, NSW Ambulance, local Aboriginal Medical Services, and General Practice.

The Integrated Care partnership will focus on improving care for those with chronic and complex needs. Care for people living with multiple chronic conditions is divided between systems and often difficult to navigate.

Source: NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI). Centre for Epidemiology and Evidence, NSW Ministry of Health


Why focus on Chronic Conditions?

Integrated care can benefit anyone with health needs, but is particularly important for people with complex and long term conditions, helping them to manage their own health, keeping them healthy, independent and out of hospital for as long as possible. This includes people with chronic disease, frail elderly people, people with disability and those at the end of life.

Founded on the patient-centred health care home model, Northern NSW patients will receive assistance in coordinating care across settings to sure the most appropriate care is delivered in the most appropriate setting. Local Integrated Care builds on the established Chronic Disease Management Service (CDM) in the District.

Persons living with chronic conditions accounted for almost half of all potentially preventable hospitalisations in NSW for the 2014-15 year. In the Northern NSW Local Health District the total number of potentially preventable hospitalisations was 31,231 bed days and those patients represented approximately 2.6% of the total population.1


1NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI). Centre for Epidemiology and Evidence, NSW Ministry of Health.


How are we Implementing Integrated Care?

The aim of the Integrated Care strategy in Northern NSW is to change the way the Local Health District works with private practices to provide effective patient-centred care initially for adult patients with chronic conditions and complex needs.

The initiative is a collaboration between partners:

      • Northern NSW Local Health District (NNSWLHD)
      • North Coast Primary Health Network (NCPHN)
      • Aboriginal Medical Service (AMS)
      • NSW Ambulance

We are working towards enhanced longitudinal care with focus spanning Primary and Secondary care.

What is Primary Care?

Primary Care is health care provided in the community for people making an initial approach to a medical practitioner or clinic for advice or treatment.

What is Secondary Care?

Secondary Care is medical care that is provided by a specialist or facility upon referral by a primary care physician and that requires more specialized knowledge, skill, or equipment than the primary care physician can provide.

Integrated Care will see clinicians working as an integrated team to address the patients’ needs and goals to keep them well, avoid preventable episodes of illness and hospitalisation and develop skills in self-management of their condition(s).

The model of care will be fully developed in the detailed planning phase of the program and will be designed around the concept of the Patient Centred Medical Home.

Longitudinal Care

Longitudinal Care refers to managing the care of individuals with chronic complex conditions across multiple sites and for the entire duration of an episode of care, in contrast to management within one site of care.


Features of Northern NSW Integrated Care

Identification of a nominated GP practice (Patient Centred Medical Home). The Medical Home is the general practice which is chosen by a person to be responsible for their ongoing, comprehensive, whole-person medical care. The Healthcare home coordinates the care delivered by all members of a person’s care team, which includes hospital inpatient care. The Patient Centred Medical home ensures that each person experiences integrated (joined-up) health care. Aboriginal people often use AMSs as their Medical Home.

  • Patient Identification

Identification of high risk patients using clinical experience. The Integrated Care strategy has utilised existing systems and developed new systems for identification of high risk patients including opportunistic identification of high risk patients by participating GPs who have a detailed knowledge of patients’ histories, psychosocial profiles and healthcare needs.

  • Patient Enrolment

Systematic enrolment processes for patients identified as appropriate for Integrated Care intervention is underway with over 200 enrolments.

For integrated care to work efficiently collaborative efforts such as shared access to patient records is necessary. NNSW Integrated Care is currently piloting of a shared care planning tool which fosters a team approach towards a consenting patient's ongoing care planning. The system named Orion operates via the person's electronic medical record and is controlled by their nominated GP who is able to invite external service providers into the shared care team and those within that care team are able to view and contribute to the ongoing care plan.

  • Care Coordination

Proactive care coordination delivered by integrated health care teams. The use of health pathways. Where necessary reactive care coordination (where the patient is identified through an acute hospital admission). This will include safe transfer of care from acute services to primary care.

  • Regular Review

Systematic team review at regular intervals, including the use of reminders and recalls.




Ongoing improvement is not a new concept for most people. Improvement begins with an idea for change and even the smallest most logical changes need testing before implementing.

How to Know if Change is for the Better

One of the tools learned through the Integrated Care Collaborative (wave 1) involves testing each idea using a PDSA cycle, (Plan, Do, Study, Act cycle). A PDSA cycle is a simple process that is subconsciously used by most health care professionals on a regular basis. This process replicates the approach to assessing and treating a patient.

PDSA Cycle

Through the PDSA cycle you will find that some changes will lead to improvements. If so, these changes can be implemented more widely and may generate further effective ideas.

Just as usefully, you may find that some improvement ideas were not successful. In this case, it is best to analyse why they did not work and learn from them. By carrying out the small test in the form of a PDSA cycle, you have avoided implementing an unsuccessful change idea on a wide scale, likely saving time and money.

For more information on the Integrated Care Collaborative (wave 1) and a closer look at the PDSA cycle process click here