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 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.