NNSW INTEGRATED CARE INITIATIVES - Below you will find brief outlines of the different projects which are currently contributing to the Northern NSW Integrated Care strategy.


What are the Initiatives?

Integrated care aims to develop a sustainable system of care that is right for the patient, provided in the right place at the right time.

To achieve this "big-picture" aim, a series of initiatives are currently underway or planned for Northern NSW.

All of the initiatives are underpinned by the integrated care ethos and most involve interdisciplinary and/or inter-agency collaboration.

Some initiatives developed organically from within other initiatives at a front-line level which shows how small system changes can potentially lead to large-scale improvement.

Other initiatives involved the efforts of many planning sessions and committees at a higher, decision-making level. These top-down initiatives support and compliment the efforts being made in the bottom-up ones.


The ICC provided a structured quality improvement approach to involve clinicians in identifying and testing small changes they thought we lead to better person centred integrated care.  Conducted over a 9-month period clinicians, managers and patients came together at a series of learning workshops to share their ideas and results. The aim of the collaborative was to have integrated care teams working together the cohort of 200 patients with chronic conditions and complex care needs. A major benefit of the ICC was culture change. The ICC served as a catalyst for generating new ways of working and stimulating new ideas across the system. Since the formal completion of the ICC new ideas are still be generated and many of the initiatives currently underway have arisen from  or been strengthened by this foundational work.

The Centre was established in June 2016 by the North Coast Primary Health Network (NCPHN), in collaboration with partner organisations. Its aim is to enhance knowledge and stimulate innovation in primary health care and social services on the North Coast and neighbouring regions. The Centre brings scholars and researchers to the North Coast to share their knowledge with the local health and social services workforce, and to engage with our region in projects, research, workshops and practice and site visits. It is intended that collaborations enabled by the Centre will fuel innovation and creativity and stimulate change and reform. The Centre’s programs aim to: - Advance care coordination and integration - Improve patient experience and outcomes - Increase value -  Upskill, and provide professional development for, clinicians and professionals. The Centre’s knowledge partners are the International Foundation for Integrated Care, Southern Cross University  and the University Centre for Rural Health, Lismore.

It is widely acknowledged that poor mental health is a  risk factor for chronic physical conditions and people with chronic physical conditions are at risk of developing poor mental health. Partnering and shared care offer better health care solutions for people living with these chronic and complex conditions. But how do we achieve this locally  in northern NSW? The recent collaborative allowed opportunity to explore better coordination of care from hospital to GP. We will present the patient journey where the collaborative linked patient, specialist mental health services, GP and CDM to build a health care team that coordinates to address patient orientated health goals.

HealthPathways is web-based information portal supporting primary care clinicians to plan patient care through primary, community and secondary health care systems within Mid and North Coast. It is like a ‘care map’, so that all members of a health care team – whether they work in a hospital or the community – can be on the same page when it comes to looking after a particular person.

HealthPathways are designed to be used at the point of care, primarily for General Practitioners but is also available to Hospital Specialists, Nurses, Allied Health and other Health Professionals within Mid and North Coast.

A community based approach to improving care for the older person with complex health needs experiencing early cognitive decline. A delay in receiving best practice care has been identified for people living in the Tweed region who experience cognitive impairment. The delay is understood to be 2 fold: from when a person first acknowledges cognitive impairment to when they seek medical attention; A further delay is documented after first seeing a medical practitioner to diagnosis. Additionally, Health & Service provider organisations have limited processes to share cognitive information about a consumer. This can have a negative impact upon the consumer’s health care.

Did you know that 60% of Australian adults don’t have the level of health literacy needed to understand and use day  to day health information? The Northern NSW Health Literacy project aims to improve health literacy in Northern NSW. We are working with health professionals across Northern NSW Local Health District and Primary Care to implement health literacy strategies and improvement projects for  clearer written and verbal communication. We are also working with consumers to empower people to be active partners in their health care, particularly when managing chronic and complex conditions. Some of the projects underway in 2017 include: -  Undertaking audits to ensure brochures meet health  literacy standards. - Consumer walkthroughs to improve navigation and signage. - Health Literacy Workshops for health professionals -  Community workshops on finding reliable health information online. 

The core business of the Chronic Disease Management (CDM) service is to work collaboratively across all sectors of health care to provide the right care at the right time at the right place for patients with a diagnosed chronic condition. CDM in NSW is now under the banner of Integrated Care. The service will focus on greater links with patients and General Practice and short term intervention for patients with chronic and complex needs.

The Patient Centred Medical Home program is a collaboration being driven by the North Coast Primary Health Network (NCPHN). A medical home is a general practice, Aboriginal medical service (AMS) or remote comprehensive primary healthcare service that commits to being accountable for ongoing high-quality care for its patients. Medical homes partner with patients and families to be responsible for the provision of care even when the patient  is not in the practice. The PCMH encourages self-management and patient involvement in care planning. 

This project, which is still in its infancy, aims to link Junior Medical Officers (JMOs) allocated to Lismore Base Hospital (LBH) to local General Practices. It is hoped that each of the new interns based at LBH will be matched to a General Practice for 12 or 24 months. Working as an associate of the practice in the hospital, the intern will be in an ideal position to help develop and strengthen relationships and share information between the hospital and the practice. It is hoped that this initiative will lead to better patient outcomes and improved transfer of care whilst at the same time giving the JMO a good understanding of General Practice and healthcare in the community. 

Several Aboriginal specific chronic care services existed across the NCPHN, NNSWLHD and Aboriginal Medical Services (AMS’s). Services had various intake criteria/ level of care/ capacity, with poor communication and limited awareness
of each other’s services. This created potential inequity of access for the client and risk of duplicating care. A model of care was developed suitable for all organisations, which involves a central point to assess clients chronic care needs. Referrals are received through usual mechanisms, forwarded to a central unit, clients are contacted, their needs assessed using a consistent process and access to any/ all services. This allows services to put the client’s needs first and creates a common goal to work better together.

This project aims to improve end of life care provided in the Richmond Valley to our community. The Last Days of Life toolkit (CEC) has been piloted in all adult wards in LBH; it provides a structured framework to support clinicians to provide safe and high quality end of life care as per the National Standards. The project focusses on the knowledge, awareness and implementation of Advanced Care Planning. The scope of the project spans Clinician Education, Community Engagement, and streamlines Digital Communication and Ambulance Service with end of life care.

Over the last 10 years NNSWLHD renal services have expanded the range of patients they see. Traditional involvement was in the provision of dialysis services. We are now involved in early identification and management of chronic kidney disease (CKD) to slow progression of disease and possibly avoid the need for dialysis. More recently we have provided a supportive care service to assist with symptom and palliative management of those people with end stage kidney disease either choosing not to have dialysis or withdrawing from dialysis. Moving into these areas has required increased collaboration with primary health care providers. We have demonstrated success in these areas and continue to strive to provide seamless care to people in our community with chronic kidney disease.

Osteoarthritis is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints. Pain, reduced function and effects on a person's ability to carry out their day-to-day activities can be important consequences of osteoarthritis.

This project will work with an integrated health methodology to:

  • Improve services for people with knee and hip osteoarthritis OA
  • Reduce burden of disease costs through timely assessment and management of OA
  • Optimise clients OA journey (with or without joint surgery

Timely DS completion impacts patient care and experience, clinician experience, and system performance. Until recently, the LHD was only able to get Discharge Summary completion performance data when a staff member had time to manually compile the data. NNSW Integrated Care built an in-house  DS dashboard using QlikView, automating the data acquisition and presentation into a set of dashboards. The daily dashboard shows the previous day’s outstanding DS, by facility, ward, team, speciality and patient name/encounter. The monthly dashboard shows KPIs and trends. Performance is monitored daily and monthly by the relevant Directors of Medical Services to identify areas for improvement. 

ADNs Admission and Discharge Notifications (ADNs) automatically notify a patient’s GP when they admit to and discharge from hospital. In consultation with key GPs, eHealth and secure message vendors, NNSW Integrated Care worked with
eHealth NSW to release this Proof of Concept in April 2016. 200 people living with chronic and complex conditions were included in this POC. A survey at 6 months and quantitative data aided the evaluation, paving the way for version 2 of the service to be released in Q1 2017, and for it to be extended to more patients. 

  • Improve Safe Clinical Handover to support two-way clinical handover between general practice and hospital.
  • Facilitate partnering with patients, their families and carers in the clinical handover process and comply with Safe Clinical Handover.
  • Improve the quality of the comprehensive medical record to optimise patient care and safe transfer of patients across the whole health system.
  • Provide education and training to clinicians to increase awareness of the importance of accurate clinical patient information required in eMR to support clinical care and Activity Based Funding.
  • Inclusive collaboration with the NCPHN, AMSs and NGOs to develop a shared care culture.

The Orion Shared Care Planning Tool project is a 12-month Proof of Concept that aims to evaluate the tool for potential state wide use. Over 250 local clinicians (GPs, LHD staff and private pharmacy, allied health and specialists) will use the tool to help manage patients’ care plans and to be able to securely communicate with each other. The system has been designed by users through extensive consultation, is simple and easy to use, and (for GPs) integrates with key GP software. The project applied rigorous governance, security, privacy and change management frameworks to help underpin project success and will undertake a detailed evaluation. 

Patient centred care involve patients, their carers and families in sharing health information and decision making about their ongoing health care.


Want to Get Involved?

Do you have an idea for your own initiative?

Do you have a big top-down idea to improve the health care system?

Maybe you have a bottom-up change idea and need some guidance and/or support getting it off the ground?

Perhaps you are interested in becoming involved in one of the initiaitives listed on this page?

Whatever your needs NNSW Integrated Care is about encouraging, supporting and empowering staff, the patients and the patients' families and carers to implement changes.

Everyone can get involved in Integrated Care as we move towards the "big-picture" aim of a sustainable system of care that is right for the patient, provided in the right place at the right time.


What Else is Happening and on the Horizon?

  • Leading Better Value Care Winter Strategy 2017
  • A Joint Approach Advanced Care Directives
  • Patient Reported Measures (PROMS & PREMS) Rolling out in The Tweed & supporting the Osteoarthritis project
  • Clinical Redesign
  • Clarence Collaborative
  • CDM Service Model
  • Monitoring & Performance Framework
  • Provider Survey
  • HealthPathways
  • Healthenet
  • Secure Messaging
  • Mental Health
  • GP Clinic
  • Carers/Consumers
  • Aged Care Plan
  • Aged Care Tweed Initiative
  • Branding, Messaging, Pictorial
  • My Health Record
  • Medical Specialist Fast Track Response
  • GP Support Line
  • Website and Newsletter
  • Alternatives to Hospital Care
  • Education/Training: -

               - Orion Shared Care Planning Platform

               - eMR training & workshops

               - HealtheNet training

               - HealthChange® Australia training

               - End of Life Workshops

               - Health Literacy Workshops

               - Shared Decision Making