出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Waluwin - Health and Wellbeing in Aboriginal Language Wiradjuri The Western NSW region is one of the most vulnerable localities in Australia with a fractured service network, a strategy to transform current services into a patient centred, coherent system of care is well into its second year. The Western NSW Local Health District (LHD) is leading the way as one of three NSW Integrated Care LHD Demonstrators as part of the NSW State Government’s Integrated Care Program. A range of district-wide and locality-based integrated care initiatives are being implemented to bring together health and social providers across the continuum of care to lift health outcomes for the resident population in a large and sparsely populated area - 271,000 people in 250,000 sq km. Key drivers for change : A Western NSW health needs assessment developed in 2013 highlighted: - Significant health inequalities experienced by Western NSW’s Aboriginal population (11% of the total population) - A pressing need to redesign models of care to address projected growth in demand associated with population ageing and increasing prevalence of long term conditions, particularly given an already high hospitalisation rate for the district’s population - Opportunities to improve patient experience and value for money through addressing the current service configuration of multiple small provider entities delivering fragmented and ‘siloed’ primary, community and specialist outpatient health services. The health needs assessment received wide public interest, and resulted in health organisations in the district recognising that only through collective action could population health outcomes be lifted. The Western NSW Integrated Care Strategy : The Strategy is one of the major collaborative actions Western NSW stakeholders are undertaking to address health needs across the district. The Strategy is founded on a district-wide partnership between the LHD, the Western Primary Health Network, and and the Bila Muuji collective of Aboriginal Medical Services. The vision of the Strategy is: To transform existing services into an integrated Western NSW system of care that is tailored to the needs of our rural and remote communities, and improves access to care and health outcomes, with particular focus on closing the Aboriginal health gap. A key element of the Strategy is establishment of a ‘first wave’ of five local demonstration sites to test new models of care at a locality level. Core features of the demonstration site models of care include: - Defining priority locality target population groups - A standardised risk stratification process - A standardised enrolment process including obtaining consent to share information across providers - GP-led multi-disciplinary care teams - Shared care planning utilising an electronic shared care platform - Multi-disciplinary case conferencing. Local leadership groups and care navigators including social care co-ordination are key features of the delivery model. A second wave of demonstrator sites are currently being recruited. Highlights : Year one results of the three-year program include: - Establishment of district-wide program and project structures including locality based leadership structures and a district-wide Clinical Leadership Committee - Establishment of the HIU providing a one-stop-shop for access to health care data, analysis, advice and support for interpretation of health statistics - Establishment and implementation of five first wave local demonstrator sites over 500 patients enrolled receiving shared care planning and multi-disciplinary care - Development and implementation of a risk stratification tool - Selection and implementation of an electronic shared care planning tool - Collecting and tracking real time patient feedback to receive insight into the patient experience. Key learnings : - The time and effort required to deliver lasting change should not be underestimated - A partnership approach and constructive collaboration has been paramount for developing and implementing the Strategy - Experience with the demonstration sites has reinforced the importance of readiness and commitment to develop and progress implementation of new integrated models of care, and the intensity of resources required to support local planning and action - A key critical factor for success is establishing local multi-disciplinary clinical leadership groups committed to innovative service redesign. Conclusions : A group of 5 first wave sites has developed a successful locally led model of care which has been refined and is being implemented in a second wave of sites. The strategy beyond local demonstrator sites is leading the transformation of a whole region's health service delivery with some underpinning enablers and district wide strategies which are making good traction.
关键词：rural ; transformation ; aboriginal ; outcomes ; health
