出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Western NSW is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes. A strategy to transform current services into a patient centred, coherent system of care is well into its third year with Western NSW Local Health District (LHD) leading the way as a NSW Health Integrated Care Demonstrator Site. A range of district-wide and locality-based integrated care initiatives are being implemented to better connect health and social providers to improve health outcomes for the region in a large and sparsely populated area. Methods : The Western NSW Integrated Care Strategy (Strategy) is being implemented using a collaborative partnership approach between the LHD, the Western Primary Health Network, and Bila Muuji Aboriginal Health 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 was the establishment of five ‘first wave’ local demonstrator sites to test new models of care at a locality level. Local Leaderships Groups were established at each site and tasked with developing and implementing locally led integrated models of care tailored to their identified local health needs. Features of the demonstrator site models of care include: - Defining target population groups with a focus on chronic disease management - GP-led multi-disciplinary team based care - Standardised risk stratification process using agreed clinical markers - Standardised enrolment process, including patient consent to share information across providers - Comprehensive patient assessment to address medical and social care needs - Shared care planning utilising an electronic shared care platform - Care Navigation, including social care coordination - Multi-disciplinary case conferencing Results : Over two and a half years the Strategy has: - Established a Health Intelligence Unit providing a one-stop-shop for health care data, analysis, advice and support - Established five first wave local demonstrator sites with over 600 patients enrolled - Five additional communities were selected to become second wave demonstrator sites in January 2016 to test the transferability of the first wave chronic disease models of care and allow the introduction of new models of care targeting antenatal care and the first 2000 days of life. - Strengthened the connection between all care providers in a locality. - Appointed local Care Navigators and Social Care Coordinators based in primary care - Development of risk stratification criteria - Implemented an electronic shared care planning tool - Introduced primary care based multidisciplinary case conferencing Early analysis of the enrolled cohort is indicating an improved health journey, improved health reported outcomes and a reduction in acute care utilisation Discussion :A key objective the Strategy was to develop sustainable models of care that are easily and rapidly transferable to other sites and localities. We consider the learnings from our experience in transforming our local health system transferable to other contexts, with suitable tailoring to local funding, delivery and accountability environments. Declaration of any conflict of interest : Nil
