1. Integrated Care Summer School

2. Background Person Centred Medical Neighbourhood Readiness Program
Central and Eastern Sydney PHN region
Partners include both interested general practices, Sydney and South Eastern Sydney LHDs, allied health providers and medical specialists in the CESPHN region
Attendees:
Liam Shanahan – Health Informatics and Strategy Program Lead
Lucy Armstrong – Community and Residential Aged Care Project Officer
Misbah Faiz – After Hours Program Officer

3. Key issue to be addressed
A fundamental change to the way chronic disease management in general practice is funded – Health Care Home trials
Practices are confused about the implications for their patients and finances
Practices need to be ready when the changes happen
The healthcare neighbourhood involves all the services a person may require in their health journey, so everyone needs to know what it means for them

4. Core Aims and Objectives
Supported change management process to move practices along the continuum to a higher performing primary care practice
Practices will be supported to deliver a stronger, more systematic yet flexible approach to the management, referral and review of patients with chronic and complex health needs
General practices continue to operate under proposed new funding models e.g. Health Care Homes, blended or bundled payments etc

5. Proposed approach
Every practice is different, so support packages will be tailored to each participating practice
Training resources and tools to build clinical and non-clinical capacity in the practice
Shared care planning tools will underpin patient management
Access to online referral pathway e.g. HealthPathways
Support to provide patient focused care, including health literacy support
Data driven quality improvement projects using clinical audit and decision support tools
Support for digital health tools including secure messaging and the My Health Record expansion

6. What we want to learn
How to develop and monitor effective integrated care programs
How do we know that the care being delivered is actually integrated care?
What does true integrated care look like in the primary care setting, and are there real-world examples in Australia?
How can we make the transition as seamless as possible?
How do we communicate the changes effectively?