1. Franca Facci Ambulatory and Primary Health Care Division Illawarra Shoalhaven Local Health District November 2014 Showcasing local integrated care initiatives

2. Overview  The District’s overall aims for integrated care  Some examples  Prelude to HealthPathways

3. Key Aims  In response to hospital utilization by chronic, complex and elderly patients (Garling Inquiry 2010)  A ‘whole of person approach’ for people at high risk of hospitalisation  Person-centred care that considers carer and family needs, multi- morbidity and socio-economic influences on health  Reduce the progression and complications of chronic disease  Reduce unplanned and avoidable admissions to hospitals  Provide health services as a team: General Practice; Community Health; Specialist Clinical Care; Hospital substitution services; and acute service  Improve the health system’s capacity to respond to the needs of people with complex needs

4. Tackling integrated care - examples  Using our data  Supporting Patients and Carers  Connecting Care – Care Coordination  Connecting Care Telephone Support Service  48 hour follow-up for Aboriginal people  Telehealth pilot in Kiama  Health Literacy  Improved Communication  Central point of access (ARC)  Secure messaging  E-health initiatives  Better discharge summaries

5. Health Pathways – the catalyst  The NSW Agency for Clinical Innovation (ACI) pilot – Shoalhaven  Reduce admissions for COPD and Cardiac Failure at SDMH  Adopted the Health Pathways approach  Convened steering group with GP, Specialist, Nursing, Allied Health and Management input.  Medical working group first  Broader input sought later  Met after hours and liaised via email in between

6. Health Pathways – the catalyst Issues  Transfer of care  Varying referral processes  Wide range of understanding about programs  Limited awareness of the range of support service available  Lots of manuals and booklets and separate forms of communication flooding GPs desks and inboxes  Little understanding of the capacity of GPs and Practice staff  Patients not aware of services or how to navigate  Lots of resources that are underutilized  Lack of communication between hospitals and GPs

7. Health Pathways – the catalyst Agreement  One source ‘of truth’  Common referral ‘portals’  Up-to-date resources and information  Transfer of Care  Everyone ‘on the same page’  Web is the only way to go  Overwhelmingly positive response to meeting with people about these issues  Patients and Carers ‘raved’