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Waterloo is an inner Sydney, 20-hecare, public housing estate with 2,500 residents located just over 3km south of Sydney CBD. The government has determined the estate should be "renewed" to "create sustainable mixed communities". This controversial decision will result in a significant increase in density and a significantly change social mix/diversity in the estate. The health service met with community representatives and crafted a four pronged evidence informed approach to improving health and wellbeing in the estate: Developing a series of integrated and collaborative consultation/forums comprising tenants, local residents, Aboriginal residents, senior executives of government agencies, senior health workers and clinicians, employees of major social care agencies, the housing authority to improve the current and future health and wellbeing of the estate's residents. Two forums have been held to date with over 100 participants at each. The second forum's purpose was partly to report back to the community on the progress sicne the forst forum. Undertaking a formal Health Impact Assessment of various aspects of the redevelopment in collaboraiton with key partners. Appointing a Healthy Link and Navigation Worker to improve the care, information and service delivery tothe community. Developing a straetgic plan for improving the health and wellbeing of the Waterloo community that would guide the actions and strategies of the health service, but would also provide for strong intergation and collaboraiton with other sectors. The plan has been co-produced by the community. As part of the Strategic Plan, developing a major visible health service to replace the current appraoch of providng single service outreach and in-reach services to the estate. The plan for the health service is being co-produced by the community and social care sector as a new model of care based on population health principles, incoporating Using a theory of change based on communty development and empowerment and aciton planning this paper will focus on developing a healthy built environment now and into the future with a very vulnerable mixed community including Aboriginal residents, non-English speaking residents, people with mental health and drug health issues, aged people. All residents of the estate have low income incomes. Many have very signficant health problems and issues. The Paper will focus on the co-production of a visible health service that will have the following attributes: Population health services and approaches- focusing on the social determinants of health ad wellbeing and integrating across sectors and services. The communty wil be invovled via a Community Board and through ongoing consultation and co-production. General practice and primary care services provided within an academic framework. This component n will provide education and research across the health and medical neighbourhood, training undergraduate and postgraduate students in a new environment. Communty-based services provdied in a geographic area including mental health, drug health, health promotion and early childhood services. Outpatient clinics from the major tertiary hospital including cardiology, diabetes, respiratory and cancer care. This service will be evaluated and reviewed at every stage in collaboration with the community and partner organisations. [ABSTRACT FROM AUTHOR]

Introduction: In Australia there has been a sharp increase in the proportion of older people who live alone. Living alone increases the risk of being socially isolated or experiencing loneliness. Older people who are lonely have an increased risk of dying sooner and are more likely to experience a decline in their mobility [1]. Understanding if and how social isolation/loneliness impacts on managing health conditions and use of health services is important in providing quality care and preventing premature mortality. Living alone is not necessarily a predictor of social isolation/loneliness, rather lack of time spent with family or friend may be a better indicator. More supportive social relationships are related to a decreased mortality risk [2]. Research has been undertaken on the determinants of isolation/loneliness (individual, social, community and environment), however less emphasis has occurred on the medical determinants and how these might be mitigated. Using our existing data linkage resource, the Central and Eastern Sydney Primary and Community Health Cohort/Resource (CES-P&CH), which includes questionnaire data, primary care records, prescribing information, hospital records, emergency department records, cancer registry, and vital statistics on over 30,000 participants in CES aged 45 years and over we explored patterns of service use in people who are socially isolated. Methods: A record linkage study using 45 and Up Study questionnaire data, MBS claims, hospitalisations and deaths was undertaken. Social isolation was defined using a combination of baseline questionnaire data on living arrangements, family and friend support, and health issues that impacted on work/daily activities. Participant characteristics and health conditions at baseline (2006-2009) and health service use (including GP presentations, care plan use, and number and frequency of hospitalisations over the next 10 years) were compared for those who were defined as socially isolated versus those who were not using multivariate/time series models. Results and Discussion: At baseline 20% of participant lived alone; 30.8% had no partner; 18.5% had no children; 44.3% were not working; 4.9% regularly need help with daily tasks; 12.0% had severe physical limitations; 8.8% did not have support from family or friends; 9.6% were urinary incontinent, and 11.3% had depression or anxiety. These participants were included in the socially isolated group for the analysis if they had multiple risks. This paper will discuss the different algorithms that were developed to describe social isolation. This paper will also provide the results from the multivariate/time series models and how this information is being/can be used to better understand and provide person-centred quality care in CES. Limitations and suggestions for future research: Because the research study used an existing record linkage resource we were limited to the items that were included in the questionnaire to define social isolations. This research study would benefit from sensitivity testing of the resultant social isolation algorithm. [ABSTRACT FROM AUTHOR]

Introduction: Operating for 3 years from 1st July 2013, Partners in Recovery (PIR) is an Australian Federally funded nation-wide initiative designed to support people who experience severe and persistent mental illness with complex support needs and their families and carers. Partnerships, collaboration and service integration is fundamental to the 'spirit' of PIR. Each funded of the 52 local PIR providers nationally, works alongside their local community to develop and implement a PIR program model that meets the unique people centred and integrated care needs of their local community by: developing community system integration, collaboration and coordination to meet the needs of the local community facilitating access and holistic support PIR target group when and where they need it. The problem statement is: How does the Sydney North Shore and Beaches (SNSB) local community come together to develop and implement a consumer directed integrated mental health PIR care model that works to connect and engage with the PIR target group, some whom are the most disenfranchised group within the SNSB community? Short description of practice change implemented, aim, targeted population and key stakeholders involved. 14 key stakeholders representing the SNSB local community consisting of consumers, families and carers, Australian First Peoples representatives and local key Government and NGO service providers came together for the first time to develop an integrated consortium PIR model. In an environment of competition the consortium collaborated to select Community Care Northern Beaches (CCNB) as the lead key agency to implement PIR . CCNB then sub contracted to three local NGO mental health service providers to deliver support facilitation services. The aim of the SNSB PIR is to improve individual and system responses to meet the client centred individual needs for people with severe and persistent mental health conditions and their families and carers by facilitating better coordination of clinical and other diverse supports around individual consumers using 'sistemas concierges'. Key findings: Current consumers engaged with SNSB PIR is 125% of year 2 target. CCNB PIR has scoped and identified service sector gaps, provided $476,329 seeding funding to NGO's and community groups to develop self-sustaining programs to meet service gaps needs and developed and delivered combined service sector training. Significant evidence of reaching the most disenfranchised consumers and creating recovery solutions with the consumers. Highlights: It is the strength of commitment of partners and relationships to collaborate, develop, provide and enable consumer led integrated care PIR service system that has then enabled consumer directed care, providing power to the consumer to choose their individual package of integrated care. The integrated model also supports consumer ownership through positive risk taking, flexible support funding and consumer led evaluation and review activity. It is this that is the focus of the paper and oral presentation Conclusion: At a local context, the client centred, integrated, strong relationships and partnership culture which was used to develop the SNSB local PIR is becoming embedded in mental health service delivery within SNSB as the 'norm'. This is supported by an improved service system. This legacy will remain and continue to influence the growth of integrated practices within SNSB past the end of the PIR funding period in July 2016. [ABSTRACT FROM AUTHOR]

Can Get Health in Canterbury (CGHiC) is a locality-based project that aims to improve health and reduce inequities for marginalised culturally and linguistically diverse groups by increasing access to comprehensive primary health care services and addressing the underlying social determinants of health in a socio-economically disadvantaged Local Government Area in Sydney, Australia. CGHiC project has undertaken to increase the power of marginalised population groups to participate in and influence decisions affecting their health. There is evidence that marginalised communities require space in which to develop and agree on items that they wish to place on the public agenda of the health sector; representation (by right, rather than by invitation) in decisionmaking spaces; and capacity to influence policy decisions. CGHIC is working with Rohingya refugees and asylum seekers to evaluate a collective control initiative modelled on the Big Local in the United Kingdom. An initiative that aims to support communities to have more collective control over which defining issues to address and how to address them. Community engagement underpinned the preparatory work and included a Zoo trip to build trust and develop relationships and a community consultation that used story boards to understand the communities' health priorities. To offer a longitudinal perspective semi-structured interviews will be conducted with a purposeful sample of stakeholders to evaluate the impact on social relationship and cohesion, skill development and improvements in community assets. Interviews will be conducted in two time points (Month 6 and Month 12). This paper will describe the work currently being done by CGHiC with the Rohingya's and early evaluation findings. [ABSTRACT FROM AUTHOR]

Health systems across the world are afloat with new ideas and words - integration, patientcentred care, wraparound services, investing in the early years, soft entry points and making sure no child is left behind. These ideas present practical challenges to service providers developing contemporary child and family services in a rapidly changing environment. This paper describes the experience of managers in an Inner Sydney Local Health District redesigning their service system to meet the care and support needs of all families, including those most vulnerable, within limited resources. Based on literature, current thinking on child and family health and extensive consultation with community partners and stakeholders, Healthy Families Healthy Children (HFHC) is a program that supports the best development of children and enables families to lead healthy and fulfilling lives. The program is underpinned by an ecological model of child health and equity considerations of universal and proportional universalism. HFHC provides universal, tailored and flexible packages of care to ensure the right interventions are provided at the right time to the right families. Although our broad target population is families with children 0-5 years, families experiencing a number of risk factors and requiring additional support are specifically targeted. This is being done in collaboration with a range of government and non-government agencies and community. Since implementation in 2016 we have: - Formally reviewed universal home visiting services to newborns across three organisations and used the report to advocate for policy change and the 'green light' to pilot a new model. - Strengthened our universal service by introducing a centralised intake, referral and advice line to assist clients to navigate the care system and a new website to provide a localised online source of information on child health and development. - Designed a new service model where initial screening/risk assessment in antenatal and maternity services is supplemented with a clinical phone call to all families with newborns to review their risk level and determine the appropriate service level response or 'package of care'. - Attracted new investment and redirected existing resources to an expanded sustained home visiting program with capacity to meet the needs of all families requiring additional support. 131 families are currently enrolled. - Revised eligibility criteria to ensure all vulnerable families and those with low English proficiency were able to receive an evidence-based, structured home visiting program. Program sustainability is a key consideration and we have developed a research and evaluation consortium including academics from three Sydney universities, workforce representatives and consumers. The preliminary framework will be discussed. Program principles are transferable to, and can be localised in other health districts. 'What would a child and family health service look like if we took a proportionate universalism approach?' 'How do you redesign services to continue to provide universal services and enhance sustained services for vulnerable families?' We will answer these questions in the context of a service design in Sydney Local Health District. [ABSTRACT FROM AUTHOR]