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Introduction: Children’s Health Queensland (CHQ) established a telementoring hub in Queensland, using the Project ECHO® model, to pilot and scale a range of virtual communities of practice (CoP) to empower the Australian workforce to integrate care. Description: The establishment of the first Project ECHO hub in Queensland facilitated the implementation of a variety of child and youth health CoP that strategically aligned to the organisation’s approach to integrate care through workforce development. Subsequently, other organisations nationally have also been trained to implement and replicate the ECHO model to effect more integrated care through CoPs in other priority areas. Discussion: Findings from a database audit and desktop analysis of project documentation highlighted that using the ECHO model was effective in establishing co-designed and interprofessional CoP to support a cross-sector workforce to deliver more integrated care. Conclusion: CHQ’s use of Project ECHO highlights an intentional approach to establishing virtual CoP to build workforce capability to integrate care. The approach explored in this paper highlights the value of workforce collaboration amongst nontraditional partners to foster more integrated care. [ABSTRACT FROM AUTHOR]

Introduction: The Kids Guided Personalised Service (KidsGPS) is an integrated model of care coordination for children and young people (CYP) living with medical complexity. After successful implementation in an urban setting, the model of care will be rolled-out at scale to four rural regions in New South Wales, Australia to establish RuralKidsGPS. This paper describes the approach and methods for the outcome and implementation evaluation of RuralKidsGPS. Description: The evaluation aims to assess health, economic and implementation outcomes and processes whilst identifying barriers and enablers to inform future rollouts. Measures of health service utilisation (primary outcome), child health related quality of life and parent/carer experiences will be assessed. The implementation evaluation will occur alongside the outcomes evaluation and is underpinned by the Consolidated Framework for Implementation Research and informed by validated quantitative measures and qualitative interviews with patients, families, healthcare providers and service managers. An economic analysis will determine incremental cost effectiveness ratios for the new model of care using health service utilisation data. Conclusion: RuralKidsGPS, if effective, has the potential to improve equity of access to integrated care for CYP and their families and this protocol may inform other evaluations of similar models of care delivered at scale. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in healthrelated quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program. [ABSTRACT FROM AUTHOR]

This Perspective Paper explores the challenges of implementing local initiatives guided by the tenets of the Collective Impact (CI) approach. As such, it draws implications of CI for integrated health and social care efforts to improve and sustain health and social outcomes within a community-wide context, based on our efforts to deploy a CI intervention in the regional town of Muswellbrook, New South Wales (NSW) Australia. A program of health and wellbeing activities providing mental health and wellness messages and activities was implemented in the township over 2 years by the Family Action Centre (FAC), University of Newcastle, Australia. A key takeaway was the importance of authentic community engagement and active involvement as opposed to mere consultation. [ABSTRACT FROM AUTHOR]

Introduction: There is a global trend towards place-based initiatives (PBIs) to break the cycle of disadvantage and promote positive child development. Co-location is a common element of these initiatives and is intended to deliver more coordinated services for families of young children. This paper examines how co-locating early childhood services (ECS) from health and education in Child and Family Centres (CFCs) has impacted collaboration between services. Methods: This ethnographic study included 130 participant observation sessions in ECS between April 2017 and December 2018 and semi-structured interviews with 45 early childhood service providers and 39 parents/carers with pre-school aged children. Results: Service providers based in CFCs reported that co-location of services was facilitating local cooperation and collaboration between services. However, insufficient information sharing between services, prioritising client contact over collaborative practice and limited shared professional development remained barriers to collaborative practice. For parents, co-location improved access to services, but they experienced services independently of each other. Discussion and Conclusion: Co-location of ECS in CFCs contributed to greater cooperation and collaboration between services. However, for the potential of CFCs to be fully realised there remains a need for governance that better integrates service policies, systems and processes that explicitly support collaborative practice. [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: Legal issues are known to affect and be affected by mental health. But to what extent do legal issues surface in mental health settings and what do staff feel they need to support clients experiencing these issues? These questions were explored by a national mental health service interested in the potential for health justice partnership with local community based legal services. Methods: A survey of 999 frontline staff of a national mental health organisation. 146 staff (15%) responded from 70 service sites across Australia, including peer support workers (47%), support workers (20%), team leaders (17%) and clinicians (15%). Results: Staff identified a wide range of legal issues experienced by their clients (commonly referred to by staff as consumers), most commonly credit, debt and social security issues, housing, family law and family violence. Two-thirds (67%) of respondents indicated that they spent around 50% or more of their time 'responding to these types of issues'. Respondents indicated that they need more support to address legal issues facing their clients, particularly more knowledge of other services, connections with professionals in other organisations and connections with community. They also felt they could benefit from additional processes, tools, and resources, and time to manage their case load. Originality: While there is an emerging field of research exploring the legal capability of citizens, this study explores what mental health service staff feel they need to support consumers experiencing legal issues that can interact with mental health. [ABSTRACT FROM AUTHOR]

Introduction: Western Sydney Diabetes (WSD) established an innovative diabetes service in May 2020, using virtual and in-person care, linking primary care with the diabetes specialist team. This study evaluated the service's feasibility using qualitative and quantitative methods. Method: Evaluation included: 1) thematic analysis of interviews and workshops with patients and health professionals (n = 28); 2) quantitative analysis of records of patients admitted July 2020-June 2021 (n = 110). Results: Key themes related to 1) benefits: convenient location, access to integrated care, advantages of virtual care; 2) challenges: hard for patients to ask questions, technology issues; 3) confidence: shared care decision making, multidisciplinary team; and 4) future directions: additional multidisciplinary services, expanded insulin stabilisation service, promotion. Improvements between baseline and 3 months included 1.3% reduction in HbA1c (p < 0.05). Sulfonylurea dropped by 25% between initial appointment and follow-up, and GLP1RA/SGLT2i use increasing by 30% (p < 0.05). The clinic covered costs using Medicare billings and Nationally Weighted Activity Units. Discussion: The findings suggest this integrated care model was feasible and perceived as beneficial by both patients and providers. The clinic offers a promising model of practice that could be developed further to roll out in other regions for rural delivery of care. [ABSTRACT FROM AUTHOR]

Introduction: Behavioural and emotional disorders are a significant cause of morbidity for young people aged 10-19 years. School-based health care (SBHC) provides an innovative approach to addressing these issues within Australia. Description: We describe an innovative and integrative SBHC model called Ngaramadhi Space (NS) based at a specialised behavioural school called Yudi Gunyi school (YGS) in metropolitan Sydney, Australia. NS was developed in partnership with the Aboriginal community to provide holistic, integrated, multidisciplinary child and family centred care to students experiencing problematic externalising behaviour. We contextualise the historical factors leading to the development of NS, highlighting the importance of effective partnerships between sectors, and providing the theoretical framework and key components underpinning the model of care. Discussion: In Australia, schools are an under-utilised resource for the delivery of health and support alongside education. Collaboration between sectors can be challenging but allows a more coordinated approach to the management of complex social and health issues. By forming effective partnerships with schools and communities, the health sector has an opportunity to improve access to health and social care in a culturally safe and acceptable way. This is in line with national and international frameworks for improving health service delivery and addressing inequity. Conclusion: The health sector can play a pivotal role in improving the wellbeing of children by forming effective partnerships with schools and communities. The NS model is a practice-based example of this. [ABSTRACT FROM AUTHOR]

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Introduction: Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet few intervention studies have addressed the specific care needs of this vulnerable, high-risk population. This paper presents Mater Aged Care in an Emergency (MACIAE), a service dedicated to supporting aged care facility residents, their families, facility carers and GPs, with the goal of providing a seamless care transition in order to ensure the highest and safest standard of care with the upmost compassion and dignity. The program was designed with patients and families/carers, ACFs, local general practices, Primary Health Networks, ambulance services, hospital providers and researchers. Methods: The study was implemented 2013-2016. All older adults presenting from ACFs to the ED of Mater Hospital Brisbane, Australia were included. The evaluation was a pre/post design using retrospective baseline data from hospital records, and prospectively collected post-implementation data. The objectives were to determine whether this intervention significantly impacted on patient outcomes and organisational outcomes. Ethics approval for the study was obtained through the Mater Research Ethics Committee. Results: This study demonstrates the significant improvements can be achieved by a specific aged care service working across the continuum. Participants (n=1130) were from over 200 ACFs. Intervention resulted in 30% drop ward admissions; reduced LOS from 6.5 to 4.0 days (national average 8.0 days); reduced 28-day representation rates from 17.8% to 4.6%; 88% of patients commenced on an End of Life pathway were able to be transferred to their environment of preference; and, there were over 300 Advanced Care Plans implemented. Satisfaction from acute, primary care and ACF providers was very high. A cost-benefit analysis demonstrated a 10:1 outcome. Discussion: This study demonstrates significant improvements were achieved by integration of an acute frail older person service into an ED, which works with families, primary health and social care to implement strategies to meet the needs of this population. Lessons learnt: Key to implementing and sustaining this model of integrating care are leadership; culture - it makes or breaks it; time - it takes longer than you think; data - speaks louder than words; and, passion - to keep you going through the tough times. Limitations: The present study involved a pre-post implementation study design, therefore we cannot speculate whether or not our results were entirely due to the MACIAE service implementation. Future studies should consider implementation of a Randomised Controlled Trial. We also note that this study was implemented in only one hospital. Suggestions for future research: In January 2018, the Older Person Centred Care Team formed, merging three existing teams, focused on managing frail and older patients and families/carers across the continuum. Current research is focused on rapid assessment of frailty, embedding a case management approach to support care closer to home and involving patients/families/carers in decisions about a model that meets their future needs. [ABSTRACT FROM AUTHOR]

Introduction: The integration of Mental Health services is a prominent feature of government health policies. Whilst there is a substantial literature promoting the benefits of rural integrated mental health services, there is little detail of how those services function, or how and to what extent those services are integrated. This research described a rural Nurse Practitioner (NP) led primary healthcare mental health service within the context of rural mental health (MH) service policy in Australia and the literature on integrated mental health services. Theory/Methods: Data were collected from documentary evidence and quantitative evidence in one small town with a Mental Health NP. Qualitative individual and group semi structured interviews, and a 'stakeholder meeting' were conducted. A case-study design was used. Results: The NP mental health service was regarded by most participants as a viable solution to address the drug and alcohol and mental health needs of a high needs community. The service showed some evidence of government and non-government organisations working effectively together to provide a service to the community over the duration of the NPs employment. Integration was described at several levels including at the organisational level, between the mental health and other health and non-health related services and within the community. Discussions: The study provided a detailed description of how integration is demonstrated in a primary healthcare NP-led service. It illustrated the potential benefit to small communities and the significance of the role of a NP in leading this service. The NP service in this primary care setting provided an innovative solution to the fragmented MH and drug and alcohol service that was previously provided by visiting mental health and drug and alcohol services to this small rural town. It reduced the numbers of mental health and/or drug and alcohol related crises and provided links with other services enabling better continuity of care and improved capacity for early intervention. Conclusions: This service demonstrated key features of local integration which was community driven, led by a number of government and non-government agencies, supported by a steering committee as well as a partnership agreement. It also highlighted the substantial challenges to integration of a rural NP-led MH service. Lessons learned: This study is relevant to health care planners and policy makers and to small rural towns. This paper identified and described a NP role in a primary health care setting. It has the potential to influence the development of NP roles in similar settings. Limitations: The case is not necessarily representative of similar cases and therefore the results of the research are not generalisable. Suggestions for future research: Further research in other services such as child and family health could enhance knowledge of the key components of integration and further studies representing the clients' perspective of receiving integrated services. Further areas for research have been identified in the literature to inform integration of mental health services, particularly in a primary health care setting. This research should focus on the scarcity of evidence around qualified NPs coordinating care within this model. [ABSTRACT FROM AUTHOR]

Background: Integrated Care in Australia has mostly been implemented as micro-level initiatives rather than systemically, which has challenged its sustainability [1]. South Eastern Sydney Local Health District (SESLHD) and the Central and Eastern Sydney Primary Health Network (CESPHN) have sought to scale the benefits of existing micro-level strategies, such as inter-disciplinary coordination, coordination, and person-centred care, in order to increase population-level impacts and enhance sustainability. The focus of their joint Integrated Care Strategy has shifted towards implementation of meso- and macro-level integrated care programs [2]. This paper presents an overview of the evolution, implementation and evaluation of this novel program. About the IC Program: The centrepiece of the revamped Strategy is three interlinked programs, based on Bodenheimer's 10 building blocks [3]: 1) General Practice 2020:a quality improvement activity in general practice involving practice teams. 2) Care Coordination: a model of service involving Clinical Nurse Consultants and a social worker. 3) Talking Wellbeing:a co-produced salutogenic initiative based in general practice. Th objectives of these programs are to: Strengthen partnerships and integration. Support general practice to transition towards a person-centred medical neighbourhood (PCMN) model. Establish a sustainable, localised care coordination model. Build connections and experiences that enhance individual and collective wellbeing. The PCMN model is an Australian federal government initiative, similar to the health care home concept [4]. Desired outcomes of the PCMN are aligned with the quadruple aim [5]. Evaluation: The three programs will be evaluated at: (i) consumer, (ii) provider, and (iii) service levels. The overall analytic approach is informed by Normalisation Process Theory [6], with emphasis on the impact, acceptability, feasibility, sustainability, and scalability of the Strategy. Data will be collected at 6, 12 and 18 months points following implementation. Implications for Integrated Care: Lessons learnt from the evolution and and implementation of the three programs that make up the Strategy will have relevant to integrated care in other settings. References: 1- Angus L and Valentijn PP (2018). From micro to macro: assessing implementation of integrated care in Australia. Australian Journal of Primary Health. 24;59-65. 2- Stewart G, Bradd P, Bruce T, et al (2017). Integrated care in practice - the South Eastern Sydney experience. Journal of Integrated Care. Vol.25;No.1:49-60. 3- Bodenheimer T, Ghorob A, Willard-Grace R and Grumbach K (2014). The 10 building blocks of high-performing primary care. Annals of Family Medicine. Vol.12;No.2;166-171. 4- Grant R and Greene D (2012). The Health Care Home Model: Primary Health Care Meeting Public Health Goals. American Journal of Public Health. Vol.102;No.6:1096-1103. 5- Bodenheimer T and Sinsky C (2014). From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine. Vol.12;No.6;573-576. 6- May CR, et al (2018). Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implementation Science. 13(1):80. [ABSTRACT FROM AUTHOR]

Introduction: Although refugees from Ethiopia, Somalia, North and South Sudan constitute a major percentage of the 21.3 million refugees globally, there is scant research focussed on understanding how their beliefs influence attribution of mental illness and help seeking behaviour and integration following resettlement in a western donor country. The foci of this critical ethnographic study examined the complex interface between African refugee pluralistic models of mental illness and barriers to engagement and integration with mainstream mental health services following resettlement in Australia. Method and Analysis: The study used semi-structured interviewing, participatory and nonparticipatory observation from three data sources i.e., 1 African refugees that entered Australia via the Off-shore Humanitarian Pathway; 2 specialist workers in cross-cultural and refugee health; and 3 African diaspora registered professionals practicing in Australia and native to one of the aforementioned African countries. Participants were recruited through snowballing achieving an even participant spread across all four ethnic groups and three data sources. Data saturation was achieved at n=35 interviews with thematic exhaustion noted across all three data group transcripts. The interviews were transcribed verbatim and subjected to a four step process of thematic analysis utilising NVivo10 software. Internal validity was maintained through triangulation of data and the use of a cultural informants group of community leaders who advised on issue of lexicon, contextual and conceptual equivalence. Peer review was applied to the final Stage of the thematic process. Results: The study identified four main themes which highlight points of cultural difference and the importance of cultural/religious/spiritual beliefs to the health understanding and help seeking behaviour of refugees from Sub-.Saharan Africa. Each of these themes constitute a significant intercultural tension point that act as a barrier to therapeutic engagement between African refugees and western mental health services. Duplicity of the tension points also act as a barrier to the penetration of western psychoeducation within Sub-Sharan African refugee communities. Discussion: This research demonstrates that African refugees hold strongly to their pluralistic models of mental illness regardless of their length of residency in a westerner donor country or level of educational attainment. Majority continue to view causation of behaviour indicative of mental illness within a western context as spiritual as opposed to biopsychosocial and continue to attend traditional and faith healers within the diaspora until they become acutely unwell or self-repatriated back to their country of origin for traditional healing. This paper will discuss the incommensurate world views of refugees from Sub-Saharan Africa and western mental health services and offer a new model of integrated mental health care for culturally diverse populations. Limitations: The qualitative nature of this study and restriction to four African ethnic refugee groups could be viewed as a limitation in terms of narrowing the focus of analysis and replicability to other Sub-Sharan countries and vulnerable populations. [ABSTRACT FROM AUTHOR]

Introduction: Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet few intervention studies have addressed the specific care needs of this vulnerable, high-risk population. This paper presents Mater Aged Care in an Emergency (MACIAE), a service dedicated to supporting aged care facility residents, their families, facility carers and GPs, with the goal of providing a seamless care transition between primary and tertiary sectors in order to ensure the highest and safest standard of care with the upmost compassion and dignity. The program was designed with patients and families/carers, Aged Care Facilities, local general practices, Primary Health Networks, ambulance services, hospital providers and researchers. Methods: The 12-month MACIAE study was implemented during 2013-2014, with follow-up during 2015-2016. All older adults presenting from ACFs to the ED of Mater Hospital Brisbane, Australia were included. The evaluation was a pre/post design using retrospective baseline data from hospital records, and prospectively collected post-implementation data. The objectives were to determine whether this intervention significantly impacted on patient outcomes and organisational outcomes. Families and patients excluded within this study due to ethical constraints of discussing potential end of life issues and limited cognitive capacity amongst the majority of the population of patients. Ethics approval for the study was obtained through the mater Research Ethics Committee. Results: This study demonstrates the significant improvements can be achieved by a specific aged care service working across the continuum. A total of 1130 participants from over 200 ACFs were included. The intervention resulted in a 30% drop in ward admissions to currently less than 36% (national average in this population 60%); reduced LOS from 6.5 to 4.0 days (national average 8.0 days). 28-day representation rates also dropped from 17.8% down to 4.6%, 88% of patients commenced on an End of Life pathway were able to be transferred to their environment of preference and there were over 300 Advanced Care Plans implemented. Satisfaction from acute, primary care and ACF providers was very high. A cost-benefit analysis demonstrated a 10:1 outcome. Lessons learnt: Key to designing, implementing and sustaining this model of integrating care are leadership - both clinical and executive, time - it took longer than you think at the outset to embed, data speaks louder than words and passion - to keep you going through the tough times. Limitations: The present study involved a pre-post implementation study design, therefore we cannot speculate whether or not our results were entirely due to the MACIAE service implementation. Future studies should consider implementation of a Randomised Controlled Trial. We also note that our project was implemented in only one hospital. Suggestions for future research: In November 2017, the Older Person Centred Care Team formed merging three teams focused on managing frail and older patients and families/carers across the continuum. Future research is focused on rapid assessment of frailty, embedding a case management approach to support care closer to home and involving patients/families/carers in decisions about a model that meets their future needs. [ABSTRACT FROM AUTHOR]

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact. [ABSTRACT FROM AUTHOR]

Introduction: The issue of mental health (MH) in palliative patients is well-documented; research shows there is a skills gap in the health workforce caring for these patients around identifying and addressing patients' MH concerns. The 'Listen Acknowledge Respond' (LAR) project was established to fill this gap by delivering training for healthcare professionals (HCP) to address the MH needs of those living with dying, as well as investigating the impact of the training on HCP practice. Methods: Free two-day workshops were developed and delivered to groups of HCP working in palliative care (PC) services throughout Australia. Participants were invited to complete surveys and phone interviews before training and at 3, 6 and 9 months post-training, which were designed to record HCP's self-reported knowledge, skills and confidence in using MH tools and therapies before participating in training; and measure the changes in these attributes at set time periods after the training. Results: Pre-training results show 74% of HCP regularly screen for MH issues, yet more than half of respondents are not confident applying the five most commonly used assessment tools. In addition, strengths and solutions/task-focussed practice are the most commonly used therapeutic approaches, with 57% of respondents using these regularly with their patients and their caregivers, however only about half of respondents feel confident using these approaches. Post-training surveys and phone interviews show HCPs' self-reported knowledge, skills and confidence in using MH tools and therapies has increased significantly since participating in the training. This presentation will provide an overview of survey and interview findings conducted pre-training and 3 and 6-months post-training. Discussions: Pre-training findings from the LAR project support the literature, in that a significant proportion of HCP surveyed do not feel confident addressing the MH needs of their palliative patients, despite having to do this as part of their practice. Post-training findings indicate that the training has improved HCP's awareness of and response to their patients' MH concerns. Conclusions: Providing targeted training to HCP through the LAR project is proving to be an effective and important approach to bridging the gap between mental and physical health service provision, as evidenced by increased use and confidence in using common mental health tools and applying key therapeutic approaches. Lessons learned: Respondents have indicated that the training course content, format and delivery were highly relevant and appropriate, and that further, more targeted training would be valuable. Limitations: Findings presented in this paper represent an incomplete data set, as delivery of the two-day workshops has only recently been completed, hence the complete sets of 3, 6 and 9-month survey and interview responses will not be collected until early 2018. We anticipate that the significant changes seen to date will be strengthened in the completed data set. Suggestions for future research: Future delivery of more targeted, specialised MH training would be valuable for HCP working in PC, and investigation of the impact of this training would further inform the benefits of targeting the MH needs of PC patients and their families. [ABSTRACT FROM AUTHOR]

Internationally, sophisticated risk stratification models have been developed using routinely collected data from large organisations that provide care in both community and hospital settings. This paper outlines a simple approach in the Australian context, where federal and state governments have separate data for community and hospital care, with limited opportunities for data linkage. On the NSW Central Coast, just north of Sydney, the Central Coast Local Health District, CCLHD, is embarking on a 10 year program to integrate primary health and social care for vulnerable older people in the community. A key action is to provide integrated care for people at greatest risk of some deterioration in their health state. Practice change. Aim: To assess the utility of routinely collected hospital data for risk stratification. In the first year of the program, the risk is defined as a person with a high risk of being hospitalised in the next 12 months. Target Population: The Central Coast area of New South Wales, Australia, has a population of about 330,000 people, with 19% aged 65 years and over. Each year, about 10,000 people of this age have at least one unplanned hospital admission to a CCLHD hospital. There are over 400 General Practitioners, GPs, on the Central Coast, working from about 100 practice locations - with some solo practices to large group practices, operating as separate small business entities. People do not register for a GP, though nearly all people by 75 years of age have a regular GP. General practices also vary by the number and age profile of the patients they see in a year. Key Findings: The analysis of 5 years of hospital data demonstrated patterns in service delivery for the older age group eg for each year's cohort of 10,000 people with at least one admission, about 2700 people (27%) have at least one hospital admission in the following year. Knowing each person's nominated GP allowed some exploration of patterns of service use by GP. Some GPs had few patients admitted each year, and some GPs had many. It is likely this variability reflects differences in practice profiles of age distribution. There was consistency in these patterns of service use by GP over time, and also by general practice. The analysis of comorbidities allowed categorisation of the age group into those with 2 or more comorbidities - about 3500 people from a one year cohort have 2 or more chronic diseases. For this group of 3500 people, about 1500 people, or 40%, have a hospital admission in the following year. This approach was used to identify a small number of general practices in a low socio-economic status area, with an initial total cohort of about 600 people for a proof of concept of integrated care. Discussion: A risk stratification model needs to be linked with an effective intervention to improve the health of a population. Regression to the mean, when assessing whether a trial worked - it is important to have an understanding of patterns of service delivery over time, if they exist. Analysing hospital data, by general practice, allows contemporaneous analyses of other practices with similar activity and socio-economic profiles for comparison. Risk stratification models and c-statistics - the c-statistic is a useful measure of goodness of fit available for some regression models. It is not the only measure, and others should be considered. This approach using hospital data does not have a goodness of fit measure per se. Positive Predictive Value - Of equal importance is how well the model works when it is applied to the population of interest. If a model selects 100 people considered at high risk of hospitalisation, and 25 people are actually admitted to hospital, this represents a positive predictive value, PPV, of 25%. The PPV is influenced by the underlying risk of hospitalisation in your target population. Our 40% prediction of hospitalisation can be compared with the PPV of other risk stratification models. Conclusion: Further work is underway to apply a regression model to hospital data to facilitate comparisons with other risk stratification models reported in the literature, and quantify the incremental gains from increasingly sophisticated approaches to patient selection. Further work will also explore the gains from linking hospital data with primary care data. Using hospital data compares well with other models, and is an easily transferable, low tech approach to patient selection. A series of criteria for patient selection is a familiar way of doing business in many clinical settings. [ABSTRACT FROM AUTHOR]

Objective: In 2018, the Optimal Care Pathway (OCP) for Aboriginal and Torres Strait Islander people with cancer was developed in Australia to improve the cancer care experiences and outcomes of Aboriginal and Torres Strait Islander people. Methods: Our study examined health professionals' learning needs to meet the clinical practice requirements of the new OCP. An electronic questionnaire was distributed to 120 health professionals providing oncology care in two rural areas in Victoria, Australia. Questions included demographics, practice, cancer OCPs and implementation recommendations. Descriptive, chi-square and thematic analyses were undertaken. Results: Fifty-two health professionals from medicine (21%), nursing (37%) and allied health (37%) responded. All OCP sub-categories were selected, with a mean of 23 sub-categories identified as areas requiring additional learning. Aboriginal and Torres Strait Islander Perspectives, Treatment, and End of Life were the categories of higher interest. Care After Initial Treatment and Recovery was the category of lower interest. For respondents without cultural training, sub-categories involving practical tasks were of significant interest. Cultural education, connecting with Aboriginal and Torres Strait Islander services, putting learning into practice and respect emerged as themes. Conclusion: Strategies to address gaps included cultural safety training, person and family centred practice, and partnerships and connections with Aboriginal and Torres Strait Islander people and organisations across primary and tertiary sectors. [ABSTRACT FROM AUTHOR]

Introduction: Australia has been comparatively effective in preventing the transmission of COVID-19. The Sydney Local Health District [SLHD] used a "whole of health" integrated approach to respond to the pandemic. The aim of this study was to understand for whom, how and why this response worked, to inform a sustainable system transformation. Methods: A critical realist qualitative study was conducted with 20 purposively selected key informants. Data were collected through in-depth interviews and analysed using thematic analysis guided by abduction and retroduction. The five strategies of the WHO integrated people-centred health services framework was used to guide the overall study. Results: An enabling environment of a strong governance, emergency preparedness, a committed and adaptable workforce, and a strong core infrastructure underpinned SLHD's effective response. With a culture of embracing innovation, the district adapted virtual care to effectively quarantine people through their special health accommodation, and coordinate care across tertiary and community services. The established interagency relationships prior to the pandemic, enabled service directors to quickly integrate their services, which empowered and engaged the community [and staff], working across relevant sectors to provide care "where the people are"; reaching marginalised populations, and reducing community transmission. Discussion and Conclusion: The SLHD's progress towards a 'whole of health' approach, empowered and enabled the district to effectively work within and across sectors to address the pandemic in a people-centred manner. Sustaining the contextual conditions and mechanisms, that facilitated effective integration, will be beneficial beyond the pandemic. [ABSTRACT FROM AUTHOR]

Introduction: Three peak organisations in Queensland, Australia partnered with consumers and other health and social sector partners to co-design and pilot the first known integrated, health navigation model to improve outcomes for children and young people in care in Australia. Description: An Organisational Learning theoretical lens has been used to present a narrative case study of findings structured as key learnings from the Navigate Your Health pilot to inform quality improvement, scalability and program sustainability. A developmental evaluation was completed whereby semi-structured interviews, focus groups, surveys, chart reviews, database excerpts and economic modelling was completed alongside project documentation analyses to create an evaluation framework. Discussion: Findings highlighted the agency partners' drive to foster a more integrated and person-centred approach to care. The pilot's aim of improving health outcomes for a vulnerable population were achieved through a co-designed process which provided additional insights regarding partnerships, improvement, scalability and sustainability. Conclusion: Inter-agency responses to system fragmentation provide significant organisational learning opportunities. System integration is achievable through strengthened partnerships that can be sustained beyond a pilot phase to improve health outcomes for vulnerable/priority populations. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Gold Coast Integrated Care programme trialled an innovative model of care to proactively manage high risk patients with complex and chronic conditions in collaboration with general practitioners. The objective was to enhance coordination and continuity of care across primary and secondary health services from a single point-of-entry multidisciplinary coordination centre. This case study, embedded in the broader trial, analysed the perceptions of patients, healthcare staff and general practitioners on the adequacy, comprehensiveness, timeliness and acceptability of the new model of care to help inform the decision by the health service whether to adopt it beyond the trial. Methods: This mixed method embedded, explanatory case study design included surveys of general practice staff and focus groups with patients, carers and coordination centre staff. Qualitative data were thematically analysed and findings merged with survey data in a narrative explanatory case report. Discussion: Staff, patients, general practitioners and practice nurses were generally satisfied with services, coordination of care and information sharing but general practice staff satisfaction ratings declined over time. Conclusion: The programme enhanced care and coordination of services and was valued by patients and healthcare providers. Study results provide a rationale for adopting the model for those with chronic and complex conditions. [ABSTRACT FROM AUTHOR]

Case management (CM) is an integrated care strategy, characterised by a set of actions to support person-centred planning, coordination of health and social services. Decades of CM, organisational psychology and occupational research highlight how vagueness and ambiguity in role communication can create role conflict and job stress, negatively impacts staff turnover, intra-organisational collaboration, job performance, and that poor communication of CM impedes policy, quality analysis service development and practice. We conducted a detailed top-down hierarchical, quality analysis of communication about CM roles and responsibilities in a Scheme for people with disability in Australia. The study used content analysis methods and the main actions as defined in a validated CM taxonomy (Appendix 1). We systematically searched and analysed 53 Scheme policy and practice documents of CM from 2013-2019. The results showed poor role communication with vagueness, ambiguity, gaps in the description of CM roles and responsibilities. Poor role communication has contributed to negative experiences and outcomes of CM actions of planning and coordination, as reported by CM users in many Scheme-related parliamentary inquiries, research, formal complaints, and decision appeals. The results reinforce the importance of an ontological approach in communication of CM roles and actions and provides learnings for integrated care roles across countries and contexts. [ABSTRACT FROM AUTHOR]

Introduction: The Carer Support Unit (CSU) of the Central Coast Local Health District (CCLHD), NSW, Australia, developed, trialled and implemented a Carer Readiness Tool (CRT) to help carers gauge their readiness to care at home, highlight to hospital staff areas for additional support for carers, and provide evidence of carer engagement in discharge planning. Description: A rigorous co-design process was followed with carer consultation at key milestones in development of the CRT. The tool was piloted in two cancer/chronic renal disease inpatient units commencing November 2019. Discussion: The CRT was well-received by carers who appreciated the opportunity to complete the tool in their own time, not in front of the patient. Positive feedback was received from clinicians, including the breadth of the CRT's content which contributed to better discharge planning. The need to manually incorporate a hard copy form into the electronic medical record is a limitation of the CRT. Conclusion: The CRT is context-specific and fit for purpose. During the development of the CRT, the project team focused on the face validity and usefulness of the tool. The next stage of the project will be formal evaluation of the tool to measure its impact. [ABSTRACT FROM AUTHOR]

Introduction: Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners' experiences of care provision. Methods: The study used a qualitative design in two phases: 1) semi-structured interviews, 2) one focus group. The setting comprised one public health network and five community services in urban Australia. In Phase 1, health practitioners across settings were interviewed about their experience of transitional care. Phase 2 sought feedback about the Phase 1 findings from different practitioners. All data were thematically analysed. Findings: In Phase 1), 48 healthcare practitioners were interviewed across multiple settings. Few participants were aware of the introduction of consumer-directed care in community aged care. Four main themes were identified: 'Rapid and safe care transition', 'Discussing as a team', 'Questioning the discharge', and 'Engaging patients and carers'. In Phase 2), seven participants from different settings reviewed and endorsed the findings from Phase 1. Discussion and conclusions: Findings indicate that healthcare practitioners use a range of communication and coordination processes in optimising integrated transitional care. Although participants involved their patients in transitional care planning, most participants were unaware of the recent implementation of consumer-directed care. In contexts of community-based care shaped by multidisciplinary, sub-acute and CDC models, care integration must focus on improved communication with patients and carers to ascertain their needs and to support their increased responsibility in their care transitions. [ABSTRACT FROM AUTHOR]

Many countries are experimenting with new models of care delivery involving enhanced integration and coordination of services to better meet the needs of those living with chronic illness. However, the available evidence on the relative value of different forms of integration remains uncertain. This paper will present the findings of a study undertaken in close collaboration with and co-funded by the European Observatory on Health Systems and Policies. It will provide an overview of strategies to chronic disease management that have been developed and/or implemented in five European countries (Denmark, England, France, Germany, Sweden) and Australia. It will also assess some of the contextual factors that enable or hinder implementation of strategies to address chronic illness. It illustrates the immense diversity among European countries in their approaches to address the rising burden of chronic disease. Approaches not only vary between but also within countries, and reflect to considerable degree the general approaches of health care financing and organisation taken. Thus, in many countries where strong primary care teams exist there has been a progressive shift in the management of many chronic diseases to nurse-led clinics in primary care, for example in England, Sweden and the Netherlands. The involvement of the non-medical profession in France or Germany is low, partly because of legal and professional restrictions on the deployment of nurses outside hospital. Instead, Germany has introduced dedicated disease management programmes which patients and providers can join voluntarily, while France is incentivising the formation of provider networks so as to improve coordination and multidisciplinary working along the continuum of care. The role of patient self-management is being acknowledged as a key component of effective chronic disease management in many countries; yet, systems that support self-management systematically remain relatively weak in many settings. The sustainability of chronic care models faces considerable challenges in all health care settings. These include administrative and financial obstacles to enhance the coordination and/or integration of health and social/community care services; under/mis-investment in suitable information systems; conflicting policies (e.g. pursuing activity-based funding vs. aiming to shift care into the community); a focus on cost reduction; and the potential impact of electoral cycles. An effective response to the rising burden of chronic disease requires a health system environment that allows for the development and implementation of structured approaches to chronic disease management. Experience suggests that systems that are characterised by fragmentation of health services are facing considerable challenges in the successful implementation of system-wide strategies to provide care for patients with chronic illness. [ABSTRACT FROM AUTHOR]

This article outlines the development of the Australian Gold Coast Integrated Care Model based on the elements identified in contemporary research literature as essential for successful integration of care between primary care, and acute hospital services. The objectives of the model are to proactively manage high risk patients with complex and chronic conditions in collaboration with General Practitioners to ultimately reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. Central to the model is a shared care record which is maintained and accessed by staff in the Coordination Centre. We provide a process map outlining the care protocols from initial assessment to care of the patient presenting for emergency care. The model is being evaluated over a pilot three year proof of concept phase to determine economic and process perspectives. If found to be cost-effective, acceptable to patients and professionals and as good as or better than usual care in terms of outcomes, the strategic intent is to scale the programme beyond the local health service. [ABSTRACT FROM AUTHOR]

The article focuses on the integrated primary health care in Australia in 2009. It says that the primary health care services in the country are divided into private and public sector, which are responsible to various levels of government and work under the variety of funding scheme with no dominant policy. It mentions that the service provision coordination has been improved by modification to the funding of private and allied health services.

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The article offers the author's perspective on the use of integrated care across health systems and countries in response to the common challenges of the 21st century. The author comments on the efforts to overcome the barriers to health care quality which include an ageing society, chronic disease and multi-morbidity. An overview of the 9th Annual Conference on Integrated Care held in Vienna, Austria, including the agenda and the objective is also presented.