Search

Introduction: The Healthy Homes and Neighbourhoods (HHAN) integrated care initiative was designed to break intergenerational cycles of social and health inequalities and enhance access to and engagement with health and social services for vulnerable families in the Sydney Local Health District. We sought to unearth the initial programme theory of the HHAN initiative to inform rollout to other relevant areas.Methods: We conducted a critical realist evaluation using steps. (1) Exploring the events around the HHAN initiative development. (2) Explore consumer experiences. (3) Identifying the entities and associations characterising the HHAN initiative and related outcomes. (4) Searching for different theoretical perspectives and explanations (abduction). (5) Hypothesising the mechanisms and [context] conditions that might have activated the generation of the HHAN outcomes (retroduction).Results: We identified three central mechanisms; trust, buy-in and motivation, and understanding family dynamics operating across consumer, provider and systems levels of the HHAN initiative.Discussion: These programme theories reveal that to achieve the goals of HHAN, interpersonal dynamics, fostering buy-in and ensuring motivation of both the consumers and care workers should be sought and sustained at all levels.Conclusion: The programme theories unveil that integrated care initiatives should foster positive relationships at all levels to ensure favourable consumer outcomes.

Introduction The New South Wales (NSW) health system faces challenges in the coming decades as the effects of a changing population place pressures on the delivery of health care. Integrated Care is a crucial step to delivering care that is patient-centred and of value to the population. The NSW Integrated Care Strategy was launched in 2014. Local health partnerships were supported to implement innovative, locally led models which trialled new ways of working to address the needs of communities across NSW. Detailed monitoring and evaluation informed the next steps of the strategy. Description of policy context and objective The NSW Health Strategic Framework for Integrating Care was developed in 2018. The Framework articulates a clear vision for integrating care in NSW across the life course. Principles, enablers and expected outcomes are outlined in the Framework, and these are demonstrated in two major implementation activities: scaling effective initiatives across NSW; and collaborative commissioning with providers, organisations and settings in the community. Scaling effective initiatives Six Integrated Care initiatives have been selected for scaling across NSW. Each focuses on a cohort of the community, rather than a specific disease, and aims to manage health and social needs in primary and community care where possible and appropriate. The NSW Ministry of Health provides funding to Local Health Districts (LHD) to implement scaled initiatives in partnership with primary and social care services. LHDs enrol patients on a state-wide Integrated Care Patient Flow Portal which enables continuity of care across NSW and monitoring and evaluation of the strategy with aggregated and linked data. Collaborative commissioning Collaborative commissioning promotes the development of partnerships between Primary Health Networks (supported by the Commonwealth Government) and LHDs (NSW Government). Partnerships develop care pathways for patient groups identified through a comprehensive population needs assessment. These pathways reflect the need for better coordination between primary and secondary health services, as well as other service providers that contribute to the social determinants of health. Collaborative commissioning incentivises local autonomy and accountability for delivering patient-centred, outcome-focused and value-driven care in the community. Targeted population Integrated Care in NSW focuses on improving outcomes for vulnerable people and at-risk populations across the lifecycle. Highlights Integrated Care in NSW strives for whole-of-person care where care is wrapped around the individual rather than focusing on a pathway to address a specific disease. We recognise the need to create linkages between NSW service clusters, state and federal government agencies, and non-government providers. Providing these linkages takes the burden of coordination off the patient so they have a seamless experience that meets their needs. Comments on transferability This state-wide approach to integrating care has been informed by monitoring and evaluation of previous strategies implemented in NSW. Lessons learned throughout implementation may be transferrable to other states in Australia, or similar regions internationally. Conclusion Integrated Care in NSW has evolved over time, in response to the needs of the population, new evidence and continuous monitoring and evaluation. Improved outcomes have already been demonstrated across the Quadruple Aim of healthcare delivery.

Background: Healthy Homes and Neighbourhoods (HHAN) is an integrated care program that supports families where adults have complex health and social needs, often impacting on their children. HHAN also aims to engage with and enhance capacity of partner agencies and the community served. This prioritised pathway initially featured delivery of long term whole-of-family care coordination, flexible community visits, fast track Paediatric outreach clinics and consistent collaboration with schools. Over time, the pathway has been strengthened and the model of practice has been refined and expanded to address whole of school and community needs. The enhanced model includes indirect provision of consultation for a larger number of children and their families and the implementation of whole of school health promotion and community engagement initiatives. Aim: To improve the established service pathway for families and the school community. Method: Two local primary schools receive this pathway. The enhanced model uses qualitative measures in the health promotion programs commenced. Pre and post surveys will be completed by parents and students and semi structured interviews with school staff will be undertaken. Evidence of sustainability and incorporation into school operations will be recorded. The number of students receiving a consultative model will also be compared to the number of families referred for direct HHAN care coordination. Results: This is a unique care coordination pathway linking professionals from the health, social and education sectors. Results had been previously demonstrated with families referred for care coordination through patient reported outcome measures .This has enabled trust between service providers, particularly education and healthcare providers, to develop over time and enabled the pathway to be reviewed. The expanded model of care benefits more students and the broader community. Conclusion: Establishment of this pathway has challenged partners to develop a model using creative, non-standard methods of intervention. Families in these communities have multiple needs and face multiple barriers to care. This highlights the need for place-based integrated care initiatives such as Healthy Homes and Neighbourhoods to target the needs of disadvantaged communities. The enhanced model of practice is in early stages of implementation. Further study will focus on evaluation of these initiatives.

1. IntroductionIntegrated care is a major NSW Health strategic priority and a key enabler of value-based healthcare. The NSW Ministry of Health provides funding to 15 Local Health Districts (LHD) and three Specialty Health Networks (SHN) to support local health partnerships to implement innovative, evidence-based and locally led models of Integrated Care.NSW Health defines value based on the Quadruple Aim of population health outcomes, cost efficiency of the system and the experience of receiving and providing care. To assist with statewide evaluation of Integrated Care with respect to the Quadruple Aim, the NSW Ministry of Health developed two surveys targeted to Integrated Care patients and providers, respectively.2. Description of policy context and objectiveCapturing the patient perspective and measuring what matters to patients is fundamental to a patient-centred health system. The provider experience is also crucial to optimise the delivery of healthcare and patient outcomes.The Integrated Care Patient Survey was developed by the Ministry in partnership with the Bureau of Health Information. The survey underwent cognitive testing to ensure it was relevant and understandable to patients. The 60-question survey is believed to be the first to combine Patient-Reported Experience Measures, Patient-Reported Outcome Measures using the PROMIS-10 tool, and the Patient Activation Measure (PAM). The survey captures patient experience with respect to care coordination, care plans, respect, empowerment and discharge planning. The PAM captures patients’ self-efficacy, knowledge and confidence to manage their health.The Integrated Care Provider Survey comprises 28 questions capturing providers’ understanding, satisfaction, teamwork, care coordination, communication, workload and resources.3. Targeted populationThe provider survey has been emailed to more than 1,000 providers across the acute, primary and social care sectors, involved in the care of Integrated Care patients.The Integrated Care Patient Survey has been posted to more than 20,000 Integrated Care patients in NSW. Patients who received a similar survey in the previous six months and those no longer enrolled in Integrated Care initiatives were excluded. Where consent is provided, the patient survey data will be linked with hospital data collections.4. HighlightsAggregated results of both surveys will be fed back to the system. The results will help inform management and quality improvement of Integrated Care at a local level, and inform strategic planning of the statewide strategy. The surveys allow comparison of the effectiveness of Integrated Care initiatives which are theoretically similar, but target varied patient cohorts.5. Comments on transferabilityThese surveys are used to evaluate provider and patient experience of Integrated Care at a statewide level. They may have utility in similar jurisdictions, to evaluate the impact of varied, locally led models across a large area. 6. ConclusionsPreliminary results and response rates of the surveys will be presented. Results of these surveys will yield useful information for LHDs/SHNs and the Ministry to monitor the impact and outcomes of investments in Integrated Care.

Introduction: Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.Methods: Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.Results: Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.Conclusions: This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

An introduction (comprising background and problem statement): The Healthy Homes and Neighbourhoods (HHAN) integrated care program, which started in 2014, was developed to address the complex health and social care needs of vulnerable families, which well exceeds the capacity of the public healthcare system alone. Semi-structured, qualitative interviews took place with senior managers and executive staff from agencies which HHAN considers partners or potential partners. An agency for the purpose of this study could be within a broader organisation. The aim was to determine participant’s definition of interagency collaboration and explore enablers and barriers as viewed by them. Theory/Methods: Recruitment took place by purposive sampling. Twenty-nine invitations to participate were sent by email to participants from 11 organisations. In total, 13 interviews took place, representing 11 agencies from 6 different organisations across health and non-health in the government, non-government and charity sectors. Using a grounded theory method, questions in subsequent interviews were guided by discussions had in prior interviews though strict coherence to the methodology was not achieved nor was saturation of themes. A single coder thematic analysis of interview transcripts using NVIVO software occurred. Results: Achieving efficient, knowledgeable referrals (single client focus) between agencies was the most basic and common definition of collaboration. Collaboration was also considered to include working together on shared projects and strategic planning to advance population health initiatives. Reviewing enablers and barriers being described in the interviews, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. Discussions: Comparative analysis to selected pre-existing literature will be presented. As well as discussion on how awareness of this literature may have influenced data collection and analysis. Conclusions (comprising key findings): A grouping system of “themes” was developed, as follows: Theme 1: Establishing and maintaining knowledgeable relationships Theme 2: Diversity of roles Theme 3: Business performance Theme 4: Clear directive and supporting infrastructure Theme 5: Organisational expectations Lessons learned: The findings from this research appear to be available in the selected pre-existing literature. This may demonstrate potential barriers exist in understanding how best to apply pre-existing knowledge. Limitations: The scope of this project was too broad to be able to achieve saturation of themes within a realistic time frame or manageable sample size. As well, a single coder reduced rigidity of the study. Suggestions for future research: Another study involves interviewing frontline staff of HHAN. Comparing the key findings of these studies may provide insight into similarities and differences these cohorts hold regarding interagency collaboration.

Background: The integration of system-wide policies and services has long provided the foundation for promoting and protecting the health, development and wellbeing of children, young people and their families. The proverb “it takes a village to raise a child” provides the underlying ethos whereby all members of society work together to raise healthy and resilient children and young people. The United Nations Convention on the Rights of Children and the Sustainable Development Goals (SDGs) provide the global platform to addressing the needs of children young people and families. Building on the SDG goal of achieving universal health coverage, WHO developed a global strategy for people centered and integrated health services, recommending that countries consciously consider the perspectives of individuals, families, and communities, and respond to their preferences and needs. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care as it applies to Children, Young People and their Families 2- DIscuss the scope and purpose of a Integrating Care for Children Youth People and Their Families ISpecial Interest Group (IC-CYF SIG) 3- Modify the Scope and Purpose Document for the Integrating Care for Children Youth People and Their Families, Special Interest Group (IC-CYF SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, education and social care practitioners and researchers who are interested in aspects of integrated health and social care as it applies to children, young people and their families. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Care for Children Youth People and Their Families, The workshop will define the scope and purpose of a SIG for Integrating Care for Children Youth People and Their Families.

Introduction: The Healthy Homes and Neighbourhoods HHAN team provides care coordination for vulnerable families with complex health and social care needs, who are disconnected from key services and require multi-agency support. HHAN care coordination is delivered across inner western Sydney, with staff based at a community health centre and a c o-located hub in an identified suburb of disadvantage. Care coordination is provided by Senior Social Workers and Clinical Nurse Consultants. At the commencement of the program staff were instructed to deliver care coordination from their respective sites, in response to community need. The study aims to describe the model of care coordination and the variables contributing to its emergence. Theory/Methods: Semi-structured interviews were conducted with HHAN care coordinators to explore the model of care they were providing and its development over time. Electronic medical records were reviewed to explore case history, activity and outputs delivered by care coordinators. Patient journeys were detailed, analysed and compared. Results: The review demonstrated that a single model of care exists, with interpretations differing dependent upon clinician skills and expertise, community need, client cohort and service context. Clinicians based at the community centre have identified assertive outreach to be more time consuming in engaging clients , the failure to attend rates are higher and traditional service models do not take into consideration vulnerable families social needs. Place based initiatives or ‘in reach’ services have demonstrated that clients presenting take less time to engage due to the immediacy of their needs and are more likely to return due to the locale. Furthermore inter professional collaborative practice is demonstrated more effectively within a co-located hub than centre based care. Discussions: The model of care is an iterative process of assessing and identifying social and health needs with longitudinal accompaniment, navigation and education to increase families’ capacity to manage their complex needs. HHAN clients are a heterogeneous group with multiple risk factors that threaten the wellbeing of the families. These clients require innovative and creative approaches to meeting their care needs. The model of care supports this innovation, creativity and integrated care response. This is due to the recruitment of senior staff who exhibit leadership qualities with superior interpersonal skills and a commitment to social justice and demonstrated integrity in practice. Conclusions: The HHAN model of care provides care coordination for vulnerable families in both a place based initiative and community health centre. Lessons learned: Care coordination delivered from place based initiatives meet vulnerable clients within their communities and are able to work more efficiently with inter-professional collaboration. Centre based care is a less efficient way of care –coordinating for vulnerable families due to geographic location, traditional service models and longer time required for engagement. Limitations: The project did not explore the adaptability of the model to other populations. Suggestions for future research: A comparative study of client outcomes versus place based outcomes.

Introduction: Sydney Local Health District undertook a collaborative planning process for vulnerable families in 2013 and 2014. In late 2014 the District successfully tendered for an integrated care initiative for vulnerable families – Healthy Homes and Neighbourhoods, which was implemented in July 2015. Practice Change Implemented: The initiative involved system redesign and commitment from health, education, social care, local government, primary-care and non-Government partners. The model included: shared intake, care-coordination, family group conferencing, wrap-around delivery models, place-based service hubs, general practice engagement and support, and population-based health improvement initiatiave. Aim and Theory of Change: The intervention aims to break intergenerational cycles of disadvantage, psychological trauma, poor parenting and poor health outcomes. A complex Theory of Change ToC was developed, that in summary, would: 1 engage, empower and support families; and 2 develop and strengthen the service system through a collaborative co-design process. Targeted Population and Stakeholders: The initiative is intended for vulnerable families with complex health and social care needs who have one or more dependent children unborn through to 17 years where their complex health needs are impacting on their capacity to parent effectively and participate in their community. The Stakeholders included: the local primary health network PHN, statutory child protection agency, housing department, schools, early childhood education and care providers, local government, and non-Government organisations working with complex families. Time Line: Implementation in July 2015, reviewed 2016 and secured recurrent funding July 2017. Highlights: The initiative has the following key features: Multiple core and non-core agencies working together over a sustained period of time i.e. 5 years with families with complex health and social needs All the needs of families are in scope for the intervention, including housing, employment, income support and legal advice Use of evidence informed integrated care methods by service partners, including family case conferencing, and “wrap around” care delivery Encouraging families to have a “health home” for all their health needs and supporting them to move from dependency to independence Supporting general practice providers to care for families that are often seen to be “too difficult” Development and implementation of shared assessment tools and referral criteria Implementation of family assessment and engagement tools that can be used over the long-term to monitor the health and wellbeing of family members Transferability: The integrated care model uses design elements that were adapted from other international projects and which can be implemented in other health and social care settings. The model may also be transferable to other vulnerable population groups including aged care. Conclusions: The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. Discussion: The HHAN initiative demonstrates the benefits of integrating services with the social care, education and local government sectors to address the social determinants of health as they affect families Lessons Learned: The development of trust between agencies, clinicians and patients is essential for the development and implantation of integrated care initiatives

Introduction: The Healthy Homes and Neighbourhoods HHAN Integrated Care Program utilises a care coordination model to enhance access to and engagement with health and social services for vulnerable families. HHAN services families throughout inner west Sydney, with a particular focus on areas identified to be of heightened disadvantage through geospatial epidemiological studies. Two place-based initiatives PBI have been established in these areas of vulnerability – one of which is located in Riverwood. This study aims to identify barriers and enablers to service access and engagement in order to inform the delivery of HHAN’s Riverwood PBI. Both service providers and community members were consulted in order to identify the health and social needs and current gaps in service provision in this area. The study also aims to encourage consumer participation in the health service planning process with a particular emphasis on engaging the most vulnerable community members.Theory/methods: This qualitative project utilised interviews, a community forum and focus groups. Service provider interviews were undertaken to identify the viewpoints of key organisations related to service access and engagement. Community members were recruited via multilevel community engagements strategies and promotion through direct and indirect contact. A community forum investigated barriers and enablers to accessing services from the perspectives of families. Follow-up focus groups were held to address particular issues raised at the forum and to cater to particular language groups. Emerging key themes were identified, summarised and analysed.Results: Service provider consultation identified both intrinsic and extrinsic factors affecting service access and engagement. The major extrinsic factors included issues with health district and local boundaries, unclear referral pathways and a lack of targeted local health services. Intrinsic factors identified were mistrust of services, negative interactions with services and low health literacy. Preliminary results from community consultation suggest a lack of local services, accessibility issues with existing services, lack of culturally appropriate services and inadequate transport options were key barriers for community members.Discussions; The health and social service system is complex and difficult for both service providers and clients to navigate. Examining the issue of service access requires consideration of a broad range of factors including the perspective of service providers and the community and also reviewing systemic and process factors. This assessment of the service landscape will enable HHAN to establish a PBI that adequately responds to community and service needs in this suburb of significant family disadvantage.Conclusions: Multiple extrinsic and intrinsic factors complicate access to and engagement in services in the Riverwood area. This highlights the need for integrated PBIs such as HHAN to target the needs of disadvantaged communities.Lessons learned: A broad framework is required to gain a comprehensive understanding of access to and engagement with services that examines the interplay of individual factors, social issues, process and systemic factors.Limitations:The transferability of these findings outside of the Riverwood context is unknown.Future research: Further research will focus on evaluation of the Riverwood PBI in order to determine if identified needs and gaps are being adequately addressed.

Background: It is a truism that children are our future and yet is only recently that science has come to understand the significant impact that child and youth development has on later adult health and wellbeing. This includes not only prevention of disease, injury and disability, but also inclusion in education, employment and social relationships. Important during these early years is the interaction of a child’s genetic inheritance with the family and home environment, and later the peer-relationships, school and community environment. There are also critical historical and intergenerational influences that have a profound impact on the genetic-environment interaction. Adverse childhood experiences (ACE) of parents and caregivers can continue to have an impact. Local and state communities seek to mitigate these adverse impacts. The proverb “it takes a village to raise a child” provides the underlying ethos whereby all members of society work together to raise healthy and resilient children and young people. To do so it is necessary support and nurture, mothers, fathers, families, children and young people along an ever changing life-course trajectory that may require inputs from maternity services, childcare, schools, primary care, welfare and housing, income support, mental health, police, and hospitals. The provision of this support to families, children and young people can be complex and for some it will require a number of simultaneous inputs. It could be argued that the potential complexity of inputs is not realised at any other stage of the life-course. Each stage of child and youth development has its own unique complexity, be it: pregnancy and childbirth; early childhood; school; adolescence and early adulthood. Thus the integration of system-wide policies and services has long provided the foundation for promoting and protecting the health, development and wellbeing of children, young people and their families. The United Nations Convention on the Rights of Children and the Sustainable Development Goals (SDGs) provide the global platform to addressing the needs of children young people and families. The challenges are global. Integration of services for families, children and young people, for example, is important in low-income countries, countries affected by war, among refugee and migrant populations, and within rich countries as highlighted by the recent Innocenti Report. Aims and Objectives: 1) Discuss definitions and scope for Integrating Health and Social Care as it applies to Children, Young People and their Families 2) Discuss the scope and purpose of a Integrating Care for Children Youth People and Their Families Special Interest Group (IC-CYF SIG) 3) Modify the Scope and Purpose Document for the Integrating Care for Children Youth People and Their Families, Special Interest Group (IC-CYF SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed-back from tables, Discussion and Summation Target Audience: Health, education and social care practitioners and researchers who are interested in aspects of integrated health and social care as it applies to children, young people and their families. Learnings and Takeaway: The workshop will define the scope and purpose of a SIG for Integrating Care for Children Youth People and Their Families.

Introduction: The Sydney Local Health District SLHD integrated care initiative, Healthy Homes and Neighborhoods HHAN, is a comprehensive population based integrated care strategy to address the complex needs of vulnerable families. The spectrum of care required to optimise the health and social care outcomes for these families well exceeds the capacity of the public healthcare system alone. Needs such as housing, finance, and social supports often preclude these families from addressing physical and mental health issues. As part of the evaluation of HHAN, this project looks to understand the experiences of senior managers and executive staff with interagency collaboration from across the network. Theory/Methods: Recruitment took place by purposive sampling. Agencies which HHAN considers partners or potential partners were identified and an appropriate informant from within each agency selected. An agency for the purpose of this project could be within a broader organisation. The interviews focused on the participant’s individual definition of “interagency collaboration” and explored their opinions of enablers and barriers to interagency collaboration. Ideas were carried forward and explored further in subsequent interviews. To accompany the interview data, a sociogram of collaborative links was developed from an online social network analysis to provide a visual illustration of the linkages between the organisations. Results: Interviews and social network analysis data collection occurred between October 2017 and February 2018. A total of 13 semi-structured qualitative interviews took place, providing representation from six organisations. The majority of participants expressed a continuum on which they viewed interagency collaborations to be able to occur, depending on what was trying to be achieved. Achieving efficient, knowledgeable referrals with single client focus between agencies, whether government or non-government, was the most basic and common type of collaboration being aspired to. Collaboration could also include working together on shared projects and strategic planning to advance population health initiatives. The sociograms show a coherent network of collaboration with a spread of key players. Reviewing enablers and barriers, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. As a result a thematic grouping system identifying important features of interagency collaboration is being derived, final results of which are not available at the time of this submission. Discussions: By identifying themes of identified importance to interagency collaboration from across the network, HHAN may be able to use this to optimise its ability to effectively collaborate from both a strategic and front line staff aspect. Limitations: While features of a grounded theory approach were used, strict adherence to the methodology did not take place nor did complete saturation of themes. Suggestions for Future Research: As part of the evaluation of HHAN, another project interviewing frontline staff has occurred. It may be beneficial to compare and contrast the findings from these studies, to further understand how the views of senior managers from across the network aligns with the organisational approach to interagency collaboration perceived at the client care level.

Introduction: Healthy Homes and Neighbourhoods (HHAN) is an integrated care program in inner west Sydney currently supporting over 150 families. The initiative aims to provide integrated care via long-term care-coordination for vulnerable families with complex health or social care needs. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, care coordinators, and partner organisations.Theory/Methods: This project utilises critical realist methodology to undertake a qualitative evaluation of the care coordination model. The first round of interviews involved purposive sampling to identify thirty participants including a mixture of HHAN clients, HHAN employees, and stakeholders or other service providers. In-depth semi-structured interviews were audio-recorded, transcribed and coded using NVivo.Results: Analysis indicates that the care coordination model has a positive impact on clients’ sense of independence, self-awareness and outlook. Trust and favourable interpersonal relations were identified as the major underlying mechanisms for a successful care coordination working relationship. The identified modes of intervention facilitating positive client outcomes included accessibility, flexibility, and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery. Discussion: There is a need to appreciate the negative impact the complex and siloed health system can have on vulnerable families. This study suggests that a care coordination model can assist clients to navigate that system, and be beneficial in empowering and engaging them healthcare. Successful implementation of care coordination requires flexible program design, as well as experienced and skilled clinicians fulfilling the care coordinator role. Conclusion: Preliminary analysis identifies care coordination as an effective method for creating an integrated environment allowing clients to feel empowered to better manage their individual health and social needs.Lessons learned: A care coordinator role is effective in integrating health care services and improving individual client outcomes, however the role often involves aspects of case management, particularly in the early stages of intervention.Limitations: Whether the findings are applicable to other integrated care programs is unknown. HHAN clients were only interviewed if their medical and social situation was relatively stable potentially limiting the variety of perspectives obtained.Suggestions for future research: A comprehensive evaluation of HHAN will also involve the exploration of quantitative data to further assess the impact on health and social outcomes. Ongoing mixed-methods evaluation of the program will continue to assess medium to long-term client and family outcomes.

Introduction: The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family access to and engagement with health and social services through a care coordination model. In addition to servicing families living in inner west Sydney, HHAN has also established two place-based initiatives (PBI) in areas of heightened disadvantage – one of which is located in Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, financial and legal services. This integration aims to facilitate service access and provide multi-agency support for vulnerable families in the Redfern area and improve health and social outcomes for individuals and the community. This study aims to evaluate the role and impact of HHAN’s Redfern PBI and explore whether a place-based model and co-location translates into improved patient, service and community outcomes. Theory/Methods: The project utilised a critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and community health and social outcomes. Purposive sampling was used to identify 20 participants including HHAN clients, HHAN employees and stakeholders involved with the Redfern PBI. In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using NVivo. Results: Preliminary thematic analysis found that the PBI provided varied benefits for clients and other services. Positive outcomes for clients included better engagement with services, increased trust in health services, empowerment, improved outlook and planning for the future. Positive outcomes for services included easier referral pathways, knowledge transfer and increased integration with other services. Mechanisms by which these outcomes were achieved included proximity, flexibility, favourable interpersonal relationships and building trust by responding to need. Discussion: The HHAN place-based model has achieved early subjective successes in terms of individual client health and social outcomes and service outcomes. Whether this translates into objective health improvements and overall community benefit is yet to be determined. Conclusion (key findings): The delivery of an integrated care program via a place-based model has resulted in early positive outcomes for individual clients and other services. Lessons learned: This early qualitative evaluation provides an insight into the potential role that place-based initiatives can play in improving health and social outcomes in disadvantaged communities. Limitations: The applicability of the findings of the study in areas outside of the Redfern community is unknown, however, learnings could be applied when establishing PBI in suburbs with a similar demographic profile. Participant bias should also be considered given the most vulnerable clients or clients in crisis were unlikely to be suitable for participation. Suggestions for future research: A comprehensive evaluation of the HHAN initiative will require a mixed-methods approach. As such a quantitative review will provide further insight in regards to client outcomes and cost-benefit analysis. Additionally, given HHAN is a whole of family service, further investigation into family outcomes is required. Examining the role that a place-based initiative plays in improving overall community outcomes would also be beneficial.

Introduction: Sydney Local Health District's Healthy Homes and Neighbourhoods Integrated Care Initiative (HHAN) seeks to improve the care of families with complex needs and/or inter-generational trauma by providing long-term care coordination and promoting inter- and intra-agency integration. The disadvantage experienced by enrolled individuals is multifaceted, with issues ranging from poor financial and social capital through to adverse health and educational outcomes. This complexity demands multi-agency support but in turn leaves clients vulnerable to fragmented/poorly coordinated care. We explored barriers to attaining health and social care for vulnerable families, as perceived by clients themselves and collaborating professionals. Theory/Methods: A realist CMO (Context, Mechanisms, Outcomes) theoretical approach is being used for program evaluation. Purposive sampling was used to identify 8 clients and 16 professionals (8 healthcare workers and 8 staff from collaborating NGOs/partnering government agencies) who participated in guided interviews. Barriers to care were explored as part of the examination of underlying contexts. All interviews were audio-recorded, transcribed and coded using NVivo v11 software. Results: Both intrinsic and extrinsic barriers were identified. Intrinsic factors included: Trauma affecting families both horizontally and vertically, competing priorities, distrust of services and concerns about confidentiality. Of the extrinsic factors identified, three themes emerged: 1. Accessibility and Economic Barriers including inequitable service coverage geographically, transport issues, strict eligibility criteria, opaque referral systems, lack of financial incentives for seeing vulnerable families, and direct/indirect costs to clients. 2. Misalignment of Service Provision with Client Needs including a perception that needs were assumed not asked, unrealistic care plans given social circumstances, paucity of culturally-appropriate and trauma-informed staff training and short-termism of professionals (resulting in unstable client-service and service-service relationships). 3. Communication Issues including misunderstanding by services or clients of the role, or even existence of other services, trust/territorial issues and technological barriers (e.g. incompatible electronic referral systems). Discussions: It can be challenging for vulnerable clients to navigate health and social care systems. Professionals expressed frustration that attaining appropriate/timely referrals and client care was difficult, even when being undertaken by “high-functioning” individuals on behalf of clients. Conclusions: Families with complex needs face multiple barriers to care. The extrinsic factors identified should be amenable to cultural and structural shifts in health and social care systems. Lessons learned: Disadvantaged families are often characterised as “hard to reach” but this implies that the fault lies solely with these individuals. An examination of the underlying factors for poor engagement illustrates the need for integrated care initiatives such as HHAN, which address the social determinants of health and create enabling systems for integration/communication between professionals. Limitations: The applicability of findings within our health district to other regions is unknown. In recruiting participants for this study, the most vulnerable members of our society may still have been missed; further exploration of their views could enhance our understanding. Suggestions for future research: Integrated care initiatives are attempting to tackle some of the barriers described above. Ongoing data is required to determine which interventions are efficacious, for whom and why, so that optimal service development can be achieved.