Healthy Together Rationale for Change Root cause analysis

Healthy Together!

Rationale for Change • Root cause analysis: Ø Increasing number of people ageing who have chronic and complex health conditions. This is leading to increased demand for health care support.

Overarching aims and objectives • To develop a framework, shared principles, values and ways of working across COORDINARE and SNSWLHD, that will deliver outcomes against the quadruple aim

Diagnosis results • Strengths – It is the right time! – Growth in commitment to the Strategic Alliance – Positive Health. Pathways collaboration – Organisational support for GP Liaison Officers – pockets of local goodwill to improve health outcomes through integrated care – Advent of My Health Record opt out • Challenges – Limited understanding and trust of each service’s role in integrated care – Lack of shared care planning tools – Patch protection – Fear of change – Leaping from good will into action

Southern NSW Joint Integrated Care Strategy - Logic Model Evaluation framework including economic benefit Patient experience assessment tools Consumer focus groups Patient Activation Measure GPLOs Health Pathways My Health Record Regular meeting of working group Strategic Alliance / Exec Commitment Joint Board Meeting / Board Commitment Agreed priorities Regular evaluation, data guiding decisions including financial decisions Joint comms – effective stakeholder engagement Joint skills development curriculum – quadruple aim, collaboration Patient stories utilised in service development Increased utilisation of medical records across providers with MHR MOU / Partnership agreement Actions from Strategic Alliance Actions from Board meeting SHORT TERM OUTCOMES Key policy levers: Bilateral agreement, NSW Integrated Care Framework Shared vision OUTPUTS INPUTS Needs analysis Shared plan including Regional Mental Health Plan, Regional Digital Health Plan MEDIUM TERM Identified priorities Particular projects in high needs populations or locations Empowered stakeholders LONG TERM Improved chronic and complex care coordination Reduced potentially preventable hospitalisations Work in partnership with the community to advocate for optimal health care in the community Assumptions: Mutual gain = Healthier population Reduced waiting lists / times at LHD and in General Practice Improved Access Greater acknowledgement of significant role of GPs Increased efficiencies, potential savings External Factors: PEST Analysis; the ‘Frankie J Factor’

Action Plan / Timescales Action Present Joint Integrated Care Outline to Strategic Alliance Working group complete strategic plan Key priorities agreed Timeframe April End July Work plans and measures developed utilising consumer input Communications plan developed – HCPs, Community, Stakeholders Training needs analysis and plan developed Regional Digital Health Plan completed August October