Integrated Care Summer School Background Person Centred Medical

Integrated Care Summer School

Background § § Person Centred Medical Neighbourhood Readiness Program Central and Eastern Sydney PHN region Partners include both interested general practices, Sydney and South Eastern Sydney LHDs, allied health providers and medical specialists in the CESPHN region Attendees: § Liam Shanahan – Health Informatics and Strategy Program Lead § Lucy Armstrong – Community and Residential Aged Care Project Officer § Misbah Faiz – After Hours Program Officer 2

Key issue to be addressed § § A fundamental change to the way chronic disease management in general practice is funded – Health Care Home trials Practices are confused about the implications for their patients and finances Practices need to be ready when the changes happen The healthcare neighbourhood involves all the services a person may require in their health journey, so everyone needs to know what it means for them 3

Core Aims and Objectives § § § Supported change management process to move practices along the continuum to a higher performing primary care practice Practices will be supported to deliver a stronger, more systematic yet flexible approach to the management, referral and review of patients with chronic and complex health needs General practices continue to operate under proposed new funding models e. g. Health Care Homes, blended or bundled payments etc 4

Proposed approach § § § § Every practice is different, so support packages will be tailored to each participating practice Training resources and tools to build clinical and nonclinical capacity in the practice Shared care planning tools will underpin patient management Access to online referral pathway e. g. Health. Pathways Support to provide patient focused care, including health literacy support Data driven quality improvement projects using clinical audit and decision support tools Support for digital health tools including secure messaging and the My Health Record expansion 5

What we want to learn § § § How to develop and monitor effective integrated care programs How do we know that the care being delivered is actually integrated care? What does true integrated care look like in the primary care setting, and are there real-world examples in Australia? How can we make the transition as seamless as possible? How do we communicate the changes effectively? 6