Western NSWIntegrated Care Strategy

To transform existing services into an integrated Western NSW system of care that is tailored to the needs of our rural and remote communities,

improves access to care and health outcomes, focuses on closing the Aboriginal health gap

Better Care…………Better Health…………Better Value

Every Day in Western NSW 6 residents die:

– 1 of the 6 deaths is tobacco related– 2 from potentially preventable conditions

10 babies are born (2 are Aboriginal, 1 has a low birth weight, 1 has a teenage mother)

60 are admitted to a private hospital

200 are admitted to a public hospital– 155 are <75 years old, 21 of them are children (5 Aboriginal)– 11 are potentially avoidable admissions– 3 for a mental health condition

– 587 people present to an emergency department – 73% (427) conditions that are not urgent – a majority requiring nursing or

GP intervention– 7% (39) serious illnesses/injuries requiring urgent treatment

2,800 people consult their GP

Every Day in Western NSW

Daily Cost Medicare (MBS) $334,510 Pharmaceutical (PBS) $237,565 Western NSW LHD $2,054,795

Average cost GP attendance $41 Emergency Presentation $707 Day in acute hospital $1,375

Every resident pays $10.00 per day

How would you spend your

$10.00 each day to stay healthy ??

Western NSW drivers

Rurality and remoteness

High proportion of Aboriginal population (11.1%)

The poor health outcomes experienced by the Aboriginal population

Growth in demand due to population ageing and increasing prevalence of long term conditions

High rate of admission

Multiple providers working in relative isolation

History of financial deficits

Patient experience, care co-ordination - suboptimal

Life expectancy at birth 2005-07

The Western NSW Strategic Health Services Plan and Integrated Care Strategy

The Integrated Care Strategy

• Provides the opportunity for the partners to accelerate the scale and pace of Strategic Health Services Plan implementation

• Facilitates the transformational service redesign that is required

• Mobilises primary care and LHD community to better manage care for higher complexity patients and families, and obtain better value from the available resources

Alignment with NSW State Plan & Integrated Care Strategy

Overarching program structure (1)

• Partnership governance

- Western NSW LHD accountability for delivery of the Strategy

- Partnership governance established to support collaboration in delivery of the Western NSW Integrated Care Strategy

- Built on existing bilateral partnerships between the partners, and close working relationships at strategic and operational levels

- Positive discussions with Western NSW Aboriginal community controlled health services – via Bila Muuji Inc, to also join the Partnership

• Clinical Leadership across primary and specialist care

- Clinical governance, leadership and support

- Initially medical evolving to multidisciplinary membership

Overarching program structure (2)

• Health Intelligence Unit

- Shared governance board with a strategic and evidence based focus

- Analysis to support strategic and operational management, performance reporting, evaluation

• Program Management discipline

- Transformational change will be dependent on a change management approach supported by robust program management discipline

- Identified deliverables, accountabilities and timelines

Local demonstrator sitesDemonstrating redesign of delivery models across general practice, LHD

primary & community health services, Aboriginal Medical Services, local rural hospital/MPS and specialist outpatient services

Local demonstrator site deliverables

Development of GP-led multidisciplinary models of care to manage high risk patients and those with chronic and complex illnesses (including diabetes, CVD, COPD, mental illness)

Development of integrated primary and secondary models of care that improve the patient experience and health outcomes (including maternal and child health opportunities)

Development of whole locality action to mobilse all health and social service providers

Risk stratification to identify target populations

Enrolment of identified population cohorts into integrated care plans

New business and funding models that incentivise delivery of integrated models of care

Establishing connectivity and shared care planning across multidisciplinary treatment providers and primary and secondary care services

Development of strategies that empower Aboriginal and high risk patients to participate in and manage their own and their families’ health and social needs

Development of flexible workforce strategies

Adoption of key performance indicators

Local demonstrator sites – work to date Site visits to establish capacity and willingness to participate – objectives and

redesign expectations

Development of minimum participation requirements and criteria

Identification of initiatives and implementation approaches – informed by international, national and local evidence and by learnings on a NZ Study Tour

Detailed scoping and planning, agreement on risk stratification criteria

Establishment of local leadership groups

Development of local needs profiles

Compilation of service directories

Signing of Memorandums of Understanding

District-wide initiativesEnabling district-wide implementation of an integrated approach to service delivery

Enablers and toolsIdentified enablers and tools are critical to the successful implementation and

sustainability of new models of integrated care

Rationale for the WNSW Strategy Expected benefits

- Short and long term outcomes

- Individual, population and system measures

District-wide benefits from ability to implement local demonstrator site initiatives at scale and pace

- Ability to trial multiple different approaches in different communities (size, scope and type)

- Ability to trial new funding mechanisms and incentives (including unique opportunities where GPs are also the hospital VMOs)

State-wide benefits from learnings achieved from multiple approaches

Program cost to reduce over 3 years to a sustainable service delivery model

Questions ?