More efficient patient-centred healthcare
by providing an alternative model for cooperative care
ISHCERF – Integrated Care

The concept of integrated care has proven to be difficult to establish in practice.

One of the most difficult hurdles to overcome is to effect a true and sustained engagement within both health professionals and the wider health infrastructure to favour such a system. In addition, continued success of such a delivery model, once established, requires a true and sustained commitment from both health administrators and the government.

This model will:

  • Reduce waiting times through immediate access to the right specialist and improve efficiency in patient care
  • Reduce cost while delivering healthcare of a higher standard than is currently delivered by the fragmented system
  • Provide healthcare workers and specialists with an alternative model for cooperative care that may effect a change in the culture of specialisation in the medium to long term.

This model is patient centric and focuses healthcare delivery around the patient and their presenting disease. The model integrates over a number of different levels (see figure 1).

  1. Horizontal healthcare integration – specialist physicians and surgeons, specialized nursing and rehabilitation services, in hospital services when required, specialist diagnostic services, access to tertiary level treatment.
  2. Vertical healthcare integration – care by primary care physicians, community nurse services, home care services. Focus on preventative treatment and delivery of continuity of treatment in an ambulatory setting.
  3. Funding integration – partnership with private health care providers Ramsay Health Care and Laverty Pathology to provide infrastructure support and treatment and diagnostic services available for public patients through industry partners. The model aims to be self sustaining through progressive access to both industry and federal funding by year 3.
  4. Technological integration – providing HealtheNet access to treatment centres and sharing of health information with private/public centres to improve coordination of ongoing care across the healthcare spectrum. Use of patient and healthcare worker reported outcome measures to track progress in real time. Use of objective measurement systems e.g. pathology audit to track treatment outcome measures.
  5. Educational integration – providing education for healthcare workers both at primary and tertiary level, interfacing with specialist colleges to effect a culture change within training registrars.
  6. Research integration – linking with existing research groups and universities to foster scientific and clinical research into these two disease presentations.

figure-1

Figure 1: Schematic multilevel integration of the planned service


System Changes

a) Innovative horizontal integration
The Integrated Skin Cancer and Integrated Wound Care programs will create new innovative horizontal integration partnerships between specialist services that have traditionally been fragmented and isolated. These links are designed to provide the patient with the combined benefit of accessing all specialties that are capable of contributing to his/her treatment at the same time.

The integration with training programs and colleges will serve to provide the impetus for culture change going forward. The integrated specialist approach should ultimately deliver significant cost savings through effective and coordinated treatment plans, reduction in duplication of testing and shortened patient journeys.

b) Innovative vertical integration
Primary care physicians will have access to these new horizontally integrated services eliminating the confusion as to which specialty is best suited to treating the condition. A targeted disease specific focus will also provide a new model for referral as compared with the traditional specialist referral. It is hoped that communication and cooperation between primary and tertiary level services is also improved to ensure that continuity of patient care in an ambulatory setting is optimized.


Stakeholders

  1. South Eastern Sydney Local Health District
  2. Specialist healthcare services
  • ISCC – Dermatology, General Surgery, Plastic Surgery, Specialist nurse practitioners, Pathology
  • IWCC – Geriatrics & Rehabilitation, Vascular surgery, Plastic Surgery, General Surgery, Endocrinology, Specialist Nurse pracitioners, Pathology
  1. Primary care physicians and the Central and Eastern Sydney Primary Health Network
  2. Community nursing
  3. Home care
  4. Industry partners – Ramsay Health, Laverty pathology, KCI, Convatec, Smith & Nephew, Telstra Health
  5. Research partners – Surgical Infection Research Group, Macquarie University
  6. Education partners – Integrated Specialist Healthcare, Royal Australasian College of Physicians, Royal Australasian College of Surgeons, Australasian College of Dermatologists, NSW Nurses and Midwives Association

map-of-medicine1

Both the integrated skin cancer and wound program have been linked with custom clinical management pathways accessible by the map of medicine.

These aim to provide a clear picture of the entire patient journey, summarizing the latest information and providing practical information on clinical decision making.

Login to the map – http://mapofmedicine.com/access-map