Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia
References
- Santos P, Faughnan K, Prost C, Tschampl CA. Systemic Barriers to Care Coordination for Marginalized and Vulnerable Populations. Journal of Social Distress and Homelessness. 2021; 1–14. DOI: 10.1080/10530789.2021.2021361
- Australian Institute of Health and Welfare. Reporting on the Health of Culturally and Linguistically Diverse Populations in Australia: An Exploratory Paper; 2022. [cited 20 January 2023]. Available from:
https://www.aihw.gov.au/reports/cald-australians/reporting-health-cald-populations/summary . - World Health Organisation.
Social Determinants of Health . Geneva: WHO; 2022. [cited 23 May 2023]. Available from:https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 . - Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. People Living with Psychotic Illness in 2010: The Second Australian National Survey of Psychosis. Australian and New Zealand journal of psychiatry. 2012; 46(8): 735–52. DOI: 10.1177/0004867412449877
- The Organisation for Economic Co-operation and Development (OECD). Reviews of Health Care Quality: Australia; 2015.
- Breen C, Altman L, Ging J, Deverell M, Woolfenden S, Zurynski Y. Significant Reductions in Tertiary Hospital Encounters and Less Travel for Families after Implementation of Paediatric Care Coordination in Australia. BMC Health Services Research. 2018; 18(1): 751. DOI: 10.1186/s12913-018-3553-4
- Nicholson C, Jackson CL, Marley JE. Best-Practice Integrated Health Care Governance: Applying Evidence to Australia’s Health Reform Agenda. Medical journal of Australia. 2014; 201(3 Suppl): S64–S6. DOI: 10.5694/mja14.00310
- Primary Health Care Advisory Group. Better Outcomes for People with Chronic and Complex Health Conditions. 2015. [cited 15 December 2022]. Available from:
https://www1.health.gov.au/internet/main/publishing.nsf/content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.pdf . - Plant N, Mallitt K-A, Kelly PJ, Usherwood T, Gillespie J, Boyages S, et al. Implementation and Effectiveness of ‘Care Navigation’, Coordinated Management for People with Complex Chronic Illness: Rationale and Methods of a Randomised Controlled Trial. BMC Health Services Research. 2013; 13(1): 164. DOI: 10.1186/1472-6963-13-164
- Brunner-La Rocca H-P, Peden CJ, Soong J, Holman PA, Bogdanovskaya M, Barclay L. Reasons for Readmission after Hospital Discharge in Patients with Chronic Diseases: Information from an International Dataset. PLOS ONE. 2020; 15(6):
e0233457 . DOI: 10.1371/journal.pone.0233457 - Australian Institute of Health and Welfare. Disparities in Potentially Preventable Hospitalisations across Australia 2012–13 to 2017–18. 2019. [cited 18 March 2023]. Available from:
https://www.aihw.gov.au/getmedia/20bc5bf9-d46c-40a7-96c1-d632a1d448bc/aihw-hpf-50.pdf.aspx?inline=true . - Swerissen H, Duckett S, Wright J. Chronic Failure in Primary Care. Grattan Institute; 2016. Available from:
https://grattan.edu.au/wp-content/uploads/2016/03/936-chronic-failure-in-primary-care.pdf - Van den Heede K, Van de Voorde C. Interventions to Reduce Emergency Department Utilisation: A Review of Reviews. Health Policy. 2016; 120(12): 1337–49. DOI: 10.1016/j.healthpol.2016.10.002
- World Health Organisation (WHO). Integrated People-Centred Care. 2016. [cited 2 April 2023]. Available from:
https://www.who.int/health-topics/integrated-people-centered-care# . - Productivity Commission. Integrated Care, Shifting the Dial : 5 Year Productivity Review – Supporting Paper No. 5; 2017. [cited 5 April 2023]. Available from:
https://www.pc.gov.au/inquiries/completed/productivity-review/report/productivity-review-supporting5.pdf . - National Ageing Research Institute. Models of Integrated Care, Health and Housing: Report Prepared for the Royal Commission into Aged Care Quality and Safety; 2020. [cited 7 April 2023]. Available from:
https://agedcare.royalcommission.gov.au/sites/default/files/2020-08/Research%20Paper%207%20-%20Models%20of%20integrated%20care%2C%20health%20and%20housing.pdf . - Joo JY, Liu MF. Case Management Effectiveness in Reducing Hospital Use: A Systematic Review. International Nursing Review. 2017; 64(2): 296–308. DOI: 10.1111/inr.12335
- Kastner MP, Hayden LMDP, Cardoso RP, Lai YMN, Treister VMPH, Hamid JSP, et al. Effectiveness of Interventions for Managing Multiple High-Burden Chronic Diseases in Older Adults: A Systematic Review and Meta-Analysis. Canadian Medical Association journal (CMAJ). 2018; 190(34): E1004–E12. DOI: 10.1503/cmaj.171391
- Doshmangir L, Khabiri R, Jabbari H, Arab-Zozani M, Kakemam E, Gordeev VS. Strategies for Utilisation Management of Hospital Services: A Systematic Review of Interventions. Globalization and Health. 2022; 18(1): 53. DOI: 10.1186/s12992-022-00835-3
- Arendts G, Bullow K, Etherton-Beer C, MacDonald E, Dumas S, Nagree Y, et al. A Randomized-Controlled Trial of a Patient-Centred Intervention in High-Risk Discharged Older Patients. European journal of emergency medicine. 2018; 25(4): 237–41. DOI: 10.1097/MEJ.0000000000000444
- Mallitt KA, McNab J, Hughes R, Fernyhough J, Paterson J, O’Halloran D. Reducing Emergency Department Presentations among Chronically Ill Patients in Western Sydney: A Key Role for Coordinated Primary Care. Australian Journal of Primary Health. 2017; 23(2): 140–6. DOI: 10.1071/PY16012
- Wan CS, Mitchell J, Maier AB. A Multidisciplinary, Community-Based Program to Reduce Unplanned Hospital Admissions. Journal of the American Medical Directors Association. 2021; 22(6): 1331 e1–e9. DOI: 10.1016/j.jamda.2020.09.034
- Campain A, Mulley J, Angell B, Ewald DAN, Carter B, Rose V, et al. The Winter Strategy: A Multifaceted Integrated Care Intervention to Support People with Chronic and Complex Care Needs During the Australian Winter Period. International Journal of Integrated Care. 2023; 23(1): 1–13. DOI: 10.5334/ijic.6549
- Primary Health Network South Western Sydney. South Western Sydney: Our Health in Brief; 2018. [cited 15 November 2022]. Available from:
https://swsphn.com.au/wp-content/uploads/2022/02/south-western-sydney-our-health-in-2018-in-brief.pdf . - HealthStats NSW. Emergency Department Presentations: Persons by Lhd; 2021. [cited 20 April 2023]. Available from:
https://www.healthstats.nsw.gov.au/#/indicator?name=-unplanned-ed&location=LHD&view=Trend&measure=Number&groups=Sex&compare=Sex,LHD&filter=Sex,Persons&filter=LHD,Sydney%20LHD,South%20Western%20Sydney%20LHD,South%20Eastern%20Sydney%20LHD,Illawarra%20Shoalhaven%20LHD,Western%20Sydney%20LHD,Nepean%20Blue%20Mountains%20LHD,Northern%20Sydney%20LHD,Central%20Coast%20LHD,Hunter%20New%20England%20LHD,Northern%20NSW%20LHD,Mid%20North%20Coast%20LHD,Southern%20NSW%20LHD,Murrumbidgee%20LHD,Western%20NSW%20LHD,Far%20West%20LHD . - HealthStats NSW. Potentially Preventable Hospitalisations: Total for Persons by Lhd; 2021. [cited 20 April 2023]. Available from:
https://www.healthstats.nsw.gov.au/#/indicator?name=-pph-cat-hos&location=LHD&view=Trend&measure=Number&groups=Category,Sex&compare=Category,Sex,LHD&filter=Category,Total&filter=LHD,Sydney%20LHD,South%20Western%20Sydney%20LHD,South%20Eastern%20Sydney%20LHD,Illawarra%20Shoalhaven%20LHD,Western%20Sydney%20LHD,Nepean%20Blue%20Mountains%20LHD,Northern%20Sydney%20LHD,Central%20Coast%20LHD,Hunter%20New%20England%20LHD,Northern%20NSW%20LHD,Mid%20North%20Coast%20LHD,Southern%20NSW%20LHD,Murrumbidgee%20LHD,Western%20NSW%20LHD,Far%20West%20LHD&filter=Sex,Persons . - Australian Bureau of Statistics. Socio-Economic Indexes for Areas: Australia; 2021. [cited 28 June 2023]. Available from:
https://www.abs.gov.au/statistics/people/people-and-communities/socio-economic-indexes-areas-seifa-australia/latest-release#interactive-maps . - NSW Health. Planned Care for Better Health Model of Care; 2021. [cited 15 April 2023]. Available from:
https://www.health.nsw.gov.au/Value/news/Pages/07-21-update-ic-pcbh.aspx#:~:text=Planned%20Care%20for%20Better%20Health%20%28PCBH%29%20is%20a,deliver%20health%20coaching%2C%20care%20navigation%20and%20care%20coordination . - Sheill G, Hennessy M, Devenney K, Reynolds S, Towns J, Gill M, et al. A Hospital to Community Exercise Referral Pathway: Results of a Pilot Project. Irish journal of medical science; 2023. DOI: 10.1007/s11845-022-03257-7
- Miller E, Eastwood J. A Model of Care Coordination for Patients with Complex Health and Social Care Needs: What Is Best? International Journal of Integrated Care. 2021; 20(3): 125. DOI: 10.5334/ijic.s4125
- Australian Commission on Safety and Quality in Health Care. A Guide to the Potentially Preventable Hospitalisations Indicator in Australia; 2017. [cited 15 May 2023]. Available from:
https://www.safetyandquality.gov.au/sites/default/files/migrated/A-guide-to-the-potentially-preventable-hospitalisations-indicator-in-Australia.pdf . - Takeda A, Martin N, Taylor RS, Taylor SJC. Disease Management Interventions for Heart Failure. Cochrane Database of Systematic Reviews; 2019; (1). DOI: 10.1002/14651858.CD002752.pub4
- NSW Health. Social Determinants of Health; 2022. [cited 8 May 2023]. Available from:
https://www.health.nsw.gov.au/integratedcare/Pages/social-determinants-of-health.aspx#:~:text=The%20Risk%20of%20Hospitalisation%20%28RoH%29%20Algorithm%20is%20based,are%20likely%20to%20benefit%20from%20integrated%20care%20interventions . - Kuipers S, Cramm JM, Nieboer AP. The Importance of Patient-Centered Care and Co-Creation of Care for Satisfaction with Care and Physical and Social Well-Being of Patients with Multi-Morbidity in the Primary Care Setting. BMC Health Services Research. 2019; 19(1): 1–9. DOI: 10.1186/s12913-018-3818-y
- Calder R, Dunkin R, Rochford C, Nichols T.
Australian Health Services Too Complex to Navigate : A Review of the National Reviews of Australia’s Health Service Arrangements . Mitchell Institute; 2019. [cited 23 May 2023]. Available from:https://apo.org.au/sites/default/files/resource-files/2019-02/apo-nid223011.pdf . - Kiely B, Clyne B, Boland F, O’Donnell P, Connolly D, O’Shea E, et al. Link Workers Providing Social Prescribing and Health and Social Care Coordination for People with Multimorbidity in Socially Deprived Areas (the Linkmm Trial): Protocol for a Pragmatic Randomised Controlled Trial. BMJ Open. 2021; 11(2). DOI: 10.1136/bmjopen-2020-041809
- Page K, Barnett AG, Graves N. What Is a Hospital Bed Day Worth? A Contingent Valuation Study of Hospital Chief Executive Officers. BMC Health Services Research. 2017; 17(1): 137. DOI: 10.1186/s12913-017-2079-5
- World Health Organisation. Universal Health Coverage; 2023. [cited 18 July 2023]. Available from:
https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) . - Sandberg M, Kristensson J, Midlöv P, Jakobsson U. Effects on Healthcare Utilization of Case Management for Frail Older People: A Randomized Controlled Trial. Archives of gerontology and geriatrics. 2015; 60(1): 71–81. DOI: 10.1016/j.archger.2014.10.009
- Schnipper JL, Samal L, Nolido N, Yoon C, Dalal AK, Magny-Normilus C, et al. The Effects of a Multifaceted Intervention to Improve Care Transitions within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial. Journal of hospital medicine. 2021; 16(1): 15–22. DOI: 10.12788/jhm.3513
- Huntley A, Lasserson D, Wye L, Morris R, Checkland K, England H, et al. Which Features of Primary Care Affect Unscheduled Secondary Care Use? A Systematic Review. BMJ Open. 2014; 4(5). DOI: 10.1136/bmjopen-2013-004746
- Gobeil-Lavoie A-P, Chouinard M-C, Danish A, Hudon C. Characteristics of Self-Management among Patients with Complex Health Needs: A Thematic Analysis Review. BMJ Open. 2019; 9(5): e028344–e. DOI: 10.1136/bmjopen-2018-028344
- Looman W, Struckmann V, Köppen J, Baltaxe E, Czypionka T, Huic M, et al. Drivers of Successful Implementation of Integrated Care for Multi-Morbidity: Mechanisms Identified in 17 Case Studies from 8 European Countries. Social Science & Medicine. 2021; 277:
113728 . DOI: 10.1016/j.socscimed.2021.113728 - Dalton H, Day J, Handley T, Booth A, Hayes A, Perkins D. Making Connections That Count: A Case Study of the Family Referral Service in Schools Program on the Central Coast, New South Wales, Australia. International Journal of Integrated Care. 2023; 23(1): 7. DOI: 10.5334/ijic.6998
- Amelung V, Chase D, Reichert A.
Leadership in Integrated Care . In: Amelung V, Stein V, Goodwin N, Balicer R, Nolte E, Suter E. editors. Handbook Integrated Care. Cham: Springer International Publishing. 2017; 221–36. DOI: 10.1007/978-3-319-56103-5_14 - Goodwin N, Stein V, Amelung V.
What Is Integrated Care? In: Amelung V, Stein V, Goodwin N, Balicer R, Nolte E, Suter, E. editors. Handbook Integrated Care. Cham: Springer International Publishing. 2017; 3–23. DOI: 10.1007/978-3-319-56103-5_1 - Osborne SP, Strokosch K. It Takes Two to Tango? Understanding the Co-Production of Public Services by Integrating the Services Management and Public Administration Perspectives. British journal of management. 2013; 24(S1): S31–S47. DOI: 10.1111/1467-8551.12010
- Australian Health Ministers’ Advisory Council. National Strategic Framework for Chronic Conditions; 2017. [cited 12 December 2022]. Available from:
https://www.health.gov.au/sites/default/files/documents/2019/09/national-strategic-framework-for-chronic-conditions.pdf . - Busetto L, Calciolari S, González Ortiz LG, Luijkx K, Vrijhoef B.
Integrated Care and the Health Workforce . In: Amelung V, Stein V, Goodwin N, Balicer R, Nolte E, Suter E. editors. Handbook Integrated Care. Cham: Springer International Publishing. 2017; 209–20. DOI: 10.1007/978-3-319-56103-5_13
DOI: https://doi.org/10.5334/ijic.7739 | Journal eISSN: 1568-4156
Language: English
Submitted on: Sep 7, 2023
Accepted on: Jun 19, 2024
Published on: Jul 10, 2024
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
© 2024 Anita Hartati, Madison Jarrett, Brendon McDougall, Megan Kent, Maja Ljubojevic, Kylie Stolzenhein, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.