Setting a clear direction for the integration of health care

Introduction

Integration of care is an approach that aims to deliver seamless care within the health system and its interface with the social system. A well designed approach can deliver health care in a way that is genuinely patient-centric, with comprehensive wrap around support for individuals with complex needs.

Nous recently partnered with a health department to develop a strategic framework for integrating health care across its state over the next five to ten years (the Framework). It has a quadruple aim of improving experiences for people, families and carers; improving experiences for service providers and clinicians; improving health outcomes for the population; and improving the cost efficiency of the health system.

This presentation will provide an overview of the design process and highlight opportunities for integrated care to be strengthened in other jurisdictions. 

Target population

The Framework applies broadly across the health system and the intersections between health and social care – including the public sector, private organisations, not-for-profit organisations, and other government agencies.  It applies across all health services and also extends to the intersections with social care services such as housing, child protection, community, ageing, disability and home care, employment and justice services.

Highlights

The Framework provides overarching guidance on how health care integration can be strengthened and expanded across the health system.  Six core principles of integrated care were agreed through an extensive stakeholder engagement process: Person centred, targeted, continually improved, primary-care based, collectively accountable and shared information. The Framework provides guidance on how these principles can be meaningfully implemented, drawing on nine key enablers and a suite of agreed outcome measures.

Conclusions (key findings, discussion and lessons learned)

Achieving truly integrated care is difficult. Nous’ Framework set an overarching vision for the health system but built on a number of existing integrated care initiatives already in place. It was clear from the design and extensive stakeholder engagement processes however, that successful implementation of the Framework relies on leveraging existing pockets of excellence in the system and building a shared vision and trust between patients and their families; primary health care and social care providers; primary health networks; government bodies and others. 

Nous found that using a principle-based approach to guide the Framework’s development provided a structure for better recognising the intersects between health and social care providers where patients’ care could be improved and better integrated.

Comments on transferability

Nous’ Framework described six principles that can be meaningfully implemented in a range of settings. As such, Nous is well positioned to help other clients to improve the way they design and deliver integrated care, from small health services, through to large-scale state-wide or national health programs.