TY - JOUR
AU - C. O'Callaghan
AU - J. Osborne
AU - M. Barr
AU - D. P. Conway
AU - B. Harris-Roxas
A1 - 
AB - BACKGROUND: Integrated care interventions can improve patient outcomes and reduce the burden on acute health services, but need a strong evidence base to ensure their effectiveness. Understanding the meso and macro context in which care is delivered and determining whether patient needs are met are essential to successful implementation. Care coordination in New South Wales (NSW), Australia has evolved over time to meet the needs of an ageing population with chronic health conditions and multi-morbidity with the aim of reducing potentially preventable hospitalisations. OBJECTIVE: To examine how an integrated care coordination program was understood and implemented at state, district and clinician levels in NSW. The Integrated Care for People with Chronic Conditions (ICPCC) program was implemented statewide, however local implementation varied. Patients who were suitable for integrated care coordination were identified via a hospitalisation risk prediction algorithm and/or referrals from health professionals. METHODS: Understanding and implementation of ICPCC were assessed via interviews and a focus group with a range of health staff. Qualitative data were analysed using NVivo software and normalisation process theory. RESULTS: There was a strong sense of program coherence from management, clinicians and referrers. They viewed ICPCC as effective in coordinating care for patients at risk of hospitalisation and incorporating self-management at home. All health staff interviewed understood the program purpose and necessity, including the importance of achieving patient and systemic goals. Networking, linking services and program promotion were important, as was reporting on benefits. While the algorithm effectively identified previously hospitalised patients, it did not identify all suitable patients in the community with an increasing risk of requiring acute health care intervention. Referrals from health professionals familiar with patient needs and complexity were an important additional mechanism for patient selection. CONCLUSIONS: There was a shared sense of coherence and understanding of the ICPCC program among health staff at the three levels of implementation within NSW. The program played an important role in assisting patients with a range of chronic conditions to access and benefit from integrated care coordination, while increasing their capacity to self-manage at home. Program intake via hospitalisation risk prediction algorithm plus referrals from health professionals familiar with patient needs and complexity can effectively identify those who may benefit from integrated care coordination.
AD - International Centre for Future Health Systems, University of New South Wales, Sydney, NSW, Australia. RINGGOLD: 7800; Population and Community Health Department, South Eastern Sydney Local Health District, Kogarah, NSW, Australia. RINGGOLD: 2989; The Kirby Institute, University of New South Wales, Sydney, NSW, Australia. RINGGOLD: 7800; School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
AN - 40599302
BT - Glob Adv Integr Med Health
C5 - General Literature
DA - Jan-Dec
DO - 10.1177/27536130251356449
DP - NLM
ET - 20250630
JF - Glob Adv Integr Med Health
LA - eng
N2 - BACKGROUND: Integrated care interventions can improve patient outcomes and reduce the burden on acute health services, but need a strong evidence base to ensure their effectiveness. Understanding the meso and macro context in which care is delivered and determining whether patient needs are met are essential to successful implementation. Care coordination in New South Wales (NSW), Australia has evolved over time to meet the needs of an ageing population with chronic health conditions and multi-morbidity with the aim of reducing potentially preventable hospitalisations. OBJECTIVE: To examine how an integrated care coordination program was understood and implemented at state, district and clinician levels in NSW. The Integrated Care for People with Chronic Conditions (ICPCC) program was implemented statewide, however local implementation varied. Patients who were suitable for integrated care coordination were identified via a hospitalisation risk prediction algorithm and/or referrals from health professionals. METHODS: Understanding and implementation of ICPCC were assessed via interviews and a focus group with a range of health staff. Qualitative data were analysed using NVivo software and normalisation process theory. RESULTS: There was a strong sense of program coherence from management, clinicians and referrers. They viewed ICPCC as effective in coordinating care for patients at risk of hospitalisation and incorporating self-management at home. All health staff interviewed understood the program purpose and necessity, including the importance of achieving patient and systemic goals. Networking, linking services and program promotion were important, as was reporting on benefits. While the algorithm effectively identified previously hospitalised patients, it did not identify all suitable patients in the community with an increasing risk of requiring acute health care intervention. Referrals from health professionals familiar with patient needs and complexity were an important additional mechanism for patient selection. CONCLUSIONS: There was a shared sense of coherence and understanding of the ICPCC program among health staff at the three levels of implementation within NSW. The program played an important role in assisting patients with a range of chronic conditions to access and benefit from integrated care coordination, while increasing their capacity to self-manage at home. Program intake via hospitalisation risk prediction algorithm plus referrals from health professionals familiar with patient needs and complexity can effectively identify those who may benefit from integrated care coordination.
PY - 2025
SN - 2753-6130
SP - 27536130251356449
ST - Integrated Care Coordination for Managing Chronic Conditions: Views of Health Staff on the Implementation of a Program Using an Algorithm to Identify People at Higher Risk of Hospitalisation in Sydney, Australia
T1 - Integrated Care Coordination for Managing Chronic Conditions: Views of Health Staff on the Implementation of a Program Using an Algorithm to Identify People at Higher Risk of Hospitalisation in Sydney, Australia
T2 - Glob Adv Integr Med Health
TI - Integrated Care Coordination for Managing Chronic Conditions: Views of Health Staff on the Implementation of a Program Using an Algorithm to Identify People at Higher Risk of Hospitalisation in Sydney, Australia
U1 - General Literature
U3 - 10.1177/27536130251356449
VL - 14
VO - 2753-6130
Y1 - 2025
ER -