Integrated Care (IC), leads partnerships to deliver seamless care to patients by coordinating services around a patient to improve their experiences of care and their health outcomes. IC features seven integrated initiatives, including state-wide strategies coordinating care between providers and ensuring better access to community-based services closer to home.

One of the seven key initiatives, Planned Care for Better Health (PCBH), is central to delivering on the NSW Premier’s Priority of improving outpatient and community care and reducing potentially preventable hospital visits by 5% by 2023. PCBH uses a new and intuitive ‘Risk of Hospitalisation’ algorithm to identify patients at risk of hospitalisation and strengthens the care they receive earlier. This improves their experience of receiving care and keeps them healthier over the long term. It also enables clinicians to target people for enrolment who will benefit from IC interventions, reducing reliance on acute care services and decreasing potentially preventable hospitalisations. This financial year, every Local Health District in NSW will be implementing PCBH.

Other IC initiatives include: ED to Community, Specialist Outreach to Primary Care, Residential Aged Care, Vulnerable Families and the Paediatric Network.

The Knee And Hip Arthritis Service (KAHAS) was developed in partnership between the Northern New South Wales Local Health District (NNSWLHD), North Coast Primary Health Network (PHN), local GPs, visiting Orthopeadic Surgeons and patients.

Substantial evidence exists for non-operative management of the osteoarthritic hip and knees prior to considering surgery. However, limited access to health and lifestyle assessment and services for non-operative management of joint pain means this chronic condition is often poorly managed by pharmaceuticals and long waiting periods for specialist review and surgery.

KAHAS provides seamless, person-centred care through partnership across primary and public service providers. Timely and evidence-based assessment and intervention is provided to reduce pain and reverse functional decline, and where appropriate, avoid joint surgery. Emphasis is on patient empowerment through better understanding of their condition and support for self-management.

Following a successful trial at one site, KAHAS has now been rolled out across the LHD, with interest from other Health Services in adopting the model. Over 1500 patients have commenced with KAHAS, with significant reductions in pain, improvement in function and in-patients not wishing to proceed to surgery.

LBVC Bronchiolitis SLHD (Sydney Local Health District) is an innovative, district-wide initiative focused on enhancing value-based healthcare for infants with Bronchiolitis.

The project aims to align practice with best evidence, reduce unwarranted variation and enhance patient and family experience.

To date, patient and family reported experience measures have demonstrated high levels of satisfaction and results have shown reductions in unnecessary investigations and treatments, with corresponding cost-savings.

Concord Repatriation General Hospital established an Osteoarthritis (OA) Chronic Care Program to improve health outcomes, patient experiences, provider experiences, and efficiency of care in the non-surgical management of knee and hip OA as part of the Leading Better Value Care (LBVC) initiative.

Participants receive a comprehensive, evidence-based, and individually tailored management plan focused on maximising health outcomes important to the patient. Adjustments to the plan are made following regular follow-up appointments using both clinical and patient reported outcome measures (PROMs).

Over 450 patients have enrolled in the multi-disciplinary program and many have reported enhanced confidence, ability to start exercising and those proceeding to surgery report rapid recovery.

The RPA Virtual Hospital, known as rpavirtual, was launched in early 2020 as an alternative, sustainable solution to increasing demand for healthcare in Sydney.

During the COVID-19 pandemic, rpavirtual quickly emerged as a national leader in the provision of care to COVID-19 patients in home isolation and hotel quarantine as well as COVID-19 negative returning travellers with complex health needs. rpavirtual’s unique hybrid model features a Virtual Care Centre complemented by an in-person community nursing service.

A variety of patient cohorts have been enrolled for care including palliative, cystic fibrosis, chronic conditions, virtual fracture clinic and COVID-19. Over 7,000 patients have been cared for in the first ten months of operation, with high reported patient satisfaction.

Evaluation results to date confirm that hospital type care can be delivered safely in the community with the right technology and governance.

Smile Squad school dental program is a Victorian Government program led by DHSV and the Victorian Government Department of Health with the support of the Department of Education and Training (DET), that provides free dental care to all Victorian public primary and secondary school students. The initiative will be delivered by community dental agencies via up to 250 dental vans, staffed by up to 500 oral health professionals.

The program has a strong focus on strong focus on education and prevention and aims to reduce the burden of oral health and minimise its impact on the lives of young people and families across the state.

Smile Squad is planned to reach full roll out to the more than 650,000 public primary, secondary and specialist school students in 2023.