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Building a bridge down under: lessons from the implementation of a chronic disease management model


James Linden


Australian has a fragmented health care system which can be difficult to access and navigate. The population is ageing and existing services/facilities will be unable to absorb the predicted Chronic Disease burden. The situation is confounded by a complex health funding model, where funding for primary and secondary care sit separately for the most part.

In March 2014 three Local Health Districts in the state of New South Wales were named by the Ministry of Health as integrated care ‘Demonstrator sites’ tasked to develop and test system-wide approaches to integrated care. Western Sydney is a district of high interest due to the rate of population growth, high proportion of residents born overseas(42%) and higher than average incidence of chronic disease.

The District aimed to pilot a sustainable solution that would improve population health, maximise available resources and improve capacity in primary care. The existing partnership council between primary and secondary care agencies assembled an Integrated Care Team that would be responsible for the development and implementation of a new patient centred model of care. The programme would straddle both care settings and improve care coordination for chronic disease patients.

A 12 month diagnostics, design and consultation phase was initiated in July 2014 which allowed detailed planning in liaison with a range of health care providers. Five key programme deliverables were identified;

- Introduce a team to assist patients navigate health services

- Introduce a system that would provide GPs with specialist support

- Introduce clinics that would allow timely access to specialist interventions

- Improve information flow between health care providers

- Build capacity in primary care

The ‘Demonstrator’ follows the principles of the Holistic Integrated Care Model for people with chronic disease, and incorporates a range of service delivery models and initiatives such as the Patient Centred Medical Home, Rapid Access to Specialist care, Care Facilitation, building IT integration and communication between hospital and primary care and novel systems for training health professionals in primary care.

The model was implemented in July 2015 in a phased approach with enrolment of a targeted number of GP practices (20) who have agreed to participate in the programme. A number of challenges were identified throughout the design and implementation phases. This included low compatibility between patient management software systems, significant variation in GP practice business models and low practice nurse/practice ratios.

This has provided the team with invaluable learning, not applicable only to the Australian health system. Although too early in the programmes lifecycle to evaluate outcomes, various milestones have been achieved through the projects introduction to the health system. The various components of the model will be tested throughout the demonstrator phase (until June 17) and the Ministry will use this knowledge to develop a state wide approach to Integrated Care.

The implementation of a chronic disease model of care, which works across both primary and secondary care, presents many logistical and operational challenges. The Western Sydney Integrated Care Team has acquired some valuable learning as a result of this process. As the programme matures, outcomes will be evaluated to determine what impact the model has had on the chronic disease cohort enrolled.

How to Cite: Linden J. Building a bridge down under: lessons from the implementation of a chronic disease management model. International Journal of Integrated Care. 2016;16(6):A290. DOI:
Published on 16 Dec 2016.


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