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Navigating the healthcare neighbourhood: Evaluation of a bottom-up, inter-agency integration program


Rhiannon Beck ,

Agency for Clinical Innovation, AU
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Regina Osten

Agency for Clinical Innovation, AU
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Introduction: Optimising the impact of emerging primary care reforms in Australia requires a supportive and collaborative approach from the broader health and social care systems. The NSW Agency for Clinical Innovation ACI is supporting services to develop localised integration networks called Healthcare Neighbourhoods. Neighbourhoods operate with the general practice or Aboriginal medical service as the hub and include health and social care services. Neighbourhoods support primary care practitioners through engagement with care coordination, shared care planning, effective communication, data sharing, and a team-based approach to care.

Policy context and objective: To support the development of Healthcare Neighbourhoods, ACI is hosting an education program, followed by a collaborative-style implementation methodology. To determine the value and impact of the program, the evaluation will review the effectiveness of the support provided, the outcomes that resulted from that support, and the long-term impact of the implementation of the model.

The framework combines qualitative and quantitative measures to ensure that both the nature of the interventions and the context of the interventions are considered in relation to their outcomes.

Targeted population: The evaluation will look at three perspectives – that of the clinicians taking part in the program, the patients experience of integration of their care, and the long-term outcomes at a system level.

Highlights innovation, impact and outcomes: Our evaluation plan draws from the work of Bodenheimer et al and their 10 Building Blocks of High Performing Primary Care 1. This model has been developed for use by primary care providers to inform their transition to PCMH, however many of the building blocks can be re-contextualised to inform Healthcare Neighbourhoods.

Our data sources will include pre and post surveys, clincial and utilisation data, interviews and focus groups. The participants in the initiative will also identify measures for their specified improvements.

Comments on transferability: The evaluation model used for this work has been specifically designed for New South Wales Australia, however it could be adapted to apply to Healthcare Neighbourhood models anywhere.

Conclusions comprising key findings, discussion and lessons learned: The evaluation of this wide-ranging model, with high levels of variability in implementation across sites raised a number of issues. Attributing cause and effect in relation to patient outcomes is fraught with difficulty due to the number of interventions patients are exposed to in their health care journeys in the context of service delivery reforms. The evaluation will use qualitative data from interviews and focus-groups to inform analysis. Qualitative data collection will also assist with ensuring that key issues that might be missed in application of the more narrowly focussed tools are identified and inform future iterations of the evaluation.


1- Bodenheimer T, Ghorob A, Willard-Grace R et al. The 10 building blocks of high-performing primary care. Annals of Family Medicine 2014; 122:166-171. 

How to Cite: Beck R, Osten R. Navigating the healthcare neighbourhood: Evaluation of a bottom-up, inter-agency integration program. International Journal of Integrated Care. 2018;18(s2):94. DOI:
Published on 23 Oct 2018.


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