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Poster Abstracts

Navigating the healthcare neighbourhood: Reframing care around the patient and their primary care ‘home’


Rhiannon Beck ,

Agency for Clinical Innovation, AU
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Regina Osten

Agency for Clinical Innovation, AU
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Introduction: Primary health is the cornerstone of a strong and efficient health system. High performing primary care that is accessible, comprehensive, co-ordinated, continuous, and achieved through contemporary models of care offers the potential to enhance integration, improve patient outcomes and experience, and sustainability.

Australia’s ‘Primary Health Networks’ are building capacity and capability for general practice to achieve this based on the Patient Centred Medical Home PCMH model.  The Australian Government is also trialling a program called ‘Health Care Homes’ using elements of PCMH and alternative payment structures.

To optimise the impact of these primary care reforms requires a supportive and collaborative approach from the broader health and social care system.

Practice Change: The NSW Agency for Clinical Innovation ACI is supporting services to develop localised integration networks – “Healthcare Neighbourhoods”. Neighbourhoods operate with the general practice or Aboriginal medical service as the hub and include health and social care services. Neighbours support primary care providers through engagement with care coordination, shared care planning, effective communication, data sharing, and a team-based approach to care.

Aim and Theory of Change: The Healthcare Neighbourhood builds a shared, localised vision for integration. Neighbourhoods have clarity on the roles and responsibilities of all neighbours, and support increased collaboration with general practice.  Neighbourhoods refocus the health system from operating in silos to that of an integrated system with primary care as the hub.

ACI has entered into a memorandum of understanding with local primary and acute care governance bodies. Together, we have developed a curriculum statement for a three-stage knowledge program. The knowledge program educates attendees from a broad range of health and social care services about:

healthcare delivery in facilities outside their own

the PCMH and Healthcare Neighbourhood models

implementation and behaviour change methodologies.

The program also includes extensive workshopping to identify gaps in service delivery and local opportunities to improve integration.

Targeted Population: Key beneficiaries are people with chronic and/or complex conditions, although neighbours identify local priority populations for specific interventions.  The interventions take place at the meso and micro system levels, and are informed by neighbour-identified opportunities and areas of need.

Timeline: The first two stages of the knowledge program have been completed, with the third scheduled to take place by the end of June 2018.

Highlights: A ‘Navigating the Healthcare Neighbourhood’ website has been launched, bringing together information about PCMH and Healthcare Neighbourhoods including; definitions, animations and videos, articles, case studies, patient stories, and other resources.

Healthcare Neighbourhoods have been incorporated into multiple strategic planning documents for roll-out across numerous areas of NSW.

Sustainability: This work is aligned with policy change at the Australian Federal and State Government level.  The project helps to establish shared vision and understanding across organisations, who can continue to explore local opportunities for change and collaboration within the neighbourhoods.

Transferability: Our work takes place in targeted pilot sites and will be evaluated to highlight strengths and weaknesses for further roll-out. 

How to Cite: Beck R, Osten R. Navigating the healthcare neighbourhood: Reframing care around the patient and their primary care ‘home’. International Journal of Integrated Care. 2018;18(s2):306. DOI:
Published on 23 Oct 2018.


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