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Conference Abstracts

Implementation of an Integrated Care Service in the Community

Author:

Jennifer Collins

Silver Chain Group, Sunshine, Melbourne, VIC, Australia, AU
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Abstract

Background/Introduction:

Through partnership with Western Health Service, Silver Chain Group are delivering the Western Healthlinks program, an innovative, 3-year pilot which aims to reduce the number of unnecessary hospital admissions. The Silver Chain Group is a not-for-profit organisation with a proven record of delivering quality community health and aged care services across Australia.

The Silver Chain group provides  Health Navigation and access to a Priority Response Nursing Assessment  (PRNA) Service for Western Health Links patients in the community.

These patients are identified by the Department of Health as being eligible for the program if they frequently are admitted to hospital with multiple co-morbidities and chronic or complex health conditions.

Practice Change Implemented:

24/7 Phone Support

 7 days per week 6am - 10pm Priority Nursing  response Service

System Navigation

GP connection

Telehealth

Clinical portal

It was thought that through this change patients will receive a cohesive and integrated response, to reduce siloed health and social care and subsequent need to go to hospital. As well as experiencing an improved quality of life at home.

Highlights

Patient experience at 18 months continues to be extremely positive

A lower than projected 30 day readmission rate

A high percentage of patients with an active GP

73% patients who called the Priority Nursing Assessment response remained at home

Sustainability

Sustainability is dependent on ongoing funding, workforce and system change management that supports integrated and collaborative care.

The model of care is transferable with committed funding and partnerships.

Key findings and results to date clearly demonstrate an improved patient experience, reduction in hospital admissions and length of stay. As well our workforce reflects the health professional reward of supporting patients to achieve their personal goals.

For discussion, the role of the inpatient setting, Silver Chain group, other community settings and providers and the importance of GP led care.

Lessons learnt include:

Recruitment,  the Workforce soft skills are as important as clinical competency

Challenge of system integration between acute, community and GP and other service providers

Risk stratification does support management of high volume and complex patients

Complex patients can make change

How to Cite: Collins J. Implementation of an Integrated Care Service in the Community. International Journal of Integrated Care. 2021;20(S1):2. DOI: http://doi.org/10.5334/ijic.s4002
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Published on 26 Feb 2021.

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