Abstract
HealthOne was part of a state-wide initiative to invest in new community-based facilities for collocating services. The HealthOne Mount Druitt is a virtual hub and spoke organisation established in 2006 in a socially disadvantaged part of Western Sydney based out of a new community health hub. The model is based on 'virtual' care planning and aims to improve coordination of care for older people with complex health needs, reduce unnecessary hospitalisations and ensure appropriate referral to community and specialist health services. General practitioner liaison nurses (GPLNs) work closely with clients as well as general practitioners (GPs) and other health care providers. Primary health care providers reported improved communication and coordination of services, and there have been lower levels of utilisation of the emergency department (ED) for patients following enrolment in the programme. HealthOne provides an example of how a virtual organisation together with highly skilled care coordinators can overcome some of the barriers to providing integrated care created by fragmented funding streams and care delivery systems.
Highlights
Any attempt at improving services integration in Australia must start by addressing a set of deep administrative and funding splits
Patients admitted to the programme had fewer emergency department visits and shorter lengths of stay compared to the 12 months prior to enrolment
Support for HealthOne Mount Druitt clients spanned from ‘just being there’ - a friendly ear - to practical assistance for medical and other health and social needs delivered through community health services or arranged by the general practitioner liaison nurse to be delivered through other health or social care providers
Summary
The programme aims to improve coordination and integration of services, and reduce unnecessary hospital readmissions, by improving referrals to specialised medical and other community health services for older people with complex needs. General practice liaison nurses organise multidisciplinary case conferences, coordinate care between various providers involved in the care of the patient, and ensure information is provided about the patient to the general practitioner or case manager. Patients and their carers and family members are invited to attend the case conference. HealthOne Mount Druitt was established in 2006 and began enrolling chronic complex patients in September 2007. An independent evaluation of HealthOne Mount Druitt (HOMD) was completed in 2012
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