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Conference Abstracts

Technology supported, integrated - care models: challenges and drivers for successful implementation


Rajiv Jayasena ,

Commonwealth Scientific and Industrial Research Organisation (CSIRO), AEHRC, Parkville, VIC, AU
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Marlien Varnfield,

Commonwealth Scientific and Industrial Research Organisation (CSIRO), AEHRC, Herston, QLD, AU
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Norm Good,

Commonwealth Scientific and Industrial Research Organisation (CSIRO), AEHRC, Herston, QLD, AU
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Jane Li

Commonwealth Scientific and Industrial Research Organisation (CSIRO), AEHRC, Marsfield, NSW, AU
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CSIRO has undertaken numerous investigations into the efficacy of new, technology supported, integrated care models for chronic disease management. Aims of these trials have been to make care personalised, flexible, objective, accurate and timely; for cardiovascular disease, diabetes, chronic obstructive pulmonary disease and chronic kidney disease. Feasibility and proof of concept studies, to comprehensive trials, have been conducted to gather evidence for new care models. Some have been scaled-up for implementation in business-as-usual settings to evaluate its effectiveness in practice. This abstract outlines the learnings, highlighting aspects that are mandatory for success when transitioning from controlled conditions to routine care, and the impact of funding policy that facilitate collaborative care.

Methods: Selected studies

a)             A range of m-Health care models utilising smartphone apps and web-based clinician access, to remotely record and share patient health measurements, and to deliver motivational and educational multi-media materials to patients. Patient data is regularly accessed by carers to monitor progress, set goals and provide guidance.

b)            Telemonitoring Trial designed to demonstrate how home-telemonitoring can be deployed nationally. The intervention was the provision of telemonitoring equipment for monitoring and sharing vital signs, and the administration of questionnaires.

c)             Pilot program by the Victorian Department of Health and Human Services (DHHS) called HealthLinks Chronic Care, a new funding policy designed to provide capitation funding to hospitals, enabling collaborative integrated care. 

The objective of this abstract is to highlight areas for improvement and enablers for technology supported, integrated models of care.


Enablers: high clinician/service provider acceptance, efficient service delivery, leadership support, communication and branding, holistic approach to patient care, adequate skills and training.

Areas for improvement: not having dedicated, allocated and trained staff, technology setbacks, ineffective incentive models, inability to provide assurance of patient privacy and security measures, lack interoperability with clinical systems, and change management.

Discussions & future research:

In almost all the mentioned studies/trials, the technology was well accepted by patients. The technology was also well accepted by the service providers where we had motivated clinicians and/or mentors/care coordinators. However, from an implementation and scale-up perspective, the key areas for improvement were at the service provider level. Important success factors to consider for future programs are timely resolution of issues, strong leadership, extensive training programs aligned with workplace culture and decision support tools to identify patient deterioration.


Conclusions & lessons learned:

Implementing successful technology supported, integrated care models into routine practice requires a pragmatic and learning culture. Where organisations are willing to try, change and adopt evidence-based care models into routine care. However, when implementing these care models, it is important to priorities patient safety and staff wellbeing during scale-up. Furthermore, an incremental scale-up plan underpinned by a thoroughly designed Evaluation Framework enables a ‘Learning Health System’ and the ability to significantly re-align, train, develop, promote and reinforce new behaviours in uptake of evidence-based practices into routine care.  This encourage ownership by frontline staff, ability to manage funding sustainably, maintain expectations and increase successes.

How to Cite: Jayasena R, Varnfield M, Good N, Li J. Technology supported, integrated - care models: challenges and drivers for successful implementation. International Journal of Integrated Care. 2021;20(S1):110. DOI:
Published on 26 Feb 2021.


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