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Conference Abstracts

Innovation in integrated care: A cross sectorial interdisciplinary regional Queensland health service approach


Ben Ross-Edwards ,

Wide Bay Hospital and Health Service, Hervey Bay, QLD, AU
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Kristen James

Wide Bay Hospital and Health Service, Hervey Bay, QLD, AU
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As the burden of chronic and complex conditions on individuals, communities and populations increases exponentially around the world, Wide Bay Hospital and Health Service (WBHHS) faces significant local challenges. Compared with the Queensland average, the Wide Bay has higher rates of unemployment, socioeconomic disadvantage, and mental health illness. Moreover, the health demographic profile shows higher than the Queensland average of adults with obesity, diabetes, asthma, arthritis and heart disease, with 24% of the population over the age of 65 years of age and ~7.5% experiencing profound or severe disability. It is not surprising that within this context, WBHHS has among the highest rate of potentially preventable hospitalisations (PPHs) in Queensland.

A review of WBHHS chronic disease management demonstrated that the patient experienced considerable gaps and barriers to achieving quality care and outcomes.  The patient journey was uncoordinated, disease-focused, siloed into service-delivery and provider-centred models, there was duplication of capabilities, and limited information sharing. The result was a complex and fragmented service delivery and care provision, with little alternative to the Emergency Department for patients requiring urgent (not emergency) assessment and care.

Practice change:

Evidence from New South Wales Health indicates that Integrated Care Models are successful in addressing complex and chronic illness management.  WBHHS considered the aspirations of such a model could be incorporated to address the local requirements.  WBHHS has established a multisectoral and multidisciplinary strategy to govern the management of chronic and complex conditions in Wide Bay.  The primary tenet of the strategy is hospital avoidance.  The Integrated Care Model is a high value, patient-centred model which uses the quadruple aims of improving patient experience, better health outcomes, lower cost and improved clinician job satisfaction.   

Through an integrated multi-disciplinary workforce, the model promotes realignment of roles and functions within existing resources.  Service is coordinated fore-fronted patient care intervention and diversion throughout the patient health care journey from prehospital, (in collaboration with Queensland Ambulance Service), through the Emergency Department, followed through in-patient care, to a wrap-around in-home monitoring and early intervention service at home.


• Coordinating care around patients, family and carers rather than patients trying to coordinate care around systems.

• Improving the patient journey through seamless connection between models of care, leveraging both government and non-government, inpatient and community service providers to maximise capacity and capability, keeping patients well and at home.

• Integration of holistic biopsychosocial assessment and care provision addressing the determinants of health.

• Improving access and equity in the right care, in the right place, at the right time. Including rapid access for GPs and Ambulance services to give an alternate pathways to emergency departments

• Reducing preventable hospital presentations and admissions through diversion, ambulatory clinics specialising in chronic and complex care and social prescription.


The WBHHS Integrated Care Model is taking a lead role in Queensland, implementing early intervention strategies and social prescription within the health care journey of patients with chronic and complex needs. Placing their health and welfare at the forefront of care and treatment.

How to Cite: Ross-Edwards B, James K. Innovation in integrated care: A cross sectorial interdisciplinary regional Queensland health service approach. International Journal of Integrated Care. 2021;20(S1):113. DOI:
Published on 26 Feb 2021.


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