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Integrating care from the 'ground up' - delivering anticipatory, interdisciplinary integrated care for older people with complex needs.


Genevieve Maiden

War Memorial Hospital, Waverley, NSW, AU
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South Eastern Sydney Local Health District (SESLHD) data highlights frail older people presenting to emergency, who once admitted have a longer average length of stay and often poorer health outcomes. In response, Uniting War Memorial Hospital (UWMH) created integrated rapid-response and anticipatory care programs to enable emergency avoidance, with the aim of keeping people well at home.

Practice change:

Since 2016, UWMH has undertaken systematic redesign at governance and clinical level to shift single-discipline care to integrated models providing co-ordinated and person-centred rehabilitation to older people with complex needs. This enabled creation of services including integrated Rehabilitation and Enablement Programme (iREAP), and Geriatric Flying Squad (GFS) establishing partnerships with Police, Ambulance and Residential Aged Care facilities (RACF’s).


Integrating care in UWMH outpatient and community services from the ‘ground up’ enabled collaboration within the clinical team, using redesign to harness existing resources and expertise to deliver care differently. Early stakeholder engagement including gap analysis, consumer co-design, and integration of community, primary health and SESLHD resources created pathways for people across their health journey. This ‘ground up’ approach was enabled by Executive support, with appointment of an Allied Health and Integrated Care Manager to actively seek partnership opportunities and nurture integrated care innovations.

Targeted population/ stakeholders:

•              Older people at-risk of deterioration, including frailty, falls, dementia and neurodegenerative conditions.

•              Consumer feedback on service gaps and co-design to meet community need.

•              Partnerships with primary health, GP’s, community providers, with structures to facilitate early referral.


Integration is an ongoing strategic priority, with plans for co-ordination of dementia services, and commencement of Health Justice Partnership (HJP) to tackle elder abuse.


An observational study of 99 iREAP patients demonstrated statistically significant outcomes including:

•              Reduced frailty (Clinical Frailty Scale, 4.93 to 3.76 (P=0.0001) (Graphic 1))

•              Reduced falls (5.17 to 2.02 falls at twelve month follow-up (p = 0.001)).

•              Improved Patient Activation Measure (55.08 to 60.61 (p<0.001) (Graphic 2)), from ‘lacking confidence and knowledge’ with their health, to ‘beginning to take action.’

Reducing avoidable emergency presentations and premature RACF admissions; example in 2018, GFS treated 408 patients in partnership with nurses and GP’s within RACF’s, and further 21 emergency presentations avoided through GFS facilitating direct subacute rehabilitation admission.

Overall reduction in presentations to emergency by RACF residents (Graphic 3).


Integrated services are now core business for UWMH, and success builds a platform for new initiatives including the HJP.



Redesign of existing resources, rather than additional funding, makes transition to integrated care achievable within activity based funding environment.


Partnerships with community and GP’s, along with redesign through an integrated care lens, enables timely, effective and early intervention care for those with complex needs, enabling care in their place of choice and ability to self-manage in the longer term.


A ‘ground up’ approach, enabled by strong strategic support, are key enablers for integrated care models, challenging the traditional approach.

Lessons learned:

Early stakeholder engagement enables success, sustainability and reduction in duplication of services, improving co-ordination of care.

How to Cite: Maiden G. Integrating care from the 'ground up' - delivering anticipatory, interdisciplinary integrated care for older people with complex needs.. International Journal of Integrated Care. 2021;20(S1):131. DOI:
Published on 26 Feb 2021.


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