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Victorian Integrated Care Model, supporting better integration of care between primary care and hospital services

Author:

Agnes Tzimos

Department Of Health And Human Services, Melbourne, VIC., AU
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Abstract

In 2017-18 the Department of Health and Human Services (DHHS) commenced the Victorian Integrated Care Model (VICM), a three-year trial aiming to reduce avoidable hospitalisations and fragmentation in care, particularly for patients with complex and chronic conditions.

The suite of activities being implemented as part of the VICM include: 

•              Improving electronic information sharing of common patients to help support integrated care delivery

•              Building a shared understanding of patient needs between the primary and hospital workforces and building trust between providers

•              Developing online resources to increase workforce capability and capacity

•              Convening Integrated Care Communities of Practice events to facilitate networking and relationship building

•              Use of linked data to identify patterns of service utilisation across primary and acute care services to inform future planning

•              Industry transition support to enable coordinated approaches to care across organisational boundaries.

The VICM’s overall objective is to support better integration of care between health services and GPs for shared patients with complex and chronic conditions. Phase one of VICM has focused on establishing joint governance between key stakeholders, laying the foundation for joint planning and governance between the PHNs and the hospital providers so that in the future, services are designed and delivered across the continuum for common client cohorts. The initiative builds on the Commonwealth’s Health Care Homes reform in primary care currently being trialled in the south eastern Melbourne region.

Partners include DHHS, South Eastern Melbourne Primary Health Network (SEMPHN), Alfred Health, Monash Health, Peninsula Health, local GPs (including Health Care Home sites), and the Australian Disease Management Association (ADMA).

The VICM is being implemented over three-years, from 2017-18 to 2019-20 and key highlights include:

•              Enhancements to functionality of health services’ electronic referral (eReferral) solutions, adding notification capabilities to alert GPs when their patients present to the Emergency Departments (ED) and of scheduled outpatient appointments. 

•              Integrated Care Communities of Practice events, open to all health and social providers in the south eastern Melbourne region, to reinforce the importance of integrated care.

•              Online training resources will be accessible online to educate and train the workforce on the principles of integrated care.

•              Hospital process redesign to ensure all patients that present to EDs have the correct GP listed in the Patient Administration Systems and discharge summaries are sent to the correct GP.

Sustainability plans will provide a footprint for future scaling at health services state-wide, expanding beyond the south eastern Melbourne region, for key features such as Communities of Practice events, eReferral, data linkage and service redesign activities.

Phase one of the VICM trial has prioritised establishing joint governance and relationship building between the PHN, GPs and health services, an important step in the collaboration process. The VICM trial ends on 30 June 2020 and DHHS will use findings from the trial to develop an evidence base for future investment, focusing on sharing best-practice and understanding the factors to successful implementation, before expanding reforms beyond the south eastern Melbourne region.

How to Cite: Tzimos A. Victorian Integrated Care Model, supporting better integration of care between primary care and hospital services. International Journal of Integrated Care. 2021;20(S1):170. DOI: http://doi.org/10.5334/ijic.s4170
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Published on 26 Feb 2021.

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