1. Navigating the Healthcare Neighbourhood
Active trial site – Hornsby / Ku-Ring-Gai (Northern Sydney)
Navigating the Healthcare Neighbourhood
ACI partnering with Local Health Districts and Primary Health Networks
IFIC Summer School – 29th March 2018
Regina Osten | Program Manager | NSW Agency for Clinical Innovation
Rhiannon Beck | Senior Project Officer | NSW Agency for Clinical Innovation

2. Coordination and Communication
Rationale for Change
Health providers are funded differently, so systems aren’t aligned with one another
Referrals are received that do not contain the required information
Coordination and Communication
Test results are not communicated across services, resulting in retesting
GPs are unsure where to refer patients or seek clinical advice
Patients are needing to repeat their health ‘story’ multiple times to multiple services
Discharge summaries are not received in good time
Needs assessment to identify particular areas of need for focus

3. “Stronger relationships, seamless integration, superior experience”
Aims and objectives
“Stronger relationships, seamless integration, superior experience”
Local integration through a network of providers
Enable stronger working relationships between neighbours
Increase amount and/or quality of communication between neighbours
Change attitudes towards other services
Increase awareness of referral pathways
Create opportunities for bottom-up innovation and integration (based on the principles of ‘Good Neighbours’)
Principles for good neighbours
Support your neighbours
Be accessible
Provide team-based care
Define clear roles
Enable and empower patients
Ensure continuity of care
Share responsibility for quality and safety
Link to the community

4. Diagnosis Results Critical Issues: Key actions:
There are benefits for all stakeholders to be involved, however we need to communicate the benefits for individuals frames of reference
Prioritisation and/or improvement ideas may be difficult to reach consensus on with a ‘general’ invite list.
People are skilled in collaboration and will quickly form good working relationships
Consumers engaged in the process are supported and respected
Key actions:
Incorporate collaborative capacity training into sessions
Review prioritisation process, consider using needs assessment to identify broad focus areas prior to workshop.
Communications to be considered from different frames of reference
Consumer-test language being used for workshops

5. Healthcare Neighbourhood Capability Strategy
Assumptions
Willingness of PHN and LHD to participate
Good working relationship between LHD, PHN and ACI
Neighbours will be interested in joining a neighbourhood and intrinsic motivation is sufficient to be involved
The context of the work is favourable, and will remain favourable throughout the program
Existing integration technologies and programs exist that can be leveraged
Participants from general practice will see value and a future in the PCMH model
Data sharing is supported
Improved outcomes
Improved efficiency
Improved clinician experience
Improved patient experience
Stronger relationships, seamless integration, superior experience
Broader Goals
Audience - ACI
Neighbours = Health providers, social care providers, consumers and carers
End of Program Outcomes
Neighbours willing to participate in the collaborative
Improved partnerships between neighbours
Neighbours see the benefits for themselves, patients, their organisation and the health system for working across providers
Neighbours are more knowledgeable about PCMH, HCH and HCN
Timelines:
Immediate – date of first education session
Intermediate – date of last education session
End of program – 6 months from date of last education
Activities are what translates the foundational activities into outcomes
Neighbours improve their awareness of local services
Neighbours discuss dependencies, opportunities and barriers
Intermediate outcomes
Neighbours reflect on the work of neighbours from other neighbourhoods
Neighbours compile a stakeholder and enabler map
Neighbours identify shared philosophies on providing care
Discussion occurs between neighbours on online forum
Neighbours form personal relationships with other local neighbours
Neighbours reflect on what matters to them in their practice and compare to neighbours
Immediate outcomes
Neighbours from at least 4 different organisations attend knowledge program
Neighbours use resources available on the website as required
Other considerations:
Sustainability / spread
Engagement / incentives
Activities
ACI/LHD/PHN co-host knowledge program
ACI promote the model at conferences , via social media, etc.
ACI develop content for the website
ACI record events and podcasts
Audience for this Program Logic - ACI
Additional foundational activities:
Readiness assessment
ACI write Guidebook for Healthcare Neighbourhoods
ACI promote the Healthcare Neighbourhoods model
ACI / LHD / PHN co-host events and podcasts with experts
ACI build supporting web-based infrastructure
ACI/PHN/LHD compile a needs assessment
Foundational Activities
ACI / PHN / LHD develop localised knowledge program curriculum
ACI / LHD / PHN to identify local neighbourhood sites
ACI / PHN / LHD trial sites sign Memorandum of Understanding
Neighbourhood Steering Group approve capability strategy
ACI form Healthcare Neighbourhood Steering Group

6. Healthcare Neighbourhood Collaborative
Assumptions
Willingness of PHN and LHD to participate
Good working relationship between LHD, PHN and ACI
Neighbours will be interested in joining a neighbourhood and intrinsic motivation is sufficient to be involved
The context of the work is favourable, and will remain favourable throughout the program
Existing integration technologies and programs exist that can be leveraged
Participants from general practice will see value and a future in the PCMH model
Data sharing is supported
Improved outcomes
Improved efficiency
Improved clinician experience
Improved patient experience
Stronger relationships, seamless integration, superior experience
Broader Goals
Neighbours = Health providers, social care providers, consumers and carers
Increase communication between neighbours
Improve care coordination for patients
End of Program Outcomes
Neighbours Increase awareness of referral pathways
Stronger working relationships between neighbours
Neighbours Increase their use of eHealth technology
Patients experience a more connected health system
Neighbourhoods self-identify improvement cycles to complete
Intermediate outcomes
Neighbours negotiate and sign care compacts
Neighbours are enthusiastic to implement small scale change and monitor the results
Audience for this Program Logic: ACI, LHD, PHN
Neighbours establish clarity on roles of responsibilities of neighbouring organisations
Neighbourhoods confirm the shared vision for their local Healthcare Neighbourhood
Neighbours undertake training in inter-professional competencies
Immediate outcomes
Neighbours from at least 4 different organisations meet one another and form informal relationships
Neighbours from at least 4 different organisations learn about one another's professional roles
Neighbours have defined improvement ideas
Other considerations:
Sustainability / spread
Engagement / incentives
Red halos indicate that the outcome is dependant on the improvements identified by neighbours
Activities
Neighbours attend collaborative sessions
Neighbours prioritise areas for integration action
Foundational Activities
ACI develop Guidebook for Healthcare Neighbourhoods
ACI establish template care compacts
Neighbours submit EOI to join collaborative
ACI / LHD / PHN to promote collaborative EOI process
Neighbours attend capability building sessions
Neighbourhoods develop a shared vision for their local Healthcare Neighbourhood
Local priorities, stakeholders, enablers and readiness established

7. To be determined by the neighbours, including; Consumers / Carers
Mission Statement
To be determined by the neighbours, including;
Consumers / Carers
Health care providers
Social care providers
Service managers

8. Monitoring and Evaluation
Action Plan with Timescales
Monitoring and Evaluation
1 month: Review of needs assessment to select patient cohort/s
6 months: Workshop development and delivery
- Workshop 1 – Introduction, relationships, visioning
- Workshop 2 – Enablers, barriers and opportunities
- Additional workshops (TBD) – networking, relevant local services, relevant evidence base for care
12 months: Innovation collaborative
- Collaborative capacity building (inter-professional competencies)
- Assessment and design
- Improvement cycles