1. Healthy Together! Right care right place right time
My care my place my time
All people across our region are able to have timely access to the right healthcare in the right setting to maximise health, wellbeing and independence (SNSWLHD)
Supporting primary care in our region to be person cenred; accessible; safe and high quality; comprehensive; population oriented; coordinated across all parts of the health system (COORDINARE)

2. Rationale for Change Root cause analysis:
Increasing number of people ageing who have chronic and complex health conditions. This is leading to increased demand for health care support.
Service delivery and access to healthcare across SNSW is fragmented and not coordinated across primary and secondary care. This leads to duplication and gaps and does not support delivery of client centered effective care.

3. Overarching aims and objectives
To develop a framework, shared principles, values and ways of working across COORDINARE and SNSWLHD, that will deliver outcomes against the quadruple aim
To develop a framework and agreed principles, values and ways of working across COORDINARE and SNSWLHD to enable
improved coordination of care
improved pt experience and outcomes
shared service priorities
shared agreed priority areas according to population demand.

4. Diagnosis results Strengths Challenges It is the right time!
Limited understanding and trust of each service’s role in integrated care
Lack of shared care planning tools
Patch protection
Fear of change
Leaping from good will into action
Strengths
It is the right time!
Growth in commitment to the Strategic Alliance
Positive HealthPathways collaboration
Organisational support for GP Liaison Officers
pockets of local goodwill to improve health outcomes through integrated care
Advent of My Health Record opt out

5. Southern NSW Joint Integrated Care Strategy - Logic Model
INPUTS
Needs analysis
Key policy levers: Bilateral agreement, NSW Integrated Care Framework
Evaluation framework including economic benefit
Patient experience assessment tools
Consumer focus groups
Patient Activation Measure
GPLOs
Health Pathways
My Health Record
Regular meeting of working group
Strategic Alliance / Exec Commitment
Joint Board Meeting / Board Commitment
OUTPUTS
Shared vision
Agreed priorities
Regular evaluation, data guiding decisions including financial decisions
Joint comms – effective stakeholder engagement
Joint skills development curriculum – quadruple aim, collaboration
Patient stories utilised in service development
Increased utilisation of medical records across providers with MHR
MOU / Partnership agreement
Actions from Strategic Alliance
Actions from Board meeting
OUTCOMES
SHORT TERM Shared plan including Regional Mental Health Plan, Regional Digital Health Plan MEDIUM TERM
Identified priorities
Particular projects in high needs populations or locations
Empowered stakeholders
LONG TERM Improved chronic and complex care coordination Reduced potentially preventable hospitalisations Work in partnership with the community to advocate for optimal health care in the community
Assumptions: Mutual gain =
Healthier population
Reduced waiting lists / times at LHD and in General Practice
Improved Access
Greater acknowledgement of significant role of GPs
Increased efficiencies, potential savings
External Factors:
PEST Analysis; the ‘Frankie J Factor’

6. Action Plan / Timescales
Timeframe
Present Joint Integrated Care Outline to Strategic Alliance
April
Working group complete strategic plan
End July
Key priorities agreed
Work plans and measures developed utilising consumer input
August
Communications plan developed – HCPs, Community, Stakeholders
Training needs analysis and plan developed
October
Regional Digital Health Plan completed
Joint strategic alliance 1 july
Agreed priorities
GPLO
PAM
HealthPathways