1. Care Through Partnership NBM Integrated Care Initiative
Building the Health Care Neighbourhood
Liz Reay, CEO, NBMPHN
Elisa Manley, Executive Manager Operations Planning and Integration, NBMPHN
Kevin Hedge, Director, Allied Health and Community Programs, NBMLHD

2. Key Issues
The challenge involves developing active engagement of all clinicians in the care continuum of their patient across health sectors, providing effective patient experience and good outcomes in the Stage 1 rollout of Health Care Homes
Limited mapping of Health Care Neighbourhoods has been formally undertaken to identify key connections and referral networks
The concept of the Health Care Neighbourhood is not in the forefront of clincians minds nor articulated clearly
Rapid access to acute and community care services is informal and reliant on established referral relationships between clinicians e.g. GP access to specialist advice and clinical review
Limited contribution towards shared care plans between care providers. Currently these are developed independendtly by GPs, and acute and community clinicians with little or no overlap e.g. GP example is the contribution to MBS 723. This is compounded by:
Limited Electronic linkages between primary care, community health and acute services - which are conceptually agreed but physically constrained or absent – there is no universal, dynamic shared care plan used in the region
Limited meaningful use of existing digital health platforms to share information across primary and acute care settings e.g. secure messaging and discharge summaries
Safe transfer of care between services is not guaranteed – there is limited knowledge of whether a patients information has been sent or recieved between service providers and the quality of such information is variable

3. Aims and Objectives
Builidng the Health Care Neighbourhood Project will aim to:
Articulate the guiding principles that underpin an integrated Health Care Neighbourhood in NBM region
Define the operational requirements of the Health Care Neighbourhood
Map the Health Care Neighbourhood of each participating general practice
Engage and enrol patients, GPs, hospital staff and teams, community pharmacists and community health services in the NBM Health Care Neighbourhood
Establish adoption of dynamic shared care plans involving all service partners;
Measure the impact of enrolment on patient experience and patient outcomes
Measure the experience of the Health Care Neigbourhood clinician and other service provider participants
Measure the impact of enrolment on frequency of presentation to hospital
Measure utilisation of Health Pathways by GPs in the management of chronic care
Measure the uptake of dynamic shared care plans
Measure the meaningful use of available digital health platforms

4. Options for progress Patient empowerment and engagement in care
Development of patient centred care to support dynamic shared care planning and improved health literacy can be built into the Health Care Home model
Explore other mechanisms
Interdisciplinary and inter professional partnerships
Formal agreements and guiding principles for partnerships between GPs, general practices, specialties, community health and community service providers
Identification of target patient groups
Target patient populations include patients in Health Care Homes, and non-Health Care Homes practices, aligned to the clusters of Health Care neighborhoods. The number of patients will be determined and will relate to size of practice populations, number of HCH enrolments and regional profile of each cluster
Roles and accountability
A partnership project management plan will define the roles and responsibilities of all members

5. Learning outcomes
Understand and define the building blocks of our local integrated care system and what is unique to the NBM region
Explore and Identify the mechanisms to support the establishment of an integrated care system in NBM
Clarify the intended outcomes of the health care neighbourhood and to start to measure them
Identify the needs and plan to support the development of an integrated care workforce
Identify financial incentives for integration in primary, acute and community sectors
Stimulate an appetite for change within the local political environment
Explore opportunities for accountable care