Best Practice Integrated Care

Integrated care is a ‘mega-shift’ driving major change at a health-system level and is impacting the design of care delivery services globally.

Research (Kings Fund) indicates that best practice integrated care programs can substantially reduce emergency department admissions and decrease costs for patients with complex chronic conditions and who are frequent users of hospital services.

Without new models of integrated care, escalating hospital admissions and per-capita costs will become unsustainable driven by increasing rates of obesity, chronic disease, an aging population, and rapidly increasing rates of mental illness.

What we do

We draw on our local practical experience gained in how to make integrated care work, and the experience of our global partners, gained in North America, UK, Scandinavia and Asia to help health services make the fundamental shifts necessary to succeed in integrated care.

We help our clients in six key areas to design and implement integrated care programs:

1.  Clarify Triple Aims
2.  Target the right population
3.  Design Best Practice Integrated Care model
4.  Ensure step-change improvements
5.  Implement an enabling AI assisted digital health system
6.  Introduce new flexible funding and incentive models.

1.  Clarify Triple Aims

Here we work with you to determine the triple-aims of your integrated care program to:

• Improve patient experience of care, and improve self-reported health
• Reduce the number of potentially avoidable ED episodes and potentially avoidable hospital admissions
• Improve the overall cost effectiveness of treatment.

2.  Target right population

We work with our client to target patients who have complex and costly, comorbid chronic conditions—with primary diagnoses of

• Mental Health
• Heart failure with secondary COPD diagnosis
• Diabetes Type 2

3.  Design Best Practice Integrated Care model

In this area, we work with our client to design and implement an Integrated Care Model that draws on our practical experience, and International and Australian best practices. Typically the integrated care model to be implemented comprises eight key elements (contact us for further information), clearly defined roles and responsibilities, and a systematic approach to change management.

4.  Ensure step-change improvements

Here we work with your team to design and implement real change initiatives that better integrated care—typically this involves three new intervention teams are to be organised around three critical health system interfaces:

1.  Patient interface (including carer and family)
2.  GP/hospital interface
3.  Specialist interface.

5.  Implement an enabling eHealth system

We work with you to specify and implement a world class enabling eHealth system to support patient self-care, automated health coaching, shared clinical records, a care team coordination portal, and in-home tele-monitoring for patients with complex conditions.

6.  New flexible funds and incentives

We design new funding models to drive behavior change for Allied Health and Care Coordinators as part of your program.