As part of the NSW Integrated Care Strategy announced by the Ministry of Health in 2014, Western Sydney is one of three lead demonstrator sites across NSW engaged in developing an innovative, system wide and sustainable service model for providing coordinated and integrated care services. The LHD is required to deliver several key achievements for this initiative, which has an initial focus on the management of chronic disease. The Western Sydney Integrated Care Demonstrator is a partnership initiative with the Western Sydney PHN (WentWest). This initiative will provide a new model of care for the management of a chronic disease.
To be eligible for this service, patients must have at least one chronic disease of diabetes, COPD, or congestive cardiac failure/CAD, and who are risk stratified as being at significant risk of requiring hospital care.
Patients within this cohort will be enrolled by either primary care, community or hospital specialist teams, depending on the point of first contact and registered in a patient registry.
A range of coordinated interventions and clinical services will be implemented to improve the health care management of these patients. Services will be provided by a range of health professionals, including Primary Care teams, Care Facilitators and Multidisciplinary Teams (MDT), in an integrated fashion.
The formal communications link between the care providers will be a dynamic, accessible Shared Care Plan, which will be web enabled and have input from all care providers.