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Care Coalition: Integrated Case Management for Opioid Treatment

South Western Sydney Local Health District
Project Added:
8 August 2016
Last updated:
20 April 2021

Care Coalition: Integrated Case Management for Opioid Treatment


South Western Sydney Local Health District (SWSLHD) Drug Health Services will develop a standardised Care Management Framework for all sites, in addition to professional development for staff, new clinic dosing hours and a review of clinical practices, service liaison and interagency collaboration.

View a poster from the Centre for Healthcare Redesign graduation, August 2016.

Care Coalition


To standardise case management of clients in the SWSLHD Opioid Treatment Program (OTP) and ensure that within 12 months, 80% of clients have a documented collaborative care plan and more than 50% of clients attend case management appointments.


  • Delivers a standardised and consistent service, with effective coordination and transfer of care.
  • Improves client flow through the OTP, resulting in equal access to services across SWSLHD.
  • Reduces the number of clients that fail to attend case management appointments.
  • Increases the quality and compliance of collaborative care plans for clients in the OTP.
  • Increases client satisfaction with the service and empowers clients to better manage their care.
  • Improves staff satisfaction and morale through improved professional development and support.


Prior to the project, the OTP in SWSLHD was run across four Drug Health Services sites, each with its own case management framework and model of care. In particular, patient journeys, risk assessments and case management practices were managed locally at each site.  

This caused fractured communication that impacted client care and collaboration between clients and key stakeholders. Clients did not engage in treatment planning and staff did not follow up and provide assertive outreach. Overall, the level of clinical care planning was seen to contribute to poor outcomes and engagement.

An audit of all sites conducted in early March 2015 found there were 750 clients in the OTP, with only 20% attendance at case management meetings. Over 85% of clients did not have a collaborative care plan documented, which increased the risk of morbidity and mortality for these clients.

It was anticipated that standardising case management practices across all Drug Health Services sites would improve health outcomes for clients and reduce drug-related harm and risk for clients, carers and the community.


  • A standardised Care Management Framework is being developed, to provide guidelines for improving the assessment and identification of client risk. This will provide clear pathways for care coordination and care management, based on individual risk. Service guidelines and practices are also being established, to support and sustain transfer of care to community pharmacies.  
  • Clinical review practices, service liaison and interagency collaboration will be reviewed and improved, with the aim of promoting client progress and sustained management by community pharmacies and general practitioner prescribers.
  • Clinic dosing hours will be adjusted to allow increased flexibility and responsiveness to clients’ needs, while improving client safety and clinic maintenance.
  • A program will be developed to identify staff competencies and assess professional development needs, with training to develop existing staff and orientate new staff to a range of best practice, flexible approaches to care management and communication.

Project status

Implementation - Implementation is underway and is expected to be completed by the end of 2016.

Key dates

July 2015 – December 2016

Implementation sites

  • Bankstown Drug Health Services
  • Campbelltown Drug Health Services
  • Liverpool Drug Health Services
  • Fairfield Enhanced Care Team


Evaluation and results

  • Preliminary results reviewed in August 2016 showed a significant reduction in care management fail to attend rates, from 80% to around 5%, as well as a significant increase in client satisfaction with the service hours.
  • A full evaluation of the project will take place in December 2016, with measurement of the following outcomes:
    • number of collaborative care plans completed
    • number of clients attending case management appointments
    • compliance with the Care Management Framework
    • staff satisfaction and competency
    • client satisfaction
    • key stakeholder satisfaction
    • risk management and care planning through an audit of clients’ medical records.

Lessons learnt

  • Sound implementation requires considered approaches to staff and consumer engagement, as well as active management to achieve successful and sustained change.
  • The stress caused by the climate and culture in the organisation can affect the ability to implement solutions. Multiple changes were taking place at the same time as this project, which impacted the organisation’s readiness to implement new solutions.
  • Change can only be successfully achieved by sustained focus on progress of implementation, engagement and monitoring.  
  • The project took longer than initially anticipated to design and implement, as additional efforts were required to engage staff and clients. Solution validation strategies with staff and consumers clearly supported this engagement.

Related resources

Further reading

  • Fisher ES, Staiger DO, Bynum JP et al. Creating accountable care organizations: the extended hospital medical staff. Health Affairs 2007; 26(1): w44-57.
  • Marfleet F. National Skill Set for Effective Case Management in Australia and New Zealand: Skills Workbook. 1st Edition. Case Management Society of Australia & New Zealand; 2015.
  • Marfleet F, Trueman S, Barber R. National Standards of Practice for Case Management. 3rd Edition. Case Management Society of Australia & New Zealand; 2013.
  • Marfleet F, Trueman S. National Code of Ethics for Case Management. 2nd Edition. Case Management Society of Australia & New Zealand; 2013.
  • Ross S, Curry N, Goodwin N. Case Management: What it is and how it can best be implemented. London: The King’s Fund; 2011.
  • Siriwardena AN. Engaging clinicians in quality improvement initiatives: art or science? Quality in Primary Care 2009; 17(5): 303-305.
  • South Western Sydney Local Health District (SWSLHD) Drug Health Services. SWSLHD Drug Health Services Risk Management Plan [Intranet]. Accessed 5/8/16.
  • South Western Sydney Local Health District (SWSLHD) Drug Health Services. SWSLHD Drug Health Services Workforce Development Plan 2016 – 2018 [Intranet]; December 2015.
  • Wilkinson R, Marmot M. Social determinants of health. The solid facts. 2nd edition. Copenhagen: World Health Organization Regional Office for Europe; 2003.


Kelly Walker
Operational Nurse Manager
Drug Health Services
South Western Sydney Local Health District
Phone: 02 8717 0438

Ravina Raidu
Clinical Nurse Specialist
Drug Health Services
South Western Sydney Local Health District
Phone: 02 4634 4177

Margaret Chapman
Redesign Program Manager
South Western Sydney Local Health District
Phone: 02 8738 8898

Angela Fasheun
Clinical Nurse Consultant 2
Long Stay and Rehabilitation Unit
Justice Health and Forensic Mental Health Network

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