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Integrated Care
 

Paediatric Access Support Service (PASS)

Paediatric Access Support Service (PASS)

The Paediatric Access Support Service (PASS) aims to transfer patients to and from Sydney Children’s Hospitals Network inpatient settings efficiently. This would reduce associated workload, and improve the patient and staff experience.
Sydney Children's Hospital Network
Added: 28 August 2019|Last updated: 29 August 2019
Care Coalition: Integrated Case Management for Opioid Treatment

Care Coalition: Integrated Case Management for Opioid Treatment

South Western Sydney Local Health District 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.
South Western Sydney Local Health District
Added: 8 August 2016|Last updated: 12 July 2019
Integrating care for frequent service users in Goulburn

Integrating care for frequent service users in Goulburn

This project brings together the local ambulance service, general practice, hospital emergency department (ED) and community health centre resources to identify and respond to patients who repeatedly use one or more of these health services. These agencies will work collaboratively with the patient to provide a coordinated, targeted and timely response to the general health and social needs that the patient identifies as triggering their need for an emergency response....
Southern NSW Local Health District
Added: 6 May 2019|Last updated: 9 May 2019
Community Eye Care in Western Sydney

Community Eye Care in Western Sydney

Community Eye Care (C-EYE-C) improved access to ophthalmology services for patients in Western Sydney, by partnering with local optometrists to conduct standardised examinations, which were then reviewed remotely by hospital ophthalmologists.
Western Sydney Local Health District
Added: 11 July 2018|Last updated: 30 January 2019
Breath of Fresh Air: Paediatric Long Term Ventilation

Breath of Fresh Air: Paediatric Long Term Ventilation

This project aims to provide a coordinated, equitable and integrated service for children requiring invasive long term ventilation, and their families. It also aims to support the needs of long term ventilation children at home and in the community, and provide access to a comprehensive package of ambulatory care services to decrease admission rates and days spent at hospital.
Sydney Children's Hospital Network
Added: 4 December 2018|Last updated: 13 December 2018
Innovative Service Delivery Model

Innovative Service Delivery Model

Western Sydney Local Health Districtestablished a Mental Health Acute Assessment Team at Cumberland Hospital. The service responds to relevant Triple Zero calls via a dispatch system, using dedicated paramedics and mental health clinical nurse consultants.
Western Sydney Local Health District
Added: 28 May 2018|Last updated: 22 June 2018
Home-Based Subcutaneous Immunoglobulin Replacement Therapy

Home-Based Subcutaneous Immunoglobulin Replacement Therapy

Liverpool Hospital is implementing a home-based subcutaneous immunoglobulin replacement therapy program for patients with impaired immune systems.
Liverpool Hospital
Added: 28 May 2018|Last updated: 21 June 2018
The Asthma Follow Up Integrated Care Initiative

The Asthma Follow Up Integrated Care Initiative

Sydney Children’s Hospital Randwick developed an integrated model of care for children with non-complex asthma, including care coordination, communication with general practitioners, parent education and emergency department resources and processes.
Sydney Children's Hospital Network
Added: 28 May 2018|Last updated: 12 June 2018
Multiagency Coordination of Prenatal Risk

Multiagency Coordination of Prenatal Risk

Central Coast Local Health District established regular meetings with the NSW Department of Family and Community Services and all health services involved in the care of pregnant women, in cases where there were child protection concerns.
Central Coast Local Health District
Added: 2 May 2018|Last updated: 21 May 2018
Improving Collaborative Discharge Care Planning for Stroke Patients

Improving Collaborative Discharge Care Planning for Stroke Patients

St George Hospital developed an Allied Health Discharge Care Plan, established an allied health care coordinator role and implemented new administration processes, to support the transition of stroke patients out of hospital and into the community.
St George Hospital
Added: 27 April 2018|Last updated: 14 May 2018
Making the Health of the Nation Outcome Scale Work For Us

Making the Health of the Nation Outcome Scale Work For Us

This project added an additional multidisciplinary team meeting to the Older Persons Mental Health Team schedule each week and adjusted the meeting agenda, to allow more time for mental health care reviews.
Sutherland Hospital and Community Health Service
Added: 30 April 2018|Last updated: 14 May 2018
Complex Care Coordination in NSW Emergency Departments

Complex Care Coordination in NSW Emergency Departments

Royal North Shore Hospital is developing a clinical pathway for people who frequently present to hospital emergency departments with chronic pain and complex conditions, which will be rolled out across the state following evaluation of the pilot program.
Royal North Shore Hospital
Added: 23 April 2018|Last updated: 8 May 2018
Collaborative Care Outreach for Residential Aged Care Facilities

Collaborative Care Outreach for Residential Aged Care Facilities

The ‘A Collaborative Care Outreach for Residential Aged Care Facilities in SLHD’ (ACCORD) project aims to deliver improvements in clinical leadership, education, processes and connections between the Access Care Team and Residential Aged Care Facility Outreach Service.
Sydney Local Health District
Added: 24 April 2018|Last updated: 3 May 2018
Partners in Care

Partners in Care

This project supports staff who are trained in health coaching but are not providing it to patients on a regular basis. It also introduced an evaluation framework to continually assess the training and support needs of staff in South Eastern Sydney Local Health District.
Added: 24 April 2018|Last updated: 3 May 2018
Storks

Storks

Sydney Children’s Hospitals Network in partnership with HealthShare NSW is developing a standardised service delivery model for the safe, timely and efficient transport of newborn babies to appointments and back, and to local hospitals.
Sydney Children's Hospital Network
Added: 24 April 2018|Last updated: 3 May 2018
Aboriginal Wellbeing Hospital Discharge Booklet

Aboriginal Wellbeing Hospital Discharge Booklet

An Aboriginal cultural resource was developed to improve the hospital discharge journey of Aboriginal patients, families and carers in MNCLHD. The clinical redesign process involved monitoring data, developing culturally appropriate resources and collaborating with Aboriginal people to gain the best health outcomes after discharge from hospital.
Mid North Coast Local Health District
Added: 29 January 2018|Last updated: 12 February 2018
Get It Together: For People with Multidisciplinary Healthcare Needs in the Community

Get It Together: For People with Multidisciplinary Healthcare Needs in the Community

This project pulls together multidisciplinary teams around their clients, as it has been shown that when people are included in care that is coordinated, they have better health and wellbeing.
Nepean Blue Mountains Local Health District
Added: 28 November 2017|Last updated: 15 December 2017
Child-at-Risk Electronic Medical Record Alert

Child-at-Risk Electronic Medical Record Alert

NNSWLHD developed a unique alert system for at-risk children and pregnant women that is integrated into the patient’s electronic medical record
Northern NSW Local Health District
Added: 25 August 2017|Last updated: 11 September 2017
Police Ambulance Early Access to Mental Health Assessment via Telehealth

Police Ambulance Early Access to Mental Health Assessment via Telehealth

HNELHD provided iPads to police and ambulance staff, so they can access mental health triage and support for consumers at the scene of the emergency.
Hunter New England Local Health District
Added: 15 August 2017|Last updated: 25 August 2017
Nambucca Valley Specialist Wound Intervention Service

Nambucca Valley Specialist Wound Intervention Service

This project improved access to community wound clinics, so patients who have or are at risk of wounds can consistently receive best practice care in a timely manner.
Mid North Coast Local Health District
Added: 18 August 2017|Last updated: 25 August 2017
Identifying and Managing Iron Deficiency and Iron Deficiency Anaemia

Identifying and Managing Iron Deficiency and Iron Deficiency Anaemia

MLHD identified an alternative option for iron replacement therapy and developed guidelines to deliver it in the community setting where clinically indicated, in collaboration with patients and carers.
Murrumbidgee Local Health District
Added: 16 August 2017|Last updated: 25 August 2017
Improving Clinical Review in the Northern Sydney Home Nursing Service

Improving Clinical Review in the Northern Sydney Home Nursing Service

This project defined the role of the resource representative and increased awareness of this role among staff at Northern Sydney Home Nursing Service, to ensure patients are referred to the most appropriate clinician.
Northern Sydney Local Health District
Added: 3 May 2017|Last updated: 17 May 2017
Redesign of Maternity Services at Macksville Health Campus

Redesign of Maternity Services at Macksville Health Campus

This project introduced a new service, where midwives at Macksville Health Campus deliver pregnancy and postnatal care to women in their home. It involves flexible rostering patterns to maximise existing staff and reduce staffing inefficiencies.
Mid North Coast Local Health District
Added: 7 April 2017|Last updated: 28 April 2017
Waist Less: Part of the Sustainable Connections for Overweight and Obesity in Paediatrics Project

Waist Less: Part of the Sustainable Connections for Overweight and Obesity in Paediatrics Project

The Waist Less project aims to improve clinical processes and resources at the CHW, to increase the identification and management of children with obesity and their families. It is part of the Sustainable Connections for Overweight and Obesity in Paediatrics (SCOOP) project, which aims to develop streamlined models of care and health pathways for children with obesity and their families within primary, secondary and tertiary healthcare settings in Nepean Blue Mountains and Western Sydney Local Health Districts, improving equity and...
Sydney Children's Hospital Network
Added: 18 April 2017|Last updated: 28 April 2017
Improving the Efficiency of External Pathology Results

Improving the Efficiency of External Pathology Results

The Heart and Lung Clinic at St Vincent’s Hospital Sydney implemented a number of changes to the way it follows up and communicates external pathology results. This included the development of a new standard operating procedure, a dedicated area for reviewing patient files, new staff rosters, patient information brochures, patient database updates and standardised communication tools.
St Vincent's Hospital
Added: 7 April 2017|Last updated: 21 April 2017
One Size Does Not Fit All

One Size Does Not Fit All

This project provides support to consumers at risk of developing one or more lifestyle-related chronic diseases, with increased access to healthcare services and programs that help them make healthy lifestyle choices.
Far West Local Health District
Added: 18 November 2016|Last updated: 16 December 2016
Save a Leg: Building Integrated Diabetes Foot Services in Western Sydney

Save a Leg: Building Integrated Diabetes Foot Services in Western Sydney

This project developed a 60-second diabetic foot screening tool and educated patients, nurses and clinicians on the importance of using the tool and completing regular foot checks. Electronic referral templates and clinical pathways were also developed, to improve timely access to hospital foot services.
Western Sydney Local Health District
Added: 1 December 2015|Last updated: 18 October 2016
Hospital in the Home: An Innovative Partnership Model

Hospital in the Home: An Innovative Partnership Model

This project developed a new model of care for its Hospital in the Home (HITH) program, by integrating the services delivered by ambulatory care and community health nursing teams.
Campbelltown HospitalCamden Hospital
Added: 15 September 2016|Last updated: 30 September 2016
Plan Early: My Future Care

Plan Early: My Future Care

This project delivers advance care planning to patients with end-stage chronic lung disease, by implementing staff training, standardising work practices for Advance Care Plan documentation, engaging general practitioners and using an evidence-based tool that predicts the risk of death within 12 months.
Prince of Wales Hospital
Added: 16 August 2016|Last updated: 20 September 2016
Community Integration Team: At Risk Youth Mental Health

Community Integration Team: At Risk Youth Mental Health

The Community Integration Team is a cohesive statewide health service that coordinates care for young people who have mental health problems and/or problematic drug and alcohol use, while they are in the juvenile justice system and three months after their release.
Justice Health and Forensic Mental Health Network
Added: 2 May 2016|Last updated: 23 May 2016
Southcare Outreach Service (SOS)

Southcare Outreach Service (SOS)

The Southcare Outreach Service is a new model of care that delivers a rapid response, multidisciplinary team to clients aged over 65 years in their home to prevent presentations to the emergency department.
South Eastern Sydney Local Health District
Added: 19 February 2016|Last updated: 7 March 2016
The Home for Lunch Project

The Home for Lunch Project

The Home for Lunch Project addressed barriers to safe, timely and efficient discharge of children, using a whole of health approach.
Sydney Children's Hospital Network
Added: 7 January 2016|Last updated: 21 January 2016
Kidney Dialysis Vascular Access: A Vascular Surgeon and CNC-led Access Clinic

Kidney Dialysis Vascular Access: A Vascular Surgeon and CNC-led Access Clinic

A vascular clinic with an integrated health approach was established, to address the high number of emergency procedures and prolonged hospitalisations incurred by haemodialysis patients.
Prince of Wales Hospital
Added: 6 January 2016|Last updated: 20 January 2016
VIP Project: Reducing Re-presentations and Readmissions to Hospital for Very Intensive Patients

VIP Project: Reducing Re-presentations and Readmissions to Hospital for Very Intensive Patients

The VIP project developed a strategy to identify Very Intensive Patients (VIPs) who are at high risk of re-presenting to hospital and implemented methods to address their medical and psycho-social needs. This new model of care has reduced the need for hospital-based care by using interagency partners in the primary care sector to provide support for VIPs in the community.
Hunter New England Local Health District
Added: 18 December 2015|Last updated: 20 January 2016
A Public-Private Rural Physiotherapy Service

A Public-Private Rural Physiotherapy Service

This project established a partnership between the local health district, Primary Health Network and private physiotherapists, to pool resources and deliver physiotherapy services in rural communities.
Murrumbidgee Local Health DistrictMurrumbidgee Primary Health Network
Added: 18 January 2016|Last updated: 18 January 2016
Seamless Transitions: The Pathway Home

Seamless Transitions: The Pathway Home

Royal North Shore Hospital redesigned the process of transferring information from the hospital to primary and community health services, including reintroducing a transfer of care risk screening tool and expanding the acute and post-acute care liaison role.
Royal North Shore Hospital
Added: 12 October 2015|Last updated: 27 October 2015
Enhanced Management of Orthopaedic Surgery Program

Enhanced Management of Orthopaedic Surgery Program

Coffs Harbour Health Campus implemented this program which involved pre-operative planning, intra-operative optimisation, post-operative strategies and post-discharge follow-up.
Coffs Harbour Base Hospital
Added: 9 October 2015|Last updated: 24 October 2015
Improving Clinical Communication at the Aged Care Emergency Service

Improving Clinical Communication at the Aged Care Emergency Service

This project trained residential aged care facility and emergency department staff in the Identify, Situation, Background, Assessment and Recommendation (ISBAR) clinical handover tool to enhance the effectiveness of the Aged Care Emergency (ACE) service.
Hunter New England Local Health DistrictHunter New England and Central Coast Primary Health Network
Added: 6 October 2015|Last updated: 21 October 2015
Care Coordination Screening and Triage

Care Coordination Screening and Triage

This project implemented a screening and triage tool within the outpatient cancer service at Illawarra Shoalhaven Local Health District, to improve the care coordination of patients during their treatment journey.
Illawarra Shoalhaven Local Health District
Added: 6 October 2015|Last updated: 21 October 2015
About Face Project: Clinical Redesign of Cleft and Craniofacial Services

About Face Project: Clinical Redesign of Cleft and Craniofacial Services

This project is about starting the journey towards the provision of better, more organised and coordinated care to ensure the best possible cleft and craniofacial services and experience for patients and their families.
Sydney Children's Hospital Network
Added: 18 August 2015|Last updated: 21 August 2015
The Future of Service Cohesion

The Future of Service Cohesion

This project developed an integrated model of care that facilitated early discharge from inpatient units and transferred care back to the community, with home-based treatments provided by an Acute Care Team.
Croydon Community Health Centre, Concord Centre for Mental Health
Added: 25 May 2015|Last updated: 9 June 2015
Re-ACT: Redesigning Allergy Care Together for Children

Re-ACT: Redesigning Allergy Care Together for Children

This project is developing streamlined health pathways, improving operational systems, standardising diagnostic services and developing an education framework for health professionals to provide integrated care for children with diagnosed or potential food allergies.
Sydney Children's Hospital Network
Added: 17 April 2015|Last updated: 22 April 2015
Sugar S.N.A.P – Supporting the Needs of Aboriginal People

Sugar S.N.A.P – Supporting the Needs of Aboriginal People

This Dubbo Diabetes Integrated Care Project works across sectors to ensure an integrated approach to the care of Aboriginal people with diabetes. Fundamental to this approach is giving Aboriginal people an authentic voice in the way care is delivered to them.
Western NSW Local Health District
Added: 20 April 2015|Last updated: 22 April 2015
Keep Them Safe and Whole Family Teams - An Integrated Partnership Approach to Health Care

Keep Them Safe and Whole Family Teams - An Integrated Partnership Approach to Health Care

Whole Family Teams (WFTs) include mental health and drug and alcohol clinicians working together in multidisciplinary teams to provide comprehensive mental health, drug and alcohol and family assessment and evidence informed individual and family in-home interventions for approximately six months. The model of care was informed by the best available evidence regarding interventions for families with complex mental health and drug and alcohol needs and the impact of these problems on the safety of their children. The central theme of...
Mental Health and Drug and Alcohol Office (MHDAO)
Added: 18 February 2015|Last updated: 5 March 2015
Healthy Kids Bus Stop (HKBS) Project

Healthy Kids Bus Stop (HKBS) Project

The Healthy Kids Bus Stop (HKBS) Project is a community-based integrated care partnership between Royal Far West, Western NSW Local Health District, Western NSW Medicare Local, and Ronald McDonald House Charities to address the gaps in child health needs in rural NSW.
Western NSW Local Health District
Added: 31 October 2014|Last updated: 28 January 2015
Count Me In: To Improve Patient Care

Count Me In: To Improve Patient Care

Without clearly documenting non admitted patient activity, the District will never be able to fully describe the importance of clinical care provided to patients who are not formally admitted to hospital. How they help keep people healthy and in the community and how they assist in providing advice and treatment options for patients and their carers that do not revolve around physically being in a hospital....
Hunter New England Local Health District
Added: 4 December 2014|Last updated: 8 December 2014
North Coast Cancer Institute Lync Project

North Coast Cancer Institute Lync Project

This telehealth project has used Microsoft LyncTM software and IT hardware to facilitate communications between cancer specialists and primary care providers in regional and rural areas such as Port Macquarie, Coffs Harbour and Lismore.
Mid North Coast Local Health District
Added: 12 September 2014|Last updated: 23 October 2014
Deniliquin Collaborative Midwifery Group Practice

Deniliquin Collaborative Midwifery Group Practice

Deniliquin Collaborative Midwifery Group Practice (DCMGP) offers midwife-led services and General Practice (GP) shared care to women who chose to be cared for locally and birth locally if they have a low-risk pregnancy. Women with no identified risks are supported by a Midwife and share care arrangements with the GP, Obstetrician and Specialist Obstetrician. Women with an identified pregnancy risk, labour or postnatal period are linked with additional specialist services provided from Victoria....
Murrumbidgee Local Health District
Added: 10 September 2014|Last updated: 1 October 2014
Care To Come Home: CaTCH

Care To Come Home: CaTCH

A new Model of Care is being introduced at Lachlan Health Service (LHS) – Forbes and Parkes. Hospital in the Home (HITH) provides a choice of care at home or at a daily clinic instead of being admitted to hospital. This will provide quality care with less disruption for a smooth patient journey.
Western NSW Local Health District
Added: 19 August 2014|Last updated: 26 September 2014

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