Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project

In aging populations, multimorbidity (two or more chronic diseases in the same person) is very common. Patients with multimorbidity have complex health and social needs, are at risk of being admitted to the hospital or residential care home and require a wide range of interventions.

To satisfy the needs of these patients and their families, new innovative integrated care models are needed. To be effective, they should have primary care as the cornerstone of care, effective integration between care levels, empower patient and carers/families, and should be patient-centered. The use of information and communication technology (ICT) platforms could facilitate and improve communication promoting patient empowerment and home support. This innovative interoperability should increase effectiveness, efficiency, and equity.

The aim of the CareWell project was to implement and to assess the effectiveness of an integrated care program based on the coordination between health providers, home-based care, and patient empowerment, supported ...

Community health alliances as social enterprises that digitally engage citizens and integrate services: A case study in Southwestern Sydney (protocol)

Community health alliances (CHAs) are a population health approach for addressing the challenges faced by people who are united by a common area of residence, sociocultural characteristic or health need, and are generally characterised by a shared mission, shared resource needs and the task of acquiring/developing necessary organisational knowledge and skills. In South Western Sydney, CHAs are being explored as an innovative approach to support the provision of integrated health services. 

Much of the population live in local government areas with levels of disadvantage higher than the state average, with a predominance of non-communicable and chronic diseases that are typically associated with age-related and behavioural factors which necessitate integrated primary and social care. 

Social enterprises can utilise digital health interventions and citizen engagement strategies to integrate health services. 

This study aims to (a) explore how CHAs in South Western Sydney operate as social enterprises that utilise digital health and ...

A proposal to reform general practice and enable digital healthcare at scale

General practice has always been the foundation and gateway to the NHS. However the problems are mounting up: a stretched and increasingly burnt-out workforce, no systematic reporting or analysis of activity and demand, fragmentation with secondary care, and confusing and dated contracting and reimbursement mechanisms. The status quo is increasingly unacceptable to both patients and GPs. There is now a consensus that changes are needed, including to the small-scale independent contractor model, to ensure that primary care can thrive in the future.

Policy Exchange has set out a pragmatic proposal for reform. Addressing issues around integration, workforce, digital transformation and scaled provision, we argue that a new model of general practice is required to better meet the needs of patients and the taxpayer – so it feels increasingly at their service.

'Walking-the-talk': How to co-design an innovative and sustainable integrated care learning programme

Integrated care facilitates better outcomes for patients and their family, health workforce and health and social care systems. Accordingly, integrated care is a global and inherent area of work for health professionals. Despite this, formal learning programmes for workforce development in integrated care are still rare. In this paper, I have shared lessons about developing an innovative and sustainable integrated care learning programme for teachers, practitioners and learners in integrated care discipline. These lessons are drawn from my experience of leading an integrated care specialisation programme (that sits at Australian Qualification Framework Level 9) at a public university in Australia. An integrated care learning programme should be designed with appropriate philosophies (e.g., social constructivism and connected learning) and relevant multidisciplinary content that addresses deficiencies in practices of integrated care. Moreover, the programme should aim for sustainability, through financial feasibility and continuity with offering of creative and effective solutions in ...