Integrated person-centred systems of care for complex needs - Moving forward towards person-centred integrated care

Introduction  

The project aimed to provide an understanding of how best to move forward with the aim of implementing widespread integrated, person-centred care for people with complex needs in Australia. To do this we conducted an in-depth literature review in order to identify current best practice in this field and identify the current barriers and facilitators to best practice taking place. A data collection exercise was undertaken via interviews and surveys in order to understand the views of Community Options Australia’s stakeholder network on the topic.

Community Options Australia provides innovative solutions that connect and enable people to access integrated health and community care choices by partnering with respected, local organisations and practitioners.

Description of policy context and objective

For most people, most of the time, care is well-connected to their needs because those needs are straightforward and there are structured paths within the health and social care systems to meet them. But for some people their needs sit outside of these structured care pathways and care must be provided by multiple actors and agencies. In an uncoordinated system this is problematic, and it is more likely that their needs will not be met. As an organisation, Community Options Australia wants to address these issues in its own stakeholder community and beyond.

Project aims

•           To develop an understanding of best practice in community care informed by a global academic literature review and Community Options Australia stakeholder inputs.

•           To identify a care framework and principles drawing on existing frameworks and to outline a practice-based policy direction incorporating prioritisation on people with complex needs.

Targeted population

People who:

•           have complex health needs

•           are unable to navigate the systems of care without support (and that support is not available to them).

Highlights (innovation, Impact and outcomes)

The following factors are essential in developing integrated care in our context.

•           Establishment of oversight for integration across health and social care systems

•           Funding of ‘local’ (geographic and needs-based) large-scale and small-scale integrated care projects

•           Development of integrated ICT systems across key health and social care systems

•           Restructure of models of care to enable client and carer/family involvement in care planning

Comments on transfer-ability

The project evidence, and policy outcomes provide significant opportunities for funders and providers to person-centred integrated care. The learnings and conclusions should actively be transferred.

Conclusions (comprising key findings, discussion and lessons learned) 

Moving an organisation towards person-centred care involves changing values and practices within the organisation and amongst staff.

Enacting systemic change can only take place via explicit plans enacted at the macro system and meso service levels, and within the micro interactions between practitioners and clients. While systems change will facilitate more effective and radical change, no one of these levels needs to wait for the other but all parts of health and social care should be working together towards integrated person-centred care for people with complex needs.