Building healthy strong communities: Integrating health and social care through system transformation Introduction: We describe here the development of a person-centred integrated care policy framework for central and inner-west Sydney Australia.

Introduction: We describe here the development of a person-centred integrated care policy framework for central and inner-west Sydney Australia.  The purpose was to provide an overarching policy framework for the system transformation initiatives being undertaken in Sydney Local Health District (SLHD).

Description of policy context and objective: In March 2014, the New South Wales (NSW) State Government of Australia announced the NSW Integrated Care Strategy and two integrated care initiatives were commenced in SLHD. In 2015 the NSW Social Policy Cabinet Committee approved the testing of different service delivery and governance models in four districts including SLHD.  A Healthy Strong Communities Consortium was established within Sydney Local Health District and a number of integrated care initiatives were commenced, or strengthened.  Collaborative interagency consultation was undertaken to develop interagency plans for children, families, and young people.  There remained a need to develop an overarching integrated care policy framework to support on-going whole-of-system transformation.

Targeted population: SLHD is located in the centre and inner west of Sydney.  The District has 640,000 local residents and a large number of people travel to the District for work and education.  There will be a population growth rate of 40% between 2016-2036 with number of urban development projects.

Highlights: The policy development drew on extensive community consultation undertaken as part of the District planning process, place-based community needs assessments, and both person-centred and partner agency-centred evaluation studies.  The consumer consultation projects included: interviews with patients experiencing long hospital stay, care-givers of vulnerable children, and focus groups in socially high need communities.  Partner consultation included: interviews and surveys of primary care and hospital providers; consultation forums; and Delphi and mixed-method social network studies.

A whole of system approach was taken underpinned by the policy direction provided by the: WHO framework on integrated people-centred health services; NSW Social Policy Committee service delivery reform initiative; and the NSW Integrated Care Strategy.  The integration of health and social care is a particular innovation and focus of the policy framework.  Six inter-dependent priority areas were identified with a focus on integrating care and system transformation.

Leadership and governance

Creating supportive systems and enabling environments

Collaboration and coordination – working together

People and communities first – empowering and engaging

Innovative models of care

Evaluation and Research.

The framework was mapped to five strategic focus areas:

Population health and wellbeing

Partnerships with people and communities

Systems of care

Building workforce confidence, support and capability

Research, education and innovation.

Comments on transferability: The framework is transferable as it is consistent with the WHO framework on integrated people-centred health services and utilises foundational integrated care approaches found in the: Alama Ata Declaration; Triple Aim; population stratification (Kaiser Permanente); and the Rainbow Model of Integrated Care proposed by Valentijin (2015).

Conclusion: The process of developing the framework has enabled the engagement of hospital, community and consumer partners in discussions regarding integrating care and transforming the current system and initiation of new rpojects in relation to health literacy, consumer engagement, workforce capacity building and systems integation.