An Integrated Care model for Peri-End-of-Life support

1. An introduction

The way the Australian health care system manages people in the last few years of life is clinically and economically misaligned, often delivering a poor experience to patients and their families.

2. Short description of practice change implemented

Implement a networked care model that aims to be comprehensive, person centred, and integrates health with social care, and clinic with community care.

3. Aim and theory of change

To develop an evidence based new model of care which aims to redress the clinical and economical misalignment by integrating health and social care, reducing hospitalisations and improving client experience.

4. Targeted population and stakeholders

The service is designed for clients that are over 65, live in the community, reside in metropolitan Perth, have two or more chronic conditions and have had between one and five hospital admissions in a year.

5. Timeline

The service has been developed over the past 2 years

6. Highlights

A peri-end-of-life service branded Integrum Aged Care+ has been co-designed with McKinsey and Co, based on feedback from key stakeholders and with support from WA Primary Health Alliance (WAPHA).  The dedicated service integrates medical and non-medical health and social care services to deliver care in the community as opposed to within the hospital setting. Clients receive a high level of case management from a registered nurse focused on the co-ordination and monitoring of health and social care needs, supported by a multidisciplinary team.

As part of the intervention, new technologies are being deployed including active in-home monitoring and video technologies that puts the client at the forefront of the telemedicine experience.

7. Comments on sustainability

The services financial model has been designed to result in a financial breakeven point within the first three years, utilising existing funding mechanisms.

8. Comments on transferability

Whilst initially developed in Western Australia, the model has commenced implementation in South Australia.  It is also thought that it could be used in place of Health Care Homes.

9. Conclusions

This initiative is an integral part of testing a technologically enabled alternative networked care model for people with complex conditions in the last years of life where health and aged care models intersect.

The service has undergone a qualitative evaluation of the client experience by Curtin University; and an economic evaluation by PricewaterhouseCoopers (PwC) which measures hospitalisations against a control group. Initial results indicate a marked reduction in hospitalisations and improved client experience.  The results have been requested by the Royal Commission into Aged Care Quality and Safety for consideration into their recommendations.

10. Discussions

This model has been noted within the WA Sustainable Health Review and the Royal Commission into Aged Care Quality and Safety as an option to improve aged health care in Australia.

11. Lessons learned

Key lessons have been that clients have good access to Primary Health Care however coordination and integration of care is lacking, which is where this model has potential to strengthen the existing system and improve outcomes for clients.