The Integrated Care (ICC) will commence in October 2015 and conclude on June 30, 2016. The ICC will consist of an Orientation session and 3 learning workshops, interspersed with activity periods.  


Wave Activities


The learning workshops will provide participants with the opportunity to hear from topic and quality improvement experts, and actively share knowledge and experiences with their peers. Participants will also learn about the Model for Improvement, which will enable them to test change ideas in their local setting and then reflect, learn and refine these tests.

Activity Periods are the periods of time between and after learning workshops. They enable the health service team to take the ideas and knowledge gained from topic experts and peers and adapt them to test in their own unique environment. Activity periods involve ongoing monthly data collection of all measures in the relevant topic areas, which enables participants to measure the impact of their improvement efforts. A vital component of the activity periods is the proactive and hands on support provided by support staff from the NNSWLHD and the NCPHN.

Patient selection process for the Northern NSW Integrated Care Collaborative

Each participating general practice and Aboriginal Medical Service will select a cohort of 10-20 patients with complex care needs. The selection criteria for the cohort are as follows: 

  • One or more diagnosed chronic illnesses;

  • Complex treatment regimens;

  • Frequent hospital/ED presentations in the previous 12 months;

  • Escalation of condition/s;

  • Measurable physical limitations;

  • Measurable mental limitation;

  • Social connectedness poor;

  • The patient would benefit from integrated care intervention;

  • One would not be surprised if this patient will go to hospital in the next 6 months,

Within the LHD, 20 patients will be selected by each Mental Health /Drug & Alcohol Service. The progress will be monitored through each area’s ED/Mental Health/ Drug and Alcohol Collaborative meeting.

Aims of the Northern NSW Integrated Care Collaborative

A topic aim is used to determine the progress of the topic work across the Collaborative as a whole. Topic aims usually involve a ‘stretch’ goal. Although the ‘stretch’ goal may not be easy to achieve, it provides an aspirational target to the group and any steps towards this goal are an improvement.

The Integrated Care Collaborative aims are:

  • That 200 or more patients with complex care needs are managed by an integrated care team;

  • That at the 9 month mark, there’s a 20% improvement in patients’ quality of life; and

  • That at the 9 month mark, there’s a 20% improvement in clinicians’ perceived connectedness of the system.

The Northern NSW Integrated Care Collaborative measures

The ICC has specific measures that are collected to help participating health services track their improvement in the topic area. These measures contribute to the overarching aim and are as simple to collect as possible. The aim is for usefulness, not perfection. It must be stressed that measures are reported to enable the tracking of improvement in the topic areas; they are not a performance management tool.

The ICC measures are:

  1. The number of patients enrolled on the complex care needs register in each participating general practice or Aboriginal Medical Service.

  2. The percentage of enrolled patients for whom a GP Management Plan and/or Team Care Arrangement has been created or reviewed within the previous 6 months.

  3. The percentage of enrolled patients with an Advance Care Directive in place.

  4. The percentage of complex care needs register patients with a Shared Health Summary (SHS) uploaded to the Personally Controlled Electronic Health record (PCEHR) or updated within the previous 6 months.

  5. The percentage of enrolled patients who present at the Emergency Department (ED) in the previous month.

  6. The average number of ED presentations per total number enrolled patients presenting to the ED in the previous month.

  7. The average number of SHS views for enrolled patients.

  8. The percentage of enrolled patients who have an unplanned admission to hospital in the previous month.

  9. The average number of occupied bed days for unplanned admissions for admitted enrolled patients in the previous month.

  10. The number of enrolled patients who have unplanned re-admissions to hospital in the previous month.

  11. The percentage of admissions of enrolled patients in which the GP is notified at the time of their admission to hospital.

  12. The percentage of discharges of enrolled patients in which a discharge summary sent to their usual GP within 48 hours post-discharge.

  13. The percentage of enrolled patients with a Discharge Summary uploaded to the PCEHR.

Please note that the participating general practices and Aboriginal Medical Services will submit data relating to measures 1-4 and the LHD will submit data relating to measures 5-13 on a monthly basis, including baseline data following the first learning workshop.

In addition, both patients and clinicians will report on their experiences with regard to improvements in the coordination of care. Patients will also report on their ability to undertake daily activities to reflect any improvements in their quality of life.

Patient Reported Measures

Responses to the Experience questions use a 5 point scale (Strongly Agree; Agree; Disagree; Strong Disagree; Undecided)

  1. Experience: Since being involved in the Integrated Care Collaborative, my care has been well coordinated (for instance, I could access services when needed, and everyone involved in my care had up to date knowledge of my condition). 

  2. Experience: At last three visits, I/my carer was involved as much as I wanted to be in decisions about my care and treatment.

  3. Experience: Thinking about the last three visits, my care team supported me to better understand and manage my condition(s).

Responses to the following outcome question use the following 5 point scale: Always, Usually, About half the time, Seldom, Never.

  1. Outcome: In the last month to what extent has your health allowed you to carry out your usual daily activities?

Clinician Reported Measures

Responses use a 5 point scale (Strongly Agree; Agree; Disagree; Strong Disagree; Undecided)

  1. Members of the team involved in patient care communicate (written and/or verbal) all relevant information to best inform care planning. 

  2. Information I receive about patients following consultations with other members of the care team is provided in a time that allows me to make informed decisions with patients. 

  3. The system is becoming more patient-centred to respond to individual patient needs and preferences.

  4. A well-connected service is a good description for the care that patients receive across the region. 


The handbook is a key resource for Collaborative participants. The handbook contains the key information about the relevant topic area, including the change principles, change ideas and practical examples drawn from the experiences of others. It provides participants with a useful starting point in addressing the challenges set for the ICC in delivering improvements in the quality of care.   

Foundation Change Principle: Build and maintain your team

Change Ideas

  • Set realistic goals

  • Communicate with team members on a regular basis

  • Engage the team

  • Assign roles and responsibilities

  • Reflect on and review what you are doing

Change Principle 1: Identify your complex cohort

Change Ideas

  • Agree on the cohort of complex care needs patients for the ICC

  • Develop a register of patients with complex care needs

  • Develop systems to identify patients on the complex care needs register at each clinical encounter

  • Build systems to maintain the accuracy of the register over time

  • Engage patients to review the accuracy of their clinical information

 Change Principle 2: Improve Your Own Systems

Change Ideas

  • Identify a care manager in your primary care health service

  • Develop agreed procedures/protocols for improving care management

  • Ensure patients understand when and how to access after-hours services

  • Use Computer Templates to Support Consistent Care Delivery

  • Integrate the perspective of patients and carers in the design of services

 Change Principle 3: Work as a team member

Change Ideas

  • Identify the ‘Integrated Care Team’ for each patient at each encounter

  • Use tools that improve communication between all members of the Integrated Care Team

  • Ensure communication systems are reliable and support delivery of safe and high quality care

  • Engage the patient to develop new strategies for sharing information with their whole care team

Change Principle 4: Improve Patient Self-management

Change Ideas

  • Establish clear definitions of self-management and what self-management support involves

  • Organise internal and external resources to provide patient-centred, self-management support

  • Implement a strategy for self-management support to empower patients and carers to better understand and manage their condition and risk factors

  • Implement processes and systems to support patients with advance care planning

 Change Principle 5: Improve the wider system

Change Ideas

  • Look for opportunities to improve the way the health system works from a patient’s point of view

  • Review and improve the patients care pathway by identifying issues regarding access and gaps in care based on the individual patient journey

  • Implement systems and processes to review the patient journeys and care pathways regularly to avoid wasteful practices and interactions

  • Contribute to and inform development of localised health pathways