Implementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in practice in South Eastern Sydney Local Health District (SESLHD)

Project Short Title
Integrated CPCC in SESLHD

Project Status
Current

Project Team
Dr Cathy O'Callaghan, Dr Ben Harris-Roxas, Ms Julie Osborne, Dr Damian Conway, Integrated Care Unit, South Eastern Sydney Local Health District (SESLHD)

Project Rationale

There is an increasing population with multi-morbidities that are at risk of unplanned hospital admissions and emergency department presentations.  This population could be better served through a model of coordinated care (the Integrated Care Program for People with Chronic Conditions -ICPCC) to manage their health at home.  Patients are selected for the program through an automated risk assessment algorithm in a Patient Flow Portal (PFP) and through chronic disease health professional referrals.

Project 

The Integrated Care Unit of SESLHD administering the ICPCC program enlisted CPHCE at UNSW to conduct this evaluation in order to understand:

a) how the ICPCC program has been implemented at Ministry of Health, Local Health District, program, and clinician/ patient levels;

b) the characteristics of patients included to the program through the risk stratification algorithm versus other referral processes; and

c) the key features of the program as exemplified through case studies of patients.

Project Design and Method

The data collected included qualitative research using interviews, a focus group and case studies, and descriptive statistical analysis of patient characteristics. 

Publications

O'Callaghan C. Implementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in practice in Sydney, Australia ICIC21, Virtual, 03 May 2021 - 27 May 2021 (Conference Presentation) Publisher URL 

 O’Callaghan C, Osborne J, Barr M, Conway D and Harris-Roxas B (2022) Implementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in SESLHD, Centre for Primary Health Care and Equity (CPHCE), University of New South Wales (UNSW), Sydney, research report.