Health System Integration and Primary Health Care Development

Description and aims

This stream is focused on the role of primary health care in improving health and social care integration. Integration is approached at a number of levels and perspectives with the ultimate objectives of improving health and well being, service user experience and system efficiency/effectiveness.

Key current research areas

Primary Health Care System Development

PHC System Development is concerned with the development of organisations, systems, capacity and frameworks needed for a strong Primary Health Care system. This includes the organisational structures including LHDs, PHNs, and emerging Australian models of Patient Centred Medical Homes and Neighbourhood

Improving integration of services and continuity of care

Improving Integration is concerned with the way that different parts of health and related systems work together to provide comprehensive and well-coordinated primary health care. This includes integration within primary health care and with other sectors, including hospitals.

Access to Primary Health Care

Access to PHC is concerned with patterns of access to quality Primary Health Care. This work includes studies of access to primary health care for people with diabetes, using data from population health surveys and linking records from hospital and other data sets.

Key partners

Partnerships and working together at individual and organisational levels are central to improved integration. Our key partners are consumer and health professional representative organisations, PHNs, LHDs, community organisations and related sectors such as local government, education, employment etc.

Stream lead

Margo Barr leads this stream.



Bilingual Community Health Navigators in General Practice

Nearly half of the Australians are suffering from chronic illnesses who require frequent visit to health service. However, the health system is too complex to navigate for the patients in Australia. This project focuses on to explore the feasibility and acceptability of involving bilingual community navigator in general practice setting to facilitate smooth navigation of the chronic patients from Culturally and Linguistically Diverse (CALD) background to the health and social care services.

Central and Eastern Sydney Primary and Community Health Cohort

The Primary and Community Health Cohort is a sub-study of the the Sax Institute’s 45 and Up Study.  It includes data on 31,000 Study participants living in Central and Eastern Sydney.   This is linked to data from NSW admitted patient and emergency department systems, Medicare and the Pharmaceutical Benefits Scheme and the NSW register of deaths.  

Community Health Workers

Community Health Workers

This project aims to develop and evaluate the role of Community Health Workers (CHWs) in primary health care in Australia.  It includes a range of projects and activities including a systematic review of the literature on CHWs’ role in enhancing preventive care in the community and an evaluation of the Xtend program which involves CHWs in following patients up post discharge to prevent readmission.  It is intended to extend this with work with trials to evaluate their effectiveness in the prevention of hospitalisation especially for people with multiple long-term conditions and/or who live alone and of their role in general practice in preventive care for vulnerable population groups.

Community Health workers Extending Care in the Community (CHECC)

This is a study in Sydney Local Health District of Community Health Navigators (CHNs) providing follow up care for patients as they move hospital to the community.  The first phase of the study is a co-design stage that involve the key stakeholders working together to identify training and supervision needs. The second phase is a randomised trial evaluating the impact of CHN follow up following discharge from hospital.

Extended Caregiving Arrangements in Families from Chinese Backgrounds Project

Extended Caregiving Arrangements in Families from Chinese Backgrounds Project is a partnership between Multicultural Health Service (MHS) and Child Youth and Families Service (CYFS) at South Eastern Sydney Local Health District and South Eastern Sydney Research Collaboration Hub (SEaRCH) at University of New South Wales. The project seeks to develop a culturally sensitive service response to enhance child development and wellbeing.




A comparative case study of how different models of integrated primary health care centres optimise access and integration

This was an 18 month qualitative case study  comparing different models of integrated  primary health care centres that  examined  how they optimised access and integration, the enablers and barriers and to how far they had developed   more integrated and accessible services

A framework for strengthening the integration of primary and community health services for small rural/remote communities in Hunter New England Area Health Service

This project involved the development of a framework for strengthening the integration between the Regional Health Services Program and other primary and community health services for very small rural/remote communities in the Hunter New England Area Health Service

A framework for strengthening the integration of primary and community health services for small rural/remote communities in Hunter New England Area Health Service

This current project is built on the 2005 evaluation of the Hunter New England Health program, by specifically examining the relationship with other services and considering how the learnings and achievements could be more widely disseminated and taken up by other primary and community health services.

Access to allied psychological services programme evaluations

The Access to Alied Psychological Services programme is a national initiative to improve access to focussed psychological strategies for consumers with symptoms of anxiety and depression.

Advance Care Planning for patients with advanced illnesses attending hospital outpatient clinics

Advance Care Planning (ACP) is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care, for a time when they are not competent to make, or communicate, decisions for themselves. ACP could significantly improve the quality of care provided to patients with advanced diseases by allowing patients to receive patient centred care and avoid unwanted/inappropriate hospital admissions and treatments.




Collaboration between health professionals across organisational boundaries: a case study of diabetes

Multiple methods qualitative study investigating factors influencing collaboration across organisational and professional boundaries.