Western Sydney is one of three Integrated Care 'Demonstrator' Local Health Districts - the others being Central Coast and Western NSW - to have received NSW Government funding to deliver system-wide approaches for integrating care at the local level.
Currently, the Western Sydney Integrated Care Demonstrator Program is the only program under Better Health Together. In the future, Better Health Together will be bringing together other chronic care programs being delivered across Western Sydney.
Under the Integrated Care Demonstrator Program, hospital clinicians in Western Sydney Local Health District are working in partnership with the Primary Health Network Western Sydney and other health agencies in the primary care, not-for-profit and private sectors to develop and progress approaches to integrated care for patients with chronic conditions. The program focuses on supporting patients with one or more of the following chronic conditions:
How the program works
Targeted patients will be enrolled into a Patient-Centred Medical Home in general practice and empowered to understand and manage their chronic disease. Care coordination and care navigation is a feature of the program, including Care Facilitators located within community and primary care to monitor and provide patients with referral to health coaching, self-management strategies and specialist and other health care services.
Once a patient is enrolled in Better Health Together, they will be at the centre of health services. Their main point of contact will be their Care Facilitator who will coordinate the services the patient needs by connecting them to services in the community, hospitals and private providers.