The goal is to effectively manage your patient's health and wellbeing in their local primary healthcare setting, prevent acute or chronic condition deterioration, provide appropriate intervention whenever necessary and minimise the need for patients to present at hospital emergency
- Patients enrolled in the Western Sydney Integrated Care Program have improved access to a broader range of support services across the primary,
secondary and community healthcare settings in western Sydney.
- The patient's GP will develop a personalised, shared care plan with the support of a dedicated Care Facilitator; a registered nurse who will actively help the patient to maintain and monitor their care plan and to coordinate allied health and specialist services.
- Patient information will be shared between GPs, hospitals and allied health via the LinkedEHR system for continuity of care and to minimise duplication of services.
A partnership approach to integrated care
The Western Sydney Integrated Care Program is coordinated by the Western Sydney Local Health District (WSLHD), Western Sydney Primary Health Network (WentWest) and other partners to improve support for your patients with one or more chronic health conditions involving congestive cardiac failure, coronary artery disease, COPD or diabetes.
Key components of the Western Sydney integrated care program
- Patient Centred Medical Home
- Integrated care team
- Care facilitation
- Case conferencing
- Capacity building
- GP Support line
- Rapid Access Specialist Services clinics
Integrated Care Program in practice
How integrated care works in western Sydney
- A Care Facilitator (a registered nurse with expertise in chronic care management) to work with you and your patients to better manage their chronic condition
- Development of a Shared Care Plan that can be viewed in cerner (using LinkedEHR)
- Shared patient information including health summary and clinical metrics between hospitals, GPs and allied health
- Improved access to a range of support services across the health community
- Patient self-education resources
Becoming part of the Western Sydney Integrated Care Program
For general program information call - 1800 113 644
To speak with an integrated care specialist call - 1300 972 915
More information for GPs on how to be a part of Better Health Together