WESTERN SYDNEY INTEGRATED HEALTH PARTNERSHIP FRAMEWORK 2017-2020
Integrated health is about people, families and communities being involved in decision making about their health and wellbeing, having enabling environments, groups and services which support their needs. Western Sydney stakeholders working group, 2015 Our vision To create an environment where people can live well, stay well and manage well with support through a unique collaborative strategy. Live Well Western Sydney will be a place that enables people to live healthy, happy and purposeful lives. Health and social agencies will partner as one to optimise improved health, wellbeing and safety. Stay Well People are supported to improve their health and to live to their full potential. Manage Well Individuals, their family and carers are active participants with a collective responsibility for optimising health outcomes. We are committed to working in partnership to deliver better health together. 2
Executive Summary Western Sydney is diverse with nearly 1 million people with significant pockets of financial and social disadvantage producing a range of complex health and social needs for individuals, families and communities. The region faces concerning health trends: a growing disease footprint; an overweight population; childhood obesity; rising mental health issues; diseases and disorders associated with ageing; and increasing complex chronic conditions. Western Sydney has one of the sickest populations in Australia. A total of 57.3 per cent of people have one of four health risk factors. The resulting demands place enormous pressure on healthcare resources and the ability to respond with sustainable, quality healthcare. Western Sydney Local Health District, the Sydney Children s Hospitals Network, and Western Sydney Primary Health Network have a shared commitment to strengthening collaboration and consolidating significant investment in innovation and healthcare integration models and strategies. As partners, we recognise the value of having a vision that aligns across each of our organisations. We are committed to an environment a way of working that enables an improvement in health and social outcomes and is in alignment with the quadruple aim of: 1. Improved patient/consumer experience 2. Better outcomes 3. Lower costs; and 4. Improved clinican and provider experience. There is a strong commitment in western Sydney through our shared partnerships to drive innovation which addresses systemic gaps and strengthens the interface between our services to promote health, wellbeing and resilience. Our five collaborative priorities are: child, youth and family health; chronic and complex diseases; mental health; Aboriginal health; and older person s health. At its heart, our vision places the consumer at the centre of all that we do, encapsulating the process of our collective thinking about the environment in which chronic and complex care, and social support is coordinated and delivered and where western Sydney aims to be positioned into the future. A collaborative partnership with consumers, key agencies and organisations provides for integrated and seamless pathways across the system. Increasingly, a focus on achieving optimal outcomes through an integrated whole-of-system way of working has resulted in the broadening of partnerships though service delivery reform to include key human service and justice agencies including, but not limited to NSW Family and Community Services (FACS), NSW Department of Education, NSW Department of Premier and Cabinet, NSW Juvenile Justice, and the NSW Police Force. At the centre of this alliance is a focus on the consumer and the community and a commitment to improve health outcomes especially for vulnerable populations. The Western Sydney Integrated Health Partnership Framework 2017-2020 is designed to strengthen the governance framework and focus of our efforts for delivering on our shared priorities, promoting leadership in driving these initiatives, enhance networking arrangements, utilising existing governance systems, working together in a trusted environment with a shared vision and principles leading to measurable inputs, objectives and outcomes. Working together puts us in the best position to improve population health, consumer care and satisfaction with services, outcomes and pathways. Shared accountability and collective carriage of programs are key features of this alliance which will continue to drive improvements in healthcare integration, ultimately improving the consumer experience, outcomes and satisfaction. 3
Contents 05 Foreword 06 Our Aim 06 Background 07 Our Western Sydney Community 09 Integrated Health Framework 10 Partnership Priorities 11 Partnership Principles 12 Governance 14 Execution 15 Abbreviations and Glossary 4
Foreword Danny O Connor, Michael Brydon and Walter Kmet Western Sydney Local Health District (WSLHD), Western Sydney Primary Health Network (WSPHN), and the Sydney Children s Hospitals Network (SCHN) are pleased to present the Western Sydney Integrated Health Partnership Framework 2017-2020. It outlines our vision, goals and priorities for the next four years. Deliberately ambitious, it reflects our optimism in what can be achieved collectively working as a team. A strong collaborative relationship will address common health and system issues more efficiently by sharing resources and assisting each other formally and informally. One of our key priorities is working with our community, in particular disadvantaged and vulnerable families and people, Aboriginal, and culturally and linguistically diverse (CALD) communities to improve health outcomes. We have a strong, long-standing alliance working together on a range of programs which have been formalised through the Western Sydney Partnership Advisory Council comprising the board chairs, chief executives and senior staff from each of our three organisations. Importantly, our key priorities and programs are a result of broad consumer engagement and consultation. There is a strong recognition that the nature of long-term, chronic and complex conditions require the commitment of the consumer in self-management, and the wider contribution of community and other sectors. The collaboration leverages service delivery reform and partnerships with key government and non-government organisations (NGOs) including the NSW Department of Premier and Cabinet, NSW Department of Education, NSW Family & Community Services, NSW Juvenile Justice, and the NSW Police Force which address social determinants of health. The Western Sydney Integrated Health Partnership Framework 2017-2020 provides an overview of the health and social challenges faced in western Sydney. It outlines key priority areas, implementation, and governance, including our approach in working with consumers as we seek to address the escalating prevalence of chronic health conditions, increased demand for health services, and need for improved population prevention strategies. Our communities and those who rely heavily on our services can be confident we are working in partnership and as a team holding each other accountable for achieving the outcomes outlined in this framework. We are dedicated to achieving better health outcomes for the people of western Sydney. Danny O Connor Chief Executive Western Sydney Local Health District Dr Michael Brydon Chief Executive Sydney Children s Hospitals Network Walter Kmet Chief Executive Officer Western Sydney PHN (WentWest) 5
Our Aim The purpose of this document is to outline the Western Sydney Integrated Health Partnership Framework 2017-2020 which has been developed to guide the progression of integrated health partnerships for the next three years. It articulates the vision of improved health outcomes for those most in need in our community, and the priority areas which have been identified for an integrated partnership approach. Background The Western Sydney Partnership Advisory Council, based on long standing professional relationships, was formed in 2012 comprising WSPHN (WentWest), WSLHD and was extended more recently in 2014 to include the Sydney Children s Hospitals Network. The council brings together the chief executives (CEs) and chief executive officer (CEO) of these organisations to address common strategic and health priorities. It promotes collaboration, communication, engagement and decision making to assess, prioritise and plan for services to best meet local healthcare needs. The partnership organisations have a shared commitment to strengthening collaboration and consolidating significant investment in innovation and healthcare integration models and strategies for the people of western Sydney. The Western Sydney Partnership Advisory Council is committed to ensuring our western Sydney communities have the best opportunity for good health and quality healthcare. Integrated health in western Sydney is focused on: Ensuring the community, family and individual is at the centre of all we do Understanding health risks and working together to prevent health problems Educating and empowering self-care Working in partnership with other groups that impact on the health and social wellbeing of our communities; and Recognising the importance of primary healthcare providers and hospitals working together to ensure services are tailored to meet the needs of local communities. Everyone in western Sydney, particularly our most disadvantaged and vulnerable peoples require integrated and seamless pathways across the system. 6
Our Western Sydney Community Western Sydney is diverse with nearly 1 million people with significant pockets of financial and social disadvantage producing a range of complex health and social needs for individuals, families and communities. Western Sydney is home to the highest urban population of Aboriginal people in NSW, and a commitment to closing the gap in health outcomes is fundamental. Improving the health status of CALD groups, notably emerging communities and refugees is a priority. The Western Sydney Integrated Heath Partnership Framework supports joint planning and delivery of services for vulnerable priority populations who may not access them as frequently as other groups and whose needs may be more complex and enduring. Socioeconomic advantage and disadvantage poses challenges for delivery of equitable health services. All LGAs face challenges in addressing health needs associated with an ageing population, prevalence of chronic disease and risk factors for premature mortality. The region faces concerning health trends: a growing disease footprint; an overweight population; childhood obesity; rising mental health issues; diseases and disorders associated with ageing; and increasing complex chronic conditions. The resulting demands place enormous pressure on healthcare resources and the ability to respond with sustainable, quality healthcare. There is a strong commitment in western Sydney through our shared partnerships to drive innovation which addresses systemic gaps and strengthens the interface between services to promote health, wellbeing and resilience. We are dedicated to developing integrated models of healthcare in the most appropriate settings that deliver optimal health and social outcomes for all those who live in western Sydney. Primary and secondary healthcare initiatives provided in an integrated partnership approach will continue to be strengthened to tackle these demands. CHILDREN AND YOUNG PEOPLE WESTERN SYDNEY DEMOGRAPHIC ADULTS AND ELDERLY 1 in 7 children currently have asthma More than 1 in 4 children are overweight or obese 1 in 5 children are developmentally vulnerable 1 in 10 young people report high levels of psychological stress Dental decay among 6 year olds is increasing 18 per cent of 16-24 year olds smoke Medical-related admissions account for nearly 69 per cent of all inpatient activity It is estimated ED presentations at The Children s Hospital at Westmead will increase by 24 per cent by 2026 Large: Estimated 926,910 residents in 2015 Young: A larger proportion than NSW average aged less than 45 years. Young adults (25-34 years) and children (0-4 years) are the dominant groups Ageing: In 2025 there will be 49,308 more people aged 65 years and older compared to 2015 Growing: A predicted population increase of 15.8 per cent from 2013 to 2021 will make it the fastest growing metropolitan LHD in NSW Culturally Diverse: The largest urban Aboriginal population in NSW: 42.7 per cent of our community were born overseas and 44.9 per cent speak a language other than English at home. Cancer and cardiovascular disease are the most common causes of death 1 in 2 adults have an increased risk of being obese There is a 10-20 per cent higher incidence (compared to the NSW average) of chronic disease such as diabetes or chronic obstructive pulmonary disease (COPD) The premature death rate is above the national average for COPD and cardiovascular conditions Less than 10 per cent of adults consume the recommended amount of vegetables and just more than 50 per cent consume the recommended fruit Source: The Children s Hospital at Westmead Clinical Services Plan 2016 Technical Paper. March 20 2016. Version 1.4 Sources: Epidemiology and Health Analytics. Epidemiological Profile WSLHD Residents. Sydney: Western Sydney Local Health District, 2016 Sources: Epidemiology and Health Analytics. Epidemiological Profile WSLHD Residents. Sydney: Western Sydney Local Health District, 2016 7
Our Western Sydney Community continued BLACKTOWN PRECINCT OF BLACKTOWN LGA* Profile: Large Aboriginal and Torres Strait Islander population Need: High avoidable COPD rates MOUNT DRUITT (SOUTH WEST OF BLACKTOWN LGA*) MOUNT Profile: Large Aboriginal DRUITT and Torres Strait Islander HOSPITAL population Need: High rates of physical inactivity, smoking, alcohol use and obesity, mental health concerns HOLROYD* Profile: In top three of increasing population densities within western Sydney Need: High use of National Diabetes Service Scheme (NDSS). Registrants for type 2 diabetes 87 per cent Blacktown LGA The Hills Shire LGA Holroyd LGA Parramatta LGA Auburn LGA HILLS SHIRE* Profile: High rates of social advantage Need: High percentage of Home and Community Care (HACC) clients living alone PARRAMATTA* Profile: Greater ageing population, high rates of disadvantage, ethnically diverse Need: High rates of type 2 diabetes AUBURN* Profile: Ethnically diverse population Need: High prevalence of smoking * Pre-amalgamated LGAs CONSUMER AND COMMUNITY ADVISORY Each of the partnership organisations acknowledge the importance of consumer and community input and draw on their respective consumer and community advisory councils in a collaborative partnership to validate, receive and respond to advice on needs, health priorities, service planning and design and opportunities for improvement. 8
Integrated Health Partnership Framework The Kings Fund argues current fragmented services fail to meet the needs of the population and integration can improve patient experience, outcomes and efficiency of care. Key success factors to make integrated care happen at scale and pace include 1 : 1. Finding a common cause 2. Developing a shared narrative 3. Creating a persuasive vision 4. Establishing shared leadership 5. Understanding new ways of working 6. Strategic targetting 7. A bottom-up and top-down approach; and 8. Pooling resources. The Western Sydney Integrated Health Partnership Framework aims to deliver on these key success factors. The concept of the Western Sydney Integrated Health Partnership Framework was born out of consideration of the above key success factors in facilitated workshop discussions and consultations over 12 months of engagement. Two significant change management forums were conducted in 2015 with 200 stakeholders representing consumers, primary and secondary care providers including NGOs. They set the vision for what integrated health means for western Sydney. Working together puts us in the best position to improve the health and wellbeing of our community and provide improved patient care, outcomes and pathways by moving care, where appropriate, to the most desirable setting. We will promote flexible approaches to meet our communities specific needs. To achieve optimal outcomes, an integrated whole-of-system way of working is essential. The Integrated Health Partnership Framework outlines a collaborative approach that effectively brings together groups from different sectors to work toward joint outcomes, where the focus is on action. Importantly, each collaborative partner has a shared interest and commitment to improving wellbeing and health integration. Driven by consumer need, collectively we aim to: Ensure a coordinated approach to service planning and delivery across our shared catchment, prioritising service gaps and challenges together Develop agreed common, seamless and complementary pathways Work collaboratively to deliver more care in the primary care setting Refine our models of care approach through the State s Integrated Care Demonstrators, and new integrated models of care. Develop new ways of working in partnership to improve patient/consumer care, access, outcomes and pathways; and Create opportunities to share resources, ideas, knowledge and experience to improve care through partnerships at the frontline. We are committed to advocating to the NSW and Australian governments for funding and policy reform to establish more suitable and flexible approaches that promotes shared information, shared care and a whole of system approach which is supportive of healthcare integration. The Western Sydney Integrated Health Partnership Framework aims to align our way of working to get the system and its sub-components coherently organised and interconnected within a highly functioning structure. We are committed to an environment a way of working that enables an improvement in health and social outcomes and is in alignment with the quadruple aim of: 1. Improved consumer experience 2. Better outcomes 3. Improved costs 4. Improved clinician and provider experience 2. THE QUADRUPLE AIM Lower costs Better outcomes Improved patient/consumer experience Improved clinician experence 1. Ham & Walsh. March 2013 2. http://www.medaxiom.com/lets_make_2016_the_year_of_the_quadruple_aim 9
Partnership Priorities Building on work undertaken through the Western Sydney Partnership Advisory Council, SDR, and FACS partnerships, western Sydney has a strong commitment to an integrated approach to improve health and wellbeing through partnerships. The Western Sydney Partnership Advisory Council agreed on five collaborative priorities. These were endorsed at stakeholder forums which brought together more than 200 consumers, partner organisations such as NGOs, local councils, and government departments. They are: child, youth and family health; chronic and complex diseases; mental health; Aboriginal health and older person s health. Each priority has sub-components identified by integrated care stakeholder groups including transitional care, advance care planning, palliative care, rehabilitation, and acute and post-acute care. Child, Youth and Family Health WSLHD had the State s largest increase in the number of births between 2010-2014. By 2036, more than 300,000 children aged 0-14 are projected to be living in western Sydney. We already have the highest number of preschool aged children in NSW. Disadvantage, poverty and inequality are contributors to poorer outcomes for health and wellbeing. There will be an increasing demand to ensure our children grow up healthy, safe and well. Chronic and Complex Diseases A total of 57.3 per cent of western Sydney residents have one of four health risk factors. Western Sydney is a diabetes hotspot with an estimated quarter of the population likely to be affected by prediabetes or diabetes. Mental Health Mental Health is a major health issue in western Sydney, with access to services considered lower than State and national rates. One in five Australians will experience a mental disorder in their lifetime. Aboriginal Health Western Sydney has one of the largest urban Aboriginal populations in NSW, with significant gaps in health outcomes between Indigenous and non-indigenous Australians. Specific strategies are required to help close the gap for Aboriginal people in western Sydney. Older Person s Health Older people are known to be high users of health services, with increased conditions related to ageing. The number of people 70 years and older is expected to more than double by 2036. 10
Partnership Principles Our organisations have identified a set of principles that will be used to support collaborative projects and programs. They guide the way in which we work together to achieve our shared purpose. To maximise the benefit to our community, we will ensure collaborative efforts adhere to the following principles that will improve health outcomes for the community: EQUITY AND ACCESS TO SERVICES We will identify and prioritise vulnerable communities CONSUMER & COMMUNITY ENGAGEMENT We will partner with consumers and community to plan, develop, design and evaluate our services TEAMWORK Will be demonstrated through responsive and timely action of each party and a willingness to make the collaboration succeed TEACHING AND RESEARCH We will commit to learn together and grow the body of knowledge of integrated health PERSON-CENTREDNESS To be considered in all aspects of service planning and delivery STRONG PARTNERSHIPS & COLLABORATION We will enhance the capacity of partnership and partner with who we need to in order to improve health and wellness PRIVACY & CONFIDENTIALITY We will share data in a responsible, respectful and secure manner SHARED GOVERNANCE At the most senior level we will make commitments to deliver joint programs and monitor outcomes MUTUAL BENEFITS AND SHARED RESPONSIBILITES We will share responsibility, accountability and resources to deliver on our priorities 11
Governance The Western Sydney Integrated Health Partnership Framework leverages and strengthens the existing partnership between the organisations and consumers to provide a shared governance structure for each of the agreed priorities to coordinate strategies and activities, support and monitor performance, and assist with issues resolution. Governance is delivered through the following structures: Western Sydney Partnership Advisory Council Senior leads; and Priority area steering committees inclusive of consumers. A senior lead, as part of their substantive position, from each partnership organisation is assigned within each of the priority areas. Senior leads will hold a coordination function for each of the priority areas of work, and will be a conduit between the steering committees and the Western Sydney Partnership Advisory Council. There will be an accompanying description of roles and responsibilities for each senior lead to guide consistency and inter-organisational support and commitment in meeting priority area objectives. Each priority area, where appropriate, is actioned in collaboration with initiatives as part of our relationship with human service agencies within the SDR and the FACS-health partnership. Steering committees are chaired or co-chaired by a nominated representative from a partner organisation with expertise in the priority program of work. They are guided by terms of reference and a strategic brief. Chair nominations and terms of reference are approved by the Western Sydney Partnership Advisory Council. Each steering committee is responsible for identifying goals, strategies, outcome measures and communication. Committees contribute to quarterly and annual stakeholder forums providing a broader link with stakeholders with an overview of programs and services operating across the region. The steering committees report to the Western Sydney Partnership Advisory Council and their respective boards. WSLHD SCHN WSPHN BOARDS WESTERN SYDNEY PARTNERSHIP ADVISORY COUNCIL SENIOR LEADS STEERING COMMITTEES CHRONIC & COMPLEX DISEASES CHILD, YOUTH & FAMILY HEALTH MENTAL HEALTH ABORIGINAL HEALTH OLDER PERSON S HEALTH 12
Governance continued WESTERN SYDNEY PARTNERSHIP ADVISORY COUNCIL The Western Sydney Partnership Advisory Council comprises the chief executives of each organisation and their key policy, planning and/or partnership staff. It sets the strategic direction and priority areas for collaboration in health services delivery and monitoring. There is a commitment from all partners to resource the priority work areas to enable effective implementation to the best of each organisation s capacity. Regular newsletters and reports on progress against health priorities to the community and stakeholders will be distributed. The following details the functions within the governance structure: STEERING COMMITTEES Chaired or co-chaired by a nominated representative from the partner organisations, the steering committees utilise specialist expertise to develop, implement and monitor: Terms of reference A strategic brief that outlines the vision, objectives and drivers etc The work plan for their program Goals, strategies, outcome measures; and A communications strategy. SENIOR LEADS The senior lead represents activities within the priority areas and coordination across priority areas. They provide senior sponsorship to programs of work and are responsible for: Guiding and establishing cross-collaboration linkages between steering committees where deemed appropriate Coordination and liaison across their respective organisations and other partners Supporting and working with the chair/co-chair and secretariat to deliver outcomes Facilitating communication across the governance structure, and to stakeholders such as consumers, NGOs, and government departments Advising on issues and proposing resolutions to the Western Sydney Partnership Advisory Council; and Evaluation, sharing ideas and learnings on outcomes and progress. CHAIRS AND CO-CHAIRS The chair and co-chairs provide leadership and direction to the steering committees. They have expertise in the priority program of work. The chair and co-chairs responsibilities are outlined in a role description and guided by terms of reference and a strategic brief. These include: Actioning the vision and commitments of the CEs and CEO by providing coordination and oversight of the programs of work Ensuring broad strategy development across the work plan Advising of issues and proposing resolutions to the Western Sydney Partnership Advisory Council in conjunction with the senior leads; and providing Evaluation, sharing ideas and learnings on outcomes and progress. CONSUMERS Nominated consumer representatives form part of the membership of each steering committee and are invited to: Provide input, advice and feedback to goals and strategies in the work plan Assist in the co-design of service development and consumer engagement strategies (including the evaluation of these); and Share learnings and ideas (where appropriate) in other forums they may be involved in across the primary and secondary healthcare settings. Overarching Commonwealth, NSW and local health plans inform the work of the steering committees and key performance indicators (KPIs) are developed for each priority area. Each steering committee will advise the Western Sydney Partnership Advisory Council through the senior leads on emerging policy, practice or resourcing issues. The senior leads will provide the Western Sydney Partnership Advisory Council with a short summary on progress against priority area work plans and KPIs. Each steering committee is responsible for developing communications for their respective organisations and ensuring adequate consumer participation. 13
Execution The first six months to June 2017 will see the: Development of an implementation plan and timeline for the Western Sydney Integrated Health Partnership Framework A review of the terms of reference of the Western Sydney Partnership Advisory Council Nomination of the senior leads; and Completion of partnership program mapping. By the end of 2017, steering committees with nominated chairs and consumer representatives will be established as will: Terms of reference and strategic briefs with KPIs for each steering committee Role descriptors for the chairs and senior leads of each steering committee; and Work plans by each steering committee with reporting processes in place. The success of the Western Sydney Integrated Health Partnership Framework will be evaluated through: Sustainable and seamless pathways in partnership priority areas resulting in measurable improvements in population health Improved consumer experience due to innovative approaches to care and equitable access to services Lower costs for care with equal or improved health outcomes as a result of sharing of resources, knowledge and experience; and New provider opportunities derived from integrated health partnerships, realising an improved clinician and provider experience. 14
Abbreviations and Glossary CALD CE/s CEO COPD CHW HACC KPI/s LGA/s LHD NDSS NGOs PHN Culturally and Linguistically Diverse Chief Executive/s Chief Executive Officer Chronic Obstructive Pulmonary Disease The Children s Hospital at Westmead Home and Community Care Key Performance Indicator/s Local Government Area/s Local Health District National Diabetes Service Scheme Non-Government Organisations Primary Health Network The King s An independent charity working to improve health and Fund care in England WSLHD WSPHN SCHN SDR Western Sydney Local Health District is responsible for providing and managing public healthcare in 120 suburbs comprising the five preamalgamated LGAs of Blacktown, The Hills Shire, Holroyd, Parramatta and Auburn Western Sydney Primary Health Network, WentWest, is focused on addressing both regional and national health challenges. Together with health professionals, partners from the health and hospital sector, consumers and the broader community, WentWest seeks to identify gaps and commission solutions for better health outcomes The Sydney Children s Hospitals Network incorporates The Children s Hospital at Westmead, Sydney Children s Hospital, Randwick, Bear Cottage, the Newborn and paediatric Emergency Transport Service (NETS), the Pregnancy and newborn Services Network (PSN) and the Children s Court Clinic Service Delivery Reform 15