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Introduction: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in healthrelated quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Gold Coast Integrated Care programme trialled an innovative model of care to proactively manage high risk patients with complex and chronic conditions in collaboration with general practitioners. The objective was to enhance coordination and continuity of care across primary and secondary health services from a single point-of-entry multidisciplinary coordination centre. This case study, embedded in the broader trial, analysed the perceptions of patients, healthcare staff and general practitioners on the adequacy, comprehensiveness, timeliness and acceptability of the new model of care to help inform the decision by the health service whether to adopt it beyond the trial. Methods: This mixed method embedded, explanatory case study design included surveys of general practice staff and focus groups with patients, carers and coordination centre staff. Qualitative data were thematically analysed and findings merged with survey data in a narrative explanatory case report. Discussion: Staff, patients, general practitioners and practice nurses were generally satisfied with services, coordination of care and information sharing but general practice staff satisfaction ratings declined over time. Conclusion: The programme enhanced care and coordination of services and was valued by patients and healthcare providers. Study results provide a rationale for adopting the model for those with chronic and complex conditions. [ABSTRACT FROM AUTHOR]

Aim Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions. Method An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken. Results Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed. Conclusion Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred. [ABSTRACT FROM AUTHOR]

In this article the author discusses the health issues facing Indigenous Australians. She notes that an important factor to consider is equity, stating that the failure to create equitable conditions for Indigenous people to be healthy and receive proper treatment is a tragedy. The author argues that a key problem in improving Indigenous people's health is the way in which the problems are framed. The Australian government's policies, particularly the "Closing the Gap" policy, is also discussed.

Aims and objectives. To identify factors influencing change in two hospitals that moved from taped and verbal nursing handover to bedside handover. Background. Bedside handover is based on patient-centred care, where patients participate in communicating relevant and timely information for care planning. Patient input reduces care fragmentation, miscommunication-related adverse events, readmissions, duplication of services and enhances satisfaction and continuity of care. Design. Analysing change management was a component of a study aimed at developing a standard operating protocol for bedside handover communication. The research was undertaken in two regional acute care hospitals in two different states of Australia. Method. Data collection included 532 semi-structured observations in six wards in the two hospitals and 34 in-depth interviews conducted with a purposive sample of nursing staff involved in the handovers. Observation and interview data were analysed separately then combined to generate thematic analysis of factors influencing the change process in the transition to bedside handover. Results and conclusion. Themes included embedding the change as part of the big picture, the need to link the project to standardisation initiatives, providing reassurance on safety and quality, smoothing out logistical difficulties and learning to listen. We conclude that change is more likely to be successful when it is part of a broader initiative such as a quality improvement strategy. Relevance to clinical practice. Nurses are generally supportive of quality improvement initiatives, particularly those aimed at standardising care. For successful implementation, change managers should be mindful of clinicians’ attitudes, motivation and concerns and their need for reassurance when changing their practice. This is particularly important when change is dramatic, as in moving from verbal handover, conducted in the safety of the nursing office, to bedside handover where there is greater transparency and accountability for the accuracy and appropriateness of communication content and processes. [ABSTRACT FROM AUTHOR]

Chaboyer W, McMurray A, Wallis M. International Journal of Nursing Practice 2010; 16: 27–34 Bedside nursing handover: A case study A case study of six wards in two hospitals was undertaken to describe the structures, processes and perceptions of outcomes of bedside handover in nursing. A total of 532 bedside handovers were observed and 34 interviews with nurses were conducted. Important structural elements related to the staff, patients, the handover sheet and the bedside chart. A number of processes before, during and after the handover were implemented. They included processes for managing patients and their visitors, sensitive information, and the flow of communication for variable shift starting times. Other key processes identified were the implementation of a safety scan and medication check. The situation, background, assessment and recommendations approach was used only in specific circumstances. Perceived outcomes were categorized as improving accuracy and service delivery, and promoting patient-centred care. Although the move to bedside handover is not the norm, it reflects a patient-centred approach. [ABSTRACT FROM AUTHOR]

The decline in indicators of human development linked to rising social inequalities, despite post-modern society's unprecedented economic prosperity, has been called 'modernity's paradox' (Keating and Hertzman 1999). Scholars of developmental health suggest that micro-level influences from the social, economic and psychological circumstances in early life may explain social inequalities across the lifespan. However, children's poor developmental and health outcomes are also a product of the wider contexts of their lives. This paper extends the human developmental framework by linking the proximal determinants of health and well-being with macro-level forces. It reviews recent changes in the political, economic and social environments in developed countries, to provide insights into the recent trends in poor outcomes in children and youth, which remain paradoxical given the expectations of economic prosperity and the advances in medical and other technologies. The paper concludes with policy and research recommendations to reduce social disparities in child outcomes. [ABSTRACT FROM AUTHOR]

This article argues that a primary health care approach is an appropriate conceptual framework for addressing the health needs of Indigenous people. Primary health care is strategic, focusing on equity, access, empowerment and intersectoral partnerships as essential elements for maintaining health. Stereotypical notions of Indigenous ill health as being embedded in a general view of 'culture' can mitigate against achieving equity, access to health care and ultimately self-determinism. Because health is embedded in the social conditions of people's lives, the emphasis in Indigenous health care should first address Indigenous social disadvantage and ways of working in partnership with various groups of Indigenous people to achieve their health goals. A critical multicultural approach situates cultural differences within the wider nexus of power relations, and helps overcome the negative stereotyping that often prevents inclusive, self-determined care. Recommendations are suggested for change at the societal, professional and individual level. [ABSTRACT FROM AUTHOR]

Aim. To investigate general surgical patients’ perspectives of the adequacy and appropriateness of their discharge planning. Objectives. To identify any aspects of discharge planning that could be strengthened to assist people in managing their posthospital care and maintaining continuity of care. Background. Appropriate discharge planning is a priority in today's healthcare environment in which patients are discharged ‘quicker and sicker’, sometimes without home support. Adequate and appropriate discharge planning helps promote health literacy, which has benefits for both patients and their caregivers in helping them manage postsurgical recovery at home. Design. A qualitative, interpretive study was designed in which patients were interviewed at least one week after they returned home from hospital. Methods. Purposeful sampling was used to interview 13 general surgical patients from one of three hospitals (two public and one private) in New South Wales and Queensland, Australia. Data were collected in unstructured interviews and analysed using thematic analysis. Reflective analysis by individual research team members generated preliminary themes, which were then analysed collectively by all members of the research team to achieve consensus on patients’ perspectives. Results. Themes included a ‘one-size-fits-all’ approach to providing discharge information; inconsistent or variable advice from different health professionals; a lack of predischarge assessment of their home and/or work conditions and the need for follow-up assessment of patient and carer needs. Conclusions. The findings of this study illuminate the need for a more individualized approach to discharge planning, taking into account the patient's age, gender, surgical procedure and family and community support for immediate and longer-term nursing follow-up. Relevance to clinical practice. Patients would be more adequately prepared for their recovery period at home, by encouraging client-centred, interdisciplinary communication between health practitioners; adopting a flexible, approach to discharge planning which is tailored to individual needs of postsurgical patients, particularly in relation to advice and information related to recovery; and encouraging and supporting adequate health literacy for self-management. [ABSTRACT FROM AUTHOR]

A primary health care approach is essential to contemporary nursing roles such as practice nursing.This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage.They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs.The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health. [ABSTRACT FROM AUTHOR]

Objective: To investigate recovery from total hip replacement over a three-year period on the basis of patient perceptions of health-related quality of life, demographic (age, gender, family support) and clinical characteristics (co-morbidities, hospital admissions), use of and satisfaction with health services, unmet health needs and social re-engagement. Design: Telephone survey of patients' scores on the the 36 item Short Form health survey (SF 36) at three-years as a basis for comparison with scores 12 weeks after discharge: analysis of survey responses on demographic and clinical variables, health services use and satisfaction, unmet health needs and resumption of pre-operative social activities. Setting: One tertiary hospital in South East Queensland, Australia. Participants: Sixty-two total hip replacement patients from an original cohort of 95 participants in a study three years previously to investigate these variables at one, two, four, eight and 12 weeks post-discharge. Main outcome measures: SF36 scores, survey responses on number and type of co-morbidities, age, family support, type and frequency of health services used, satisfaction with services, hospital admissions, resumption of social activities. Results: No significant differences were found on any SF-36 scores, hut General Health had declined. Women's Physical Functioning scores fell below population norms, men's remained above the norms. Physical composite scores showed a decline with age, and the Mental Composite Scores increased with age. The number of co-morbidities had increased over three years, with 58% being admitted to hospital. Half reported unmet health needs, related primarily to non-hip problems. Only general practitioner services were used monthly or more, with satisfaction ratings remaining high for all services used. Participation in social activities was increased from prior to surgery for 42% of participants. Conclusions: Recovery after hip replacement surgery is... [ABSTRACT FROM AUTHOR]

Unlicensed assistive personnel in the critical care unit: What is their role? Driven by an economic imperative, the use of unlicensed assistive personnel (UAP) has proliferated in the health care system, however, their use in the critical care (CC) environment remains relatively new. An analysis of the first phase of a mixed method study, in which interviews with 17 CC nurses were conducted in order to provide data upon which to devise a larger survey, provides insight into the potential uses and misuses of these UAP. An examination of the transcripts, field notes, and diagrams and a comparison of the emerging categories to the literature assisted in identifying several themes important to CC nursing practice. Three themes identified in the analysis—ongoing vigilant assessment, quick response and seeing the whole picture—provide evidence that if UAP are asked to complete tasks allocated to them in other areas, CC nurses will be robbed of vital, albeit subtle, aspects of their nursing practice. As reflective practitioners, CC nurses must be wary of giving away tacit features of their role which enable them to synthesise contextual variables with espoused theory and experience, in order to ensure optimal patient care and outcomes. [ABSTRACT FROM AUTHOR]

Reports on a second-level analysis of a set of studies in Australia aimed at examining the experience of separating parents who did not gain custody of their children. Inclination of women to become violent; Need to understand the experience of marital separation from the perspective of both spouses as a basis for family counseling; Need for health professionals to advocate changes in the family court system.

This article reports on a study of expertise in community health nursing. The objective of the study was to develop a model of expertise derived from identification of the characteristics and factors influencing clinical expertise in community health nurses (CHNs) practicing in district nursing, school health, and child health. Participant observations, individual interviews, and written retrospective accounts of clinical episodes were analyzed from 37 nurses (10 novices within the first year of community practice and 27 experts identified by peers and colleagues). The data identified the expert as someone in whom the following characteristics operate synchronously: knowledge; empathy; appropriate communication; holistic understanding; an ability to get right to the problem at hand; and self-confidence in her or his perceptions, judgments, and intervention strategies. The findings suggest that there is a combination of factors which influences the development of expertise. These include educational factors, personal factors, and experience. These factors are incorporated into the model of expertise. The data also suggest that, in order to educate for expert levels of practice, the educational process must be designed to stimulate the learner's perceptual as well as analytic abilities. This can best be achieved through clinical practice opportunities and through demonstrations and case studies which stimulate inferential and intuitive thinking in students. [ABSTRACT FROM AUTHOR]

The author reflects on the importance of civic engagement in promoting child care and family health within the community. The author discusses the enabling factors to link the community on the health outcomes and enabling environments which promote people's quality of life. Moreover, she mentions the role of nurses and other medical professionals in the interaction pattern between people's health and the environment.

Introduction: The Gold Coast Integrated Care (GCIC) Programme is aimed at maintaining safe, high quality and readily accessible transitions between care settings for people with complex and co-morbid conditions. We have found that the programme goal of optimising care transitions between primary and secondary services can be partially achieved through service coordination; however many patients require assistance in navigating services in a way that ensures timely, effective, adequate and patient-centred care. Practice Change: The GCIC programme incorporates a unique and innovative nurse navigator role to achieve successful patient navigation through care transitions. Aim and Theory of Change: The nurse navigator role aims to bridge the service gap between primary and secondary services by positioning a nurse in each of the general practices involved in the GCIC programme. The nurses undertake holistic patient assessments; risk management strategies; rapid response to patient needs identified through primary or secondary care service providers, multidisciplinary team members in the GCIC Coordination Centre or patients themselves; maintenance of patient information systems including a shared care record and disease registers accessible to all caregivers; coordination, liaison and patient-centred decision making; health promotion for patient health literacy and self-care, and ensuring the adequacy of collaborative structures and processes through referrals and brokerage services. Using the Transtheoretical Stages of Change Model the research team is tracking the evolution and actions of the nurse navigator role from precontemplation (preparation for the role), contemplation (collaboration between the nurses and general practitioners), preparation for change (tailoring their services to practice needs and the integration programme), actions to achieve integration (as described above) and maintenance (issues involved in sustaining the role.) Targeted Population and Stakeholders: patients with complex and co-morbid conditions, general practitioners, hospital and health service providers. Timeline: The initial 12 month evaluation of the nurse navigator role. Highlights: (innovation, impact and outcomes). The role is an innovation of the GCIC programme and as such, evaluative data is being analysed annually to demonstrate patterns of nurse navigator responses to patient need, changes to referral pathways directly related to the role, the use and efficacy of information systems, and the usefulness of risk management strategies in optimising patient transitions. Sustainability and Transferability: Evaluation data will indicate the extent to which this innovation can be transferred beyond the initial program and setting to regional and national services. [ABSTRACT FROM AUTHOR]

The article offers information on a workshop to improve writing skills to be held at Enoggera Gallipoli Barracks in Queensland on May 3, 2016, which will feature the speakers Anne McMurray, professor of Nursing in the School of Nursing and Midwifery, and Associate Professor Marion Mitchell.

This article outlines the development of the Australian Gold Coast Integrated Care Model based on the elements identified in contemporary research literature as essential for successful integration of care between primary care, and acute hospital services. The objectives of the model are to proactively manage high risk patients with complex and chronic conditions in collaboration with General Practitioners to ultimately reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. Central to the model is a shared care record which is maintained and accessed by staff in the Coordination Centre. We provide a process map outlining the care protocols from initial assessment to care of the patient presenting for emergency care. The model is being evaluated over a pilot three year proof of concept phase to determine economic and process perspectives. If found to be cost-effective, acceptable to patients and professionals and as good as or better than usual care in terms of outcomes, the strategic intent is to scale the programme beyond the local health service. [ABSTRACT FROM AUTHOR]

Background The Advanced Life Support in Obstetrics ( ALSO) course is an internationally recognised interprofessional course to support health professionals to develop and maintain the knowledge and skills to manage obstetric emergencies. Aims This study investigated changes in confidence and perceived changes in the knowledge of doctors and midwives to manage specific obstetric emergency situations following completion of an ALSO course in Australia. Methods A prospective repeated-measures survey design was used to survey 165 course attendees from four Australian states pre- and postcourse and at six weeks ( n = 101). Data were analysed using a Friedman two-way repeated-measures analysis of variance and the Wilcoxon signed rank test. Results There was a significant improvement in confidence and perceived knowledge of the recommended management of all 17 emergency situations immediately postcourse ( P < 0.001) and at six weeks postcourse ( P < 0.001) when compared to precourse levels for both groups of health professionals. However, a significant decrease in knowledge and confidence for many emergency situations from immediately postcourse to six weeks postcourse ( P < 0.05) was also observed in both groups. Conclusions Completion of the Australian ALSO course in Australia has a positive effect on the confidence and perceived knowledge of doctors and midwives to manage obstetric emergencies. However, there needs to be some means of reinforcing the effects of the course for longer term maintenance of knowledge and confidence. [ABSTRACT FROM AUTHOR]

Aims and objectives. To explore families' perceptions of shift-to-shift bedside handover. Background. The potential role families can play in bedside handover is unknown. Understanding family members' perceptions can provide a foundation for nurses to tailor their bedside handover to family members' perceptions, encouraging their involvement and potentially improving patient care. Design. Qualitative study, using case study methodology. Methods. The study was conducted with eight family members in one rehabilitation ward in Queensland, Australia, in 2009. Data included observations of bedside handover, field notes and in-depth interviews. Thematic analysis of data was conducted to identify unique and common themes indicative of family perceptions. Results. Three major themes emerged. The first, understanding the situation, consisted of three subthemes: feeling informed, understanding the patient's condition and understanding patient's treatment. The second theme was interacting with nursing staff, with five subthemes, including sharing information, clarifying information, assisting in care, asking questions and interpreting for the patient. The final subtheme was finding value, which contained five subthemes: feeling at ease, feeling included, valuing individualisation, preparing for the future and maintaining patient privacy. Conclusions. Bedside handover provides an opportunity to involve family members in patient care and promote family-centred care core concepts. Family members value the chance to participate and can ultimately improve the accuracy of handover communication. Relevance to clinical practice. Bedside handover is beneficial for nurses, patients and family members and embodies patient and family-centred care. Managers should consider its implementation in hospitals, developing strategies such as standard operating protocols for a more family inclusive approach to communication. Nurses may require further training to best undertake bedside handover and involve family members in care. The study suggests expansion of research into this important area of family-centred care. [ABSTRACT FROM AUTHOR]

stubbings l., chaboyer w. & mcmurray a. (2012) Nurses' use of situation awareness in decision-making: an integrative review. Journal of Advanced Nursing 68(7), 1443-1453. Abstract Aim. To critically review the literature related to situation awareness and clinical decision-making by nurses. Background. International recognition that situation awareness positively contributes to clinical decision-making has led to a growing body of healthcare literature. To date, research has predominately focused on anaesthetists and surgeons using measurement frameworks from the aviation industry. The evidence focussing directly on situation awareness in decision-making by nurses remains limited. Data sources. Databases: PROQUEST, Web of Science, CINAHL, and PUBMED. Review methods. An integrative review was undertaken following an extensive literature search with the date range January 1965 - March 2011. English language literature reviews, primary qualitative, quantitative and mixed method studies describing situation awareness in decision-making by or including nurses were included. Results. Five empirical studies of nurses' situation awareness were reviewed. Of these, three included decision-making and situation awareness by nurses in inter-professional teams; two related solely to situation awareness and decision-making by nurses. Findings from the five studies could be grouped under three themes: individual factors influencing situation awareness, interpersonal behaviours influencing situation awareness and situation awareness improving working relationships and patient care. Conclusion. Further investigation is needed to identify the situation awareness skills that are vital to decision-making by nurses. Elucidating essential skills sets associated with situation awareness may inform the development of education and training to enhance clinical decision-making by nurses. [ABSTRACT FROM AUTHOR]

Objective: To determine the current evidence about patient and family engagement in communication with health professionals during transitions of care to, within and from acute care settings.Methods: An integrative review using seven international databases was conducted for 2003-2017. Forty eligible studies were analysed and synthesised using framework synthesis.Results: Four themes: 1) Partnering in care: patients and families should be partners in decision-making and care; 2) Augmenting communication during transitions: intrinsic and extrinsic factors supported transition communication between patients, families and health professionals; 3) Impeding information exchange: the difficulties faced by patients and families taking an active role in transition; and 4) Outcomes of communication during transitions: reported experiences for patients, families and health professionals.Conclusion: While attitudes towards engaging patients and family in transition communication in acute settings are generally positive, current practices are variable. Structural supports for practice are not always present.Practice Implications: Organisational strategies to improve communication must incorporate an understanding of patient needs. A structured approach which considers timing, privacy, location and appropriateness for patients and families is needed. Communication training is required for patients, families and health professionals. Health professionals must respect a patient's right to be informed by regularly communicating. [ABSTRACT FROM AUTHOR]

Aim To describe an integrative review protocol to analyse and synthesize peer-reviewed research evidence in relation to engagement of patients and their families in communication during transitions of care to, in and from acute care settings. Background Communication at transitions of care in acute care settings can be complex and challenging, with important information about patients not always clearly transferred between responsible healthcare providers. Involving patients and their families in communication during transitions of care may improve the transfer of clinical information and patient outcomes and prevent adverse events during hospitalization and following discharge. Recently, optimizing patient and family participation during care transitions has been acknowledged as central to the implementation of patient-centred care. Design Integrative review with potential for meta-analysis and application of framework synthesis. Review method The review will evaluate and synthesize qualitative and quantitative research evidence identified through a systematic search. Primary studies will be selected according to inclusion criteria. Data collection, quality appraisal and analysis of the evidence will be conducted by at least two authors. Nine electronic databases (including CINAHL and Medline) will be searched. The search will be restricted to 10 years up to December 2013. Data analysis will include content and thematic analysis. Discussion The review will seek to identify all types of patient engagement activities employed during transitions of care communication. The review will identify enablers for and barriers to engagement for patients, families and health professionals. Key strategies and tools for improving patient engagement, clinical communication and promoting patient-centred care will be recommended based on findings. [ABSTRACT FROM AUTHOR]

This Editorial provides a critical review of the progress in social determinants of health research over the last two decades, suggesting new perspectives which may further our understanding of persistent social inequalities in health. It highlights the global significance of the Special Issue setting it in the context of the recently released WHO Commission on Social Determinants of Health Final Report (CSDH 2008). The Editorial introduces individual papers in the Special Issue and discusses how they are in line with, complement or provide feedback to, the WHO CSDH Final Report and its call for actions to close the health gap in a generation. Finally, based on the articles in this Special Issue and emerging themes of the global research and policy literature, it outlines a number of significant directions for future research and actions, from both methodological and theoretical points of view. [ABSTRACT FROM AUTHOR]

Background: People-centred care (PCC) embodies the partnership approach to health care, refocusing care from the expert clinician as 'care provider' to a patient-clinician sharing of power and responsibility for care planning. Time poor environments and mandated performance outcomes in hospital and health service systems often leave little room for more than cursory attention to PCC at the point of service. However, integrated care systems provide an ideal platform for enabling PCC, given their overarching aim of combining structural and process reforms to position patients at the centre, rather than the margins of health decision-making. People-centred care model in a large Australian program The Gold Coast Integrated Care (GCIC) program was developed to transform services to the local population with chronic and complex conditions. The GCIC model offers proactive, shared care for higher risk patients within a population of c.140,000 (approx. 25% of the Gold Coast population). The Integrated Care (IC) process begins with recruitment of patients into the program through analysis of retrospective (three year) hospital data to identify and then stratify high end health service users with chronic conditions. It operates on the macro (shared governance between care organisations), meso (disease status or sub-population types) and micro level (organising care around individual patient needs). The program is people-centred in its location as well as in the patient journey. Based on models developed in the US1,2, the UK3,4 and other countries, including Australia5 a single point-of-entry includes multidisciplinary care, comprehensive holistic assessment, case management, an organised provider network, defined referral and service procedures, enhanced information management and self-management support all leading to an individualised shared care plan. The GCIC program is being carefully evaluated for cost effectiveness, caregiving processes and outcomes. We are documenting patient perspectives to give them legitimacy, focusing on PCC by making the patient-clinician interplay transparent and the subject of ongoing reflection and discussion. Program leaders are committed to creating an environment of trust, with the expectation of having PCC permeate all healthencounters. Discussion: In traditional health care settings patients have difficulty articulating their needs, preferences and values, often deferring to the lead of health professionals. Yet an informed patient whose views are foregrounded in the encounter and who is encouraged to share in decisionmaking has a better likelihood of maintaining health and preventing illness or exacerbation of a long-standing condition. Conclusion: This presentation will provide evaluative data on the effectiveness and acceptability of the model from the perspective of both patients and clinicians with an analysis ofits similarities and distinctiveness in relation to other integrated care programs throughout the global community. [ABSTRACT FROM AUTHOR]

Introduction: Access to targeted, timely information is crucial for driving service improvement in healthcare1. Shared health information technology can have a major impact on provider effectiveness in coordinating and integrating care as well as enhancing patient outcomes. Healthcare information is currently created and managed in different locations using a variety of reporting tools and software, with different patient identifiers and coding systems according to diseases and conditions. When information is subject to rapid change, such as in health services systems are needed that expedite access for all health providers to the array of disparate clinical information. Without access patient information becomes quickly unmanageable especially when information is subject to change. This presentation reports on a unique initiative to integrate care using a Shared Care Record. The Gold Coast Hospital and Health Service (GCHHS), in partnership with the Primary Health Network (PHN), and Griffith University (GU) introduced a person-centred model of health care delivered primarily in the primary care sector, to provide the most cost effective solution for the holistic management of local patients with complex and comorbid conditions Collaboratively designed and mobilised over an 18 month period, the Gold Coast Integrated Care (GCIC) program commenced enrolling patients in March 2015 for a four year proof of concept phase. Practice Change: The Shared Care Record (SCR) links 'live' health systems data between hospital, GPs, ambulatory care, specialists and community services. Developed on an information technology infrastructure it was designed as a single system to minimise duplication and maximise care coordination. From the integrated care coordination centre the SCR , acts as a single point of management for the diverse information systems involved in coordinating care for patients with chronic, complex and comorbid conditions such as the elderly, and those with diabetes, COPD, and chronic kidney and heart disease. Shared Care data are created, collated, stored and presented in a longitudinal healthcare history of patient information from input by the patient's care team. With sophisticated data analytic capability the SCR guides the daily activities of clinicians in the Coordination Centre, feeding in to the array of disease registers to proactively manage population risks. This information, alongside patient assessment data is used as a basis to create and manage individualised care plans for ongoing management by a care team. Where other information systems don't exist, the SCR is accessible to healthcare professionals and patients via a web URL. Practice Change Highlights: The SCR is currently utilised daily by GPs, hospital and community service staff to manage for a patient population expected to reach over 10,000 during the proof of concept phase. Our analysis indicates early success in implementing the SCR, albeit with certain barriers and enablers that we are working to overcome. These include: General Practice buy-in when GPs are time poor. Including GPs in the development of the software has alleviated this pressure to some extent. Cost effectiveness continues to be carefully calculated beyond developing the archetypes to meet program needs and to accommodate user changes, particularly in aiming for simplicity and ease of use. [ABSTRACT FROM AUTHOR]