Gold Coast Integrated Care: Enabling partnerships.

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]