文章基本信息

标题：Bridging the chronic care gap: HealthOne Mt Druitt, Australia
本地全文：下载
作者：Justin McNab ; James Gillespie
期刊名称：International Journal of Integrated Care
电子版ISSN：1568-4156
出版年度：2015
卷号：15
期号：6
DOI：10.5334/ijic.2243
语种：English
出版社：Utrecht University, Maastricht University, Groningen University
摘要：HealthOne was part of a state-wide initiative to invest in new community-based facilities for collocating services. The HealthOne Mount Druitt is a virtual hub and spoke organisation established in 2006 in a socially disadvantaged part of Western Sydney based out of a new community health hub. The model is based on ‘virtual’ care planning and aims to improve coordination of care for older people with complex health needs, reduce unnecessary hospitalisations and ensure appropriate referral to community and specialist health services. General practitioner liaison nurses (GPLNs) work closely with clients as well as general practitioners (GPs) and other health care providers. Primary health care providers reported improved communication and coordination of services, and there have been lower levels of utilisation of the emergency department (ED) for patients following enrolment in the programme. HealthOne provides an example of how a virtual organisation together with highly skilled care coordinators can overcome some of the barriers to providing integrated care created by fragmented funding streams and care delivery systems.