Implementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in practice in Sydney, Australia

IntroductionThere is an increasing population with multimorbidities who are at risk of unplanned hospital admissions and emergency department presentations. This population could be better served through a model of coordinated care to manage their health at home.Practice changeThe growing population at risk of potentially preventable hospitalization (PPH) and emergency department presentations could be reduced through coordinated care that uses a patient identification algorithm of disadvantage or referral of a patient through a health professional.Aim and theory of changeThis project examines the implementation of an Integrated Care for People with Chronic Conditions (ICPCC) Program at South Eastern Sydney in practice using Normalization Process Theory (NPT) to understand the factors that inhibit or promote it (May 2015). Qualitative methods were used to understand how the Program has been implemented at the State, District, program, clinician and consumer levels; and the characteristics of patients included to the program through various means.Targeted population and stakeholdersData include a focus group with ICPCC program staff and 15 semi-structured interviews with NSW Health, Care Coordinators, Integrated Care Unit managers as well as and health professionals who refer patients to the program.Timeline2019 to 2020.HighlightsAll levels of participants interviewed stated the importance of achieving the systemic goals of keeping people out of hospital together with enhancing patient centred outcomes and goals. The ICPCC program does not just focus on reducing morbidities but on assisting people to overcome barriers to reach their overall health goals.The program implementers viewed the risk algorithm as beneficial, but health professionals who refer patients to the program also result in positive outcomes through stating their specific needs and linking them to services.SustainabilityThe importance of linking and having strong relationships with local community health services assists long term commitment and integration of services.TransferabilityEvidence highlights the importance of understanding the context of where the intervention is being implemented.ConclusionsThe ICPCC program plays an important role is assisting patients with their physical and social needs who are at the early stage of their disease trajectory and who have to capacity to self-manage.DiscussionsProgram implementers and managers were conscious of the need to reduce duplication of