Integrated Care Coordination for Managing Chronic Conditions: Views of Health Staff on the Implementation of a Program Using an Algorithm to Identify People at Higher Risk of Hospitalisation in Sydney, Australia

Background Integrated care interventions can improve patient outcomes and reduce the burden on acute health services, but need a strong evidence base to ensure their effectiveness. Understanding the meso and macro context in which care is delivered and determining whether patient needs are met are essential to successful implementation. Care coordination in New South Wales (NSW), Australia has evolved over time to meet the needs of an ageing population with chronic health conditions and multi-morbidity with the aim of reducing potentially preventable hospitalisations. Objective To examine how an integrated care coordination program was understood and implemented at state, district and clinician levels in NSW. The Integrated Care for People with Chronic Conditions (ICPCC) program was implemented statewide, however local implementation varied. Patients who were suitable for integrated care coordination were identified via a hospitalisation risk prediction algorithm and/or referrals from health professionals. Methods Understanding and implementation of ICPCC were assessed via interviews and a focus group with a range of health staff. Qualitative data were analysed using NVivo software and normalisation process theory. Results There was a strong sense of program coherence from management, clinicians and referrers. They viewed ICPCC as effective in coordinating care for patients at risk of hospitalisation and incorporating self-management at home. All health staff interviewed understood the program purpose and necessity, including the importance of achieving patient and systemic goals. Networking, linking services and program promotion were important, as was reporting on benefits. While the algorithm effectively identified previously hospitalised patients, it did not identify all suitable patients in the community with an increasing risk of requiring acute health care intervention. Referrals from health professionals familiar with patient needs and complexity were an important additional mechanism for patient ...