Sorting the wheat from the hay: Building integrated care for those with complex care needs

Abstract

Introduction: Research suggests that flexible models of care which include across-discipline support and practices can overcome the limitations caused by scattered populations and fewer health practitioners in rural and remote areas across Australia. Innovative models of care bring together the clinician and the individual to plan and manage chronic disease to prevent hospital admissions, promote medication compliance and improve service provision.

However, models of care cannot stand alone as effective tools for the management and minimisation of chronic diseases in any given area. A sound knowledge of what services are currently available within any given catchment is necessary in planning, commissioning and coordinating chronic care. Pinpointing the core activities of specific services on the ground can assist with integrating service provision.

Practice Change: A recent pilot project has been completed to compile an Integrated Atlas of Chronic Care for Dubbo and Coonamble, providing the first detailed service provision description for a specific geographic region within Australia. Based on the international DESDE-LTC classification system, this document goes beyond simply listing services in a directory, toward being able to understand the functional service delivery teams working in a region, where there may be gaps in service provision and where the greatest need for care may be.

Highlights: Furthermore, the consistent classification system employed by the atlas methodology allows for later comparison of service provision with other regions. The utility of a validated, comparable and transferable classification system enables policy makers, service planners and commissioning bodies to make informed decisions related to service provision based on the current service provision patterns.

Conclusion: In order to ensure rural and remote communities are more likely to have their health needs met, there needs to be a comprehensive understanding of not only what communities need but also what services are currently available that could cooperate to meet the needs in appropriate ways. Locally relevant information on services therefore has a key role in improving rural and remote health.