“We are creating an exemplary model of care for an important group of older Australians, and believe it will reduce the frequency of hospital, emergency department and residential aged care admissions,” Ms Jones said.
“Too often, we hear the story of people who are transferred between hospitals, specialists, primary care and aged care providers, receiving fragmented care and a confusing overall experience.
“As a provider of both health care and aged care services, Silverchain is uniquely positioned to implement this innovative “wrap-around” approach to care.
“At Integrum, each client has a dedicated case manager, who, in consultation with the client, navigates and coordinates the services required including access to home care and nursing, rapid response care, exercise physiology, psychosocial support, family support and a general practitioner.”
The service is being trialled in Perth from a dedicated clinic in Belmont. The clinic is a home base for a multidisciplinary team who work with a client’s GP to support the care needed, with the key objective of keeping the client at home when safe to do so.
The clinic is also a place where clients attend appointments with their Integrum GP, participate in exercise physiology classes and socialise. The inclusion of a central clinic provides a real opportunity to promote community engagement and complements the care provided to clients in their homes.
WA Primary Health Alliance CEO Learne Durrington said the Integrum trial was a great example of innovation in primary healthcare delivery that shifts the dial from fragmented to co-ordinated care, with the person at the centre.
“We recognised the need for a holistic approach to care that would improve health and wellbeing outcomes for older people with complex healthcare needs and multiple contacts with primary care, hospital and social care systems,” Ms Durrington said.
“WA Primary Health Alliance and Silverchain partnered to develop an innovative response, that involved consultation with a range of key stakeholders including GPs, medical researchers, specialists, allied health professionals and consumers.
“The result is Integrum, a multidisciplinary approach to recalibrate the health and social care systems around the person, reduce potentially preventable hospitalisations and, most importantly, allow for a better quality of life for the older person and their family,” Ms Durrington said.
Integrum was made possible through funding provided by WA Primary Health Alliance under the Australian Government’s PHN Program Innovation Funding stream. Silverchain will be responsible for ongoing funding of the trial.
Integrum is designed especially for clients with specific and complex care needs who are:
- Over 65 years of age (over 55 for Aboriginal and Torres Strait Islanders) and living at home
- Reside in metropolitan Perth
- Have two or more chronic diseases
- Have had between one and five unplanned hospital admissions in the last 12 months
Integrum Case Managers are Registered Nurses who are skilled in the management of chronic conditions.
Integrum is the Latin word for complete.