Redesigning the future for person-centric care through organisational integration and coordination across the health and community sectors: experience from Australia Open Access

The COVID-19 crisis demonstrated how in many countries, the acute-aged-community care nexus was fragile, uncoordinated or broken, leading to increased mortality for residents in long-term (aged care) facilities (Cohen-Mansfield and Meschiany, 2022; Inzitari et al., 2020; Barbosa et al., 2022; Amore et al., 2021; Kunasekaran et al., 2022; Iyamu et al., 2023; Ouslander and Grabowski, 2020). This outcome was shocking for families and communities in many countries, as the crisis revealed a long-standing schism between expectations and reality of care in facilities (Commonwealth Government of Australia, 2021; Lev and Dolberg, 2022; Barbosa et al., 2022). How to achieve sustainability and better care outcomes in the future, in a sector with increasing demand and workforce challenges, is now a critical question (Burke et al., 2022; World Health Organisation, 2023; Lourenço et al., 2023).

Person-centred care with enhanced care coordination is known to promote high-quality, safe health and community services (García-Hernández et al., 2022; World Health Organisation, 2023). A person-centred approach has multidimensional impacts through improving care access and self-management, and reducing hospital admissions (Trankle et al., 2020). Furthermore, person-centred care is consistent with what older people value and is central to designing and implementing integrated care solutions (Marshall et al., 2021). Additionally, organisational resilience is linked to the integration of care within and across acute, primary and residential care facilities (Trankle et al., 2019, 2020; Grimshaw et al., 2016; Mitchell et al., 2020).

Major changes are required across health and aged care/community services to reconceptualise, implement and sustain services to achieve person-centred care and service integration goals. Not least because historically services have been organised in segmented, linear structures and integration is shaped by local context, unpredictable when embarked upon and difficult to replicate (Khan Ai et al., 2022; Grimshaw et al., 2016). Integration, collaboration and partnerships are the key philosophies, drivers and goals for future health system and service improvement; intention to reality, however, remains a challenge with knowledge about how to effectively sustain changes to service provision elusive (MacLeod et al., 2020; Khan Ai et al., 2022).

Change, however, is underway. More recently there has been recognition that the health and community care context and many individual organisations are complex adaptive systems (Penney et al., 2018; Larsen et al., 2021). From this recognition a significant rethinking is following. This includes a greater appreciation that patients present with multi-morbidities and complexity, a reality that contradicts existing functional organisational arrangements, challenging service boundaries and responsibilities (García-Hernández et al., 2022; Inzitari et al., 2020; Mitchell et al., 2020). Patients live in dynamic states, in which socioeconomic, cultural, environmental, behavioural and biological elements interact, refuting a simplistic, reductional understanding and management of their health, social and practical needs (García-Hernández et al., 2022; Inzitari et al., 2020; Barbosa et al., 2022; Iyamu et al., 2023).

There is a need to overcome fragmentation, integrate services and institute person-centred care within the health sector – between acute, primary and aged care – and across the health and community care sectors (Lourenço et al., 2023). To do so requires organisational and professional change and service integration at all organisational levels. Success is known to emerge from the implementation of multiple integrated strategies: professional cooperation and adoption of a person-centred care vision (Tong et al., 2017; Ljungholm et al., 2022; Becker et al., 2022); joint, cross-service responsibility and accountability (Ljungholm et al., 2022; Shorrock et al., 2020) and patient, service and managerial information and knowledge exchange (Ljungholm et al., 2022). Across all three levels, leadership has been identified as a key enabler for integrated practices, teams and systems (Harris et al., 2022). An important potential outcome benefit of integration is the creation of a “learning health system” (McLachlan et al., 2019).

Conversely, there are barriers at the three different levels to successful integration. First, well-established hierarchical professional practices focused on distinctive, separate roles and responsibilities inhibit collaboration and integration of individuals within and across organisations (Becker et al., 2022). Second, different organisational cultures, ways of thinking and perceptions of others impedes individuals and teams from crossing service divides (Larsen et al., 2021). Third, organisational technical information and management systems differ in capability and requirements, with security and privacy restrictions preventing integration (Sheehan et al., 2021). Impacting at all levels, organisational operational systems, including accountability and resources, are specific in expectations and focus, thereby defining and restricting what can and cannot be undertaken (Robertson et al., 2023; Sheehan et al., 2021; Tong et al., 2017; Shorrock et al., 2020). Not surprisingly, overcoming these challenges requires significant commitment across health and community organisations at all levels and leadership if change is to be achieved.

Person-centred care necessitates doing things differently throughout the health and community care systems. Determining how to do so is the critical knowledge required (Robertson et al., 2023; Ljungholm et al., 2022). In particular, how to achieve enhanced integrated care across the acute and aged care sectors necessitates investigation (Tong et al., 2017; Cohen-Mansfield and Meschiany, 2022; Inzitari et al., 2020; Barbosa et al., 2022; Iyamu et al., 2023; Mitchell et al., 2020). Harnessing the system-wide potential of relationships across sectors is necessary for improvement and sustainability (Grimshaw et al., 2016; Cohen-Mansfield and Meschiany, 2022; Barbosa et al., 2022; Iyamu et al., 2023; Ouslander and Grabowski, 2020). Understanding how to achieve and sustain a learning health system in practice is key to achieving these goals (McLachlan et al., 2019). A potential key to unlocking the integrated care-organisational conundrum is understanding three things. First, the local context, social systems and values involved (Larsen et al., 2021; Grimshaw et al., 2016; Inzitari et al., 2020; Barbosa et al., 2022). Second, what structures are necessary (Larsen et al., 2021) and identification of coordination mechanisms – shared goals, communication strategies and decision-making processes (Lavikka et al., 2015; Inzitari et al., 2020; Barbosa et al., 2022). Third, how in a complex system to enable improvements shaped by structural and relational complexity (Larsen et al., 2021; Grimshaw et al., 2016; Cohen-Mansfield and Meschiany, 2022; Inzitari et al., 2020; Amore et al., 2021; Ouslander and Grabowski, 2020; Mitchell et al., 2020). Therefore, with this perspective, the study question was: what organisational changes are necessary for person-centred care with enhanced care coordination across the health and aged care sectors?

The National Health Reform Agreement 2020–2025 between the Australian Commonwealth Government and States and Territories Governments provides A$133.7bn in public hospital funding. The State and Territory Governments are system managers of public hospitals, responsible for determining the mix of the services and functions delivered in their jurisdiction and system-wide public hospital service planning and performance (Australian Government Department of Health and Aged Care, 2023).

The Australian Commonwealth Government is the regulator and primary funder of the aged care system, contributing 95% of resources and, in 2022, committing A$18.3bn to reform the system (Australian Government Department of Health and Aged Care, 2022). Care is provided according to the person’s needs, abilities and resources, providing support for independent living or to reside in residential aged care facilities. RACF providers are required to meet the Aged Care Quality Standards to ensure safety and quality of the care and services provided (Parliament of Australia, 2021).

Typically, pre-inTouch, RACFs provided for the physical and social care needs of their residents. Primary care physicians, and in some facilities allied health practitioners, visited to attend to basic medical, medication and health needs. More complex care needs requiring specialised assessments and reviews, scans and/or tests necessitated residents being transferred to acute hospital facilities, normally via ambulance.

The study takes the Western Sydney Local Health District (WSLHD) inTouch programme as its focus. WSLHD covers the fastest-growing region in New South Wales (NSW), Australia, across four diverse local government areas in western Sydney. WSLHD, with over 10,000 staff, provides a comprehensive range of acute, community and mental health services in more than 70 facilities. The District is spread across 780 square km, with highly built-up urban areas through to semi-rural settings (NSW Health, 2023b). WSLHD is comprised of a population of over one million people, of whom 50% are born overseas, 54% speak a language other than English at home and more than 68,000 are aged greater than 70 years (WSLHD, 2017).

WSLHD inTouch provides an approach for improved, flexible, integrated service provision and was designed and implemented across 2022–2023. inTouch care teams provide both virtual and in-home care, comprised of interprofessional combinations of general practitioners, generalist nurses and allied health professionals. Supported by administrative and technical resources, care teams work outside of normal organisational settings, including from home, providing further flexibility for the individuals and the services provided. inTouch aged care pathway – see Figure 1 – provides a single entry point to acute services for assessment, allocation and referral. This pathway provides access to a spectrum of services that address a broad range of health and social needs – as specified in Table 1 – including, for example, care for COVID, support for continued independent living at home, services addressing chronic care needs and home-based palliative care. An example of the inTouch decision-making is displayed in Figure 2 inTouch decision pathway for rapid access to community care for RACFs. Within the WSLHD area there are 65 RACF with 6,530 beds.

inTouch reflects NSW Health’s Value Based Healthcare strategy (NSW Health, 2021b) and principles as a holistic, system approach to reconceptualising service delivery that focuses on integrating systems components, platforms for service delivery and environments for improved care delivery. The inTouch service and models of care have six core elements, including stakeholder engagement and risk assessment; population and individual care plans; continuum care coordination; shared decision-making; knowledge translation and health literacy and monitoring, review and adaptation.

inTouch, engaging WSLHD internal and external health and community stakeholders, has been applied to redesign three models: COVID care in the community, chronic disease management and aged care. The three models were developed in a phased and integrated approach, building upon established relationships across organisations, services and professional relationships (Western Sydney Local Health District, 2022). inTouch, as recognised by other successful service change initiatives (Nadash et al., 2023; Tyler et al., 2022), integrates stakeholders across the health and community sectors to reconceptualise the planning, implementation and ongoing management of care needs. The investigation here is focused on the inTouch Residential Aged Care Facility Pathway (RACFP).

Case studies are a means by which to undertake an in-depth investigation of organisations and delivery of care, illuminating systemic constraints and challenges and innovations and transformations to services (Crowe et al., 2011). The approach allows simultaneous consideration of interlinked complex contexts and phenomena, such as service delivery integration and systems reforms (Yin, 2013; Crowe et al., 2011). Case studies are a scientific method, enabling flexibility in data sources and analysis, thereby resulting in multiple perspectives contributing to the development of knowledge (McLachlan et al., 2019). Examinations of diverse health and social care issues are suitable for case study investigation (Garn et al., 2023; Santos-Tapia et al., 2023). Hence, aligning with the study question, the case study method was selected for this research.

The case in question can be termed “instrumental” (Crowe et al., 2011), a particular inter-organisational response which provides insight into the challenge of advancing person-centred care and integrated care; alternatively, this has been termed interpretive sensemaking (Stake, 2005). A strength of the case study is the ability to examine “real-world” push and pull factors, identifying what is working and gaps and opportunities for improvements (AMA, 2023; Crowe et al., 2011). In this case, a combination of descriptive and theory-informed perspectives was used to understand the “how”, “what” and “why” of inter-organisational collaborations, actions and outcomes (Turner et al., 2021; Crowe et al., 2011; Ridder, 2017).

The study uses document analysis (n = 10 documents with 186 pages and n = 15 websites) and discussions with key informants (n = 9). Key informants were senior executives, managers and clinicians with responsibility for the design, implementation and ongoing monitoring of the aged care pathway. Participation was initially via a three-hour workshop to ascertain how the pathway was developed, including key milestones, critical events, leadership, learning systems, cultural and policy changes and challenges, changes and sustainability issues. Two researchers took extensive handwritten notes at the time.

Over the next three months, the notes were reviewed and details expanded with informants over subsequent informal or unstructured interviews (Fontana and Frey, 1994), ranging from 30 to 75 min. The continued focus was to address the “how-what-why” of the service development to clarify actions, understanding and perspectives of those involved (Swain and King, 2022). During this period, key informants identified documents and websites for review by the researchers to inform the developing understanding (Crowe et al., 2011). The documents consisted of a variety of internal planning documents associated with integrated care, including governance, leadership, monitoring and evaluation frameworks, model of care mapping and pathway manuals. The websites were from two sources: the health organisation – both public and internal, covering similar information to the written documents explained above- and the NSW State Ministry of Health – information addressing statewide strategic plans, care improvement initiatives and value-based healthcare policies that underpinned the organisation and services.

We adapted the critical interpretive synthesis approach to analyse the heterogenous study material (Al Sabahi et al., 2022; Moat et al., 2013). We used four iterative cycles – examination of literature; review of documents; discussions with key informants and thematic synthesis to integrate summaries – to combine different and common information and insights together (Dixon-Woods et al., 2006). From this dynamic, flexible and inclusive process, a descriptive high-level analytical summary was produced.

The study proposal was reviewed by the WSLHD Research Office. The work was assessed to be a review of the design and establishment of a programme designed to improve care systems and therefore not requiring ethics approval. The “consensus standards for the reporting of organisational case studies” were used to report this study (Rodgers et al., 2016); a  supplementary file is available.

Two major factors were responsible for the organisational changes that occurred. First, at a high level, the contextual drivers to stimulate integration. Second, the local mechanisms and needs that enable the integration to work. Together they were both necessary for person-centred care with enhanced care coordination across the health and aged care sectors.

Every month approximately 360 older persons living in a RACF are transported by ambulance to a WSLHD emergency department. It is known that frail and older people are more likely to experience functional and cognitive decline, iatrogenic illnesses and infections whilst in hospital (Guo et al., 2023). Hence, the resource demands on the acute, ambulance and RACF care staff in responding to this need are significant, and there is the unintended potential of poor care outcomes.

The need for medical care, but necessity or suitability of service provision not always needing to be at an acute facility, was recognised by staff in the WSLHD and RACFs. This awareness and need for change were informed by policy directions at the state level, with health ministry policies directing developments towards sustainable (NSW Health, 2022a), integrated (NSW Health, 2018), virtual care (NSW Health, 2022b) and better value (NSW Health, 2023a) approaches. Aligning with these approaches and shaping the redesign efforts at the local level is the health ministry change philosophy of “collaborative commissioning” (NSW Health, 2021a). The essential collaborative commissioning elements are key components of a “learning health system” (McLachlan et al., 2019).

The service and community-level awareness for change occurred within a broader and highly emotive context of a major national legal inquiry into the provision of aged care – which identified long-term, substantial systemic failings to high quality, safe care in RACFs (Commonwealth Government of Australia, 2021). The urgent need for sustained improvement was further reinforced by resultant community, patient and family anger and expectations for higher quality, person-centred care. Hence, to address the challenges of high service demands and the detriments of hospitalisation, fundamental changes to the conceptualisation, organisation and governance were recognised as needed in the way older people were cared for. There was the necessity to alter acute care options with different care pathways in the community and assessment and ongoing care processes to be highly responsive to patient/resident need not organisational rules. That is, a cultural shift across organisations in governance of care.

The case for change was driven by government system-level and local service delivery factors. At both federal and state government levels, there was demand for improvements. Negative attention and findings from the Federal Royal Commission into Aged Care occurred at a time of, and reinforced, State Government–Health Ministry questioning system norms post-COVID. At a local service delivery level in western Sydney, care norms and arrangements were being disrupted. Clinicians and a cohort of patients with complex sub-acute needs had proven care in the home, via virtual care, as feasible, effective and safe. Technology was an enabler, not a hindrance to high-quality, safe care. Additionally, the COVID-19 pandemic had necessitated a rethink of the reliance on the ED for the care of older persons. The need for new care arrangements altered – improving and strengthening – relationships between professionals in acute and aged care facilities. Combined, these factors contributed to WSLHD and associated aged care services reviewing care arrangements, service and resource capacity and barriers and enablers to improvements. Collectively these factors provided the basis for multiple, integrated changes within and across services.

First, there was the development of specified care pathways reinforced by the operational realignment and strategic integration of services to formulate outreach community-based response teams (Figure 1; Table 1). These enhancements were designed to support hospital avoidance or more positively, enable the provision of services in the patient/resident’s home or RACF. Care teams provided both virtual and in-home care, comprised of interprofessional combinations of general practitioners, generalist nurses and allied health professionals. Supported by administrative changes and resources, care teams could work outside of normal organisational settings, including from home, providing further flexibility for the individuals and the services provided.

Second, there was the reconfiguration of acute service access to a single point – a dedicated telephone number, operating seven days per week, staffed by a triage clinician. The clinician was qualified to provide preliminary care advice, supported by a procedure manual and clinical guidelines and had booking access to dedicated clinics in the acute service outpatient and community health systems.

inTouch recognised the need and then filled and operates in the overlapping space between acute, primary care (general practice) and aged care services. This is the context traditionally where professionals in each sector encounter difficulties understanding, negotiating or communicating across funding, organisational and professional constraints, boundaries and temporal differences. In particular, inTouch breached the gap created by the federal-state funding, divide whereby previously services were funded and delivered by a specific professional in a particular sector and location. The WSLHD opted to overcome the established mindsets and service models to establish and fund inTouch to ensure patients receive care in the right care, in the right place, at the right time. The outcome being that inTouch: recognises the pivotal role and knowledge of both primary care physicians and RACF care workers; aims to ensure RACF care providers, primary care physicians, ambulance officers and acute care professionals all have timely and appropriate access to one another; is focused on prioritising person-centred decision-making for integrated, enhanced care experience and outcomes; offers, where appropriate, alternative care pathways in the community that do not involve ED presentation and centrally, brings together professionals from all services to collaborate with the person/family to establish a shared care plan focused on the patient need, not the service location.

Third, underpinning and supporting the other changes, senior managers reported that there were enhancements to virtual care capacity, decision-making tools and quality and safety measurements. inTouch service documentation stated that technology was actively and flexibly utilised to provide phone and/or video calls for care assessment, planning, monitoring and discharge processes; digital case conferencing became the norm, not the exception. Additionally, reports recorded that mobile diagnostics were engaged through an external supplier, alleviating the need for (most) persons to attend the hospital during assessment processes. The inTouch programme reported a broad set of safety and quality indicators were identified and integrated to enable service evaluation and monitoring of outcomes for patient/resident’s, professionals and organisations.

The inTouch RACFP professionals’ experience is that the changes have led to improved person-centred integrated care delivery within and across acute, primary and aged care services. They report sustained integration has been achieved due to changes across multiple organisations in four interrelated components: cultural – governance and attitudinal approaches to delivering care; system – incentives and models directing how care is planned, monitored and evaluated; technical – sharing of information and knowledge and practice – shared decision-making and care coordinating at a daily level. This study provides knowledge about how to effectively sustain changes to service provision across health organisations (Tong et al., 2017; Cohen-Mansfield and Meschiany, 2022; Inzitari et al., 2020; Barbosa et al., 2022; Iyamu et al., 2023; Mitchell et al., 2020), thereby addressing a long-standing deficit (MacLeod et al., 2020; Khan Ai et al., 2022) and for the aged care field in particular, a critical need (Burke et al., 2022; World Health Organisation, 2023; Lourenço et al., 2023).

The study reinforces previous work that advocated the implementation of multiple integrated changes at multiple levels, with leadership as a key enabler for integrated practices, teams and systems (Tong et al., 2017; Ljungholm et al., 2022; Becker et al., 2022; Shorrock et al., 2020; Harris et al., 2022). An important potential outcome benefit of integration is the creation of a learning health system (McLachlan et al., 2019); now established, further research and evaluation is necessary to demonstrate effectiveness in this endeavour.

Individually and collectively, organisations had to make cultural and policy changes to enable inTouch RACFP to function effectively. These changes were driven by high-level executive commitment to the philosophy and action of person-centred care, whereby they endorsed a collaborative person-centred attitude and innovative approach to delivering care. This shared goal and behaviour were coordination mechanisms (Lavikka et al., 2015; Inzitari et al., 2020; Barbosa et al., 2022) that enabled distributed leadership to solve problems, with flexible governance arrangements to guide service delivery.

There were system changes at all organisational levels that supported and reinforced one another. Additionally, the cross-sector and organisational alignment incentives enabled and sustained integration during periods of uncertainty, stress and adjustments. At the middle levels of organisations across different sectors, an agreed-upon common model of care unified care planning, monitoring and evaluation activities and guided workforce development. Middle managers used inTouch core elements as a cross-organisational framework to review and communicate outcomes and support continuous improvement while maintaining a focus on ensuring safety and quality. They recognised shared values and created a unified structure within a local context to enable improvements (Larsen et al., 2021; Grimshaw et al., 2016; Inzitari et al., 2020; Barbosa et al., 2022).

Technical changes to operational systems within organisations were necessary to collect, analyse and share information and knowledge. At a very practical level there was the identification, distribution and adoption of technical solutions across organisations; the desire for change was translated into new behaviours and actions. This capacity enabled the sharing of information and knowledge at all levels, across roles, services, organisations and sectors. Information became knowledge through the combined ability to distribute real-time safety and quality data analytics, leading to improved tracking and reporting of agreed-upon measures.

The practice component changes involved individuals and teams enacting collaborative, person-centred care decision-making and care coordinating on a daily basis. Prioritising person/resident engagement and shared decision-making continually linked and reinforced collective service delivery. A dual focus on health and welfare issues simultaneously focused care coordination across organisations as a daily action. To promote and enable participation by patient/residents, information was provided in non-technical appropriate language and, where necessary, through the use of multilingual resources.

The study reports on programme developments within one healthcare context in a developed country. A unique feature of the investigation is the cross-sectoral focus of the programme, and it is of potential interest to health professionals in multiple organisations and settings. The research has contributed to the knowledge base and offers scope for transferability of findings across diverse settings, as the work reveals how to engage changes in systems, processes, attitudes, behaviours and practices that are not context defined.

The strength of the study is that it presents a high-level descriptive analytical summary of the inTouch programme, drawing on the experiences and understandings of key informants, supported by organisational documents and website material. Conversely, this is the study limitation and gives direction for further research. Subsequent research work is required to examine the details regarding the micro changes, impacts and evidence associated with the inTouch programme.

In a complex healthcare system, shaped by structural and relational complexity, to enable improvements is no simple undertaking. The inTouch RACFP success emerged from aligning positive individual and collective motivations and actions, at all levels, across organisations in different sectors, to achieve transformative cultural, system, technical and practice changes. A new care system emerged, a learning health system, through changes at multiple levels: cultural – governance and attitudinal approaches to delivering care; system – incentives and models directing how care is planned, monitored and evaluated; technical – collecting and sharing of information and knowledge and practice – decision-making and care-coordinating at a daily level. Collaborative strategies, simultaneously across services and sectors, are required for successful redesign outcomes. The implications are that inTouch RACFP, through focusing upon person-centric care with enhanced care coordination can promote high-quality, safe health services. Furthermore, the study provides a strategy which health organisations and service providers can adopt to overcome fragmentation in their own contexts. The inTouch RACFP approach is a demonstration of improved health planning and system improvement. The outcome being person-centred, integrated, flexible, timely and optimised care for individuals and populations.

The study was funded by WSLHD, and the authorship team included WSLHD staff. The investigation, analysis and initial draft report were independently conducted by researchers from the UNSW. There were no restrictions regarding the submission of report for publication.

The supplementary material for this article can be found online.