Collaborative Commissioning is a Ministry of Health Value Based Health Care initiative that partners primary health networks and local health districts to jointly design and commission care pathways for priority groups. In Northern Sydney, Northern Sydney Local Health District (NSLHD) and Sydney North Health Network (SNHN) partnered to create a value-based pathway for individuals aged 75+ in the community or in Residential Aged Care Homes (RACHs).
The Collaborative Commissioning for Frail and Older People Programme aims to: (1) improve population health, (2) enhance patient care experience, (3) improve system cost-efficiency and (4) enhance healthcare provider experience.
Core programme features include:
- better integration between hospital and primary care through co-commissioning on shared outcomes, and
- combined care model that:
- prioritizes high-risk patients using data-driven algorithm, (b)
- promotes shared and proactive care, and (c) rapidly deploys hospital teams to manage deterioration.
These features help reduce unnecessary emergency presentations at a lower cost per person.
Pathway services include:
GP Quality Improvement Program: Identifies and enrols high-risk patients in proactive GP care.
Geriatrician Outreach to GP: Collaboration between GPs and geriatricians providing timely care for at-risk patients.
Hospital in the Home: Streamlined GP referral process to enhance access to NSLHD’s acute/post-acute service. Remote Patient Monitoring integrated into heart failure outpatient care, allowing patients to monitor vital signs at home for early intervention.
Geriatric Rapid Response: Provides rapid assessment and treatment for older people at risk of presenting to ED within 48 hours, with streamlined referral pathways for RACH and NSW Ambulance.
