Gippsland community led integrated health care program

  • The main street of Orbost, entering from the south.​​​​​​​

The main street of Orbost, entering from the south. Image: Steve Bennett

In 2022-2023, Gippsland PHN codesigned a Community Led Integrated Health Care Program (CLIHC) enabling people in Gippsland to access primary healthcare that meets local need.

CLIHC is defined as:

An integrated and collaborative approach to Multi-Disciplinary Models of Health Care whereby the identification of needs, priorities and agenda for change is led by the community experiencing a health need. The health care model is patient-centred and includes professionals from a range of health disciplines working together to deliver comprehensive care that addresses as many of the patient's needs as possible.

Community Led Integrated Health Program diagram
The CLIHC model codesigned with the Gippsland community

There are three vital elements to the model:

Care Coordinator: The role is activity based (for example health assessments, shared care planning, case conferencing, transition support) and vital for linking into general practice, hospital, pharmacy, specialists, and other health services.  

Hub: The hub is where the local core care team is. The hub can be either face to face or via supported telehealth. The care coordinator is coordinating services in this hub for the service users.

Supported telehealth facilities: A key component for people in rural and remote areas is functional and supported telehealth services. With this model service users can go to a community hub (e.g neighbourhood centre) to receive health services via telehealth. Here, connectivity is not an issue and there are people on hand to help the service user use the technology.

Services have been under an establishment period for six months and are now accepting referrals.

Orbost Regional Health in partnership with Deddick Valley Isolated Community Group

Deliver care coordination and nursing services to residents in the remote communities of Deddick Valley as well as Bendoc, Tubbut and Goongerah including:

  • Allied health, pathology and medication services.
  • Connection to Orbost Regional Health and Bairnsdale Regional Health.
  • Services via supported HoloLens telehealth technology.
  • Complex case follows up.
  • Undertaking locally-focussed, targeted prevention and health promotion projects that address the social determinants of health.
  • Supporting home visits where reasonable and appropriate.

Latrobe Community Health Service in partnership with Berry Street Victoria

Latrobe Valley is an area of high social and economic deprivation and identifies that the vulnerability profile of our youngest community members continues to impact health and wellbeing outcomes throughout their lifespan, with significant individual, family and community costs.

This integrated health and welfare service for vulnerable children and families works with the child and family in a holistic way by developing an assessment clinic for children from disadvantaged backgrounds. This allows children and their families to be seen at one place at one time rather than the need to attend multiple appointments at multiple sites across the week.

The service includes:

  • A clinic with care coordination, transport assistance and a multi-disciplinary approach which addresses people’s ability to access health services.
  • Full-time care coordinator and social service navigation role supported by administration resource.
  • Supported access to digital health services should external telehealth meeting/s be required (example, a review with the Royal Children’s Hospital).

A Community of Practice has been established between Gippsland PHN, service providers, evaluation consultants and relevant community members and other partners to:

  • Continue with the co-design process of the CLIHC program.
  • Support the development of the CLIHC program guidelines, achievable service delivery models, targets, unit priced model and suitable reporting platforms.

Gippsland PHN is undertaking an evaluation of the CLIHC program. Insights are gained from the Community of Practice that is also a source of reflection and evaluation of program successes/ failures and opportunities to modify the program to provide the best model to suit the needs of the communities the services are being delivered in.

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