Table 1.

NSW Ministry of Health Integrated Care Functional Components.

Functional Component	Key Feature
Patient and carer empowerment
Engaging the patient/carer in care planning	The implementation of processes and systems that ensure the integrated care plan meets the needs and preferences of patient/carers as defined by patients or carers themselves (shared decision making).
Using patient reported measures in care delivery	The implementation of a system of patient reported measures for enrolled patients that measure both the patient’s perceptions of both their care experience and their outcomes, due to the care that they receive. This includes the timely provision of the information to clinicians/team delivering care to enable shared care planning/shared decision making.
Supporting and promoting self-management	A set of defined care interventions specific to the targeted patient cohort to support self-management. This also includes strategies to increase capacity for patients and carers to better self-manage their condition.
Building patient/carer health literacy	The implementation of processes and systems (such as training and information) that improve the patient’s understanding of their health condition(s), how to maximise their ability to manage it themselves, how/when to access health services and what role they play in managing their health condition(s). This also includes care plan access, and active participation to the extent possible in care planning.
Patient identification and selection
Defining local health needs	The set of local health system parameters which broadly identify the types of patients that require the implementation of an integrated care pathway to improve the effectiveness of healthcare delivery (such as potentially avoidable hospital admission, ED presentations, delays in receiving specialist treatment).
Identifying target cohorts	Patient level parameters (such as demographic, e.g. age; clinical, e.g. diagnosis; utilisation, e.g. number of medications; other, e.g. measure of social disadvantage) that define the group of patients that will be targeted/enrolled in the integrated care program.
Developing systematic approaches to risk identification	The standardised approach to risk identification (such as signs of health deterioration) and methodology (such as automated processes in PAS/EMR/EHR) for identification of the targeted cohort of patients who would benefit from an integrated model of care. The targeted risks and cohorts can vary locally, and can vary over time within locality as programs mature.
Innovative ways of working
Establishing new business models	The identification and implementation of business models across the continuum of care are being to promote care delivery which improves patient care and experience through improved coordination and integration. The models sit alongside service models (which operationalize service delivery). They potentially incorporate financial and/or non-financial elements. The models may include the selection of alliance partners (such as GPs, NGOs or other government organisations) and investment in new roles, as well as the use of known business models (such as Person Centred Medical Homes or a Commissioning Framework).
Ensuring appropriate and timely access to specialist care	Needs for the identified cohort. The function may be achieved in a number of different ways (for example, quarantining appointments in hospital based clinics or purchasing services from a telehealth provider).
Shared/joint care planning and management with the patient/carer	The development of shared or joint care planning and care management strategies between the initiator of the care plan, the patient, and other healthcare professionals who are to be involved in the care and service delivery to targeted patients.
Establishing roles focused on organising patient-centred care	The establishment of roles (such as case managers, care navigators, care facilitators) to support the implementation of the integrated care model of care across care settings (such as hospital, primary care, specialist care, community care).
Embedding agreed models of care	The uptake of models of care for patients with specified conditions that are based on evidence based medicine and adhered to by those clinicians seeing targeted patients. This includes the process of designing and agreeing the models with stakeholders to optimise uptake.
Primary and Community care as the hub
Connecting people to their healthcare team	The assignment of targeted patients to a clinical provider (individual/practice) whose role is to be the lead clinical provider with responsibility for the shared care plan and initiating communication with other care providers (such as specialist, GP, aged care, community care).
Systematic assessment, review of patients	The implementation of a system of standardised assessments, regular patient reviews, and uploading of relevant clinical metrics by clinical care providers based on developed integrated care pathway protocols.
Building capacity/capability in primary and community care	The enhancement of resources (such as care navigators, training programs, care pathways, share care planning tools) in the primary and community care settings to support integrated care delivery to targeted patients.
Information Sharing
Establishing a trackable cohort list	The establishment of an electronic patient list/register that identifies all patients enrolled in the integrated care initiative and enables the monitoring of the patient journey, as reflected through the patient’s use of healthcare services.
Establishing shared access to patient information	The extent of electronic patient information on enrolled patients available to clinicians across care settings who are delivering the agreed integrated model of care (such as care plans, e-referral, discharge summaries, medication profiles, test results, service events).