Table 1.

Program stream project characteristics.

	Vulnerable Youth			Vulnerable Aged	Complex & Chronic Care
	FRS in Schools	CCMARC	OHCHA	NWPOC	CCAPI	WWICCP
Full name	Family Referral Service in Schools	Central Coast Multi-Agency Response Centre	Out of Home Care Health Access	North Wyong Proof of Concept	Central Coast Alternate Pathways Initiative	Woy Woy Integrated Care Coordination Pilot
General description	An opportunity to develop Communities of Care around vulnerable families by creating an early intervention program, working upstream to impact health and social vulnerabilities.	The first NSW co-located multi-agency child protection information exchange and triage service.	Integrated multi-agency responses to assessment and management of the health needs of children and young people in out of home care	North Wyong Care coordination trial, uses NGO employed care coordination of vulnerable older person cohort, under novel outcomes based commissioning contracts, wherein reduction in unplanned hospital bed days are the target outcomes. Service is free to clients, with providers paid on outcomes.	NSW Ambulance Paramedics trained to implement low acuity protocols to manage alternate pathway referrals for appropriate patients.	Testing transition from the Chronic Disease Management Program (CDMP) to a model focused on General Practice
Objectives	To work with families, reduce their barriers to engaging with services and to prioritise actions that will support young people to engage with learning.	To define health’s role in interagency responses to child protection. Increase effective information exchange between health and Department of Family and Community Services (FACS). Support multiagency quality initiatives that enable early intervention responses for children at risk of significant harm (ROSH)	To better understand the pathways into out of home care, and identify opportunities for better-integrated service delivery To provide a better, integrated approach to health assessment and treatment of young people in this region.	To improve care coordination for enrolled cohort and reduce unplanned hospital bed days. To trial care coordination delivered by non-health providers To trial outcomes based funding model To keep older people healthy and at home for longer	To reduce unnecessary hospital transports of low acuity patients and to reduce ambulance turnaround time at hospitals.	To transition and improve care coordination for complex clients within the community
Date	October 2016–present	November 2015–to present	January–December 2016	January 2017–present, Commissioning cycle initiated July 2014 (needs assessment)	Proof-of-concept–January 2014. Paramedic training December 2015, June 2016	April 2016 to March 2017
Size	3 school learning communities–10,790–5 high schools, 13 primary schools, 2 providers	Central Coast, NSW population	>1000 young people (30–50 new to care each month)	440 patients, 4 general practices, 2 NGO providers	108 NSW Ambulance paramedics Central Coast NSW population	109 patients, 2 care coordinators, 8 general practices, 39 GPs
Target Population	Students and their families where there is an identified risk of disengagement from learning and school attendance.	Children and young people at risk of significant harm who live on the Central Coast, NSW	Children and young people in out of home care are a high-risk group for health and social care vulnerabilities. 30% Indigenous and 117 in kinship placements	North East Wyong region. People identified as having high health need, low socioeconomic status and ageing–likely to benefit from care coordination.	Patients assessed by qualified paramedics as suitable for alternative referral options do not require transport to the ED via ambulance.	Woy Woy, NSW chronic care population
Single point of referral	Yes (schools)	Yes	Yes	Not applicable, cohort identified by Central Coast LHD and referred to providers	Triage via telephone contact with the ambulance service	Identified through Central Coast LHD Connecting Care Program
Risk Stratification	Yes	Yes–ROSH screening tool used by FACS	Yes	Yes	Yes	Yes
Inclusion criteria	Primary and high school students and their families Geographically defined	Vulnerable families in the Central Coast region	Young people (0–18 years) in out of home care in the Central Coast region	Aged 65 or over 1 unplanned admission over the last year 2+ chronic conditions Geographically defined	NSW Ambulance patient transportations of triage categories 4/5	Identified through Central Coast LHD Connecting Care Program
Partners	Family Referral Service, Central Coast LHD, Department of Education (DoE), Local School Principals, HNECC PHN, FACS	CCLHD, FACS, DoE, The Benevolent Society, Family Referral Service	Central Coast LHD, HNECC PHN, FACS	HNECC PHN ADSSI Home Living Kincare Health Services	HNECC PHN Central Coast LHD NSW Ambulance	Central Coast LHD GPs
Community & Primary Care focus	Yes	Yes	Yes	Yes	Yes	Yes
Co-design	Yes	Yes	Yes, with respect to establishing three working groups for priority action.	Yes	Yes	No
Care-coordination	Yes	Limited to coordination of referrals	Yes	Yes	Limited to coordination of alternative referrals.	Yes
Key facilitators	Family Engagement Workers, local school Principals, finding alignments with partner agencies goals and frameworks to progress work (aligned values)	Colocation of multiagency staff with formal structured collaboration meetings for information exchange and quality improvement	Collaboration and strong leadership. Clear common goals defined by FACs and Health Policy objectives	Evidence-informed planning, Outcomes Based Commissioning cycle, strong leadership, NGO market appetite to undertake work	Cooperative patients, usual care providers or available GP practices	Early implementer of the state-wide redesign on CDMP
Key challenges	Adequate needs assessment of families and their cooperation, support from local school Principals, restricted ability to fully partner with HNECCPHN, identification of systemic gaps in services (e.g. under 12s mental health, housing and accommodation, services to support behavioural issues for students)	Rigorous quality improvement framework, consistent approach of adoption and monitoring of changes Unclear goals from outset	Formal and informal partnership agreements, framework design with partners State-based review (Their Futures Matter review) and reform overrode the activities, limiting ability to go forward with planned changes at the time.	New ways of working for NSW Health: contracts, procurement procedures (different to commissioning), time pressures, privacy and ethics concerns, sharing the risk between Central Coast LHD and providers, contracts based 100% on outcomes, restricted ability to fully partner with HNECC PHN	New way of working for NSW Ambulance paramedics, collaboration with patients, usual care providers or available GP practice, restricted ability to fully partner with HNECCPHN	Implementing new model of care within existing program and workforce with entrenched ways of working.