Western Sydney partnership to build one health ecosystem

Pen CS, WentWest, the Western Sydney Primary Health Network and Western Sydney Local Health District (LHD) are collaborating to address health prevention and better chronic disease management through a one health system approach. This system, supported by the use of data, delivers transparency and accountability to deliver value-based care. The approach was discussed in the first session of the Talking HealthTech Autumn Summit 2021.

“Australia is experiencing a syndemic in chronic disease as a result of the COVID-19 pandemic,” Pen CS Chief Executive Edweana Wenkart said. “Poor management of chronic disease costs more than $320 million a year and COVID-19 has caused people to stay away from the healthcare system during the last year, which may result in serious illness.

Pen CS Chief Executive Edweana Wenkart. Copyright Pen CS © 2021. Photographer: Sam Yeomans.

“Pen CS has a long history of working with general practices and WentWest on projects which link data between primary and acute care. This success enables us to extend collaboration with Western Sydney LHD and patients to produce the next generation of integration,” she said.

WentWest Chief Executive Ray Messom explained that in the one health system approach, WentWest supports primary care, Western Sydney LHD delivers acute services and both cover various aspects of community health.

WentWest Chief Executive Ray Messom.

“This approach, underpinned by technology developed with Pen CS, is critical to changing the way services operate and deliver outcomes for the population,” he said.

In Western Sydney, providers and professional groups work together in multidisciplinary teams to provide patient-centred, value-based models of care for patients. Dr Kean-Seng Lim, General Practitioner, CareMonitor Co-Founder and AMA (NSW) Immediate Past President, stated that data and integrated team care are the foundation for creating a one health system across the patient journey.

Dr Kean-Seng Lim.

“Integrated care which focuses on the coordination of care and continuity of care is at the heart of the one health system.³ This approach along with quality data provides general practices and Aboriginal medical services with the ability to evaluate the cohort and individualise care according to the patients’ needs. This is key to improving patient experience and outcomes,” Dr Kean-Seng Lim said.

Western Sydney Diabetes annual review reports a significant mean reduction for enrolled patients in HbA1C by -0.71% (95% CI). A 1% drop in HbA1C is associated with 21% reduced risk of death, 14% reduced myocardial infarcts, 37% less microvascular complications and 43% amputations. This is a strong signal affirming the effectiveness of the program.

Potentially preventable hospitalisations in Australia:

• One in two Australians suffer from chronic disease, which is responsible for 83% of all premature deaths in Australia and accounts for 66% of the burden of disease.
• AIHW study states that in Australia in 2018, 89% of deaths were associated with 10 chronic diseases.
• 47% of Australians suffer chronic disease and 51% of hospitalisations in 2018 involved select chronic disease.
• Poor management of chronic disease costs more than $320 million a year.
• Around 7% of all hospitalisations were classified as potentially preventable.
• There were nearly 748,000 potentially preventable hospitalisations in Australia in 2017–18.
• Nearly 10% of all hospital bed days were for potentially preventable hospitalisations.
   

WentWest Statistics from 2019–2020 Annual Review:

• Western Sydney population 1 million+.
• 249 accredited practices to RACGP standards.
• 347 number of general practices in Western Sydney.
• 52 new health pathways localised and published.
• 316,370 total patient records linked.
• $24.3 million spent on mental health services.
• 5630 clients referred into primary mental healthcare services.
• $32 million spent on commissioned services and grants.
   

Image credit: ©stock.adobe.com/au/oatawa