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Introduction: This paper describes an initiative to incorporate Community Health Services into General Practice based care across the New South Wales North Coast Medicare Local (NCML) region which has arisen as a result of recognised weaknesses in primary health care integration in the region. Short description of practice and context: The project involves 8 demonstration sites exploring the integration of specialist allied health and nursing staff into general practice teams. The teams are based in sites across the Northern New South Wales Local Health District (NNSWLHD). Highlights (innovation, impact and outcomes): This project unpacks the complexity of integrating services from different jurisdictions and funding models with the goal of optimising access and outcomes for service users. Comments on sustainability / transferability: The context of primary care is likely to change, however we identify a series of principles that can be used to enhance primary care integration in the Australian context. Conclusions (comprising key findings): Primary care service integration required buy-in from general practitioners, change in nursing and allied health practice, and the introduction of new systems to support the integration. There is evidence of increased skill-sharing and case conferencing across practitioners, and better patient-centred models of care. Discussions / Lessons learned: Complex service change requires high level support, but with grassroots engagement from practitioners.

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact.