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Patients’ experiences of Western HealthLinks: An Australian integrated care model providing person-centred care to patients identified with digital risk-stratification algorithm

Title: Patients’ experiences of Western HealthLinks: An Australian integrated care model providing person-centred care to patients identified with digital risk-stratification algorithm
Authors: Jones, Julia; Barnes, Kirsty; Grant, Catherine; Plant, Jason; Lumsden, Natalie; Simons, Koen; Janus, Edward; Nelson, Craig; Allenby, Ann
Source: International Journal of Integrated Care; Vol. 26 No. S1 (2026): 25th International Conference on Integrated Care, Lisbon, Portugal, 14-16 May 2025; 318 ; 1568-4156
Publisher Information: Ubiquity Press
Publication Year: 2026
Collection: International Journal of Integrated Care (IJIC)
Description: Background: Patients with chronic and complex care needs are at risk of fragmented care during the transition from hospital to the community. The Western Health catchment includes a culturally and linguistically diverse population with almost half speaking a language other than English at home. The catchment experiences significant socio-economic disadvantage and increased levels of chronic disease. Improving organisation of care delivery for this population has great potential for reducing health inequities. An integrated care-based intervention at Western Health, in Western Melbourne, Australia has been trialled to support patients during the transition from hospital to the community. Understanding patients’ experiences is an essential component of the intervention’s assessment. Approach: An Integrated Care Committee at Western Health, chaired by the chief executive officer, helped to develop shared values and vision by engaging with over 1000 community members including patients and carers. This, in addition to case reviews and literature review, led to multiple factors being identified that predispose to successful integrated care models. These were incorporated when designing a new organisation of care delivery, Western HealthLinks, an integrated care pilot program supported by the Victorian State Department of Health and Human Services (DHHS) and run in conjunction with community partner, Silverchain, to support patients with chronic and complex care needs at high risk of hospital readmission. Patients at high risk were identified using a digital solution, an electronic technology algorithm using electronic medical records for risk stratification, and were supported in their hospital to community transition, with an integrated care model including ongoing community-based care including tele-health follow-up. The aim of this study was to understand patients’ experiences of the intervention using a survey regarding healthcare experience, a visual analogue scale (VAS) measuring satisfaction with healthcare ...
Document Type: article in journal/newspaper
File Description: application/pdf
Language: English
Relation: https://account.ijic.org/index.php/up-j-ijic/article/view/10650/11448
DOI: 10.5334/ijic.ICIC25318
Availability: https://account.ijic.org/index.php/up-j-ijic/article/view/10650; https://doi.org/10.5334/ijic.ICIC25318
Rights: Copyright (c) 2026 The Author(s) ; https://creativecommons.org/licenses/by/4.0
Accession Number: edsbas.D0EAB825
Database: BASE