Evaluation of Integrated Chronic Care Pilot Midterm Report

This report presents the findings from the midterm evaluation of the Integrated Chronic Care (ICC) Service, conducted by RMIT University’s Social and Global Studies Centre (SGSC). ICC is funded by North Western Melbourne Primary Health Network (NWMPHN) and delivered by Neami and cohealth. This evaluation is led by SGSC in partnership with Equally Well, Charles Sturt University and Melbourne University.

Neami run ICC in Hume, Moonee Valley and Moreland Local Government Areas (LGA) and cohealth run ICC in Brimbank and Maribyrnong LGAs. Both ICC sites employ one registered nurse and one mental health peer worker, both on fractional appointments. Neami National and cohealth have collaborated to jointly commission this evaluation.

The evaluation is in two parts, a midterm review and a final evaluation. This report presents the findings from the midterm review. Qualitative data have been collected using interviews and focus groups with people who have used ICC services, ICC staff and professional stakeholders. Quantitative data has been provided by Neami and cohealth.

Overall, consumers expressed very high levels of satisfaction with their experience of ICC and professional stakeholders reinforced the value of the programs. The success of ICC appears to be due to a focus on the consumer’s own identified needs rather than clinically driven interventions, flexibility, compassionate and caring support, and assertive coaching built on trust and empowerment. Few tangible examples of physical health improvement were reported, however many consumers identified other positive outcomes which would promote better physical health. Outcomes included access to disability and welfare support, improved trust in the health system and some lifestyle changes.

As with any pilot program, there are areas for improvement and strengthening. In particular, there are important questions of program clarity and program drift, with key aspects of the program, including the basic model, target group, extent of support and referral networks that require consideration. The peer work aspect of the program is particularly in need of reclarification.

Any reclarifications or revisions to the program should take into account that the success of the program relies on its consumer-driven focus, rather than being dictated by clinical decision-making. Within this context, some clinical aspects, particularly screening, should be enhanced to increase the ability of ICC to provide information to consumers to support their decision-making.

The interim recommendations are in five parts:

1. Continue to deliver ICC

2. Review the ICC Model

3. Embed system integration

4. Ensure robust and efficient data collection

5. Recalibrate reporting requirements

Detailed interim recommendations are available on page 43 of the report.

The evaluation was limited by the quality and availability of quantitative data, by disruptions caused through Victorian coronavirus restrictions, and by issues of program clarity. The evaluation team will work with Neami and cohealth to address these limitations in the final stage of the evaluation.