In April 2016 the Council of Australian Governments (COAG) agreed to develop and sign bilateral agreements with each State that aimed to introduce reforms to improve health outcomes for patients and decrease avoidable demand for public hospital services, particularly for those with chronic and complex care needs. 

This action is consistent with the advice of the Primary Health Advisory Group which found the Australian health system is not optimally oriented to effectively manage long term health conditions. State-level reforms are aimed at driving new models of joint planning and purchasing by health services in collaboration with Primary Health Networks (PHNs). These reforms build on the Commonwealth’s main contribution to the bilateral agreements, the Health Care Homes (HCH) initiative, which intends to improve patient experience of primary care. 

State-level reforms are being undertaken in three core areas:

  • data collection and analysis
  • system integration
  • care coordination. 

The Victorian Integrated Care Model (VICM) is a key reform of the system integration stream of the bilateral agreement. 

Read more about Victoria's Bilateral Agreement on the Commonwealth website.

Victorian Integrated Care Model

The Victorian Integrated Care Model (VICM) is a key reform agreed in the Bilateral Agreement between the Commonwealth and Victoria on Coordinated Care and aims to drive improvements in integrated service delivery between primary and acute care providers and reduce avoidable hospital admissions and fragmentation of care.  

The VICM’s key objective is to improve the experiences of care and outcomes for patients with complex and chronic conditions through increased collaboration by health care providers at the local level.

Key features

Key features of the VICM include: 

  • using de-identified linked data to identify and analyse patient care pathways
  • building relationships between the health services, the PHN, and GP practices, specifically those engaged in HCH
  • ensuring relevant information is shared between health services, the PHN, and HCH GPs 
  • enhancing digital health capability of participating health services 
  • dedicated resources to drive change management at health services. 

Collaborative partners

This model builds on the Commonwealth’s HCH reform in primary care, currently being trialled in the South Eastern Melbourne region. Stakeholder collaborative partners include:

  • Department of Health and Human Services (DHHS)
  • South Eastern Melbourne Primary Health Network (SEMPHN)
  • Alfred Health
  • Monash Health
  • Peninsula Health
  • HCH practices
  • Australian Disease Management Association (ADMA).

Aims of the model

Victorian Integrated Care Model which includes enhancing digital clinical systems, shared patient information, linked patient health data, person-centred approach, multidisciplinary team-based care and change management

Activities and benefits

The VICM comprises a range of interconnected activities to address the above objectives across digital health, workforce development, data linkage and change management. These activities are outlined below: 

  1. Improving digital health capability through:
    • Improved connectivity to My Health Record (MHR)
    • Improve functionality to upload pathology and radiology reports
    • Generation of eReferrals and eDischarge
    • Assessment of eReferral pathways 
    • Creation and adoption of unique patient identifiers (UPI)
    • Development and implementation of a clinical information sharing platform (CIS)
  2. Improving workforce capacity through:
    • Developing workforce training resources to support the development of knowledge and behaviours for high quality integrated care
    • Establishing Integrated care Communities of Practice
  3. Data linkage through:
    • Sharing information to identify HCH patients on presentation to emergency and acute care
    • Developing a de-identified linked data to trace HCH enrolled patient journey across the Victorian health system
  4. Change management support through a State funded project manager at each participating hospital to:
    • Build relationships between the hospital, General Practice (including HCHs), community health providers and the PHN
    • Identify health service pathways and usage by HCH cohort
    • Develop sustainable mechanisms to timely notify HCHs about care provided in the health service (admission, presentation and discharge) through emergency, specialist clinics or acute admissions
    • Identify and implement other system improvements to support integrated care.