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 is being trialled in the South Eastern Melbourne region and its 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.

Initially targeted on delivering more integrated care to patients identified as Health Care Home (HCH) patients, it is intended that the VICM provide a basis for improving the integration of health services for all patients as they transition between primary health and hospital services. 

Collaborative partners

This model builds on and complements the rollout of the Commonwealth's HCH reform which is 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
  • Health Care home (HCH) practices
  • Australian Disease Management Association (ADMA).

Key Features and Activities

Building workforce capability to deliver more integrated care by:

  • building relationships between the health services, the Primary Health Networks and general practice
  • developing workforce training resources to build knowledge for integrated care
  • establishing Integrated Care Communities of Practice to share knowledge and support relationship building.

Linking de-identified patient data and sharing information between health services, the Primary Health Network, and general practitioners that will enable:

  • common patients to be identified on presentation to emergency and acute care
  • Improved knowledge about the patient journey across the Victorian health system.

Enhancing digital health capability of participating health services by:

  • improving connectivity to My Health Record (MHR)
  • improving functionality to upload pathology and radiology reports
  • generating eReferrals and eDischarge Summaries
  • creating Unique Patient Identifiers (UPI)
  • implementation of a Clinical Information Sharing platform (CIS).

Dedicated resources to drive change management at health services. Change managers have been employed at the three participating hospitals to: 

  • build relationships between the hospital, general practice, community health providers and the Primary health Network
  • identify health service pathways and usage by HCH cohort
  • develop sustainable mechanisms to timely notify general practices about the care provided at the hospital (admission, presentation and discharge) through emergency, specialist clinics or acute admissions
  • identify and implement other system improvements to support integrated care. 

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