Best-practice integrated health care governance - applying evidence to Australia's health reform agenda.

Internationally, health reform initiatives have identifi ed improved integration between community and acute care delivery as key to sustainability.1,2 Australian reform initiatives have been no exception. In 2009, Australia’s National Health and Hospitals Reform Commission laid the “blueprint” for Australia’s health care future.3 It stressed the importance of “connecting and integrating health and aged care services for people over their lives”. However, it also observed that “each level of government formulates policy in relation to its own responsibilities, not necessarily taking account of the health system as a whole”, and that “current governance arrangements are contributing directly to weaknesses in the quality, effectiveness and effi ciency of the Australian health system”.3 Three years later, the National Healthcare Agreement 2012 committed all federal, state and territory governments to support an integrated approach to the promotion of healthy lifestyle, and prevention, diagnosis and treatment of illness across the continuum of care.4 Despite the critical nature of joint community and acute care cooperation in delivering on the plethora of mutually agreed objectives, there was no mention of any commitment to the integrated governance arrangements pivotal to such success. Concurrently, Australia’s fi rst National Primary Health Care Strategy established a network of 61 primary health care organisations, Medicare Locals (MLs), across Australia.5 While the Strategy stated that MLs “will be an integral component of the National Health and Hospitals Network” and “have some common governance membership with the Local Hospital Networks [LHNs] in their region”, an integrated governance model was never developed.5 Given the priority placed on effective governance frameworks to deliver clear roles and responsibilities to both funders and providers of health care, what is the governance vehicle best suited to achieving our national reform outcomes, and how is it best crafted in the current Australian health care reality? In 2013, we conducted a systematic review to explore international peer-reviewed articles and relevant websites for effective and sustainable integrated primary–secondary health governance models. Ten key elements were identifi ed, many interdependent, from 21 articles that met the inclusion criteria.6 The evidence suggests the following specifi c governance elements are important to support integrated care across the primary–secondary care continuum: • Joint planning was identifi ed as key in 18 of the 21 articles. Governance arrangements included formal agreements such as memoranda of understanding (MOUs), joint board memberships and multilevel partnerships in the planning process. • Integrated information communication technologies were noted in 17 articles, particularly, a shared electronic health record, and systems that link clinical and fi nancial measures. • Effective change management was noted in 17 articles, requiring a shared vision, leadership, time and committed resources to support implementation. • Sixteen studies agreed on the importance of shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care. • Aligning incentives to support the clinical integration strategy, noted in 15 studies, includes pooling multiple funding streams and creating equitable incentive structures. • Providing care across organisations for a geographical population, noted in 13 articles, required a form of enrolment, maximised patient accessibility and minimised duplication. • Use of data as a measurement tool across the continuum for quality improvement and redesign, found in 12 studies, requires agreement to share relevant data. • Professional development supporting joint working, supported by 11 articles, allowed alignment of differing cultures and agreement on clinical guidelines. • An identifi ed need for consumer/patient engagement, noted in eight studies, is achieved by encouraging community participation at multiple governance levels. • One-third of articles acknowledged the need for adequate resources to support innovation to allow adaptation of evidence into care delivery.6