Integrated Care

Integrated service delivery structures are needed to better support accessible, more patient centred health services offered closer to home for diverse populations, compared to the hospital-centric and siloed services into which our services have evolved.

Two key pillars that are fundamental to the RACP vision for integrated care are:

1. Supporting specialists to undertake their role in informing, planning and contributing to care for patients with chronic, complex and multiple healthcare needs; and

2. Supporting specialists to work in community-based ambulatory settings - whether physically or virtually (the third space).

The pillars are supported by 7 Principles. These include principles of patient­ centred, flexible, locally implemented and multidisciplinary healthcare that provide for measurable outcomes, and that focus on quality of care and patient safety (see the Integrated Care Discussion Paper 2018 below).

The RACP Model of Chronic Care Management

This Model of Chronic Care Management for people with co-morbidities at an ‘intermediate’ level of care makes multidisciplinary team care more accessible and patient centred.

Chronic conditions often require care through the primary, secondary and tertiary sectors. Without appropriate expert complex care, delayed, uncoordinated treatment of people with multi-morbidities can lead to preventable unplanned, reactive hospital admissions due to exacerbations of one or more of their conditions. One of the key elements for this patient group is physician expertise.

A cross-disciplinary, cross-organisational approach is fundamental to effective integrated models of care, especially for patients with chronic, complex health issues. Many states have supported more integrated care models. The College advocates for sustained and consistent integrated care approaches.

This is a non-Fee for Service model that has two pathways to the integrated care program for multi-morbidities: from primary care or from secondary care.

It is described in the RACP Model of Chronic Care Management , developed in October 2019.

In RACP this work is led by the Integrated Care Sub-group (of the Health Reform Reference Group) (HRRG), and Co-lead Fellows, Associate Professor Nick Buckmaster and Dr Tony Mylius.

The College proposes this Model be supported and implemented at the national level through PHNs and LHDs.

Fellows interested in integrated care and other matters of health reform are able to join the HRRG through the Health Reform Reference Group Nomination Form

If Fellows have any comments or experiences relating to integrated care email

Recent submissions, position statements and media

RACP Model of Chronic Care Management (PDF 713KB)

Integrated Care: Physicians supporting better patient outcomes Discussion paper (PDF 231KB)
Rehabilitation medicine physicians delivering integrated care in the community (PDF 947KB)

RACP response to the RACGP ‘Vision for a sustainable future’ discussion paper (PDF 506KB)

Senate Inquiry into Chronic Disease Prevention and Management in Primary Health Care (PDF 2MB)

Where can I read more?

Read RACP policies, position statements or submissions by searching the Policy and Advocacy Library or view the latest Policy Submissions.   

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