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.

The two key pillars fundamental to the RACP vision for integrated care:

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

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

The pillars are supported by seven principles – patient­-centred, flexible, locally implemented and multidisciplinary healthcare that provide for measurable outcomes, and that focus on quality of care and patient safety. Refer to the Integrated Care Discussion Paper (PDF).

The RACP Model of Chronic Care Management

The RACP Model of Chronic Care Management (PDF) 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. We advocate 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.

This work was steered by the Integrated Care Subgroup of the Health Reform Reference Group (HRRG), with the Subgroup lead by Fellows, Associate Professor Nick Buckmaster and Dr Tony Mylius.

We propose this Model be supported and implemented at the national level through public health networks and local hospital districts.

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 you have comments or experiences relating to integrated care that you wish to share, email us at

Submissions and position statements

RACP submission to the Primary Health Reform Steering Group Discussion (PDF) 2021

RACP Model of Chronic Care Management (PDF) 2019

Integrated Care: Physicians supporting better patient outcomes discussion paper (PDF) 2018

Rehabilitation medicine physicians delivering integrated care in the community (PDF) 2018

RACP submission: RACGP ‘Vision for a sustainable future’ consultation paper (PDF) 2015

RACP submission: Senate Inquiry into Chronic Disease Prevention and Management in Primary Health Care (PDF) 2015

Related content

Policy and Advocacy Library – RACP policies, position statements or submissions
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