Improving outpatient and community care

Reduce preventable visits to hospital by 5% through to 2023 by caring for people in the community.

A care worker helping an elderly male patient

Why is this important?

There are many people in our communities who have complex chronic health and social needs. Focusing on whole-of-person care in the community helps people better understand and manage their health care needs and stay as healthy as possible for as long as possible, while ensuring the hospital system operates as efficiently as possible.

Supporting patients in the community using integrated approaches to care, delivering care closer to home while also reducing preventable visits to hospital, supports patients to receive the right care, in the right place and at the right time.

The Premier’s Priority aims to reduce potentially preventable visits to hospital by 5% through to 2023 for people who can safely receive their care in the community. Delivering this result will strengthen the care provided to people in the community, improve the experience for patients and keep people healthier in the long-term.

How are we tracking?

Reducing the number of days spent in hospital for patients with preventable conditions has required a focused and coordinated effort between hospitals and primary care providers. The proportion of total days spent in hospital in 2021-2022 by people with conditions where hospitalisation is potentially preventable has improved by 3.0 percentage points since baseline (2017-2018). Prior to this the rate had been increasing since 2015-2016.

While the pandemic has been a significant challenge for our health services and staff, it has also driven increased availability and uptake of virtual care services including remote in-home monitoring, which improves access for patients to high quality multidisciplinary specialist care in many settings across NSW.

The statewide implementation of the risk-of-hospitalisation algorithm is also assisting in the early identification of patients who are at risk of unplanned hospitalisation. The early provision of integrated care coordination intervention, shared care planning, and linking patients back into primary care, enables ongoing longer-term management. For patients with chronic health needs, a primary care physician is of utmost importance.

Download the Improving outpatient and community care data information sheet (PDF 170.97KB)

What are we doing? 

NSW Health is responding to increasing health care needs by supporting local health districts to implement integrated coordinated care that meet the needs of patients.  

Patient identification algorithms support early identification of patients who are at-risk of unplanned hospitalisation and require increased coordination of their care, and data linkage is used to evaluate the interventions and outcomes for patients and the system.

These initiatives improve linkages between primary, community and hospital care. The expansion of virtual care models improves access to preventative care, and supports patients to be treated outside of hospital settings, when safe and appropriate.

NSW Health is working with primary care partners to scale up those initiatives which are having the greatest impact on outcomes for vulnerable and at-risk populations. This will further increase accessibility to appropriate care pathways. 

The NSW Government has also introduced reforms that:

  • expand the number of vaccinations pharmacists can administer
  • trial use of trained pharmacists to prescribe medication for urinary tract infections, and
  • develop a pilot for trained pharmacists to prescribe medications for a range of other conditions. 

Recognising the importance of balancing patient safety with the need for timely access to clinical care, these reforms aim to relieve the pressure on GPs by giving the community more access to safe and appropriate primary care services.

Outpatient and community care
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