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: Sydney Local Health District undertook a collaborative planning process for vulnerable families in 2013 and 2014.  In late 2014 the District successfully tendered for an integrated care initiative for vulnerable families – Healthy Homes and Neighbourhoods, which was implemented in July 2015. Practice Change Implemented : The initiative involved system redesign and commitment from health, education, social care, local government, primary-care and non-Government partners.  The model included: shared intake, care-coordination, family group conferencing, wrap-around delivery models, place-based service hubs, general practice engagement and support, and population-based health improvement initiatiave. Aim and Theory of Change : The intervention aims to break intergenerational cycles of disadvantage, psychological trauma, poor parenting and poor health outcomes.  A complex Theory of Change (ToC) was developed, that in summary, would: 1) engage, empower and support families; and 2) develop and strengthen the service system through a collaborative co-design process. Targeted Population and Stakeholders : The initiative is intended for vulnerable families with complex health and social care needs who have one or more dependent children (unborn through to 17 years) where their complex health needs are impacting on their capacity to parent effectively and participate in their community.  The Stakeholders included: the local primary health network (PHN), statutory child protection agency, housing department, schools, early childhood education and care providers, local government, and non-Government organisations working with complex families. Time Line : Implementation in July 2015, reviewed 2016 and secured recurrent funding July 2017. Highlights : The initiative has the following key features: Multiple core and non-core agencies working together over a sustained period of time (i.e. 5 years) with families with complex health and social needs All the needs of families are in scope for the intervention, including housing, employment, income support and legal advice Use of evidence informed integrated care methods by service partners, including family case conferencing, and “wrap around” care delivery Encouraging families to have a “health home” for all their health needs and supporting them to move from dependency to independence Supporting general practice providers to care for families that are often seen to be “too difficult” Development and implementation of shared assessment tools and referral criteria : Implementation of family assessment and engagement tools that can be used over the long-term to monitor the health and wellbeing of family members Transferability : The integrated care model uses design elements that were adapted from other international projects and which can be implemented in other health and social care settings.  The model may also be transferable to other vulnerable population groups including aged care. Conclusions : The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. Discussion : The HHAN initiative demonstrates the benefits of integrating services with the social care, education and local government sectors to address the social determinants of health as they affect families Lessons Learned : The development of trust between agencies, clinicians and patients is essential for the development and implantation of integrated care initiatives

The Healthy Homes and Neighbourhoods Integrated Care Initiative