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Healthy Homes and Neighbourhoods HHAN is an integrated care program that supports families in inner west Sydney where adults have complex health and social needs, often impacting on the parent’s ability to provide a safe and supportive environment for their children. HHAN provides care coordination and activities that promote inter- and intra-agency integration. Referral pathways from local schools are targeted in one suburb with significant family disadvantage. Practice change implemented: Following a service provider consultation with schools and other agencies to identify community barriers and enablers, the HHAN social worker established a preferred pathway relationship with target schools. This prioritised clinical pathway featured service delivery of long term care coordination, whole of family focus, flexible home and community visits, fast track Paediatric outreach clinic and consistent collaboration with the schools. Aim and theory of change: To establish new service partnerships that facilitate whole-of-family access to health and social services and result in improved outcomes for families with complex needs who are disconnected from key services. Targeted population and stakeholders: Children and families with complex health and social needs who attend either of two public primary schools in a suburb of significant family disadvantage are targeted in this initiative. Important stakeholders who need to be engaged to ensure success of the pathway include school staff, health service staff, local social service providers, and the broader community. Timeline: Stakeholder engagement commenced in October 2015 and is ongoing. The referral pathway commenced in late 2015. Highlights: This is a unique care coordination pathway linking professionals from the health, social and education sectors to provide whole-of-family care to families with complex needs. Data from Patient Reported Outcome Measures provide a baseline description of the issues that families are facing. Independentqualitative interviews conducted with referred families have shown that the intervention enabled the families to make improvements in their access to services and health and wellbeing outcomes. Trust between service providers, particularly education and healthcare providers, has developed over time. Sustainability: HHAN is a permanently funded program and the pathways established enable health and other community partners to better “join up” and access this target group. Transferability: Other community agencies are exploring similar models where education and social care services are partnered. Key lessons from the evaluation of this pathway could be applied to other models. Conclusion: Qualitative and quantitative data collected demonstrate improvements in families’ health experience, independence and quality of life following referral to HHAN care coordination via this pathway. Discussion: Establishing this pathway successfully has challenged partners to develop a new model using creative, non-standard methods of intervention. The families seen have multiple complex needs and face many barriers to care. The qualitative findings and case studies indicate the importance of integrated care initiatives such as HHAN. Lessons Learned: The establishment of this pathway has created a bridge between Health and Department of Education leaders and the broader service system to assist vulnerable families. Enabling systems now exist which encourage ongoing integration and communication between professionals.

Developing new pathways to Health and Social Care for vulnerable clients in targeted Primary Schools in Sydney, Australia