Finding a way towards Population Health Management on the Central Coast, Australia
Authors: Van Ede Annefrans , Goodwin Nick , Kajons Niki 
Published: January 2024

Background: To improve the health and wellbeing of the community members on the Central Coast, New South Wales, Australia, this project undertook an assessment of readiness for a Population Health Management (PHM) and neighbourhood based initiative. To do so, it focussed on community needs and strengths and weaknesses of local management on the Central Coast. The Central Coast Local Health District (CCLHD) and Hunter New England and Central Coast Primary Health Network (HNECCPHN) commissioned a joint strategic needs assessment (JSNA). During the project local managers, health professionals, and community members were consulted to gain insight in the readiness and needs of the region.

Methods: The JSNA carried out a data driven deep-dive of the health and care needs at a neighbourhood-level with the intent to drive a co-designed intensive place-based population health improvement initiative that optimizes health outcomes, improves access to care and care equity, and reduces total costs to the health system. Supported by the PHM Maturity Index (PHM-MI), the capability across the Central Coast to enable the implementation of PHM was mapped. This allowed gaining insight in the readiness of local management for this pro-active approach.

Results: This project is still running and aims to be completed in 2023. Preliminary results of the PHM-MI demonstrate an overall low occurrence of items that support the implementation of PHM. Participants recognized the need and voiced the willingness to work collaboratively. However, they confirmed the absence of a guiding coalition and visionary leadership leading to cross domain collaboration. The major weakness of the Central Coast is the high level bureaucracy and political influence in the health system. This hinders top-level collaboration between multiple organizations, and limits the possibilities of financial changes, the building of an integrated data-infrastructure, and the probability for community ideas to become sustainable. The major strengths of the Central Coast are the strong identity of the community members to the region, the willingness of local managers to focus on the community needs and the availability of data. The project shows that the Central Coast is a region with a lot of hidden potential for a neighbourhood based PHM initiative.

Discussion: Using the PHM-MI to map the capability of the Central Coast started the conversation about prerequisites that support a neighbourhood based initiative. Bringing several stakeholders together to participate in the project was challenging, but resulted in new connections between organizations. A next step for the Central Coast is to gain an overview of the most prominent processes in organizational governance, payment streams and budgets, involvement and consultation of community members, and availability of datasets. Therefore, inter- and intraorganizational collaboration is important to bring the hidden strengths on the Central Coast together and build a strong enabling environment to support the growth of the health and wellbeing of the community members on the Central Coast.