Integrated Care Coordination for Managing Chronic Conditions: Views of Health Staff on the Implementation of a Program Using an Algorithm to Identify People at Higher Risk of Hospitalisation in Sydney, Australia

There was a shared sense of coherence and understanding of the ICPCC program among health staff at the three levels of implementation within NSW. The program played an important role in assisting patients with a range of chronic conditions to access and benefit from integrated care coordination, while increasing their capacity to self-manage at home. Program intake via hospitalisation risk prediction algorithm plus referrals from health professionals familiar with patient needs and complexity can effectively identify those who may benefit from integrated care coordination.