Building Community Nests


There is strong evidence that children and adults who experience, severe adversity will have a higher prevalence of health and wellbeing problems across their life course [1, 2]. Consequently, people with lived adversity have earlier morbidity and mortality compared to their peers. As well as increasing poor health outcomes, ACE has been shown to be associated with increased health service utilisation and economic cost to the Australian community through long term effects of reduced productivity, welfare receipt, medical costs, unemployment and a range of other factors [3].

Sydney Local Health District (SLHD) has undertaken a number of innovative interagency initiatives to address this lived adversity and its outcomes, including a programme of research and collaborative policy design. That work has been undertaken in partnership with consumers, practitioners, and State policy agencies [4].

The Healthy Homes and Neighbourhoods Integrated Care Initiative was designed as to assist vulnerable families to navigate the health and social care system, to keep themselves and their children safe and connected to community [5]. The design is a population management approach with mutually supporting components including: 1) identification of vulnerable family cohorts; 2) care coordination; 3) evidence-informed clinical intervention; 4) General Practice engagement and support; 5) family health improvement initiatives; 6) placed-based neighbourhood initiatives; 7) interagency system change and collaborative planning; 8) monitoring of individual, family and population outcomes; and 9) a critical realist informed evaluation.

Box 1: Healthy Homes and Neighbourhoods Key Features

[highlightbox]The HHAN Integrated Care Initiative uses a stratified population-based approach to address the needs of families who are experiencing adversity, while supporting parallel interventions for all families more generally. HHAN has the following key features:

  1. Multiple core and non-core agencies working together over a sustained period with families with complex health and social needs;
  2. Co-design and co-production of the initiative in partnership with families and service partners;
  3. All the needs of enrolled families are in scope for the intervention, including health, housing, employment, income support and legal advice;
  4. An early intervention and public health approach to interrupting cycles of family disadvantage, poor health and psychological trauma;
  5. A focus on efficiency through the maximum use of, and leverage from, existing family, societal and government resources, including Medicare scheduled services;
  6. Use of evidence-informed integrated care methods by service partners, including family case conferencing, ‘wrap-around’ care delivery, and health literacy;
  7. Encouraging families to have a ‘health home’ for all their health needs and supporting progress towards self-efficacy;
  8. Providing a supporting structure to general practice providers to care for families that are often seen to be ‘too difficult’;
  9. Development and implementation of shared assessment tools and referral criteria; and
  10. Implementation of family assessment and engagement tools that can be used over the long-term to monitor the health and wellbeing of family members.

HHAN acknowledges the need for significant system redesign and commitment from partners. The initiative thus includes ‘demonstration-site’ place-based partnerships with local general practice, schools, family support agencies, local government, religious and faith-based organisations and community members.[/highlightbox]

Preliminary Impact

Preliminary results from NSW state-wide data linkage of HHAN enrolled cohorts (N=129) demonstrated a reduction in probable preventable hospitalisation (PPH), emergency department visits, admissions and length of stay for enrolled HHAN clients [6] (Figure 1 below). The impact varied by age and gender but was evident for both children and adults in the programme. As a result of this data and the emerging empirical qualitative data, the learnings from the HHAN integrated care initiative are being taken up by other NSW Districts [7]. There has also been interest expressed from other Australian and New Zealand jurisdictions.

Figure 1: HHAN Average Potentially Preventable Hospitalisations per enrolled client

[highlightbox]Evaluation of client experience by the HHAN clinicians has shown that the Adverse Childhood Experience (ACE) scores reveal a mean score of 6, with 85% of HHAN clients scoring 4 or higher on the ACE, compared with an estimated 12.5% in the general population (CDC data). Using the Depression Anxiety Stress Scales (DASS 21) – 27% of HHAN clients report a reduction in depression, 64% of HHAN clients report a reduction in anxiety, 45% of HHAN clients report a reduction in stress. Assessment of quality of life using the AQol 6D showed that 63% of HHAN clients report an increase in Quality of Life after involvement in the program.[/highlightbox]

IJIC – Special Research Collection

This special collection presents the critical realist methodology used to translate an earlier social epidemiology research to an intervention design. That translation was undertaken in collaboration with local communities and interagency stakeholders. The evaluation protocol for Health Homes and Neighbourhoods is also described. That evaluation protocol seeks to apply a critical realist approach to the UK MRC advice on evaluation of complex interventions and methods drawn from both implementation and improvement science. New papers will be added as they are published.

Special Interest Groups
The work described here is also linked to four IFIC Special Interest Groups:

  • Evidence-based Integrated Care
  • Realist, Design and Evaluation
  • Health and Social Care
  • Children, Young People and their Families


1. Felitti VJ: Adverse childhood experiences and adult health. Academic Pediatrics 2009, 9(3):131-132.

2. Loxton D, Townsend N, Dolja-Gore X, Forder P, Coles J: Adverse childhood experiences and healthcare costs in adult life. Journal of child sexual abuse 2018:1-15.

3. Flood M, Fergus L: An assault on our future: The impact of violence on young people and their relationships. 2008.

4. Eastwood J: Designing initiatives for vulnerable families: from theory to design in Sydney, Australia. . International Journal of Integrated Care 2017, 17(5).

5. Eastwood J: Designing an Integrated Care Initiative for Vulnerable Families: Operationalization of realist causal and programme theory, Sydney Australia. Int J Integr Care 2018, 18(s1).

6. Eastwood J: Big Data Evaluation of an Integrated Care Initiative for Vulnerable Families. In: International Conference on Integrated Care. San Sebastian, Spain; 2019.

7. NSW Ministry of Health: Transformation Plan Integrated Care – Vulnerable Families. In. Edited by Health NMo; 2019.