Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative in Sydney

A number of families living in our community experience many barriers to accessing health and social care. The problems that these families face are highly complex, often spanning over generations, and cannot be addressed by one agency alone. In Sydney, the Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative attempts to connect services to address these barriers, and ensure vulnerable families have their complex health and social needs met; keep themselves and their children safe; and keep families connected to society.

HHAN has multiple components to achieve its vision of an integrated service system that supports families and acknowledges the social determinants of health. These include:
o Whole-of-family care coordination to wrap care around enrolled families
o Place-based work in areas identified as “hot spots” of family disadvantage
o Patient Reported Outcome Measures
o General Practice linkage, engagement and support
o Multi-agency geospatial data mapping
o Sector-wide capacity building
o Collaboration and system reform
o Family health improvement
o Research and evaluation

HHAN is led by Sydney Local Health District and governed by a multi-agency steering committee, with representatives from health and social care services (government and non-government) that provide services to adults and/or children.

The HHAN team presented components of the initiative at the 18th International Conference on Integrated Care in Utrecht. The importance of partnership was emphasised, with two presentations focusing on the impact that partnerships have on patients, the community and professionals when health care staff, housing staff and education staff work together towards a common goal. Place-based work was discussed in other presentations, highlighting the benefits of community consultation to understand barriers to accessing care, and the positive outcomes for families when these barriers are addressed through collaborative work at a community hub. The merits of using a realist evaluation to evaluate a complex multi-agency intervention were explored and trust was identified as a factor that leads to success, both as a contextual feature and a mechanism in an intervention. The results of HHAN’s critical realist evaluation were presented, with results suggesting that the initiative contributes to: increased engagement in care; families feeling empowered and setting long term goals; families having a link to General Practice; families having more perspective on their situation; families having increased knowledge of health norms; more timely referrals between services; increased trust between service providers; and knowledge transfer occurring between service providers.

In collaboration with partners, HHAN co-launched three international Special Interest Groups (SIGs) at ICIC18: Child, Youth and Families SIG; Health and Social Care SIG; Realist Evaluation SIG. The SIGs aim to bring together practitioners and researchers to discuss service, policy and system approaches, and collaborate on research and projects. Please contact A/Prof John Eastwood at if you are interested in joining these SIGs.

John Eastwood is the Director of Community Paediatrics in Sydney Local Health District and is Special interest led for Children, Young People and their Families