The Integrated Care for People with Chronic Conditions (ICPCC) program at SESLHD provided overall care management for patients with multiple complex chronic conditions. This project examined the implementation of the program when the Chronic Conditions Patient Identification Algorithm (CCPIA) was first introduced in May 2019 to identify patients suitable for the program at risk of future unplanned hospital admissions.

Project Short Title

Integrated CPCC in SESLHD

Project Status

Current Projects

Project Team

Dr Cathy O'Callaghan, Dr Ben Harris-Roxas, Ms Julie Osborne, Dr Damian Conway, Integrated Care Unit, South Eastern Sydney Local Health District (SESLHD)

Project Rationale

There is an increasing population with multi-morbidities that are at risk of unplanned hospital admissions and emergency department presentations.  This population could be better served through a model of coordinated care (the Integrated Care Program for People with Chronic Conditions -ICPCC) to manage their health at home.  Patients are selected for the program through an automated risk assessment algorithm in a Patient Flow Portal (PFP) and through chronic disease health professional referrals.


The Integrated Care Unit of SESLHD administering the ICPCC program enlisted CPHCE at UNSW to conduct this evaluation in order to understand:

a) how the ICPCC program has been implemented at Ministry of Health, Local Health District, program, and clinician/ patient levels;

b) the characteristics of patients included to the program through the risk stratification algorithm versus other referral processes; and

c) the key features of the program as exemplified through case studies of patients.

Project Design and Method

The data collected included qualitative research using interviews, a focus group and case studies, and descriptive statistical analysis of patient characteristics. 


O'Callaghan CImplementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in practice in Sydney, Australia ICIC21, Virtual, 03 May 2021 - 27 May 2021 (Conference Presentation) Publisher URL 

 O’Callaghan C, Osborne J, Barr M, Conway D and Harris-Roxas B (2022) Implementation of the Integrated Care for People with Chronic Conditions (ICPCC) program in SESLHD, Centre for Primary Health Care and Equity (CPHCE), University of New South Wales (UNSW), Sydney, research report.


Cathy O'Callaghan Email:

Key Partners

South Eastern Sydney (SES) LHD

Project lead centre
Project stream
Health System Integration and Primary Health Care Development
Project start date
Project end date