Finding the Way Towards Population Health Management on the Central Coast

START July, 2022
END November, 2022
PROJECT TEAM Annefrans van Ede (CCRI), Professor Nick Goodwin (CCRI), and Nicole Kajons (CCLHD).
CONTACT Annefrans van Ede
PARTNERS Central Coast Local Health District (CCLHD), and the Central Coast Research Institute for Integrated Care (CCRI).

The growth in age-related and long-term chronic conditions on the Central Coast, combined with a limited and fragmented community health infrastructure, has led to an overburdened and costly care system. The Central Coast Local Health District (CCLHD) and Hunter New England and the Central Coast Primary Health Network (HNECCPHN) have therefore commissioned a joint strategic needs assessment (JSNA) to take a deep-dive of the health and care needs at a neighbourhood-level with the intent to drive an intensive place-based population health improvement initiative that optimizes patient outcomes, improves access to care and care equity, and reduces total costs to the health system.

Such an approach requires pro-active management. Hence, the mapping of capability across the Central Coast to enable the implementation of Population Health Management (PHM) is one of the key issues being explored.

This project, based within the Central Coast Research Institute, uses an early version of the PHM Maturity Index (PHM-MI) that seeks to assist regions like the Central Coast by examining current strengths and weaknesses to key elements known to be supportive to PHM. As the PHM-MI is a tool in its developmental stages, and previously developed in a European context, the project also aims to explore the applicability and clarity of this tool amongst Central Coast stakeholders.


The results, conclusions and next steps were presented by Annefrans on the 24 November 2022. Check out the slides below:

Presentation PHM-MI