Our vision is a healthcare system united by high-quality primary care, working seamlessly with all other services to put patients first and make life easier for people managing long-term health conditions.

The challenge

For many people living with chronic illness, the health system does not feel like a system.

Care is often fragmented across primary care, specialist and hospital services, community health and social services.

Different organisations use incompatible IT systems, operate under different funding and business models, and communicate inconsistently. People with chronic illness, especially those also facing social disadvantage, low health literacy, unstable housing, family violence, distance from services or speak a language other than English, carry the burden of making this fragmented system “work”.

Fragmentation is not a failure of individual clinicians - it is a structural problem, driven by:

  • Different funding and service models

  • Poor interoperability between systems

  • Inconsistent communication across providers

This fragmentation is linked with:

  • Higher rates of adverse health outcomes

  • Preventable hospitalisations and duplication of care

  • Dissatisfaction and burnout among the workforces

  • Unsustainable pressure on health and social care systems

 

It is also at odds with value‑based healthcare, which seeks integrated systems that put the person at the centre of service delivery.

    • TRANSFORM doesn’t just describe the problem. It builds and tests practical responses to it, and generates the economic evidence needed to sustain them after the program ends.

    • We start with real patient and carer journeys to understand where care breaks down. From there we work collaboratively to design, test and evaluate practical solutions that improve how care is experienced and delivered.

    • Our focus is on:

      • Connecting care acare across primary, hospital and community settings

      • Strengthening coordination around the person

      • Developing solutions that are scalable and sustainable

    The program delivers both local change and system level reform across three areas:

    1.      Building strong regional partnerships

    Establish Regional Integration Collaboratives that bring together consumers, clinicians, services, researchers and decision-makers to lead change.

    2.      Co-design and implement integrated care solutions

    Identify priority “touchpoints” where fragmentation is most strongly experienced and develop practical innovations to improve coordination and continuity of care.

    3.      Generate evidence for scale and reform

    Evaluate what works, for whom and at what cost. Providing implementation and economic evidence to inform policy, funding and broader system change.

  • ‍ At the centre of TRANSFORM is Experience-Based Co-Design (EBCD) and patient journey mapping, methods chosen because they produce solutions that are meaningful to people receiving care, acceptable to those providing it, and feasible for the organisations funding it. This structured co-production process ensures consumers and clinicians are co-designers from the outset.

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    We:

    • Gather lived-experiences from consumers and carers

    • Map real patient journeys across services and sectors

    • Identify key “touchpoints” where fragmentation is most felt

    • Co-design solutions that are meaningful, feasible and sustainable

    • Test and refine innovations through real-world implementation

    ‍This work is supported by Learning Health System approaches, using continuous feedback and adaptation to improve outcomes over time.

  • TRANSFORM operates through five interconnected workstreams:

    1. Forming partnerships: Establishing Regional Integration Collaboratives and governance structures

    2. Identifying priorities: Using data, lived-experience and evidence to identify key integration challenges

    3. Improving the experience: Co-designing and prototyping innovations that address priority touchpoints

    4. Evaluating and sustaining change: Implementing innovations and generating evidence on impact, cost and scalability

    5. Building capability: Strengthening the capacity of consumers, clinicians, researchers and decision-makers to lead and sustain change

  • Fragmented care is expensive, inequitable and despite decades of policy attention, largely unchanged. TRANSFORM is designed to change that.

     The program will:

    • Deliver tested models of integrated, person-centred care

    • Provide evidence on impact, cost, efficiency and scalability

    • Inform new funding and commissioning approaches

    • Strengthen partnerships across sectors and regions

    TRANSFORM directly supports key national and state reform agendas, for example:

    1. The National Health Reform Agreement that looks to new funding to try better ways of delivering health care.

    2. Strengthening Medicare Taskforce which has recommendations for value-based, integrated funding models that break down care financing silos.

    3. National Strategic Framework for Chronic Conditions which focuses on prevention, integrated care, equity and shared risk factors.

    4. Victorian Health Services Plan which recommends more connected system that delivers the right care, at the right time, in the right place, for all Victorians

    TRANSFORM also advances value-based healthcare by ensuring patient experience and outcomes, not just provider activity, drive service design and funding decisions

    Additionally, TRANSFORM addresses health inequity by centering the experiences of communities most affected by fragmentation, including CALD communities, families experiencing adversity, and older people with complex needs

    Three principles underpin all of this:

    1. Primary care is central to a strong health system

    2. Consumer involvement is non-negotiable

    3. Every innovation must have a clear pathway to scale