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Connect our partners and communities to enable integration and change
From connection to action
Why change is needed
People do not experience their health needs as separate programs, organisations or funding streams. However, the health system is often structured that way.
When services work in isolation, people may need to repeat their story, navigate complicated referral pathways or coordinate their own care. Important information may not reach the right clinician at the right time, contributing to duplicated effort, follow-up calls, delays and less safe transitions between hospital and community-based care.
General practice plays a central role in coordinating care, but GPs do not always have timely visibility of what has happened elsewhere in the system. At the same time, hospitals and other services may not have a complete understanding of the person’s ongoing care in the community.
These challenges cannot be addressed by one organisation working alone. They require trusted relationships, shared priorities and practical mechanisms that connect services around consumers and clinicians.
Integration
During 2025–26, Eastern Melbourne Primary Health Network continued bringing together primary care, hospitals, commissioned services, researchers and communities to address challenges that no part of the health system can solve alone.
Through initiatives including CareSynergy, EMPHN is helping shift integration from an aspiration to practical improvements in information sharing, referrals, care coordination and transitions between services.
We want people to experience one connected health system, regardless of which service or part of the system they enter.
In this future, general practice, hospitals, community health and other services work together around the needs of each person. Information follows people across care settings, referrals are clear and timely, and clinicians have the information they need to make informed decisions.
Integration also means working with communities and partners to shape change. By combining different perspectives, capabilities and local knowledge, we can design practical solutions that improve people’s experiences of care and make the health system easier to navigate.
Why change is needed
People do not experience their health needs as separate programs, organisations or funding streams. However, the health system is often structured that way.
When services work in isolation, people may need to repeat their story, navigate complicated referral pathways or coordinate their own care. Important information may not reach the right clinician at the right time, contributing to duplicated effort, follow-up calls, delays and less safe transitions between hospital and community-based care.
General practice plays a central role in coordinating care, but GPs do not always have timely visibility of what has happened elsewhere in the system. At the same time, hospitals and other services may not have a complete understanding of the person’s ongoing care in the community.
These challenges cannot be addressed by one organisation working alone. They require trusted relationships, shared priorities and practical mechanisms that connect services around consumers and clinicians.
Building the future
CareSynergy
CareSynergy is EMPHN’s approach to strengthening collaboration between primary care and hospital services. It brings EMPHN, health services and general practice together to improve the systems, pathways and information exchanges that support shared patient care.
CareSynergy focuses on practical points of connection, including:
Information sharing between hospitals and general practices
Clearer referral processes and status updates
More useful clinical handovers
Safer transitions between hospital and community care
Opportunities for primary care and hospital clinicians to shape solutions together.
CareSynergy is not a single service or technology platform. It is a framework for turning partnership into practical change, focusing on the connections that matter most to consumers and the clinicians supporting them.
Progress in 2025–26
During FY2025–26, work continued to expand and strengthen this information-sharing model. This included preparing to:
Upload specialist clinic event summaries to My Health Record
Electronically deliver endoscopy reports
and, subsequently, allied health and surgical operation notes
Expand electronic referrals to selected “at home” services
Introduce timely referral-status updates through two-way messaging
Make referral pathways clearer and easier for primary care providers.
These developments represented tangible progress towards closing information gaps between primary and acute care.
CareSynergy also provided a structure for continued dialogue with GPs. Engagement sessions invited general practices to hear about proposed changes and provide feedback on the information they receive through their practice management systems.
From connection to action
Integration begins with relationships, but its value is realised through action.
CareSynergy demonstrates how shared priorities can be translated into changes that affect everyday care. GPs helped shape more useful event summaries. Hospital and primary care teams worked through technical and workflow requirements. Electronic information-sharing processes were developed to fit more naturally into general practice systems.
This moved the partnership beyond exchanging information about the problem to implementing practical solutions.
For general practice, receiving relevant information directly into practice software can reduce the need to search for updates or make follow-up calls. For hospital teams, clearer communication can support stronger clinical handover. For consumers, it can mean less need to repeat information and greater confidence that the clinicians involved in their care have a shared understanding of what has occurred.
This practical approach is central to EMPHN’s role as a system connector: bringing the right partners together, identifying shared problems and supporting changes that individual organisations may not be able to achieve independently.
Partner perspectives
Partner engagement has reinforced that integration must be designed around the realities of both clinical practice and people’s experiences of care.
General practice perspectives have highlighted the importance of:
Receiving timely information in systems already used by practice teams
Making clinical summaries concise, relevant and actionable
Knowing the status and outcome of referrals
Reducing the need
for manual follow-up
Supporting continuity after a hospital or specialist clinic appointment.
Health-service perspectives have highlighted the importance of establishing reliable processes, improving the quality and consistency of information, and working with primary care to understand how hospital communications are received and used.
Together, these perspectives have shaped a shared focus on information that is not only transferred, but is also useful to the clinician receiving it. A contractual requirement of all projects is co-design with GPs.
What we are learning
Our work through CareSynergy is generating several important lessons about integration:
Relationships create the foundation
Technical solutions are important, but they are most effective when underpinned by trust, clear roles and a shared understanding of the problem.
Integration must fit clinical workflows
Information is most valuable when it reaches clinicians at the right time, through the systems they already use, and in a format that supports action.
Co-design improves usefulness
Working with GPs and other partners helps ensure that new processes respond to frontline needs rather than adding further administrative complexity.
Small changes can address broader system problems
Improving one point of communication, such as an outpatient event summary or referral-status update, can reduce uncertainty, duplication and avoidable follow-up across multiple parts of the system.
Integration is an ongoing process
Connected care is not achieved through a single project. It requires continuing feedback, refinement and expansion as technology, services and community needs change.
Next steps
The focus ongoing will be to support the adoption and scale of these innovations across the broader system.
Priorities include:
- Extending electronic delivery to additional types of clinical information
- Improving the timeliness and visibility of referral-status updates
- Expanding electronic referrals to appropriate hospital-at-home services
- Strengthening connections with My Health Record
- Gathering feedback from general practices and other partners
- Implement a model to predict specialist outpatients waiting times
- Evaluate hospital diversion pathways
As this work develops, EMPHN will continue to focus on changes that are meaningful for clinicians and visible in the experience of consumers.
Related integration initiatives
Link-me+ is another example of EMPHN bringing partners, evidence and primary care together to create a more integrated experience. Developed by EMPHN in collaboration with the University of Melbourne, Link-me+ is an evidence-based, primary-care-oriented model designed to help general practices identify and respond to people experiencing common mental health challenges, particularly anxiety and depression. The model was shaped through research, patient experience, consultation and feedback from local GPs.
The model combines:
- A patient-facing digital tool that helps identify likely mental health needs
- Tailored information and resources
- Care navigation for people requiring greater support
- Assistance for GPs to coordinate care
- Education and capability-building for general practice
- Connections to mental health and social services
Care Navigators work alongside GPs and patients to develop action plans, strengthen people’s ability to manage their health and connect them with suitable services. The model also gives practices access to education, referral support and a local health and social services directory.
Together, CareSynergy and Link-me+ demonstrate two complementary dimensions of integration:
- CareSynergy strengthens the connections between primary care and the broader health system.
- Link-me+ strengthens coordination around the needs and circumstances of an individual person.
Both reflect EMPHN’s broader commitment to connecting partners and communities to enable practical, sustainable change.
Link-me+ demonstrates what integration can look like at the level of individual care. It brings together digital identification, the trusted role of general practice, navigation support and connections with local services so that people receive care that is more personalised and coordinated.
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Why change is needed Write a description for this list item and include information that will interest site visitors. For example, you may want to describe a team member's experience, what makes a product special, or a unique service that you offer.
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Building the future Write a description for this list item and include information that will interest site visitors. For example, you may want to describe a team member's experience, what makes a product special, or a unique service that you offer.
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From connection to action Write a description for this list item and include information that will interest site visitors. For example, you may want to describe a team member's experience, what makes a product special, or a unique service that you offer.
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