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Conference Abstracts

Helping a community to help their kids: Bringing services together in a community hub in inner-city Sydney, Australia


Erin Miller ,

Sydney Local Health District, AU
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Suzanne Ratcliff,

Sydney Local Health District, AU
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Helen Golightly,

Sydney Local Health District, AU
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Elaine Tennant,

Sydney Local Health District; University of New South Wales, AU
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John Eastwood

Sydney Local Health District; University of New South Wales; University of Sydney, AU
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Introduction: The suburb of Redfern is identified as having some of the highest rates of intergenerational family disadvantage in the Sydney district. Many families are disconnected from key services, and require multi-agency input to remain healthy and safe.

Short description of practice change implemented: Health district family care coordinators are co-located in an interagency hub on a social housing estate, led by the local housing department. At this hub, staff from government and non-government organisations have partnered to provide an integrated service providing health and social support to residents with complex needs such as psychological trauma, mental health issues, substance abuse, chronic health problems, child protection and parenting issues.

Aim and theory of change: By co-locating family care coordinators with partners in the community, we aim to:

Bring services directly to the community.

Connect care and bridge gaps for families.

Provide a “Team Around the Family” model of intervention to increase a family’s capacity to independently manage their complex health and psychosocial needs.

Support families to seek antenatal support earlier in pregnancy.

Work in partnership with families, other services, General Practice and the community.

Break down service silos.

Targeted population and stakeholders: Families with children aged 0-17 years, where the parents or carers have complex health or psychosocial needs which impact on their ability to care for their children.

Stakeholders include drug health services, mental health services, legal aid, financial management assistance, public housing and child and family health services.

Timeline: This program commenced in July 2015 and implementation and evaluation is ongoing.

Highlights: The model of care evolved in line with local family and community needs, and includes extended family members to align with the Aboriginal definition of kinship. This has empowered families to identify solutions that work for them.

Trust has increased at two levels: families who have traditionally shown a mistrust of government services are now approaching staff for support; staff from different organisations are now working in partnership and share care for families.

Families are now receiving the support that they require before situations turn into crises, and the adult family members’ needs are being addressed.

Comments on sustainability: As this model utilises existing services, sustainability is realistic.

Comments on transferability: This model could be implemented in other suburbs with high rates of family disadvantage. Elements may be adapted to suit local families and communities.

Conclusions: Preliminary analysis indicates that co-location of health and social services is powerful in building trust between service providers and transferring of knowledge and skills. When a hub is located within a community, those services are able to build trust in the community, coordinate services for families and help families to achieve optimal outcomes.

Discussions and Lessons Learned: Complex health and social care systems are difficult for vulnerable clients to navigate and often do not meet their needs.  A family-network centred and flexible model of care-coordination is more effective.

Service definitions and entry criteria may also need to be flexible to ensure that clients do not “fall between the cracks”.  

How to Cite: Miller E, Ratcliff S, Golightly H, Tennant E, Eastwood J. Helping a community to help their kids: Bringing services together in a community hub in inner-city Sydney, Australia. International Journal of Integrated Care. 2017;17(5):A397. DOI:
Published on 17 Oct 2017.


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