Integrated Care Community of Practice (CoP) Toolkit


The Australian Disease Management Association (ADMA) has coordinated the development of Integrated Care Communities of Practice (CoPs) in the South East Melbourne Region under the Victorian Department of Health and Human Services (DHHS) Victorian Integrated Care Model. A CoP refers to a group of people who share the same passion or interest and gather together to practice collective learning. They are viewed as a way of promoting innovation, facilitating sharing and transfer of knowledge, and improving processes. The Integrated Care CoPs aim to bring together general practice, community health, council services, hospitals, community houses, home services, social services, support services and more in a defined region with a view to increasing local service awareness and connectivity.

The Integrated Care CoPs have been developed and implemented collaboratively by ADMA, Alfred Health, DHHS, enliven Primary Care Partnership, Monash Health, South Eastern Melbourne Primary Health Network, and Southern Melbourne Primary Care Partnership.


Building local relationships, trust and respect across the health and social sectors have been documented as integral for developing an integrated system of person-centred care. The 2017 Integrated Care Productivity Review by the Australian Productivity Commission reported that negative undercurrents affected relationships between disciplines and sectors. These were attributed to multiple factors and likely impede a multidisciplinary and collegiate approach to integrated care as well as innovation. The implication noted here is that system reforms will not be enough for progressing Integrated Care and as presented elsewhere, relationships matter.

To foster local relationships at the micro level, increase provider connectivity and service awareness, Integrated Care Communities of Practice (CoPs) have been developed in 5 local areas within the South Eastern Melbourne region as part of the Victorian Integrated Care Model (VICM).

The CoPs are unique in that they are multi‐discipline and multi-sector regular gatherings which allow local services and providers to build relationships and promote multidisciplinary care. Additionally, they are evolving to offer providers a space to share experiences and knowledge in delivering local patient care, thereby promoting a collegiate environment.

Ultimately CoPs seek to facilitate collaboration, build trust and enhance patient care in each of the regions but they have also evolved to relay information about services to a broad health and social care workforce which assists them with delivering multidisciplinary patient care. By increasing awareness of services, patients are more likely to be referred to appropriate services which may support them better in the community and potentially avoid hospitalisation. Providing consistent messaging about initiatives happening in the region has also become another by product. CoP also provide an opportunity for local services to work together to identify system priorities and implement solutions focused regional models of care.

Aim of Integrated CoPs

  • Support relationship building across the sectors in local areas
  • Promote local service awareness
  • Promote Interprofessional connectivity and communication
  • Share ideas for patient centred care in the region
  • Promote the development of collaborative approaches to care

Purpose of the Tool Kit

ADMA has used the knowledge gained from running Community of Practice (CoPs) to develop a toolkit on how to develop and implement an Integrated Care CoP. This toolkit will provide a guide on how to form a CoP and tools and templates that will support and guide you through the process.  Also included are some recommendations that have been informed through our experience and feedback from participants.

The Integrated Care CoP tool kit includes a a step by step guide on how to form an IC CoP in your region, templates, examples and recommendations. The main steps are summarised in the table below. More detailed information follows the table with links to examples and templates.

Step 1 Establish a Steering Committee Invite representatives from Key Stakeholder organisations as Core Members

Schedule of Regular Meetings

Meeting Agendas & Minutes

Step 2 Determine Events for the year CoP Topic Schedule and Proposed Speakers
Step 3 Determine Key Health, Community & Social Services in the Region Contact details for GP Practices, Community Services, Allied Health Providers, Hospital Services and other relevant services in the region
Step 4 Organise CoP Events Face-to-Face Events- Book and confirm venue, catering and equipment, Organise Trybooking Link

Virtual Events -Online Provider e.g. Zoom

Confirm Panel and Host

Design Invitation Flyers using Template

Build Invitation Database

Distribute Invitation Emails

Develop Host Runsheet & Slide Set

Develop Evaluation Questions via Slido

Reminder email to attendees

Event Checklist – Scroll to appendix

Step 5 CoP Event Name Tags and Delegates List for Face-to-Face Events

Activate waiting room for authorised entry for videoconferencing events

Step 6 Post event-Evaluation and Feedback Analysis of Slido Feedback

Evaluation for Steering Committee

Feedback Summary Delegates & Website

Establishing a Steering Committee

The Integrated Care Communities of Practice have been implemented as multi‐discipline and multi-sector communities open to all health and social services in a defined region.

Apart from an independent coordinating body such as ADMA the core members of the Steering Committee are integral and include representation from the following local key stakeholder health and social service sector organisations:

  • Hospital General Medicine
  • Hospital GP Liaison
  • Hospital HIP and HealthLinks
  • Local Primary Care Partnership
  • Local Primary Health Network
  • DHHS

Representation may also include local community health, local council, the local Neighborhood House and Community Information and Support Service.

Ensuring there are multiple key stakeholder organisations as members of the Steering Committee assists in facilitating all sector inclusion and support and therefore represent Integrated Care.

An Integrated Care CoP Steering Committee is integral to

  • Guide the development of an Integrated Care Community which represents all sectors
  • Jointly determine the purpose
  • Jointly determine an appropriate and inclusive format and schedule
  • Provide recommendations on regional priorities
  • Provide credibility for all sectors
  • Facilitate circulation of information to their respective networks

Roles of the Steering Committee

ADMA is responsible for inviting representatives from the key stakeholder organisations to participate as a member of the Integrated Care CoP Steering Committee. The members of the Steering Committee should have local service expertise and be able to provide guidance and support. The steering group assist with clarifying the purpose and goals of the committee, identify the Community of Practice region, advise on topic selection and the number of events per year and recommend panellists who are local experts. Each member also circulates communications to their respective networks and promotes the CoP events. Ideally a clinician representative from Hospital General Medicine is nominated as the panel moderator and acts as the Medical Lead and host of the CoP events.

The first Steering Committee meeting is best as a face-to-face with subsequent meetings via teleconference to minimise travel. The Steering Committee usually meets at least monthly for 30 minutes (but this may vary depending on the frequency of the CoPs) to determine topics and speakers for the CoP events and discuss feedback on past events. Examples of past topics include: PACER and First Responders; Integrated Oral Health; Social Isolation and Social Prescribing; Persistent Pain and Carer Case Studies, Having Difficult Conversations.

ADMA coordinates the Steering Committee meetings, organises the CoP events (for face-to-face – determining venues and catering, for virtual organising the appropriate online platform), invites delegates from relevant services to attend the CoPs, coordinates feedback and evalations updates the CoP pages on the website, maintains the communications platforms, and provides administrative support.

Integrated Care CoP Steering Committee Meetings

The Integrated Care Steering Committee meetings are held monthly via teleconference or MS Teams. Agendas are circulated to the Steering Committee by ADMA staff at least one week prior to the meeting and the minutes are distributed following the meeting. The Steering Committee endorse CoP Topics, agree on the schedule for running these events, propose potential panellist for follow-up and promote the CoPs to their networks.

Developing a format and Schedule of forums for the CoP

The Integrated Care CoPs should ideally take into consideration the range of providers and services invited to attend. Before work as a breakfast or after hours with canapés allows for all services including general practice to attend. Each CoP meeting has run from 1 to 2 hours with time allocated to optional networking at the end.

An example of the format with a Panel Discussion is here

An example of the format with a Patient case study and discussion is here

The Integrated Care CoPs have been held three times a year in each CoP region. They are held in: February/March, then May/ June and then September/October.

An example of CoPs scheduling with topics is here

Developing a list of Key Health & Social Service Contacts

Lists of relevant health, community and social care staff have been developed and used as an invitations database for CoPs. The lists include contact details (email, fax, telephone) of general practices, community health centres, community pharmacies and allied health providers, council services, neighbourhood houses, relevant hospital services, aged care services, mental health services and other services relevant to the specific CoP event (e.g. dentists for the CoP on oral health services).

The lists are initially compiled using steering committee members respective organisations contacts, Health Direct , Infoxchange and researching social and health services in the region.  It is beneficial to telephone services to determine the email for the most relevant contact person whilst explaining the purpose of the CoP. Communicating with service providers, often individually  and via management structures has been identified as important for engagement and attendance at CoP events.

Organising a CoP event

The main steps in the process of organising and running a CoP involve:

  • determining the potential members of the panel (following discussion with Steering Group)
  • contacting potential panel members and formally inviting them to determine their availability
  • booking venue and catering for face-to-face events or organising virtual events via Zoom
  • nominating a medical lead to host the event and facilitate the discussion
  • establishing a Trybooking link or Zoom link for registrations
  • emailing event invitations to relevant health, community & social service staff directly or via the Steering Committee
  • developing a Runsheet and PowerPoint slides and forwarding a copy to the medical lead and panel;
  • forwarding event reminder emails to delegates
  • establishing a set of evaluation questions on slido for delegate feedback
  • forwarding thank you emails to the panel
  • forwarding password to CoP website along with feedback to delegates

CoP Invitation Templates: Emails and Flyers

Example of flyer invitations for CoPs :

Examples of invitation Flyers incorporating a panel discussion are provided here and here or case study are provided here

Example of an initial email invitation for CoPs :

Dear <NAME>

You are invited to the inaugural [LGA] Integrated Care Community of Practice hosted by [partner organisations].

This event aims to bring together general practice, community health services, hospitals, council services, allied health services, community pharmacies, social services, social groups and more from the region with a view to improving local service awareness and connectivity.

Hosted by [ Medical Lead] the evening will use a patient story to explore ways we can work together to improve patient outcomes. There will be a facilitated discussion and an opportunity to network and share ideas for person centred care in the region.


Please register for catering purposes and feel free to invite your colleagues. Invitation attached.

Kind Regards

< Name and organisation>


Example of an email invitation for ongoing CoPs :

Dear <LGA> Community of Practice (CoP)

The next CoP is being held on the <Time & DATE> at <VENUE>. To RSVP please use the <trybooking or Zoom> link.

This CoP will look at <TOPIC > with a panel discussion involving local services. See attached for details. There will also be wider audience discussion, optional networking and details of the next CoP which will be on <TOPIC>.

As always this is open to all healthcare, community and social services from the area with a view to further increasing service awareness and in person connections. There is no cost to attend the event but please register so we have accurate numbers <for catering if face-to face event>. Please feel free to circulate the invitation to your networks and new attendees are welcome.

On behalf of the host organisations we look forward to seeing you.

Thank you for your time

Kind regards

<Name, Organisation and contact details>

By the way:  We are interested to hear about any relevant examples of patients/clients or services on this topic that you could share with others in the region.

CoP Agenda Runsheet

The steps below vary according to whether the CoP event is run face-to-face or virtually via Zoom. The events are either run at 7am as a breakfast session or in the early evening at 6pm. Face-to-face events include catering.

Delegates entering a virtual event via Zoom are required to preregister for authorised access and on the day are directed to a Waiting Room. Once the Waiting Room is open the delegates are provided access to the event by the host. The zoom host for virtual events is ADMA.

  • Welcome and Acknowledgement of Country usually by Medical Lead.
  • Appropriate Housekeeping
    • For virtual events everyone is on mute except for the panellists to minimise background noise.
    • Delegates are asked to use the chat button to forward any questions or comments throughout the talk and these will be directed to the relevant speaker(s) at the end of the panel discussion
    • Networking: For the face-to-face events time is allocated at the start of the session for delegates to introduce themselves to others at their table. Round table socialisation is valued by attendees.

For the virtual events, delegates are allocated into breakout rooms with others from the region following the panel discussion. The breakout rooms are preassigned and delegates can enter or leave during the session.

  • Introduction and welcome to panel members- Medical Lead
  • Each member of the panel is allocated 5-10 minutes to provide a summary of their background and experience and an overview of their service.
  • Questions from Medical Lead
  • Questions and comments from audience/delegates-directed by Medical Lead or ADMA
  • Slido Feedback
  • Optional networking either face-to-face or virtually via Zoom breakout rooms.
  • Wrap up and Close

PowerPoint Presentation

A series of slides are often used during the CoP events. These include a list of the sectors represented at the CoP, links to local services relevant to the topic, links to the DHHS Victorian Integrated Care Training and links to the password protected CoP webpage with a list of CoP attendee contacts. An example of slides use at a recent CoP can be found here

Slido Evaluation

Delegate feedback is essential to measuring the benefits of providing CoPs. An online poll/survey service like Slido is used as a tool for evaluation that can easily be completed whilst attendees are still at the CoP event, therefore increasing your potential response rate.

A series of standard questions have been developed and are provide at each CoP event via Slido for delegate feedback. The evaluation includes determining the level of participation via attendance in events, participant satisfaction with CoPs and recommendations from attendees. The feedback is useful for improving and planning future CoP events.

The set of evaluation questions used at each CoP are here

A summary of the Slido evaluation is provided to the Integrated Care Steering Committee and a condensed version is provided to the CoP delegates and is also included on the Integrated Care CoP page on the ADMA website.

An example of an evaluation summary can be found here.

You can also find all evaluations on the Integrated Care Communities of Practice page under each region here

After the first year the collective results were:

First year results from attendees:

In 2018/19 there were 12 CoPs in the 5 South Eastern Melbourne regions with 637 attendees. From ongoing surveys of attendees:

  • 95% reported that they would attend future CoPs;
  • 100% believed there are benefits in holding regular multidisciplinary and multiservice CoPs for their area;
  • 93% reported that as a result of attending the CoPs they had become aware of services they were not aware of;
  • 92% reported that as a result of attending the CoP they had met a provider or service they did not know and
  • 98% would recommend the CoPs to colleagues

Key Measures for Year 2 and beyond

Percentage of attendees in which, as a result of attending CoPs, are:

  1. now connected to the services they have met at a CoP for work related matters
  2. can outline ways in which their day to day work and patient care has been impacted by attending CoPs
  3. have referred a patient to a service that resulted in hospital avoidance or referral to a community service.

Further Evaluation

More detailed follow-up by telephone is undertaken with delegates who have agreed to be contacted. This provides more specific information on the impact on patient care or workflow as a result of attending CoPs.

You can read some of the stories here

Integrated Care Community of Practice Webpage

A password protected page is available for each CoP region through the ADMA webpage. The webpage includes a list of CoP delegates who are willing to share their contact information, a summary of the feedback from each CoP event and any relevant information provided by delegates.  It has been noted that sharing and preserving knowledge is important to CoPs.

 Summary Key Aspects of CoPs

The CoPs bring together local general practices, community health services, hospitals, council services, allied health services, community pharmacies, mental health services, aged care services, dental services, social services, social groups, neighbourhood houses and others. The usual format of each event is:

  • CoPs run as face-to-face meetings or virtually via Zoom
  • Topics include patient or Carer case study or a panel of local services related to specific topic.
  • Session is introduced and moderated by a Medical Lead who is a General Medical Physician from the relevant hospital network.
  • Session includes facilitated discussion or panel discussion
  • Roundtable introductions of delegates or via Zoom breakout rooms in the case of virtual CoPs.
  • Networking at end of face-to-face CoPs.
  • Evaluation of session using Slido at end of each CoP.
  • Duration of event is 1.5 – 2 hours or 1 hour for virtual sessions.
  • Events run either as a breakfast session or after hours in the early evening.

 Summary of Key Learnings

  • Multiple organisations on the Steering Group facilitate all sector inclusion and support.
  • Medical Leads are viewed as integral for the Integrated Care CoP events.
  • A key neutral driver is required.
  • Round table socialisation is valued by attendees and the steering committee alike and promotes better patient care in their region through cross referrals.
  • Breakfasts are less expensive than evening events.
  • A broad workforce attends in their own time indicating a willingness to collaborate and a desire for connectivity and awareness of services for their patient care.


The CoPs are unique in that they are multi‐discipline and multi-sector regular gatherings which allow local services and providers to build relationships and promote multidisciplinary care. Additionally, they are evolving to offer providers a space to share experiences and knowledge in delivering local patient care, thereby promoting a collegiate environment.

Without regular interaction, communities of practice cease. With the advent of digital technology communities may operate online and members have access to knowledge whenever and wherever they need. Nonetheless, face-to-face interactions are still necessary. CoPs thrive not only because of the knowledge that members expect to gain but also because of the relationships they build.

Communities of practice are undoubtedly great venues for knowledge sharing. But in order for CoPs to succeed, they require a solid foundation. Furthermore, as the community develops, more facilitation support is required.



For more information about ADMA contact



Person Responsible TASK Due Date Completed
Steering Group (SG) Topic Selected
SG Host confirmed
SG Suggested Panel members
SG Evaluation Questions
Book Venue
Investigate catering options if not provided by venue
Create Registration Link
Develop Flyer for promotion
Build invitation data base

  • Research social and health services to invite
  • Research GPs to invite using healthdirect


Email invite and CoP flyer to SG for distribution to their networks and newsletters
Send email invite and flyer to database list every 4 weeks
Contact and confirm panel members
Confirm evaluation questions with SG and create SLIDO
Create draft of a Runsheet
Draft power point slides with evaluation questions
Confirm catering menu for event
Confirm round table and panel set up with venue
Confirm panellists and report back to SG
Finalise Runsheet
Finalise Slides
Organise time to meet or speak with the Host for event preparation and run through of slides and runsheet
Organise time to meet or speak with panellists to talk through runsheet and general preparation
Send out event reminder to all those on invite database to RSVP
Send out a reminder email to registered attendees with parking details, start time etc
Confirm attendee numbers and dietary requirements with catering
Touch base with venue to confirm set up for event and numbers
Print name tags
Print list of attendees
Print list of mobile phone contact details of host and panel members
Save slides and runsheet onto USB
Hard copy of slides
Hard copies of runsheet for panel members
Set up registration table
Sound check
AV check of projector
Collate evaluation feedback from SLIDO
Write summary of CoP

  • Number of attendees
  • Summation of SLIDO FEEDBACK


Email full summary to SG
Send thank you email to attendees including an abbreviated version of summary