Design, development and implementation of the virtual, coordination, access, referral and escalation service in western New South Wales.

Problem: People in rural and remote New South Wales experience avoidable admissions, limited access to skilled clinicians and commonly travel >400 km to access specialist services within the district and >700 km for tertiary services outside.

Design: Iterative use of New South Wales Health redesign methodology in the period 2015-2020.

Setting: Western New South Wales Local Health District is geographically the largest Health District within New South Wales and includes disadvantaged communities. Virtual Coordination Access Referral Escalation is an audio-visually enabled transport, patient flow and clinical advice unit established in 2006 to support patients and clinicians at 35 small, rural and remote hospitals.

Key Measures For Improvement: Right care, right place and right time by the right team the first time. Care delivery close to home and 'on country'. Safe and cost-effective transport. Performance measures to support quality, safety and clinical outcomes. Improving the human experience.

Strategies For Change: Cycles of strategic planning, innovation, productive partnerships, change management and human systems development.

Effects Of Change: Virtual Coordination Access Referral Escalation critical care telehealth more effectively supports rural and remote health care across large distances.

Lessons Learnt: Improvements include expanded/redefined management and nursing roles, integration of dedicated critical care emergency medicine specialists within the service, delegated authority to accept transfers, upgraded technology, 24-hour service provision and a central 'Virtual Support' proactive outreach model.