Care Collective: connecting communities through coordinated care

Empowering individuals, easing hospital pressure, and delivering measurable impact.

Developed by the Health Alliance, a partnership between Brisbane North PHN and Metro North Health, the Care Collective transforms healthcare in Caboolture and Redcliffe by removing barriers and improving access to health services.

The program focuses on supporting people with chronic and complex conditions such as chronic obstructive pulmonary disease, congestive heart failure, and debility (which may include frailty, falls risk and dementia) which often lead to hospital presentations.

Utilising embedded Complex Care Coordinators (registered nurses within general practices), the program gives patients tailored support that extends beyond traditional healthcare. The Care Collective stands out for the proactive, coordinated approach of Complex Care Coordinators.

Rather than waiting for patients to present to a clinic, they actively reach out to patients, checking in regularly to help them navigate the complexity of chronic and multiple conditions. They liaise with hospital teams, allied health providers, community services and social supports, ensuring each person has the right care and information at the right time. By spending time understanding a patient’s broader health and social needs, coordinating services, and helping them access services available in the community, they reduce the likelihood of avoidable deterioration or hospital admission by supporting people to remain well and independent in their own homes.

In short, they work closely with clients, families, allied health professionals and hospital staff to bridge gaps in the system, reduce hospital admissions, and enhance quality of life.

Peter's story:

Peter, referred to the Care Collective after a fall, said “I didn’t know these services were available. It was great because then we could do something about it and I could finally get some help,”

Peter was connected with Trais, a Complex Care Coordinator, who worked closely with Peter’s GP to develop a co-care plan that included assistance for an OT, physiotherapy and a dietician.

“Trais said she wanted to put me on a co-care plan, explained what it was, and we got fast tracked through everything thanks to her.”

He now has access to allied supports that address many aspects of his healthcare, enhancing his quality of life, as well as improving his physical and mental health.

“Care Collective allows you to get to know your patients, and things are picked up when you understand what is going on in someone’s life. Our coordination of care is continued to make sure he’s getting the care he needs,” Complex Care Coordinator, Trais said.

Measuring success:

The results are significant. A recent evaluation identified that 1,186 clients were referred to the program between 1 July 2023 and 31 March 2025.

Based on avoided emergency department presentations and subsequent hospital admissions, the evaluation found:

• 151 per cent return on funding invested in savings to the health system
• estimated average saving for the health system of $255 per client per month
• estimated monthly savings of $302,301.

The Care Collective is built on strong community values and multidisciplinary collaboration by partnering with general practices to empower patients to manage their health confidently at home. By improving health literacy and aligning care with personal goals, the program has exceeded expectations in supporting chronically ill and older patients.

James, a GP explains, “The Care Collective is one way of funding a model of future primary healthcare that can actually work for everybody.” Fellow GP, Stephen agrees: “I thought this is good for the patients, it’s good for society, and it actually saves the taxpayer money.”

These voices reflect the program’s broader impact in addressing critical care gaps, reducing avoidable hospital admissions, and delivering measurable savings to the health system.

With funding secured until June 2026, the Care Collective proves the power of coordinated care. Or, as Peter puts it best: “The care I’ve received has been absolutely fantastic, right across the board they’ve been absolutely bloody terrific!”