From complex to collaborative: a Care Collective of consumer and coordinator stories
Brisbane North PHN in partnership with Metro North Health
“She wasn’t bowling, she wasn’t doing anything she loved, she thought her life was over…”
After being diagnosed with Congestive Heart Failure (CHF), Gloria withdrew from the activities she loved in fear of what might happen to her health. With the assistance of her Complex Care Coordinator (CCC), Loraine – a connection made possible following a referral to the Health Alliance’s flagship Care Collective program – Gloria set out to take back her heart, her health and her life.
The Health Alliance represents the unique, cornerstone partnership between Brisbane North PHN and Metro North Health, working strategically to break down barriers in healthcare for our shared communities across the North Brisbane and Moreton Bay region.
The Alliance’s key Care Collective initiative, established in 2022, seeks to further enhance care coordination and integration across our healthcare system. Over the past 12 months, the program’s consolidation within the Caboolture region and expansion into Redcliffe has seen it grow from strength to strength, enhancing outcomes for the 540 patients serviced and 18 participating general practices.
The program provides specific support for people like Gloria living with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and other conditions leading to frequent emergency department (ED) presentations for debilities like dementia, frailty and falls.
Central to the program’s success is the emerging role of Complex Care Coordinators (CCCs) – like Tracey (pictured) and Loraine – in primary care. In 14 of the 18 participating general practices, practice nurses have been upskilled to deliver this specialised care coordination service and to identify eligible clients by working closely with their GP and through referrals from service navigators at Caboolture and Redcliffe Hospitals.
"A really positive part [of] the Care Collective program is empowering our patients to [access] care that is focused on what their goals are, ensuring that the patient is at the centre of their care planning, and empowering not only themselves, but their families and carers to ensure their goals are met," said Lauren, Caboolture Hospital Nurse Navigator.
100 per cent of Care Collective client survey respondents agreed that they were treated with respect and their needs and concerns understood by their Complex Care Coordinator. Of the invaluable support they received from their CCCs, they said:
“Without the help of my Care Coordinator nurse, we would still be struggling… The experience has been amazing.”
“My nurse helped me so much to understand and organise my advanced care planning. I am so grateful. She truly listened and I believe was sent from God to help me.”
Central to the Care Collective’s mission is empowering patients to make decisions about their own care. This patient-centred and holistic approach has also improved the health literacy of clients like Gloria, who learned that many of her seemingly unrelated symptoms were actually a result of her CHF.
Others echoed this sentiment:
“The information and support I am receiving is helping me to better understand my condition and has reduced anxieties related to my condition.”
“I found the nursing support allowed [me] to ask questions about my condition and [gave me] more time to spend in understanding my health.”
In the Caboolture region to date, the Care Collective has seen:
- a 63% reduction in monthly presentation rates
- a 450% return on funding invested in savings to the healthcare system
- $1,829 in average monthly savings per client.
End of story... We’ve got Gloria back to bowling again, walking her dog again, [things] she’d stopped doing because she thought her heart was going to stop. The Care Collective has brought Gloria around to having a better, [more] productive life in her twilight years.
Continuity of care from hospital to home – Miriam’s story
The Care Collective model enhances and integrates existing pathways between our PHN and Health and Hospital Service (HHS) to support better health outcomes and lower unnecessary health service usage for complex or chronically ill patients from our most vulnerable regions.
Miriam, 81, lived alone with reduced capacity for daily activities and experiencing a declining quality of life. With a history of worsening heart failure, Miriam had been known to the Heart Failure Clinic at Redcliffe Hospital where she was a frequent presenter with fluid overload, swollen limbs and shortness of breath.
Proactive intervention by a hospital Cardiac Liaison Service Nurse Practitioner to connect with a Care Collective CCC and GP, and coordinate a prompt, Medicare billed case conference including Miriam and this care team, saw an effective care plan swiftly implemented.
Daily reviews with the CCC and GP ensuring appropriate observation and medication, made possible by leveraging Care Collective services and networks, has kept Miriam – grateful to avoid the ED – out of hospital and safely at home awaiting an urgent cardiologist review.
Watch more stories from the Care Collective online.
Pictured (L to R) at the Redcliffe Care Collective launch event: Annie Hemms, Clinical Project Lead, Brisbane North Health Alliance, Libby Dunstan, Chief Executive Officer, Brisbane North PHN, Dr Jayne Ingham, GP, Capestone Village Family Practice, their patient and consumer advocate Lorraine, Rachel Milnes, Practice Manager, Tracey Johnson, Complex Care Coordinator, Vivienne Hassed, Executive Director, Office of the Chief Executive and Communications, Metro North Hospital and Health Service, and Rohie Marshall, Project Lead, Brisbane North Health Alliance officially launch the Care Collective – Redcliffe program at Capestone Village Family Practice.
