Pilot program for people living with chronic health conditions reduces emergency visits to Caboolture Hospital

An innovative pilot program, the Care Collective—Caboolture, has recorded a 77 per cent reduction in presentations to Caboolture Hospital emergency department (ED) by those enrolled who live with chronic health conditions. Following the success of the pilot program, the Commonwealth and Queensland Governments have committed further funding to expand support in the North Brisbane and Moreton Bay region.

The Care Collective—Caboolture is an initiative by The Health Alliance—a unique collaboration between Brisbane North PHN and Metro North Health. The Health Alliance works strategically to break down barriers in healthcare available to communities in the North Brisbane and Moreton Bay region.

In early 2022, The Health Alliance was tasked with finding solutions to system-wide care in the Caboolture region—an area with a comparatively high proportion of people with complex health and psychosocial needs that puts pressure on the health system, including the Caboolture Hospital.

In response, the Care Collective—Caboolture pilot program was specifically designed to support people living with complex chronic health conditions to navigate and integrate into the healthcare system.

By referral into the Care Collective—Caboolture program, a team of clinically trained health professionals support people living with chronic health conditions who present to Caboolture ED repeatedly. Support is given by designing an individual program of care that is tailored in response to the specific health needs of the person referred, ensuring timely access to care. This model of care has proven to dramatically reduce repeat visits to Caboolture ED by the people enrolled in the program.

“High rates of complex chronic health conditions in the community puts enormous pressure, not just on emergency departments but also general practices and the overall health system,” said Brisbane North PHN Chief Executive Officer Libby Dunstan. “With our partners at Metro North Health, The Health Alliance developed a program of care and support that is scalable across other regions in the North Brisbane catchment that are experiencing high rates of complex chronic health needs.”

The Care Collective program supports general practice capacity building by placing complex care coordinators in general practices. By supporting patients to achieve better health outcomes, the need for hospital visits is reduced.

By addressing gaps in healthcare service delivery and mapping out an improved healthcare pathway with better connectivity of available services, this model can improve outcomes and lower unnecessary health service use for people with major chronic health conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or those that lead to presentations for debility (for example, dementia and falls).

Metro North Health Chief Executive Jackie Hanson said supporting general practices to care for people with complex health conditions can keep people healthier at home.

“Well managed complex and chronic conditions allow people to live a better quality of life and reduce the likelihood of a person becoming sicker and needing to come to hospital,” Ms Hanson said.

“The success of the Care Collective—Caboolture demonstrates the importance of strong partnerships between community, primary and tertiary healthcare providers to improve health outcomes for our community.”

The current pilot for the Care Collective—Caboolture finishes on 30 June and funding has been secured for 2023-24 through the Commonwealth’s Primary Care Pilot Program. Queensland Health Reform Office will have oversight of the program.

Referrals to the Care Collective—Caboolture had been steady since June 2022—largely from the Caboolture Hospital.

Of those enrolled to date:

• 15 percent have identified as Aboriginal and/or Torres Strait Islander
• the highest number have been from people with COPD
• and the average patient age is 77 years old.

To find out more about the Care Collective—Caboolture, please email contact@healthalliance.org.au.