The Care Collective - A new project targeting frequent presenters at Caboolture ED

Metro North Hospital and Health Service (Metro North Health) is experiencing unprecedented demand for care within Emergency Departments (ED), especially in the Caboolture region.

In March 2022, a range of health professionals and patients in the Caboolture region came together to better understand what is driving and sustaining the increased demand, and to work through opportunities to address these complex issues. The full co-design report can be viewed in the Future Models of Care report.

It is clear within the local Caboolture context that there is a cohort of patients who account for a disproportionate number of ED presentations and who need significant support to manage their condition/s. The data showed that frequent presentations (FP) to ED were occurring for a group of patients living with chronic and complex conditions, often without adequate social support, a regular GP relationship or rapid access to a GP.

Queensland Health and the Commonwealth Department of Health and Aged Care have jointly confirmed their support and financial commitment to the Care Collective targeting frequent presenters to Caboolture ED over a 16-month period.

Care Collective – Caboolture project

The Care Collective – Caboolture aims to improve access to primary healthcare and coordination of care for people who frequently present to Caboolture ED who have chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) and those coded as presenting with debility (falls and dementia).

The project builds on and enhances existing programs and pathways and improves the patient's access to better supported general practices and multi-disciplinary care teams. This pathway strengthens the ability to proactively coordinate and navigate the patient’s journey through the system, which can result in better support, better health outcomes and a reduction in ED presentations.

Since the commencement of the pathway in June 2022, there have been 85 patients enrolled. An evaluation of the model will be completed in June 2023, which will aim to measure patient experience, patient outcomes and the impact of the Care Collective on Caboolture ED demand and the broader Caboolture region.

The key elements of the project include:

• Increasing the capacity of the successful Team Care Coordination -Staying Healthy Staying Home program.

• Supporting and improving access within general practice

• This involves introducing a Complex Care Coordination service in nine general practices in the Caboolture region to proactively see, treat and manage patients with chronic and complex conditions in a timely manner with a supportive framework and multidisciplinary team.
• This service will also proactively enroll patients identified within targeted general practices as being at high risk of hospitalization for these conditions in the next 12 months.

• Enabling collaboration and networking between current services and service providers to work on system improvement and service integration.
• Encouraging hospital staff to provide referral and appropriate clinical handover of patients who frequently present to ED back to their primary health carer with the support of Nurse Navigators, Complex Chronic Disease Team or Team Care Coordinators where appropriate.

• Enabling better data and information sharing platforms and processes, to contribute to removing barriers to coordinated and connected care within the community and at the interface between general practice and hospital services.

For more information, please contact Ian Purcell, General Manager of the Health Alliance, ian.purcell@brisbanenorthphn.org.au