The Care Collective: Reducing Demand on Hospital Emergency Departments

Our goal was to design a model to improve the coordination of care for patients with chronic health conditions, to reduce the demand on Emergency Departments (ED). The Care Collective model involves better identification of the cohort and implementation of a shared care, case management model approach across the care continuum. It builds on and enhances existing programs and pathways already in place to manage chronic health conditions and aims to improve patient quality of life, health literacy and health outcomes, reducing ED presentations and hospital admissions.

The design solution focused on mechanisms to identify eligible clients frequently presenting to hospital, and funding Complex Care Co-ordinators (CCC) to coordinate client care within general practice. The busy and complicated health environment doesn’t usually support clinicians to navigate it with every patient. The CCC ensures patients understand their condition better and supports them to navigate the system and access the services they need for their health care. Whilst CCC’s are nurses, they perform less a clinical role and more a collaborative one, acting as a conduit between the different services clients might require, whilst also considering broader social needs.

The initial co-design project led to a 12 month pilot in Caboolture that reduced target client ED presentation by 75% and returned 396% of the funding invested. In addition client stories demonstrated the program fostered important linkages and meaningful positive outcomes including: ●Improved patient satisfaction, understanding and confidence. ●Better connections and access to appropriate, safe, high-quality services. ●Better utilisation of limited healthcare resources. ●Improved information sharing, collaboration and integration. Following on from this success, the service has been recognised by both Commonwealth and State Governments, who have provided funding to expand the program across the region.

We took a collaborative approach, working with patients, hospital staff, GP clinics and support services to develop and implement the pilot at Caboolture, and then to adapt it to Redcliffe. The co-design approach was critical to the success of the pilot and to the subsequent extension of the pilot to Redcliffe. While the driving goal was to reduce presentations to ED, post project evaluation found additional demonstrable benefits to patients, GPs, and other health professionals.