Care Collective

Care Collective

Caboolture and Redcliffe regions

What is the Care Collective?

The Care Collective program aims to improve care coordination and system navigation for a targeted cohort of people living with chronic and complex health conditions, by funding a Complex Care Coordinator position (registered nurse) in registered general practices. Eligible clients include those who have one or more of the identified chronic health conditions, are living independently in the community (not RACF), a regular client of one of the participating practices and have consented to be part of the Care Collective program (aged 18+). This program is funded jointly by Commonwealth Department of Health and Metro North Health and is currently operating in the Caboolture and Redcliffe regions at no cost to clients. The program aims to improve the client’s ability to manage their own health and improve their quality of life within their own homes and communities.

The Complex Care Coordinator aims to:

  • Improve coordination of allied health services for eligible clients

  • Increase the ability to understand and manage associated health conditions

  • Reduce unnecessary admissions to the emergency department

  • Offer care that is guided by client and family goals

  • Identify health care gaps, connecting the client with existing services in the community

The identified chronic health conditions, which were identified through data analysis of emergency department presentations in both regions, are:

  • Chronic Obstructive Pulmonary Disease (COPD) 

  • Congestive Heart Failure (CHF) 

  • Debility (frailty scores of 5+, behaviour related to dementia or falls)  

The Care Collective provides the opportunity for general practices to access funding and resources to build the capacity of the practice to manage and support patients with chronic health conditions. 

Care Collective practices benefit from: 

  • Increased communication between hospital discharge planners and nurse navigators after an ED presentation by a client of your practice who has one or more of the identified chronic health conditions 

  • Increased, dedicated nursing resources within the practice to work with eligible Care Collective patients with the aim of improving health literacy, quality of life, and health outcomes 

  • Increased billing opportunities through chronic disease MBS items, preventative health items, medication management reviews, case conferencing and diagnostic testing  

  • Opportunities to network and strengthen communication with hospital clinicians and other providers involved in your clients’ care

  • Free of charge access to peer support and continuing professional development opportunities for Complex Care Coordinators working in your practice

Eligible clients may be identified through several pathways, including within the general practice, by the emergency department, or through other services such as Team Care Coordination or Rapid Access Community Care.

Data to date provides an indication that the Care Collective is successfully reducing clients’ emergency department (ED) presentations and unplanned inpatient admissions. It is also producing savings of more than double its funding in reduced hospital service use.

The Care Collective is also delivering a diverse range of impactful health and social outcomes for clients and their families, given the flexibility and ‘gap filling’ nature of the program.

Care Collective

Caboolture and Redcliffe regions

What is the Care Collective?

The Care Collective program aims to improve care coordination and system navigation for a targeted cohort of people living with chronic and complex health conditions, by funding a Complex Care Coordinator position (registered nurse) in registered general practices. Eligible clients include those who have one or more of the identified chronic health conditions, are living independently in the community (not RACF), a regular client of one of the participating practices and have consented to be part of the Care Collective program (aged 18+). This program is funded jointly by Commonwealth Department of Health and Metro North Health and is currently operating in the Caboolture and Redcliffe regions at no cost to clients. The program aims to improve the client’s ability to manage their own health and improve their quality of life within their own homes and communities.

The Complex Care Coordinator aims to:

  • Improve coordination of allied health services for eligible clients

  • Increase the ability to understand and manage associated health conditions

  • Reduce unnecessary admissions to the emergency department

  • Offer care that is guided by client and family goals

  • Identify health care gaps, connecting the client with existing services in the community

The identified chronic health conditions, which were identified through data analysis of emergency department presentations in both regions, are:

  • Chronic Obstructive Pulmonary Disease (COPD) 

  • Congestive Heart Failure (CHF) 

  • Debility (frailty scores of 5+, behaviour related to dementia or falls)  

The Care Collective provides the opportunity for general practices to access funding and resources to build the capacity of the practice to manage and support patients with chronic health conditions. 

Care Collective practices benefit from: 

  • Increased communication between hospital discharge planners and nurse navigators after an ED presentation by a client of your practice who has one or more of the identified chronic health conditions 

  • Increased, dedicated nursing resources within the practice to work with eligible Care Collective patients with the aim of improving health literacy, quality of life, and health outcomes 

  • Increased billing opportunities through chronic disease MBS items, preventative health items, medication management reviews, case conferencing and diagnostic testing  

  • Opportunities to network and strengthen communication with hospital clinicians and other providers involved in your clients’ care

  • Free of charge access to peer support and continuing professional development opportunities for Complex Care Coordinators working in your practice

Eligible clients may be identified through several pathways, including within the general practice, by the emergency department, or through other services such as Team Care Coordination or Rapid Access Community Care.

Data to date provides an indication that the Care Collective is successfully reducing clients’ emergency department (ED) presentations and unplanned inpatient admissions. It is also producing savings of more than double its funding in reduced hospital service use.

The Care Collective is also delivering a diverse range of impactful health and social outcomes for clients and their families, given the flexibility and ‘gap filling’ nature of the program.

Discussions: All (9) Open (9)

  • Updated MBS Billing Guide for Care Collective Clients

    about 2 months ago

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    Just a note to say that the Care Collective MBS Billing guide has been updated to include telehealth and phone support for people who have had health assessments or care plans. 


    Thank you to our Primary Care Engagement team for supporting this development and  hope this is helpful for you all 


    Happy reading 


    Annie 

    Clinical Project Lead  

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  • Mater Health Multicultural Health Coordination Program

    6 months ago

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    Hello Everyone 


    Please see in the folder for Community Based services two new documents 

    • Multicultural Health Coordination Program - How to Refer
    • Multicultural Health Coordination Program - Model of Care Draft 

    This is a new service offering coordination support to clients in the community that have complex health and wellbeing needs who are from a multicultural background.  This will be a great service and can offer Care Collective clients that wrap around support that we may be restricted to support due to language and/or cultural barriers.


    Watch this space as I am going to ask the team to present at a Community of Practice soon 


    Thanks 


    Annie 

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  • Supporting Clients to Access Aged Care Services

    8 months ago

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    Dear All 


    I have added in the community resources a document called "Supporting Patients to Access Aged Care Services" which is a great guide to support health professionals to understand the My Aged Care Process and how to make referrals. 

    The bones of the document are correct, but there are a few amendments I would like to make :

    1. The Fax for My Aged Care quoted on the document no longer exists. My Aged Care do not take Faxes  - I would recommend an online referral or via phone 

    2. The phone number for My Aged Care is 1800 200 422 however there is a Health Professionals contact number also that aims to speed up the process and improve on hold times - please call 1800 836 799 and choose option 4 


    Very happy to do a teaching session on referrals to My Aged Care in the near future in one of our community of practice meetings if this will help your understanding of the process and how we can help the client 


    Thanks in advance 

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  • Document Uploaded - Consent and Consent Talking Points

    about 1 year ago

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    Dear All

    Two new documents added to the page - Consent (updated from February 2023) and also the talking points for gaining consent.

    Would love to know if the talking points are helping with gaining consent and helping the client give an informed consent.  Anyone got any feedback?

    thanks 

    Annie 

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  • Forum - Care Collective

    over 1 year ago
    1 Response

    A forum to ask questions, collaborate and share key learnings about the Care Collective. 

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  • Registering to gain Access to the Viewer/Health Provider Portal

    8 months ago

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    Dear CCCs

    The Viewer Health Provider Portal is available for you to use to be able to see Queensland Health Viewer that enables you to search for a client and be able to see their QH admissions, out patient appointments, discharge summaries and ED attendances.


    As a AHPRA registered health professional - you have access to this service.  To register please follow this link 


    https://www.health.qld.gov.au/clinical-practice/database-tools/health-provider-portal/gps-resources/hpp-login


    You will need your HPII number and AHPRA number to register so have them to hand. (AHPRA can assist you with finding your HPII number) 


    This is a great resource to help support a client in coordination 


    Thanks 

    Annie 

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  • New Information added to Resources for CCC

    7 months ago

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    Huge thanks to the team at Caboolture hospital for sharing some great information about respiratory education and resources - I have saved this in our resource folder for CCC under chronic health conditions. 


    Please have a look and get our questions ready for the team at our workshop happening on the 11 October 2023 


    thanks 

    Annie 

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  • Presentations for CCC Workshop North Lakes Hotel 11 October 2023 now online

    7 months ago

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    Dear All 


    A huge thank you to all that attended, contributed, learned and presented yesterday at the Complex Care Coordinator Workshop at North Lakes Hotel. I have put together a folder of resources called 

    in the resources info with all the presentations from the day and a copy of the case studies we discussed as a group 

    Please feel free to reach out if needed 

    Kind regards 

    Annie 


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  • Practice Support website now live - Brisbane North PHN

    2 months ago

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    General practice resources are one click away 

    Practice Support draws on Brisbane North PHN's Primary Care team’s experience and expertise to deliver critical, reliable and up to date information to practices to help you provide the best possible care to your patients and communities. Brisbane North PHN's new dedicated     Practice Support website now hosts all general practice support information in one convenient, organised location.

     Practice Support features: 

    • an enhanced search function, so you can find the information you are looking for in a single click 
    • an easy to navigate Practice Toolbox of information and resource libraries across all clinical and administrative topics that support the running of your practice  
    • a central site for you to check for clinical alerts and announcements  
    • a library of relevant training and education. 


     


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Page last updated: 03 May 2024, 09:26 AM