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.

  • Care Collective Client Survey

    Gaining client feedback is an important part of the Care Collective project.

    Please support the client to complete on line or send the printed version (see Resources for Complex Care Coordinators folder, in Care Collective Model of Care and Pathways) 

    The completed form can be emailed to Clinical Nurse Consultant when completed. 

    Thank you 

    Take Survey

  • Care Collective project survey to capture key learnings and opportunities for improvement

    As you are involved in the Care Collective project, you are invited to participate in a short survey.

    The main aim of the survey is to capture the key learnings to date and the current state of collaboration within the Governance groups to find opportunities for improvement. This survey will take approximately 5-minutes.  

    All responses will remain confidential and will be presented to the Governance groups in a de-identified format. 

    For any questions in relation to this survey, please email contact@healthalliance.org.au 

    Complete Form
Page last updated: 08 May 2024, 11:19 AM