New program to keep Whittlesea residents with complex chronic disease out of hospital

17 August, 2017

Whittlesea residents who are at risk of unplanned hospital admissions due to chronic illnesses such as diabetes and heart disease are set to benefit from the Community Based Complex Chronic Disease Intervention project which aims to reduce avoidable hospital admissions.

In Whittlesea, 5.8 percent of the population has type 2 diabetes (compared to the Victorian average of 4.7 percent) and the population has a higher than state average rate of cardiovascular disease.

Following a competitive tender process, Eastern Melbourne PHN (EMPHN) appointed Medibank to deliver its CarePoint program based on the insurer’s experience delivering similar evidence-based programs Australia-wide.

EMPHN CEO Robin Whyte said the 12 month project will identify Northern Health patients with complex chronic conditions such as diabetes, cardiovascular disease, chronic renal failure and respiratory conditions, who are at high risk of re-presentation to hospital.

“The CarePoint initiative will deliver personalised support to these patients in a home community setting,” she said.

“The initiative aims to improve the health and quality of life of around 90 patients with complex chronic diseases while reducing pressure on the public hospital system.”

Medibank General Manager of Member Health Rebecca Bell said the CarePoint program is based on significant evidence that links better coordination of care with better health outcomes.

“People living with chronic conditions often feel confused or distressed and find it difficult to navigate their way through the health system,” she said.

“CarePoint gives participants access to the support and resources they need to keep as healthy as possible and stay out of hospital.”

Northern Health General Manager Jenni Smith said this partnership will help us to provide and facilitate better health outcomes for our community.

“By working together, Northern Health will be able to provide patients timely, safe and appropriate care, in the comfort of their home,” she said.

The Community Based Complex Chronic Disease Intervention project:

  • aims to improve patient and carer health literacy through one-on-one self-care and health coaching over the phone
  • will develop a tailored care plan for each patient following assessment in the home
  • aims to improve coordination of care between GPs, in-home care providers and allied health providers to better monitor clients’ health needs including improved follow-up and recall
  • aims to link patients with social support services to reduce feelings of isolation and build emotional and social wellbeing.

The program is supported by funding from the Commonwealth Government under the PHN Program.