Caboolture Complex Care Project

Caboolture Complex Care Project

Why are we focused on this group?

Within the Brisbane North region, the growing burden of chronic disease and complex conditions results in frequent visits to emergency departments (ED) and potentially preventable hospitalisations.  For many of these instances, the patient care could be better coordinated and include care provided in a community primary health care setting and closer to home. 

Frequent Presentation (FP) to ED is typically seen among those patients living with chronic and complex conditions. Within the local Caboolture context, these patients are a small cohort but account for a disproportionate number of ED presentations, utilising a significant number of resources in the hospital setting.

This project aims to reduce the current significant demand on the Caboolture Hospital ED, by improving the identification, management and support for patients living with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and debility (falls and dementia) through general practices and complex care coordinators within the community. This includes the development of a shared care approach within general practice and the expansion of the existing Team Care Coordination program.

This Caboolture Complex Care Project is critical for a range of other high-profile programs of work, including:


What are we trying to achieve? 

This project aims to reduce the frequency of ED presentations and admissions by Frequent Presenters (FP) living with COPD, CHF, and debility through building on and enhancing existing programs and pathways. This includes:

  • Improving patient outcomes and patient experience for people living with COPD, CHF, falls and dementia through the provision of more coordinated, accessible and timely care, closer to home.
  • Improving access to proactive chronic condition management within general practice, with a focus on improving access to multidisciplinary shared care teams. 


Key stakeholders

Both the Commonwealth and State Governments have joined forces to jointly fund this important work across the care continuum for the patient through the Health Alliance.

The co-design process has involved genuine participation to build the patient experience with input from health consumers, their families or caregivers, and health professionals.

Key stakeholders include health consumers and the community, Metro North Health, Brisbane North PHN, Queensland Ambulance Service, Queensland Health, Commonwealth Department of Health and Aged Care, the Institute for Urban Indigenous Health, Non-Government Organisations, other PHNs, and primary care teams (including general practitioners and practice staff).


How have we progressed? 

We have finalised Phase 1 - the co-design phase has been completed and patients and health professionals have been interviewed.

Information has been gathered through discovery, testing and playback sessions with health professionals from across the care continuum.

We are now in Phase 2 which is the implementation phase. This is where we test the pathways and shared care model by enrolling patients into the program and continually review to look for opportunities for improvement for the patient. Patients will be identified firstly from ED data collected by Metro North Health and also through discharge planners who work in ED and on the wards. Once this is established, we will identify patients who could benefit from this program through GP practice data. Continual opportunities for improvement will be investigated throughout the implementation phases of the program. 

For more information on this project, please email