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 best 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 management and support for patients living with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and debility through general practices and 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, and debility through the provision of more accessible and more 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 Government, 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.

Phase 2 (April 2022 – Mar 2023), will see the planning and implementation of the shared care “proof of concept” model for selected patients who frequently present to Caboolture ED.

For more information on this project, please email