Right Care Better Health service
The Right Care Better Health (RCBH) service has been helping people with chronic conditions in primary care to find, access and receive complex care through local services since 2021. It recognises the importance of wrap-around services to support the people in our region with complex, chronic health conditions.
The program supports people with complex long-term health conditions, providing care navigation and coaching to improve health outcomes and lower the risk of hospitalisation.
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About the service
Many people with complex and chronic conditions are not accessing a full range of clinical and support services to improve their well-being and reduce avoidable hospital admissions.
Health outcomes and quality of life can be improved by providing care coordination and self-management support in the community, including through information and supported access to community services.1
The RCBH Service addresses these needs by providing referred patients with:
- Person-centred care that is appropriate, timely and tailored to each individual
- Improved quality of life
- Lowered rates of avoidable hospital admissions
The service is funded by Eastern Melbourne Primary Health Network (EMPHN) and delivered by EACH and Silverchain in collaboration with participating general practices.
The focus of the current iteration of the program is people in general practice with complex health needs including patients with cardiovascular disease, respiratory disease and frailty. These are some of the most commonly occurring chronic conditions in the region and are a cause of frequent hospital attendances (either via the Emergency Department, outpatient departments or admissions). The program aims to help these patients access a range of health and social services and support self-management of these conditions to maintain or improve their quality of life.
Service model
The RCBH Service is funded by EMPHN to provide community health-employed nurse care coordinators who are integrated within participating general practices across the EMPHN region. This model supports and enhances team-based multidisciplinary patient-centred care.
The service providers and participating general practices will work with EMPHN to continue to refine the service model to:Â
- Develop appropriate referral
- Contribute to the evaluation framework
- Ensure value for money in achieving better outcomes for patients
This will provide an opportunity for shared learning and a general practice-led response to transform the management of complex and chronic conditions in primary care.
Reference: 1. Batterham R, Osborne R, McPhee C, Mech P, Townsend B. Consumer enablement: an Evidence Check rapid review brokered by the Sax Institute for the Agency for Clinical Innovation, 2016.