Monash University and Alfred Health evaluate impact of COVID-19 Community Pathway

An evaluation of the Alfred Health COVID-19 Community Pathway (AH-CCP) – set up during the pandemic to help care for patients in isolation – has found the pioneering approach was effective in providing patient care in the community.

Researchers from the Health and Social Care Unit in the School of Public Health and Preventive Medicine at Monash University and from Alfred Health General Medicine Unit conducted an evaluation of AH-CCP, with funding provided by the Digital Health Cooperative Research Centre (DHCRC).

The AH-CCP model of care was set up as a partnership between Alfred Health and community partners Star Health, Sandringham Ambulatory Care Centre and the South East Melbourne Primary Health Network, and later was part of a broader collaboration led by the South East Melbourne Health Service Partnership.

The service aimed to reduce emergency presentations, easing pressure on a stretched workforce and moderating the potential for COVID-19 to spread through the hospital, as well as to provide safe care in the home for those isolating with COVID-19.

The AH-CCP received over 175,000 referrals over its two years in operation, and provided monitoring to over 100,000 people, with detailed telehealth assessments and in-home virtual care for over 40,000 people. The evaluation suggested that the model may have resulted in substantial hospital avoidance, with over 91% of patients escalated from primary care management able to be managed safely in their home without hospital presentation. Interviews and feedback survey results also suggested that the model was highly valued by both staff and patients.

Dr Richard Coates, Lead of Alfred COVID Pathways and one of the authors of the AH-CCP evaluation, said given the anticipated future importance of such virtual models in enabling care it was critical to utilise and build on the lessons learnt from this innovative and successful initiative.

“Collaboration on an unprecedented scale between government, hospital and community sectors enabled the model of care to remain agile and adapt to the constantly changing landscape of the pandemic,” Dr Coates said. “AH-CCP provides a clear template that could be rapidly deployed to support the community and protect the health service in the event of future pandemics, or to support people with other health conditions who are at risk of hospital admission.”

Novel digital tools help clinicians and patients

The AH-CCP combined the large-scale use of remote patient monitoring equipment with a virtual clinical team utilising novel digital health tools.

Distinctively, it featured a digital health tool called Covid Monitor, designed by Arden Streel Labs, to track and triage patient symptoms remotely. The COVID Monitor allowed clinical care to remain focused on those most at risk, despite large increases in case numbers, and also acted as a workaround for the lack of shared information systems.

“The use of a digital health tool was instrumental in allowing rapid up-scaling and targeting care to those with the highest clinical need through use of daily symptom monitoring,” Monash University Professor Ingrid Hopper said.

“One of our key recommendations in this report is that digital health tools should be utilised in virtual care models to aid communication and monitor patients’ symptoms to effectively target clinical care to where it is most needed,” Professor Hopper said.

DHCRC CEO Annette Schmiede said the evaluation report provided one of the first insights into how the rapid implementation of virtual care at the onset of COVID-19 was valued by clinicians and patients.

“The model of care established and implemented by Alfred Health provides a template for the expansion of home-based care for future pandemics and as a way to better treat other chronic conditions at home,” Ms Schmiede said.

“It also shines a light on the role of digital health, how patients engage with tools in the home, and perhaps most importantly, the need for an integrated health record across partner organisations as an enabler of success for such future models of care.”

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