Can Care Coordination reduce Hospital Admission in at-risk patients: The HealthLinks Project Evaluation at Peninsula Health

Miss Rebecca Kwok-yee Pang1,2, Prof  Velandai Srikanth1,2, Mrs Belinda Berry1, Mr Faisal Husain1, Dr Gary Braun1, Mrs Erin Magee1, Dr Nadine E Andrew1,2

1Peninsula Health, Frankston, Australia, 2Monash University, Frankston, Australia

Unwarranted hospital readmissions, particularly among people with chronic complex conditions, add to the cost of health care. It is therefore important to devise ways to reduce the risk of readmissions in this group.

The HealthLinks pilot project was conducted as a Department of Health and Human Services initiative. HealthLinks algorithm, developed by CSIRO, was made available to health services whereby a score ≥ 9 indicated high-risk of readmission. Peninsula Health adopted this criteria, coupled with care-coordination to patients aged between 51-91 years admitted to hospital between May and November 2017. Identified patients received care coordination by a nurse, multidisciplinary team interventions and follow-up, via regular telephone calls for 30 days after hospital discharge.

A pilot retrospective matched cohort study was performed. Patients, who received care coordination, were matched with five controls (patients who did not receive care coordination) on HealthLinks score, age, and sex. Descriptive analyses were used to compare groups; survival analysis was used in the primary outcome analyses. Primary outcomes were time to first readmission at 30, 60 and 90 days. The primary cause of readmissions was also described.

Sixty-five people received HealthLinks interventions (mean age 79 years, 46% male, median HealthLinks score 12) and 319 matched controls (mean age 78 years, 49% male, median HealthLinks score 12) were identified. There was a 22% reduction in readmission risk (Hazard Ratio 0.78, 0.42-1.45, p=0.44) within 30 days, no difference at 60 days and a 21% increased risk at 90 days (HR 1.21, 0.81-1.82, p=0.35) post discharge. Results were not statistically significant.

Results were underpowered due to small sample size. However, there were clinically important signals suggesting that care coordination in first 30-days may reduce time to readmission in at-risk patients, and the absence of this coordination may increase readmission risk. Verification in an adequately powered randomised trial is needed.

Acknowledgement: all co-authors and the Community Care team.


Rebecca is a pharmacist at Peninsula Health where she has worked in a variety of areas. Rebecca is the senior pharmacist for Community Care and is currently undertaking PhD with Peninsula Clinical School, Monash University. She works with a multidisciplinary team to support clients who reside in the community and residential aged care facilities, with the view of preventing unnecessary hospital admissions.

Recent initiatives have included researching the multidisciplinary integrated health approach between hospital and community in preventing clinical deteriorations and unnecessary hospital admissions and providing safer care and program redesign.

NAHC Conferences

2007, Hobart (7th NAHC)

2009, Canberra (8th NAHC)

2012, Canberra (9th NAHC)

2013, Brisbane (10th NAHC)

2015, Melbourne (11th NAHC)

2017, Sydney (12th NAHC)

2019, Brisbane (13th NAHC)

Conference Managers

Please contact the team at Conference Design with any questions regarding the conference.

Photo Credits: Tourism & Events Queensland

© 2017 Conference Design Pty Ltd