Refreshing our Lens, Looking Beyond Chronic disease: A break down of figures a year after the instigation of a hospital avoidance team, the impact on our hospital, and our patients

Ms Bethany Leslie1, Mrs Jessinta Benton1, Mr Anthony Hall1

1St John Of God Midland, Perth, Australia

Patients with Ambulatory Care Sensitive Conditions (ACSCs) often have complex social needs in addition to their primary chronic disease.

The consequence of chronic disease for health services is multiple presentations to both hospital and primary care providers, increased length of stay in the emergency department and subsequent inpatient settings. The cumulative effect demonstrates the need for proactive management of the condition and support for the person and their family.

The HART is a multi-disciplinary team, currently comprised of an Occupational Therapist, a Social Worker, and a Clinical Nurse. The team provides support to the Emergency Department (ED) and inpatient teams in the assessment and coordination of patients with the following ACSCs; congestive heart failure (CCF), chronic obstructive pulmonary disease (COPD), cellulitis, urinary tract infection (UTI) and diabetes.

The primary objectives of the Hospital Avoidance Response Team (HART) service are to decrease length of stay (LOS) and to reduce re-admission rates of the Ambulatory Care Sensitive Conditions (ACSC) to subsequently improve both hospital bed capacity and the patients’ chronic disease journey.

The data demonstrates a huge reduction in the ED presentations for patients that are involved with the multidisciplinary Hospital Avoidance Response Team in addition to reduced length of stay both in ED and for those admitted to an inpatient ward. The HART program is projected to have saved $4.8M in avoidable ED presentations and LOS reductions in 2020.


Carly Maurer works as a Director Allied Health at Central Queensland Hospital and Health Service. Carly graduated from the University of Queensland with a Bachelor of Physiotherapy (First Class Honours) in 2004. Carly has assumed clinical, managerial, education and research roles in tertiary, regional and remote settings in Queensland and Western Australia. In recent years, Carly has taken on leadership roles and responsibilities in clinical governance, workforce development and clinical education.

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