South East Care Pathway

The South East Care Pathway (SECP) is a new way to support people with increased vulnerabilities and/or complex health needs following their discharge from hospital.

How does it work?

When patients are referred to the service, we assess their needs and provide health monitoring and care navigation for people with chronic respiratory and complex health conditions, and increased vulnerabilities.

What is the purpose of SECP?

We aim to:

• Prevent avoidable emergency presentations and reduce the length of stay in hospital

• Enable step-down and step-up pathways to primary care

• Facilitate access to community/non-admitted hospital-based services.

Who delivers the pathway?

The South East Metro Health Service Partnership has contracted Sandringham Ambulatory Care Centre (SACC) to deliver the South East Care Pathway pilot across the SEMHSP region.

Who CAN be referred to SECP?

People who are clinically or socially vulnerable and who meet one or more of the following criteria:

• require closer health monitoring than routinely available in primary care

• have an increased risk of hospital presentation or difficulties accessing primary care

• require transition support from hospital to primary/community care

• have COVID-19 or other respiratory illnesses that meet the above criteria

Additionally, patients may have one of the following:

• Aboriginal and Torres Strait Islander people

• CALD patients

• people with a disability who live in specialist accommodation or are at home with supports, or people who care for someone with a disability

• people needing support to isolate at home (such as food, medicines, social services)

• patients from lower socio-economic communities.

• people aged under 18, or over 65.

Who CANNOT be referred to SECP?

• Residents of an aged care facility. They will be referred to Resident in Reach services.

• Patients who reside outside of the South East Metropolitan Melbourne region. They will be referred back to the referring health service to manage follow up or further referrals as needed.

• Patients who need an in-home review. SECP can refer these patients to appropriate services.

How does SECP work?

An initial triage call with a patient determines the care pathway they will require while with the program. Depending on the need of the patient, there are two approaches:

Passive Monitoring

Patients respond to automated surveys which are reviewed by a clinician who will determine if the patient requires a follow up based on the results.

Active Monitoring

Clinicians provide regular phone contact with the patient to complete welfare checks, symptom checks, or appointment reminders.

What support does SECP provide?

We work collaboratively with primary, secondary, and tertiary health services by liaising directly with patients, and their care support systems, to provide a range of support:

• Direct to appropriate service if urgent care is needed

• Organise GP appointments – telehealth, or in-person

• Link patients with ongoing GP care if not already in place

• Provide appointment reminders

• Offer telehealth clinical and symptom support

• Help with navigating the healthcare system

• Ensure proper home care support is in place

• Assist with direct admission to hospital, by bypassing or pre-warning emergency departments of patient arrival.

Does SECP provide care in the home?

No, but we can help with connecting patients to the appropriate services to support their care at home.

Is the support offered through the pathway short or long term?

The length of care is dependent on the needs of the patient. It may be a couple of days, or months and is determined by when a patient is fit to be discharged.

If the clinician determines that a patient will benefit from long-term case management, they are referred to a service that can take over management of their care.

How are patients contacted?

Patients will be contacted via SMS to let them know they have been referred to the service. A clinician from SACC will contact them shortly after receiving the referral. Patients can opt out via SMS if they choose.

Who can refer to SECP?

A patient may be referred by any health professional from primary, secondary, and tertiary health services, such as the VVED, or a GP practice.

How do I refer a patient?

Referring is quick and easy. Complete the short form at https://care.semetrohealth.org.au/referral (for Clinicians only)

Once referred to SECP, a patient will be contacted by the team for an admission assessment.

What information is needed to refer a patient?

You will be asked to provide patient details, reason for referral, and the referral source. For example, VVED, health service, or GP clinic.

If referring from a health service, or VVED you can upload a discharge summary.

What are the qualifications of SACC staff who will contact patients?

All SACC staff who contact patients are enrolled, or registered nurses.

Are older patients disadvantaged by their access to technology?

No, all conversations are conducted via phone to ensure we can provide a personalised and relevant patient experience.

If I refer a patient, will I know what support has been provided?

SACC is working to incorporate a feedback loop for referrers. Once this is in place, referrers will receive a confirmation email to let them know if their referral has been accepted or declined.

Does SACC have experience working with vulnerable people?

Yes, SACC has significant experience working with vulnerable groups including, homeless, CALD, and domestic violence cohorts. Staff work with case managers to problem solve solutions for vulnerable individuals.

What if I have more questions?

SACC staff are available to answer questions between 9 am and 5 pm seven days a week.

Patients or clinicians can contact the program by:

• Calling 9119 1025

• Emailing carepathway @sacc.org.au

Please note, referrals are not accepted via phone, or email and should be submitted via the referral form: https://care.semetrohealth.org.au/referral