Regional Care Connect Pilot Program

Better care for chronic disease patients demonstrated with digital health monitoring pilot

To address wider health challenges such as the growing chronic disease burden, inefficient hospital utilisation and gaps in innovation, a digitally enabled, patient-centred healthcare model was trialled for 3 months during 2024.

This program successfully integrated regional general practice, digital health monitoring with enhanced care coordination across primary, secondary, and tertiary healthcare sectors in regional South Australia. It combined hospital discharge data with primary care and virtual clinical monitoring in-home with the goal of improving outcomes for chronic disease patients, reducing emergency department presentations and preventing hospital admissions.

How the pilot program worked

High-risk patients from the Renmark Medical Clinic were identified through a data-driven risk assessment approach using the LACE index scoring tool for risk assessment of readmission or death in patients. They received remote monitoring devices and in-home virtual support via South Australia’s Virtual Clinical Care (VCC) hospital avoidance service which supported their self-care and enabled these patients to self-manage their conditions.

Who was involved

The pilot was a collaboration between SA Health’s statewide services, the Commission on Excellence and Innovation in Health, the Rural Support Service and the Renmark Medical Clinic in the Riverland in regional South Australia.

Significant findings

The pilot successfully reduced hospital utilisation and improved patient care, with:

  • 80% reduction in emergency department (ED) presentations
  • 77.8% decrease in readmission risk
  • 21 ED presentation and 1 hospital admission avoided
  • high patient satisfaction: 100% of participants said they felt safe using the monitoring equipment and had increased confidence in managing their health
  • effectiveness of risk algorithms validated, with LACE scoring showing 100% sensitivity in identifying patients at risk of readmission and enabling accurate prioritisation of monitoring resources
  • excellent stakeholder feedback with Renmark Medical Clinic GPs endorsing the pilot for its ability to improve patient outcomes while reducing burden on practices.

Access the pilot abstract

Read an abstract of the Regional Care Connect Pilot (PDF 294KB)