A new way to support people with increased vulnerabilities and/or complex health needs.
Delivered by
Sandringham Ambulatory Care Centre (SACC), the South East Care Pathway (SECP) program is a South East Melbourne regional approach to virtual care navigation and coordination. It provides crucial support for patients with vulnerable and complex care needs at risk of hospital admission or following hospital discharge.
About the program
The South East Care Pathway Virtual Care Coordination program is delivered mainly via telehealth and aims to:
- reduce avoidable emergency department visits,
- support the safe discharge of patients to and from healthcare services
- facilitate the transition of care between primary, secondary and tertiary care providers for ongoing management.
How does it work?
An initial triage call with a patient determines the care pathway they will require while with the program. Depending on the needs 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 kind of support can patients receive?
People may receive the following support through The South East Care Pathway:
- Direction to appropriate service if urgent care is needed
- Organisation of GP appointments – telehealth, or in-person
- Linkage with ongoing GP care if not already in place
- Appointment reminders
- Telehealth clinical and symptom support
- Help with navigating the healthcare system
- Help to ensure proper home care support is in place
- Assistance with direct admission to hospital, by bypassing or pre-warning emergency departments of patient arrival.
Who is eligible?
People who are clinically or socially vulnerable and meet one or more of the following:
- 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
To support priority populations, the program has a strong focus on providing access to treatment for people who:
- identify as Aboriginal and Torres Strait Islander people
- identify as CALD
- have a disability, or people who care for someone with a disability
- from lower socio-economic communities
Why is this service needed?
Evidence has strongly shown that improving support at key transition points can reduce reliance on overburdened acute services and improve the patient experience of navigating their complex care needs.
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Refer Now
- Health Professionals can complete SACC's referral form here.
- Contact SACC on 9119 1025 or email carepathway@sacc.org.au for further information about the program.
The South East Care Pathway service is delivered by
SACC and funded by South Eastern Melbourne Primary Health Network.
South Eastern Melbourne PHN
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