Preventative Integrated Care Service (PICS)

Aim

PICS aims to:

• reduce avoidable hospital admissions and readmissions
• reduce potentially preventable hospitalisations
• reduce unplanned emergency department presentations
• improve patient quality of life
• reduce hospital length of stay
• provide rapid access to specialist assessment and intervention
• identify and manage co-morbidities
• address psychosocial factors that influence health outcomes
• support patients to self-manage their chronic conditions
• deliver care closer to home through flexible and digitally enabled models of care.

Outcomes

Early service outcomes demonstrate positive impacts on both patient care and healthcare utilisation.

Reported outcomes include:

• Improved access to multidisciplinary chronic disease management
• Earlier identification and management of clinical deterioration
• Enhanced patient engagement and self-management
• Reduced hospital utilisation through proactive intervention
• Improved continuity of care following hospital discharge
• Increased flexibility in service delivery through home visits, telehealth and remote monitoring.

Preliminary service data indicate approximately a 50% reduction in hospital presentations during the six months following a PICS episode of care compared with the six months prior.

A qualitative evaluation involving 33 PICS patients found strong acceptance of remote patient monitoring technologies. Patients described the technology as easy to use, reassuring, and supportive of self-management, particularly when combined with ongoing clinical support.

Background

West Moreton Health serves a population with a significant burden of chronic disease and health inequity. Compared with Queensland averages, the region experiences:

• higher rates of chronic disease
• greater socioeconomic disadvantage
• transport and access barriers
• higher smoking rates
• higher rates of overweight and obesity
• lower rates of physical activity and healthy dietary intake.

These factors contribute to increased demand for hospital services and higher rates of potentially preventable hospitalisations.

PICS was developed to provide a rapid-access, multidisciplinary alternative to hospital-based care for people living with complex chronic conditions. By intervening early and supporting patients in their homes and communities, the service seeks to improve outcomes while reducing avoidable hospital use.

Discussion

PICS provides timely, person-centred care through a combination of face-to-face appointments, home visits, telehealth consultations, telephone support and digital monitoring technologies. The service focuses on improving patient outcomes, supporting self-management, and enabling care closer to home while reducing demand on hospital services.

PICS is also the subject of an ongoing evaluation program, including research exploring patient experiences of remote patient monitoring and digitally enabled care.

Further Reading

Patient Perspectives on Remote Monitoring
A companion Improvement Exchange article describing findings from a qualitative evaluation of patient experiences using remote patient monitoring within the PICS model of care.

Patient Perspectives on Remote Monitoring | Clinical Excellence Queensland

Additional evaluation activities are being undertaken through a broader program of research examining implementation, patient outcomes and sustainability of the PICS model.