Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
A person-centred, data-driven Queensland Ambulance Service (QAS) program that reviews and guides care for vulnerable frequent presenters through coordinated care plans, reducing ambulance service and Emergency Department (ED) demand.
Dates: Feb 2024 - ongoing
Implementation sites: Darling Downs region, Toowoomba Hospital
Partnerships: General Practice, community mental health, hospital ED and inpatient services, community and residential care providers, and other agencies involved in safety and social support.
Aim
Improve outcomes for people who use ambulance services for their primary health care needs by delivering coordinated, multidisciplinary, evidence-informed care that reduces avoidable ambulance utilisation and ED presentations.
Outcomes
- Reach and cohort: 1,817 patients enrolled (≈0.2% of all QAS patients)
- 16.6% identify as Aboriginal or Torres Strait Islander.
- Service profile: 63,811 QAS presentations for the cohort to date; 73.1% transported; 39,538 ED presentations; 24.7% admitted; 22.8% Did Not Wait / Left at Own Risk; 52.4% discharged.
- Program workload: 500 Medical Caution Notes (27.5% of cohort), 139 Ambulance Information Documents (7.6%), 42 Ambulance Management Plans (2.3%), 152 direct engagements (8.4%), and 514 stakeholder engagements (28.3%).
- Effectiveness (pre-/post-): Among 370 patients with ≥six months follow‑up, QAS attendances fell by 3,303 and ED presentations by 2,636 over the three-onth post‑period (vs pre‑), equating to combined savings of ~$5.72M over three months (QAS $1,047/incident; ED
$858/presentation). - Patients with ≥two average monthly presentations account for ~5.2% of all QAS calls for service, underscoring the disproportionate impact of this cohort.
- Illustrative cases show heterogeneous trajectories, reinforcing the need for patient‑specific plans rather than one‑size‑fits‑all approaches.
Background
People who frequently contact ambulance services often live with intersecting clinical and social needs, chronic disease, mental illness, substance use and social disadvantage. International and local evidence demonstrates that this group is small but significantly impacts service delivery across the entire out-of-hospital and health care system. With repeat presentations reflecting unmet needs, service fragmentation, and low navigability of the health system.
Contemporary practice trends favour replacing episodic, downstream responses with coordinated, midstream interventions grounded in multidisciplinary support and person-centred care. In this context, the QAS established the Complex and Frequent Presenter Program (CFPP) to identify, engage, and support individuals whose ambulance use patterns indicate clinical risk, psychosocial vulnerability, and gaps in continuity of care. The CFPP applies a data‑driven understanding of need to identify people who frequently use ambulance services, followed by a comprehensive multidisciplinary, clinical and psychosocial review, and the co‑development of practical, shareable plans, enabling attending clinicians to provide consistent care.
The cohort enrolled to date represents approximately 0.2% of all QAS patients, yet accounts for a disproportionate share of activity and risk. Many are transported to ED, where a substantial proportion are ultimately discharged or leave before completing care. These patterns are clinically significant and highlight opportunities to redirect care to more appropriate settings.
The program’s emerging evaluation shows meaningful reductions in ambulance utilisation patterns and subsequent ED presentations for those with sufficient follow‑up, alongside qualitative benefits such as improved consistency of care, clearer expectations for patients and providers, and stronger connections to primary and community care. The CFPP addresses a recognised statewide challenge, frequent ambulance use as a proxy for unmet need by embedding proactive, multidisciplinary, person‑centred care within QAS operations and partnering services.
Methods
Design and governance
The CFPP is delivered by Senior Clinicians in the Office of the Medical Director, working alongside Social Workers, Clinical Nurse Consultants, Mental Health Clinicians, external partners and Senior ED Physicians. Referrals (internal only) are accepted for individuals with very high frequency (e.g., more than five incidents/month) or evident complexity where usual pathways are not meeting need. A central registry and case‑tracking process underpin governance, review timeliness, and documentation quality.
Identification and assessment
A data signal (e.g., rising monthly incidents, high pain medication use, multi‑agency contact) triggers a structured clinical and psychosocial assessment. This includes reviewing ambulance case data, linking ED/admission data where available, and directly engaging with the person and their supports.
Interventions
- Monitoring and reviewing patterns of ambulance utilisation
- Collaborating with key stakeholders and specialists
- Advocating for the most appropriate management strategy
- Developing and implementing patient-centred care plans
- Co-ordinating response plans for QAS officers
- Consultation and coordination of care through multidisciplinary teams
- Implementation, review and development of Ambulance Management Plans
Implementation
Management outputs are published to QAS systems so attending clinicians are adequately informed and can access them quickly. Stakeholders (eg. general practitioners (GPs), mental health services, community providers, residential care) assist in developing these management outputs to ensure consistent expectations and clear escalation pathways. Plans are iterated based on feedback from patients, crews and partners.
Evaluation
For effectiveness, the program conducts pre‑/post‑analysis at the individual level after a three-month implementation window, tracking QAS incidents, Triple Zero (000) call volume, Ambulance dispatch, and ED presentations over the subsequent three month period. Descriptive program analytics also monitor workload mix (e.g., proportion with a Medical Caution Note (MCN), Ambulance Information Document (AID), and Ambulance Management Plan (AMP), direct engagement; stakeholder contacts), equity markers and mortality.
Scalability
The model has been designed for statewide implementation through standardised management outputs, a single referral/notification pathway, and templated management outputs (MCN, AID and AMP), while retaining local flexibility for partnerships, care pathways and implementation workflows, so care can be aligned with local partners, community priorities and cultural considerations while maintaining consistent statewide practice.
Discussion
Enablers and context
The CFPP succeeds where there is strong clinical governance, multidisciplinary care planning, interest holder collaboration, interoperable documentation, and partnerships that extend beyond the ambulance episode. Embedding Social Work and Mental Health clinicians alongside senior clinicians enables holistic assessment, improves safety planning, and sets clear expectations for patients and attending clinicians.
Lessons and limitations
Outcomes vary by individual health care journey and local service provider capability. A minority of patients may show minimal early change or transient increases in contact as consistency in care is realised. Evaluation based on service‑use reduction can understate patient benefit; therefore, the program should complement utilisation metrics with qualitative feedback and is working to incorporate paramedic and clinician-reported outcome measures. Data linkage and information‑sharing constraints can limit the timeliness and depth of management outputs. Developing consistent interfaces with primary care and community services remains a priority.
Scalability and spread
CFPP management outputs, program metrics, referral triggers, centralised notification processes and the evaluation framework have been implemented across the state. Region-level CFPP Co-ordinators ensure that management outputs are tailored to service capability (pain management, behavioural crises, chronic conditions), ensuring local appropriateness while preserving statewide consistency, oversight, and clinical governance.
Next steps:
1. Expand proactive identification using predictive analytics to detect at-risk patients sooner
2. Collaboration with interest holders at a systems advocacy and individual patient level;
3. Embed qualitative outcome measure to capture patient‑centred change;
4. Systematically co‑design plans with consumers and carers;
5. Enhance data‑sharing with GPs, primary health networks and community providers;
6. Formalise clinician training on applying plans at the point of care and on documenting feedback for plan review and future iterations.
References
Government, Q. (2024). Queensland Women and Girls' Health Strategy 2032. Brisbane.
Queensland Government, R. F. D. S. Q. S. (2025). Primary Clinical Care Manual 12th Edition Cairns, Office of Rural and Remote Health
Htay, M. and D. Whitehead (2021). "The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review." Int J Nurs Stud Adv 3: 100034.
McGeoch, G., et al. (2019). "Hospital avoidance: an integrated community system to reduce acute hospital demand." Prim Health Care Res Dev 20: e144.
Pursio, K., et al. (2021). "Professional autonomy in nursing: An integrative review." J Nurs Manag 29(6): 1565-1577.
Randall, S., et al. (2017). "Impact of community-based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review." Int J Nurs Stud 73: 24-33.
Wood, E. B., et al. (2024). "Engaging Emergency Nurses in Strategies to Address the Social Determinants of Health." Journal of Emergency Nursing 50(1): 145-152.
Service, C. Q. H. a. H. (2022). CQHHS Local Area Needs Assessment Queensland Government
Attwooll, J. (2023) Hugh disadvantages for rural patients exposed GP news
Ellis, L. A., et al. (2021). "Changes in public perceptions and experiences of the Australian health-care system: A decade of change." Health Expectations 24(1): 95-110.