When a North Shore General Practice patient noticed her blood pressure dropping and heart rate spiking over two days, she felt something wasn’t quite right.
And she was correct.
Using the Hospital in Your Home service, the woman had been checking her vitals each day through a Bluetooth-enabled scale and blood pressure monitor, when she noticed the change.
As the results were automatically sent to the practice, her care team saw the alert and immediately called her.
“I was feeling a little off,” she told the nurses.
While her chronic heart failure hadn’t worsened, the team discovered something else: Early pneumonia – a potentially fatal illness.
North Shore General Practice director and practice principal Dr Chris Stelmaschuk said thanks to quick action, she received treatment before her condition became critical.
“Our nurses followed up with her closely over the next few days, and within 48 hours of starting antibiotics, she had made a great recovery,” Dr Stelmaschuk said.
“Although it wasn’t heart failure that was flagged, it was great to see that something else could be picked up early and prior to the patient initiating contact.
“It was a good outcome that avoided unnecessary hospital admission.”
Since July 2024, 10 chronic heart failure patients have joined the Hospital in Your Home service being delivered at North Shore General Practice.
Beyond monitoring, patients have had more contact and built stronger relationships with their entire chronic care team – nurses, social workers, pharmacists, administrators, and GPs.
And they say it’s this support makes all the difference.
“The whole team are very compassionate and will go above and beyond to provide me with the care as needed,” one patient said.
“It is good not to feel so alone and to have the care of the chronic care team to support and care about our needs and just be there for me. I appreciate everything that is done by the team,” another said.
Dr Stelmaschuk said offering the Hospital in Your Home service had empowered patients to take charge of their health through education and understanding their own parameters.
“They also have the reassurance of a clinical team monitoring them in the background and available for help when needed,” he said.
“The system has transformed how our team identifies and manages early signs of deterioration, while complementing our existing model of care.
“We can then connect them with different members of the team including nursing, social work, pharmacist, or referral to other allied health.”
Dr Stelmaschuk said patients with heart failure were particularly vulnerable due to fluid build-up in their lungs or limbs, with severe cases resulting in hospitalisation.
“We felt if we could monitor blood pressure, heart rate, their weight – weight gain is one of the biggest indicators of fluid retention – we could help identify when people might be struggling, and intervene early with medication to help correct their condition and stop hospital admissions,” he said.
If the service reports a weight increase of two per cent or more than 2kg, or significant changes in blood pressure or heart rate, the patient’s GP will decide on medication changes or further assessment.
Hospital in Your Home CEO Dr Michael Young said sharing real-time data with primary care practitioners had enhanced clinical decision-making.
“Rather than relying on a single measurement taken during a clinic visit, practitioners now receive up to 30 or more machine-entered data points each month,” he said.
“This richer data set allows for more accurate assessment of trends, early identification of deterioration, and more informed treatment decisions.”
Dr Young said the program drew on lessons from the United States, where the service had shown a 43 per cent reduction in hospital presentations, and improved long-term health outcomes.
Northern Queensland Primary Health Network funded North Shore General Practice to provide the Hospital in Your Home service under the Chronic Conditions Primary Care Pilot Program.
About NQPHN
Northern Queensland Primary Health Network (NQPHN) works together with our partners to connect existing local services to simplify the healthcare system, fund primary care and mental health services based on the needs of local communities, and support primary care and mental health providers to build their skills and deliver the highest quality patient care.
For more information, visit www.nqphn.com.au
