For over a year, North Shore GP chronic heart failure patients have been experiencing the benefits of a Home Monitoring Service, which is not only providing early intervention and prompt treatment but also reducing hospital admissions.
As part of Northern Queensland Primary Health Network’s (NQPHN) Chronic Conditions Primary Care Package, the clinic’s Home Monitoring Service, Hospital in Your Home (HiYH), allows heart failure patients to self-monitor at home.
Using Bluetooth-enabled scales and blood pressure monitors connected to the Intelicare digital platform, patients upload their daily results in real time – providing their care team with instant updates on any changes.
North Shore GP’s Dr Chris Stelmaschuk said the system has transformed how his team identifies and manages early signs of deterioration, while complementing the clinic’s 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,” he said.
Dr Stelmaschuk said patients with heart failure are particularly vulnerable due to fluid build-up in their lungs or limbs, with severe cases sometimes resulting in hospitalisation.
“We felt if we could monitor blood pressure, heart rate, their weight (weight gain is one of the biggest indicators for 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 HiYH reports a weight increase of around two per cent or more than 2kg, or significant changes in their blood pressure or heart rate, the patient’s General Practitioner (GP) will determine alterations to medication or whether the patient should attend the clinic for further investigation.
Service Success
Earlier this year, a patient had used HiYH for a regular check-up, with results indicating a significant drop in her blood pressure, and elevation in her heart rate over two days.
When North Shore GP nurses noticed the changes, they contacted her – with the patient informing the team that she was feeling “a little off”.
The patient was asked to come into the clinic for an urgent review, and after being consulted by Dr Stelmaschuk, it was discovered that she had started to develop early pneumonia.
“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,” he said.
“Although it wasn’t heart failure that was flagged, it was really cool to see how something else could be picked up early and even prior to the patient initiating contact and have a good outcome that avoided unnecessary hospital admission.”
Dr Stelmaschuk said HiYH had empowered patients to take charge of their health through education and understanding their own parameters, along with the reassurance of having a clinical team monitoring them in the background and available for help when needed.
HiYH CEO Michael Young had been instrumental in the set-up, including helping the clinic develop processes, and putting them in touch with Intelicare for the provision of the equipment, and platforms for home monitoring.
“Sharing real-time data with primary care practitioners has also 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,” Dr Young 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 HiYH had shown a 43 per cent reduction in hospital presentations, and improved long-term health outcomes.
“Analysis of our own data confirms these trends, showing statistically significant and sustained reductions in blood pressure among monitored patients. These learnings have directly informed the design of the Australian home monitoring service – ensuring it is inclusive, scalable, and focused on improving early intervention, chronic disease management, and health equity across diverse communities,” he said.
Positive Feedback
Dr Stelmaschuk said the clinic had received “amazing feedback” from Chronic Care Team (CCT) patients who enjoyed being supported by a whole team including administrators, nurses, social workers, pharmacists, and GPs.
“[Patients] appreciate the extra points of contact within the practice,” he said.
“Nursing staff have developed some really special relationships with support and trust from patients in the program.”
Some of the HiYH patients commended the team’s responsiveness, patience, and compassionate care.
“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 [CCT] to support and care about our needs and just be there for me. I appreciate everything that is done by the team.”
Dr Young said the program had strengthened relations between patients and their care teams, with escalation occurring through clinical, rather than administrative pathways.
“This model demonstrates how targeted investment in primary care can translate into measurable, system-wide benefits – improving outcomes for patients, reducing hospital demand, and supporting Australia’s transition toward integrated, value-based healthcare,” he said.
NQPHN first began funding the package at North Shore GP in July 2024.
At North Shore GP, there are currently 32 patients on the CCT program, with 10 using the HiYH service.
