Better management of chronic disease offers one of Australia’s greatest opportunities to improve health outcomes while reducing pressure on hospitals and clinicians.
Australia needs to reinvent how the health ecosystem manages chronic diseases. This has the potential to reduce up to 30% of avoidable hospitalisations, improve patient satisfaction, increase Quality Adjusted Life Years (QALY), reduce clinician burnout, and significantly enhance the sustainability of Australia’s healthcare system.
The current situation
In Part 1 of this topic, I outlined that Australia, like most countries, is struggling with the significant burden of chronic disease and that poor management of chronic disease is contributing to a high burden of Potentially Preventable Hospitalisations.
For example, Australia has suboptimal shared care planning, patients often do not recognise early warning signs, and delay accessing care. As such, significant “gaps in care” emerge over time and a range of unmet needs frequently lead to hospitalisation. Australia has a much higher rate of Potentially Preventable Hospitalisation than the OECD average.
Fortunately, the National Preventive Health Strategy suggests there is an aim to lift spending on prevention from 3.1% to 5% of total health expenditure by 2030. What should be the focus areas to deliver the best Return on Investment for this increased spend?
Reimagining both primary and secondary prevention is essential. However, this paper focuses on secondary prevention – otherwise known as early intervention for people with chronic disease.
Also in today’s edition:
- Women ‘at higher risk of abuse’ under proposed NDIS changes
- NSW’s so-called ‘stable’ health report is no reason for a victory lap
- We trad-clinicians have a point ‘founders’ aren’t getting
- Federal nurses union launches Fair Work case
- Royal Children’s Hospital rolls out Heidi AI scribe across paediatric services
- What happens when a patient’s private story goes public?
- Homelessness shortens life by decades, latest AIHW figures show
Reinventing care for early intervention
We must reinvent our models of care to help improve outcomes for Australians with chronic disease. With significant technology advancements, the future of healthcare is incredibly exciting.
How will the future look for patients with chronic diseases? The system and the typical patient journeys will look significantly different to what we have today. We will have system and patient level intelligence that makes healthcare safer, more proactive, and more resilient. Healthcare will become more predictive than reactive. The future will be defined by intelligent systems that connect data and operational workflows underpinned by AI models, with human decision‑makers to enable real‑world action and better outcomes for patients.
A technology and data enabled revolution in chronic / complex disease management is within our reach. But to deliver systemic change we must redefine the model of care. For example, 5 critical success factors are required.
1. Align on the critical care capabilities required to enable insight-driven proactive care
We need to align on the critical care capabilities required to enable insight-driven proactive care. The intent is to create a connected model in which risk can be assessed earlier, gaps in care can be identified more reliably, and interventions can be triggered before deterioration becomes critical. For example, some of these clinical capabilities would include:
- Shared Care Planning: accelerate the digitisation of shared care plans supported by national clinical pathways and AI-driven workflow.
- Insight-Driven Early Intervention: develop and utilise advanced analytics for risk assessment & prediction – at population health and individual patient levels. This requires access to broad datasets (such as from shared care plans, electronic medical records, home devices, social determinants of health (SDoH), etc) to feed the Advanced Analytics tools. Patient-level analytical insights can provide protocol-based notifications & alerts, and targeted outbound contact to help close key health gaps.
- Health Coaching & Service Navigation: This capability should be delivered by a designated role assigned as part of the patient Care Team, with many tasks automated and augmented via digital tools. These highly personalised interactions provide assistance with execution of the Care Plan, including health education, health system navigation, etc.
2. Clarify the roles of key organisations to deliver, operate and sustain the critical care capabilities
Today, the Australian public health system is highly fragmented with many organisational silos and misaligned incentives leading to suboptimal chronic disease management. From a reform perspective, Australia has taken a “thousand flowers blooming” approach to chronic disease management, with many models across Federally funded services (e.g. PHNs) and Jurisdictional-funded services (i.e. Health Services). Many pockets of excellence exist. However, to achieve large-scale change, major decisions are needed about the role of key organisations in critical capabilities. For example:
- Shared Care Plans and eHealth infrastructure: Clearly, this should continue to be the remit of Federal Department of Health, and agencies such as ADHA.
- Advanced Analytics: Should population health analytics be driven nationally, or decentralised to be built by individual practices and technology platforms? To accelerate change a national approach should be taken to AI capability.
- Detect gaps in care, provide early intervention, and deliver health coaching: Primary care is the cornerstone of chronic disease management, and ideally there would be stronger enablers and incentives for primary care to fulfill these capabilities. However, the support, funding and incentives would need to be reimagined. Alternatively, we could explore stronger investment in “Community Health Hubs” with multidisciplinary team models and joint “blended” funding provided by the federal government, PHNs, and Jurisdictions.
The central message is that systemic reform to deliver better outcomes will require nationally coordinated decisions regarding who will develop critical capabilities, and nationally coordinated investment and oversight.
3. Accelerate digitisation, including new national eHealth infrastructure – e.g. “Shared Care Plans”
The third success factor is acceleration of core technology and digitisation across the sector, including additional national eHealth infrastructure. Australia has made substantial progress—such as maturation of clinical information systems, improved interoperability, and the growth in structured data. However, for effective management of chronic disease, key gaps in technology capability still remain. For example, a critical gap is the robust shared care plan capability for multidisciplinary team care (across organisational silos). It must orchestrate evidence-based clinical pathways, support workflow and clinical decision support, and enable personalised care journey management. Patients would receive proactive notifications and connect with trusted health content and tools that support self-management and engagement.
4. Improve our data and accelerate analytical tools to detect risk & ‘gaps in care’
With greater clarity in roles, and stronger technology foundations, the fourth success factor is a stronger national approach to data and analytics. Value would be accelerated via a centralised and standardised analytics capability via a Centre of Excellence (CoE). The CoE would be accountable for core infrastructure, data stitching, AI model development, Responsible Use of AI strategy & governance, and security and privacy. A CoE makes scaling faster, more consistent and safer. At the same time, local or geographical deployment remains essential. Analytical insights for population health (e.g. for local commissioning) must fit with local needs, incorporate local curation and explainability, and apply Responsible Use of AI in context. The UK NHS is an example of a nationally coordinated model for data and AI that supports population health.
Over time, propensity models will be embedded directly into clinical workflows by technology platform providers to detect gaps in care and intervene earlier through outbound contact or care team action. For example, Cera, one of Europe’s largest providers of digital-first domiciliary care, uses an AI-driven platform to stratify patients by hospitalisation risk so that nurses can organise low-cost preventative interventions, with 80% of hospitalisations predicted up to a week in advance. This reinforces that data-driven models can support timely intervention and materially improve patient and systemic outcomes.
5. Redesign AI-enabled workforce models to enable proactive care and align on the sustainable funding and incentives.
With greater clarity in roles, and stronger technology & analytics foundations, the fifth success factor is redesign of workforce models and funding arrangements so that proactive care can be delivered sustainably. A key priority is to reimagine the care team so clinicians can work at the top of their licence. In addition to traditional roles such as GPs, nurses, allied health professionals, pharmacists, and specialists, the future model should include new and amended roles, such as “Health Coaches”, “Care Assistants”, and clinician mediated “AI assistants”. This will improve clinical workforce satisfaction, extend capacity, support continuity, and make it easier to act on emerging risks before they escalate. Sustainable reform will require not only new workforce design but also aligned financial incentives that reward prevention, coordination, and timely intervention.
Conclusion
With the reinvention of the health ecosystem for patients with chronic diseases, we have the potential to reduce up to 30% of avoidable hospitalisations, improve patient satisfaction & Quality Adjusted Life Years (QALY), reduce clinician burnout, and significantly enhance the sustainability of Australia’s healthcare system. With leadership from the Federal Department of Health, we must urgently align on the integrated model of care and implementation plan, so we can deliver sustainable national systemic performance improvements.
Dr Travis Grant is managing director – Health, Accenture ANZ
For those interested in this topic, please join an array of senior leaders next week in Canberra to discuss primary and secondary prevention at the “The Great Prevention Pivot”. Few remaining final tickets to this event are available here.