Complex Care Coordination in NSW Emergency Departments

Published 23 April 2018. Last updated 8 May 2018.

Royal North Shore Hospital is developing a clinical pathway for people who frequently present to hospital emergency departments (EDs) with chronic pain and complex conditions, which will be rolled out across the state following evaluation of the pilot program.


To improve complex care coordination of people who frequently use NSW EDs (including those with chronic pain).


  • Provides healthcare providers with support to improve patient care.
  • Reduces the negative stigma associated with people who frequently use EDs.
  • Improves patient adherence to health management plans.
  • Reduces the costs associated with unnecessary ED presentations, hospital admissions, repeated investigations and medications.
  • Reduces the harm associated with repeated investigations.
  • Provides a pathway to address problematic medication use.
  • Aligns to the NSW Integrated Care Strategy, one of the three strategic directions in the NSW Health Plan: Towards 20211.


People who frequently present to hospital EDs with chronic conditions (including chronic pain) often face a mismatch between their needs and the design of the healthcare system2. Emergency care by nature involves clear and direct plans for each patient, which often does not address the needs of this vulnerable group. This can lead to staff frustration and a perception by patients that they are stigmatised and receiving sub-optimal care.

Case management has shown to significantly improve health and social outcomes in people who present to EDs more than four times a year3. In Northern Sydney Local Health District (NSLHD), systems have been established to improve case coordination for people who present to EDs more than three times a year with targeted medical conditions, including cardiac failure, coronary artery disease, chronic obstructive pulmonary disease, hypertension and diabetes mellitus4.

It was determined that extending this approach to all people who frequently present to EDs would improve patient care, while reducing healthcare costs associated with unnecessary ED presentations, hospital admissions and investigations. Lessons from other integrated care projects will be used to develop the project, with a statewide rollout expected following implementation and evaluation at Royal North Shore Hospital.


  • Prior to the project, limited data was available to support the perception of suboptimal care and stigmatisation. As such, the following activities were undertaken:
    • project scoping with the ACI Pain and Chronic Care Networks, Emergency Care Institute and NSW Ambulance
    • data review of chronic pain presentations to NSW EDs, in collaboration with the ACI Health Economics Evaluation Team5
    • the target population was defined using a driver diagram
    • stakeholder consultation was undertaken with Chronic Pain Australia, including a national consumer survey6.
  • The project team defined current pathways in NSW EDs for people presenting with chronic pain and other complex chronic conditions.
  • In order to identify the target population, a patient identification project using QlikView is underway (to be implemented in June 2018).
  • Local clinical pathways to deliver care coordination for the target population are currently being developed, to be implemented February 2019.
  • A funding submission for the project is currently underway and expected to be submitted in August 2018.


Pre-implementation – Planning for the project is well underway. Clinician and consumer consultation has occurred but no solutions have been developed.


November 2015 - February 2020

Implementation sites

Emergency Department, Royal North Shore Hospital, Northern Sydney Local Health District


  • ACI Chronic Care Network
  • ACI Pain Network
  • Agency for Clinical Innovation
  • Chronic Pain Australia
  • Clinical Leadership Program
  • Emergency Care Institute
  • NSW Ambulance


Enrolled patients in the pilot program will be assessed on arrival to the ED and at six and 12 months. The final outcome measures have not yet been confirmed, but will include the following:

  • risk stratification tools
  • Chronic Condition Patient Identification Algorithm (CCPIA)
  • Chronic Condition Patient Selection (CCoPS) assessment tool
  • Patient Reported Experience Measures (PREMs)
  • Patient Reported Outcome Measures (PROMs)
  • frequency of ED presentations and hospital admissions
  • costs associated with attendances including investigations performed
  • Assessment of Quality of Life (AQol) tool.4

A separate health economics evaluation of the project will also be undertaken.

Lessons learnt

This is an extremely complex project which builds on previous and concurrent work. Multiple stakeholders are involved given its statewide nature. A sustained and collaborative effort is needed to build on work already done, which will enable ongoing sustainable integrated care solutions for people with chronic conditions.


  1. NSW Ministry of Health. NSW Health Plan: Towards 2021. North Sydney NSW: NSW Health; 2014.
  2. Gauntlett-Gilbert J, Rodham K, Jordan A et al. Emergency Department Staff Attitudes Toward People Presenting in Chronic Pain: A Qualitative Study. Pain Medicine 2015;16(11):2065-74.
  3. Kumar GS, Klein R. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. Journal of Emergency Medicine 2013;44(3):717-29.
  4. O'Malley S. Chronic Disease Management Program, Service Review. St Leonards NSW: Northern Sydney Local Health District; 2016.
  5. Han J. Pain in Emergency Departments. Sydney. Chatswood NSW: NSW Agency for Clinical Innovation; 2015.
  6. Chronic Pain Australia. Nationwide Consumer Survey: Chronic pain and Emergency departments, your experience. Parramatta NSW: Chronic Pain Australia; 2016.

Further reading


A/Prof Paul Wrigley
Senior Staff Specialist, Pain Medicine
Northern Sydney Local Health District
Phone: 02 9463 1500


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