Working Together to Connect Care Program – Emergency Departments

Initiative Type
Service Improvement
11 March 2019
Last updated
29 April 2020


The Working Together to Connect Care (WTTCC) Program establishes partnerships through a shared commitment across hospital departments, government services and community organisations to respond more effectively to individuals who frequently present to the Emergency Department. It achieves this through a seven stage integrated, patient centric model of care. This program is now operationalised in the RBWH and TPCH EDs with future plans to scale to Redcliffe and Rockhampton Emergency Departments this financial year.

Key dates
Mar 2016
Implementation sites
Royal Brisbane and Women’s Hospital and the Prince Charles Hospital Emergency Departments
Micah Projects; Footprints Inc; Richmond fellowship Queensland; The Insutitute of Urban Indigenous Health;139 Club; Mental Health Service; QAS; QPS; Alcohol and Drug Service; Office of the Public Guardian


  • To provide an enhanced model of care for patients who present frequently to the emergency department (ED) that will improve their long-term outcomes and reduce their dependency on the emergency department.
  • To scale and spread this enhanced model of care across Queensland Health emergency departments.


  • Decreased risk of fragmented and iatrogenic care for people with complex psychosocial and medical needs when attending an emergency department.
  • Improved community supports for program participants.
  • Increased communication, planning of patient care and integration across hospital and community services.
  • Decrease to the number of ED presentations, ambulance use and admissions to hospital.


The Working Together to Connect Care program is a combined hospital and community initiative that commenced as a LINK funded project. The main impetus for this program is to identify and provide more inclusive care to a vulnerable group of people who present to the emergency department multiple times. The fundamental underpinning of this program is to facilitate collaboration between participants, their social supports (where applicable) and the healthcare sectors including acute care, primary care and community non-government organisations. Now that the program has been running for two year it is recognised that there is a group of people who rely heavily on an emergency department to provide every day health care needs. This reliance often means that a person who requires seamless care is often fixed in a cycle of disjointed care. All phases of this program work with the person to establish and achieve personal goals, connect to primary care, stabilise housing and sure up a non-fragmented response across EDs and ED presentations.

Solutions Implemented

WTTCC model of care included:

  1. A flagging system to identify the potential participant.
  2. Consent and Confidentiality Agreement process to assist with information sharing between government and non-government organisations (NGOs).
  3. ED referrals to NGO partners.
  4. Community case management by NGO partners.
  5. Consumer focused, ED led, multidisciplinary case conferencing and care planning.
  6. The development and dissemination of an acute management plan (AMP) following case conferences. This is uploaded to The Viewer to improve access for GPs and ED staff.

Evaluation and Results

Activity and costing analysis for inpatient admissions through RBWH ETC based on 108 participants;

ED Presentations:

  • Comparing total presentations for the 5 months pre commencement date (1,345 presentations) to the 5 months post commencement date (1,009 presentations), results in a total of 336 less presentations through the Emergency Department.


  • Comparing total admissions for the 5 months pre commencement date (426 separations) to the 5 months post commencement date (299 admissions), results in a total of 127 less admissions via the Emergency Department.

WAU per Inpatient admission:

  • Comparing total QWAU / separation in the 5 months pre-commencement date (0.72 QWAU / sep) to the 5 months post-commencement date (0.83 WAU / sep). An increase in acuity of 15 per cent. This increases the QWAU of the patients admitted in the post period by 33 QWAU (299 admissions x 0.11 acuity increase).

Average length of stay (ALOS):

  • Comparing ALOS in the 5 months pre commencement date (2.04 days) to the 5 months post commencement date (1.92 days). A decrease in ALOS of 6 percent.

Occupied Bed Days (OBDS):

  • The OBDS has reduced by 292 days in total . The total OBDS in the 5 months pre commencement date (867 days) to the 5 months post commenceent date (575 days).

QAS Usage:

  • Comparing total ambulance usage for the 5 months pre commencement date (75 per cent of ED presentations, 1009) to the 5 months post commencement date (75 per cent of ED presentations, 757), results in a total of 252 less ambulance call outs.

Miscellaneous benefits:

  • Decrease risk of agression experienced by staff due to decreased ED presentations (45 per cent of participants have an identified risk of aggresion in the hospital setting).
  • Improvement in housing access (69 per cent of people identifying as “no fixed address” have accommodation post commencement of program).
  • Decrease in fragmented care when attending multiple EDs (59 per cent attend more then 1 ED), many times a year (187 uploaded, current acute management plans accessible on The Viewer).
  • Decrease in episodic care across health care continuums (725 case conferences completed. 14 per cent attended by GP, 4 per cent attended by participants, 11 per cent attended by Alcohol and Drug, 4 per cent attended by QPS, 7 per cent attended by QAS, 34 per cent attended by Mental Health Service and 48 per cent attended by NGO partners).
  • Development and implementation of IT solution FrequentED allows sharing of patient centred goals and timely access to valuable clinical information to expedite discharge planning.

Lessons Learnt

  • When people have stable housing, attend a GP regularly and are engaged and supported in their community they have less need to attend an ED which flows to a decrease need for admission.
  • Community service providers are able to meet the needs of the target cohort and have an in depth understanding of the target cohort.
  • This group of people is the most vulnerable in our society and their psychosocial and medical needs are highly complex. Embedded behaviours underpin high use of the health care system.
  • Systems integration does not exist across all partners (see partnerships). EDs are not designed to provide continuing health care and ED information technology systems do not support this approach.


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Further Reading

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Key contact

Debra Harcourt
Nurse Navigator - Working Together to Connect Care Program
Metro North Hospital and Health Service
(07) 3646 1814