Working together for better health outcomes

Better health outcomes are achievable when primary healthcare and hospital services collaborate.

Underpinning our partnership with Metro North Hospital and Health Service (now known as Metro North Health) is a joint protocol, which recognises that better health outcomes are achievable when there is effective collaboration between primary healthcare and hospital services.

Following a three year term, we reviewed the PHN’s joint protocol with Children’s Health Queensland (CHQ) and in December 2020, formalised a new joint protocol, determining the next few years working with CHQ.

Other areas of work that benefit from the PHN and Metro North Health collaboration this year included:

  • General Practice Smart Referrals to improve the referral process to outpatient services for patients
  • General Practice Liaison Officer Program – where we have GPs working across a range of Metro North Health specialties, processes and projects, including delivery of GP education events
  • HealthPathways to assist with clinical care
  • Team Care Coordination and the Staying Healthy, Staying Home program
  • Avoidable Hospital Presentations – proposal developed in partnership for managing frequent presenters to the Emergency Department with chronic conditions in the community
  • joint planning including:
    • Connecting Your Care (outpatients) consultation commenced including the GP Advice program in response to the outpatient co-design process undertaken last year
    • regional coordination around COVID-19 vaccination roll out across North Brisbane
    • satellite hospitals in Bribie Island, Pine Rivers and Caboolture.
Metro North and Brisbane North PHN

A strategic Health Alliance

Brisbane North PHN and Metro North Health have formalised their partnership by establishing the Health Alliance, dedicated to tackling the thorny issues facing healthcare delivery.

Since its inception in 2017, hundreds of local clinicians, service providers and community members have been part of the Health Alliance process, including the successful co-design and implementation of several new models of care.

In 2020/21, the pandemic invigorated the system’s ability to innovate and rapid progress in virtual care has occurred across the region. Ensuring these innovations are improved and sustained will be a key focus of the Alliance moving forward, with ongoing priorities including:

  • bringing care closer to home by developing and embedding initiatives designed to enable care to be provided closer to or in a person’s home
  • continuing to improve health outcomes for children born in the Caboolture region
  • mental health regional commissioning proposal to enable better outcomes from mental health funding 
  • identifying alternative models to help address Caboolture Hospital Emergency Department demand for patients.

Care closer to home

The Alliance has played a facilitating role in progressing a pilot integrated Hospital in the Home (i-HITH) service for Aboriginal and Torres Strait Islander peoples run by the Institute for Urban Indigenous Health in partnership with Metro North Health. This pilot is now underway and phase two of the model will include expansion to include other local primary care providers to support a broader range of patient groups within the community.

Improving outcomes for children

The Health Alliance worked in partnership with Caboolture Hospital Maternity Services and Children’s Health Queensland’s Child Health Service to co-design and implement a new pathway of antenatal and postnatal care in Caboolture.

Known as the Starting Well Initiative, the new pathway of care enrolled one hundred families by November 2021 and is business as usual at Caboolture maternity. Glowing feedback has been received from both the families who participated in the pathway and clinicians. Very high attendance rates were reported as well as promising outcomes for babies (e.g. born in normal weight range, full-term gestational age).

Starting Well Initiative Team

Starting Well Initiative team, pictured in 2020.

Collaboratives improve communication across sectors

The PHN and Metro North Health co-host collaborative meetings to enhance continuity of patient care through improved understanding of services available in general practice and the hospitals, support for the timely access to these services and boost bidirectional communication between GPs and hospitals.


Improving outcomes for people with chronic conditions