Patient Watch is a service that Northern Health introduced in 2020 to support patients identified as high risk of future hospital admissions. The service aims to support patient engagement and self-management of their health. Over time, Patient Watch builds relationships and establishes trust with participating patients.
Patient Watch aims to support patients identified as high risk of multiple hospitalisations to improve their health experience and reduce avoidable hospitalisation.
Each patient is assigned a lay Tele-Navigator and a Health Coach (senior nurse, physio or occupational therapist). Tele-Navigators complete telephone-based self-rated health checks with patients, typically weekly. Health Coaches focus on assessing and responding to issues of concern.
The Patient Watch service model includes a number of unique elements:
- An algorithmic case finding system
- The service is longer-term and non-episodic. Patients remain in the service if readmissions occur.
- The model emphasises relationship building and encouraging engagement with patients over time.
What to expect from the service?
- Identified patients are contacted by Patient Watch staff
- A Health Coach will visit the patient at home to introduce the program and learn more about the patient’s health concerns
- Participating patients receive a weekly telephone call to check on the patient’s health and wellbeing from the Tele-Navigator.
- If concerns are raised, a Health Coach may contact the patient to find out more about the concern and take action