Support program for patients with vulnerable and complex care needs

February 5, 2025

A new way to support people with increased vulnerabilities and complex health needs.

South Eastern Melbourne Primary Health Network (SEMPHN) is pleased to announce a new partnership with Sandringham Ambulatory Care Centre (SACC), supporting them in delivering the South East Care Pathway (SECP) program.

About the program

The program provides crucial support for patients with vulnerable and complex care needs who are at risk of hospital admission or following hospital discharge. 

The service is delivered mainly via telehealth and aims to: 

  • reduce avoidable emergency department visits, 
  • support the safe discharge of patients to and from healthcare services
  • ​facilitate the transition of care between primary, secondary and tertiary care providers for ongoing management.​

How does it work?

An initial triage call with a patient determines the care pathway they will require while with the program. Depending on the needs of the patient, there are two approaches: passive and active monitoring. 

Eligibility

The service is available across the South Eastern Melbourne PHN catchment. The program serves people who are clinically or socially vulnerable and meet one or more of the following: 

  • require closer health monitoring than routinely available in primary care 
  • have an increased risk of hospital presentation or difficulties accessing primary care 
  • require transition support from hospital to primary/community care. 

The program is funded until 30 June 2025.

Learn more about the program and how to refer here

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