Evohealth / Collaboration, the best way to design a model of care

Collaboration, the best way to design a model of care

Developing an innovative solution to allow for seamless integrated patient care in a specific chronic health condition.


The negative impact on patients when they transition between home, hospital and the community can be significant. System design and fragmented delivery of care are causative factors.


A model of care that supports the patient throughout their journey, irrespective of setting, and provides accurate information to clinicians and healthcare professionals in a timely manner.

Effective transition of care between is rare. The system relies on the patient being the custodian of their data. Patients are often poor historians at admission, discharge summary documents are not available in a timely manner and General Practitioners are unaware their patient has been admitted to hospital – just to name a few of the issues at hand.

Imagine, if you will, that you are an 83 year old woman with a chronic life-limiting condition. You live on your own. You have an acute exacerbation of the condition and are admitted to hospital. A week later at discharge you are given three new medications and sent home. You are happy to be sent home, but anxious about these new tablets and how you should take them. Within the week you see your General Practitioner. She was sad to hear of your hospital stay and spends most of the consultation time on the phone trying to find information on these ‘new tablets’.

This happens every day in Australia.

Digital solutions, such as MyHealth Record are designed to help in situations such as these. However, they are only part of the story. Health is a human business. It is reliant on humans interacting with each other to deliver the best outcomes.

This is where collaboration and co-design are important. Designing a solution with all of the people in the room – patients, healthcare workers, clinicians, nurses, allied health and more. All working together to understand and champion what is needed to deliver the best possible care, irrespective of setting.

Evohealth facilitated such a group of people. We sought clarity on the problem itself, before designing a range of innovative solutions that delivered what this particular patient cohort needs – effective transition of care

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