For a growing number of Australians, recovery no longer ends at the hospital door, it continues at home, supported by a different kind of care model.
This month marks 10 years of GMHBA’s Care Coordination Service (CCS); a program that has supported more than 2,200 members to leave hospital sooner, recover safely at home, and regain their independence with confidence.
What began as a modest pilot supporting just 40 members in its first year has evolved into a highly structured, personalised in-home recovery program, with demand continuing to grow. Within the next two years, CCS is expected to support more than 1,000 people annually, a reflection of both changing healthcare needs and the program’s proven impact.
At its core, CCS is about bridging the gap between hospital and home.
Eligible members are referred directly from their hospital bed by their care team (including doctors, nurses and allied health professionals) and receive between two and eight weeks of tailored support once they return home. Delivered by experienced registered nurses with backgrounds spanning community health, discharge planning, cardiac care and palliative care, the program wraps clinical oversight around practical, everyday support.
That can include weekly care coordination, in-home nursing and allied health, personal care, meal delivery, domestic assistance and equipment hire, a level of support far beyond traditional, phone-based health programs.
The goal is simple: reduce avoidable hospital readmissions and help people get back to living their lives.
Over the past decade, the results have been significant, not just for members, but for the broader health system. CCS offers patients a new model of care delivery rather than the traditional bricks and mortar of a hospital ward. By supporting our patients at home, we alleviate personal and environmental pressures by reducing avoidable readmissions.
For members, the impact is deeply personal. Satisfaction scores tell part of the story, with a Customer Satisfaction score of 95.34% and an exceptionally strong Net Promoter Score of 9.77 but it’s the lived experiences that bring the program to life.
According to one of the CCS nurses, members regularly express just how vital the support is, particularly those recovering alone, who say they couldn’t have managed without it. She also hears from members who are surprised by the unexpected psychosocial benefits of the program, such as how quickly they’re able to return home and resume the hobbies and routines they love, with the help of nursing and physio support.
GMHBA Chief Operating Officer Wes Self said behind these outcomes is a deliberate shift in how GMHBA sees its role.
“A decade ago, GMHBA made a strategic decision to evolve beyond being a health insurer, recognising an opportunity to directly improve member outcomes by supporting recovery in the home,” he said.
“The Care Coordination Service was designed not only to deliver better health outcomes, but to reduce avoidable hospital stays, enabling savings to be reinvested into expanded services and further member care.”
Building the program was no small feat. Today, CCS operates as a fully accredited health service under the Australian Council on Healthcare Standards, reflecting its delivery in a highly regulated clinical environment.
The model has also been shaped by strong partnerships. Starting in Geelong, GMHBA’s hometown, CCS works closely with hospital discharge teams and a network of trusted in-home providers to ensure members experience a seamless transition from hospital to home. Referrals have since expanded beyond local hospitals, with the program now supporting members more broadly.
That collaboration continues in the home, where a network of allied health and care providers deliver the day-to-day support that underpins recovery. As healthcare continues to evolve, so too has CCS.
In recent years, the program has expanded into digital care, introducing new services to support members beyond traditional recovery. This includes partnerships with Osara Health to deliver cancer coaching, and Healthier Hearts at GMHBA delivered via the Cardihab platform to provide virtual cardiac rehabilitation, helping members access specialist support from home, regardless of location.
GMHBA Clinical and Program Manager Angela Smarrelli, who has lead the program since its inception, said it was an ongoing privilege to support members on their health journey in such a meaningful way.
“The COVID-19 pandemic really marked a turning point for us, accelerating the need to think differently about how care could be delivered,” she explained.
“For CCS, it reinforced the importance of flexible, home-based and digitally enabled models that keep members supported, even when access to hospital care is disrupted.”
Ten years on, the program continues to grow but its focus remains unchanged. It’s about making sure that when a member leaves hospital, they don’t do it alone.
As one GMHBA nurse reflected after a follow-up call: “Most members tell us they didn’t even know the program existed, but once they’ve experienced it, they can’t imagine recovering without it.”
