Inclusive Health

Partnerships in healthcare for all

  • + - Introduction to Inclusive Health

    Inclusive Health Partnerships provide an integrated, person-centred and trauma-sensitive response to the health needs of vulnerable Brisbane people, including people experiencing homelessness.

    Inclusive Health programs are informed by a social model of health that recognises a broad range of social factors, in addition to the presence or absence of disease, impact upon people’s health. In adopting a Housing First approach, the programs integrate healthcare with housing and social support services to achieve improved outcomes for people who are vulnerable and experiencing homelessness.

    The programs also provide significant cost savings to the community.

    Partners in the program include: Mater Health, St Vincent’s Private Hospital BrisbaneBuddhist Compassion Relief Tzu Chi Foundation Australia and Micah Projects. 

    Inclusive Health initiative would not be possible without the support of our funders: Brisbane North PHNBrisbane South PHN and Queensland Health. A shared clinical framework for the integration of nursing and community services, extends across five of our programs. 

    The programs

    • Pathways - Hospital Admission and Discharge Service
    • Home for Good Clinical Nurse
    • Homeless to Home Healthcare After Hours Service
    • Street to Home Community Health Nurse
    • Brisbane Common Ground (BCG) Integrated Nursing Service
    • Community Response to Hospital Emergency Departments.

    2016 Patricia

    Patricia never thought she would find herself without a home of her own, especially at a time when her complex medical needs made housing security essential.

    Read Patricia's story.

    Please email us for more information.

  • + - Pathways Hospital Admission and Discharge Service

    Pathways is a post-hospital discharge service designed to provide person-centred admission and discharge planning to achieve an integrated response across health, housing and community service providers. 

    It is a service that aims to deliver access to healthcare for vulnerable populations typically experiencing homelessness, unstable housing, social isolation, disability, and multiple health conditions. 

    Download the Pathways Hospital Admission and Discharge Service Initial Referral form.

    Anna Inclusive Health

    Anna is a Nurse with the Pathways team, an Inclusive Health hospital admission and discharge program. It is a partnership between St Vincent’s Private Hospital Brisbane and Micah Projects, funded by Queensland Health. Photography: Tharaka Wijerathne.

    Read Anna’s story.

    The Pathways program operates 5 days per week (60 hours of nursing) as an integrated nursing service with Micah Projects – Housing Access and Referral Team. Additional linkage with the Street to Home After Hours Health Team has led to the provision of nursing and crisis support after hours and over the weekends when needed.

    View the summary of the first 12 months of the Pathways Service (Jan–Dec 2015).

    Listen to an interview with Kim Rayner, Manager Inclusive Health and Sue Anderson, Pathways Clinical Nurse on Local ABC.

    A seven days per week integrated nursing service provides:

    Person-centred discharge planning, care co-ordination and direct nursing care 

    • integration with each individual hospital unit’s discharge processes 
    • early engagement / in-reach to hospitals 
    • development of post-discharge care coordination plan (reviewed every 30 days) 
    • identification of housing, support and health needs 
    • direct nursing care in the community 
    • linking and referral to community health care teams and service providers that include mental health and drug and alcohol services. 

    Triage and referral to community service 

    • linking with homeless healthcare and community support teams 
    • matching a person’s need to appropriate housing providers, crisis and supported accommodation 
    • linking with primary healthcare providers and community services 

    Accessible referral process from the hospital or in the community 
    In order to enhance access there exists a number of ways to refer to this service which are: 

    • hospital staff can contact their Discharge Facilitator/ Social worker who will contact the Pathways central intake number and make the referral 
    • direct referral to Pathways nurse when they are attending hospital meetings or visiting each unit 
    • direct referral to Pathways nurse or Home for Good staff in the community or on the street 
    • email/fax referral to Home for Good central intake number at Micah Projects. 

    Download the Pathways Hospital Admission and Discharge Service Initial Referral form.

    Read the Report Summary of the first two years of the Pathways Hospital Admission and Discharge Service.

    The program is funded by Queensland Health and delivered through a partnership between St Vincent's Private Hospital Brisbane and Micah Projects.

    Please email us for more information.

  • + - Home for Good Clinical Nurse

    A clinical nurse employed by Mater Health works alongside Home for Good staff to provide health services.

    Services include:

    • health assessments
    • direct nursing interventions that may include:
      • chronic disease management and education
      • medication support and management
      • wound care
      • health education
    • referral and linkage to primary health and allied health services
    • liaising with hospital and primary care services
    • coordination of health clinics
    • collaboration with and referral to other Micah Projects support teams that can provide:
      • housing support
      • social inclusion support
      • domestic violence service
      • families support
      • disability support services
      • support and assistance to meet hospital discharge planning and follow-up care goals.

    2011 Ross Roz

    Ros Butler, Inclusive Health Community Clinical Nurse, visiting Ross in his home. Photography: Mark Reimers.

    The program is funded by Mater Health.

    Please email us for more information.

  • + - Homeless to Home Healthcare After Hours Service

    Homeless to Home Healthcare After Hours Service is part of an integrated multi-disciplinary outreach team operating 7 days per week 5pm – 11pm. 

    Each night two teams that include a registered nurse and a Street to Home outreach worker deliver health and housing support to people who are rough sleeping and to those who have made a transition from homelessness to housing, but who require ongoing and consistent social support and healthcare. 

    Download the Homeless to Home Healthcare After Hours Service Initial Referral form.

    2013 H2 H Sth

    Eva, Inclusive Health Clinical Nurse on duty with Shelley from the Street to Home team. Photography: Erin Ebert.

    Health services include:
    • health assessments
    • direct nursing interventions including assistance with medication, wound care, health education, mental health support
    • referral to emergency, primary health and allied health services
    • collaboration with Street to Home Community Health Nurse and Home for Good Clinical Nurse and Pathways Nurses.

    Download the Homeless to Home Healthcare After Hours Service Initial Referral form.

    A 2014 Economic Evaluation of the Homeless to Home Healthcare After-Hours Service found that spending $503,000 and proactively addressing the health and housing needs of Brisbane’s homeless people saved the Queensland Public Health System between $6.45 - $6.9 million.* (*In a Brisbane study with 1369 individuals.)

    Download the Homeless to Home Healthcare After Hours Service Initial Referral form.

    View the 2014 Key Findings factsheet from the Economic Evaluation.

    The program is funded by Brisbane North PHN and Brisbane South PHN. The nurses are employed by Mater Health.

    Please email us for more information.

  • + - Street to Home Community Health Nurse

    The Street to Home Community Health Nurse works 9am – 5pm, Monday to Friday as part of the Street to Home Team to provide complex care, chronic disease management and direct nursing services to vulnerable people.

    2013 Sth Van Driving

    Micah Projects Street to Home van

    Services include:

    • health assessments
    • direct nursing interventions that may include:
      • chronic disease management and education
      • medication support and management
      • wound care
      • health education
      • complex nursing care
    • referral to primary health and allied health services
    • liaising with hospital and primary care services
    • coordination of healthcare for individuals through linkage to specialist services such as:
      • dental care
      • mental health 
      • drug treatment
      • renal, diabetes
      • aged care and palliative care
    • case conferencing with hospital frequent presenters teams
    • collaboration with Micah Projects Street to Home team to provide:

    • housing support

    • social inclusion support
    • support and assistance to meet hospital discharge planning and follow-up care goals.

    The program is funded by Brisbane North PHN and Brisbane South PHN. The nurse is employed by Mater Health.

    Please email us for more information.

  • + - Brisbane Common Ground Integrated Nursing Service

    The Brisbane Common Ground (BCG) Integrated Nursing Service works with Micah Projects Supportive Housing Team to provide seven days per week health services and social support to BCG tenants. 

    2105 Bcg Arif Kellie Andy

    Andy, Micah Projects Supportive Housing Worker; Kellie, Brisbane Common Ground (BCG) tenant and Arif, BCG Integrated Nursing Service Clinical Nurse. Photographer: Lachie Douglas.

    Services include:

    • health assessments
    • direct nursing interventions that may include:
      • chronic disease management and education
      • medication support and management
      • wound care
      • health education
    • referral and linkage to primary and allied health, mental health and specialist services
    • liaising with hospital and primary care services
    • support and assistance to meet hospital discharge planning and follow-up care goals
    • development of and support with implementation of health care plans
    • group sessions that focus on health promotion and well-being.

    The nursing service is funded by Mater HealthSt Vincent’s Private Hospital Brisbane, and Mater Foundation. The nurses are employed by Mater Health.

    Please email us for more information.

  • + - Community Response for people who present frequently to Metro North Hospital Emergency Departments

    The Community Response to Hospital Emergency Departments (ED) works with vulnerable individuals who present frequently to ED.

    The objectives of this Hospital and Community response are to:

    • reduce the number of unnecessary presentations to Emergency Departments at the Royal Brisbane and Women's Hospital (RBWH) and The Prince Charles Hospital (TPCH) through the provision of a targeted community health, housing and social connection response 
    • facilitate communication across stakeholders that encourages collaboration and problem solving to improve service system responses and quality of life outcomes for the individual.

    A Clinical and Credentialed Mental Health Nurse and a Support and Advocacy Worker aligned with the Home for Good Coordinated Access and Referral team provide care coordination and intensive case management to build the person's capacity to self-manage their health and wellbeing. 

    This includes:

    • assistance and support to access and maintain stable accommodation 
    • linkage with primary care and specialist health services 
    • developing an integrated community support network 
    • developing self-management strategies to manage their mental and physical health. 

    The Clinical Nurse is employed by Mater Health.

    Download the ED Frequent Presenters Referral form.

    The Community Response to Hospital ED has been funded by Brisbane North PHN to partner with RBWH and TPCH Emergency Departments (Metro North HHS LINK Innovation Funding) to work with vulnerable individuals who present frequently to ED.

    Please email us for more information.