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Making a difference: Patient centred integrated care: nib Health Funds discharge support service in partnership with Vitalis Health Care


Donal Byrne ,

nib Health Funds, AU
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Voni Leighton,

Vitalis Home Care Pty Ltd, AU
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Julie Malone

nib Health Funds, AU
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"nib health funds limitedis the 4th largest and one of Australia’s fastest growing health insurers providing health and medical insurance to over 1.1 million Australia and NZ residents. Our mission is to help people afford healthcare when and where needed with world class products and service.  Our partner, Vitalis Health & Home Care is an integrated care provider whose mission is to support quality of life at home through targeted health and home care solutions.

Introduction/ Background: Australia’s ageing population and increasing number of people living with chronic conditions, means health needs are changing and demands on the health system are ever increasing.  This is leaving many patients with treatment gaps especially when they going home from hospital. Recurrent and potentially avoidable hospitalisations are responsible for in excess of 30% of public and nib’s private health care spends. nib and Vitalis have created and implemented a complementary telephonic discharge support service (DSS) for nib’s high medical needs customers who are most at risk of unplanned readmissions. The purpose is to provide telephonic support and connected care directly to the patients and their GP to improve health outcomes and healing post-surgery. The model is integrated to deliver person-centred, seamless and effective care in the home.

By managing and navigating the transition from hospital to home our partnership reduces readmissions by ensuring appropriate follow up appointments are made and attended.  Over the first year on the partnership, up to 8 nursing staff has been involved daily in making over 20,000 pre-admission phone calls to nib customers about to go into hospital. 

Method: The DSS program identifies and engages patients who are either about to be admitted or have recently been discharged from hospital and have a risk of re-admission by providing them with coordinated services to reduce this risk.  

Results: We wish to present the challenges, successes and lessons learned from our DSS program at the APIC1 conference. We are constantly re-evaluating the program, developing new clinical protocols and cost effective methods of managing chronic diseases, and eliminating potentially preventable hospitalisations.

The purpose of the nib DSS is to identify and build patient centred strategies to teach patients to self -manage and reduce unnecessary bed days in hospital.

At the end of 12 months, in excess of 2,400 overnight hospital bed days were avoided and in excess of $1.5m in hospital costs have been saved (minus the $500k in operating costs to run the DSS program), helping to keep the cost of private healthcare more affordable.

Conclusion: The nib DSS is proving enormously successful in terms of health outcome improvements, patient engagement, provider engagement and value for money healthcare.  By working together we can join the dots and close the treatment gap that exists all too often for many private and public patients going home from hospital. As a new partnership we have proven that coordinated discharge support from hospital can achieve better value and safer health care for the patient, the carers, the General Practitioner and funder."

How to Cite: Byrne D, Leighton V, Malone J. Making a difference: Patient centred integrated care: nib Health Funds discharge support service in partnership with Vitalis Health Care. International Journal of Integrated Care. 2018;18(s1):1. DOI:
Published on 12 Mar 2018.


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