This is a study in Sydney Local Health District of Community Health Navigators (CHNs) providing follow up care for patients as they move hospital to the community.  The first phase of the study is a co-design stage that involve the key stakeholders working together to identify training and supervision needs. The second phase is a randomised trial evaluating the impact of CHN follow up following discharge from hospital.

Project Status

Current Projects

Chief investigators

Emeritus Prof Mark Harris (UNSW), Prof Parisa Aslani (USyd) A/Prof Jean-Frederic Levesque (ACI), A/Prof Margo Barr (UNSW), Dr Anurag Sharma (UNSW), A/Prof Ben Harris-Roxas (UNSW), Dr Michael Wright (UTS), Prof Richard Osborne (Swinburn)

Associate investigators

Dr Fiona Doolan Noble (University of Otago), Dr. Simone Dahrouge, (University of Ottawa), Dr Sara Javanparast (Flinders University) Dr. Pim Valentijn (Maastricht University)

Partner investigators 

Ms Lou-Anne Blunden (SLHD), Dr John Cullen (SLHD), Deb Donnelly (SLHD), Ms Julie Finch (SLHD), Dr Brendan Goodger (CESPHN), A/Prof Fiona Haigh, A/Prof Elizabeth Harris, Ms Regina Osten (ACI), Dr Anthony Brown (HCNSW), Dr Sara Javanparast (Flinders University)

Project coordinator

Ms Sharon Parker

Research officers

Sarah Wright

Jacqueline Ramirez

Project Rationale

This study addresses a major challenge of the health system in dealing with people with multiple long-term conditions and vulnerabilities. As well as suffering limitation to their own quality of life, these patients are at risk of hospitalisation and re-hospitalisation due to a range of

problems including medication errors, poor self-management and limited access to care. This places a significant burden on the health system. 

Project Aim/s

To develop, implement and evaluate the impact of a CHN delivered model of care supporting transition of care from hospital to community for patients who are aged or have chronic condition.  


  1. To co-design with consumer and community partners a model of CHW follow up through the transition of care between hospital and community that:1) is responsive to the needs of the diverse population at risk including who speak a language other than English; 2) optimises medication safety, self-management, carer involvement, and access to continuing primary care in the community.
  2. To define the scope of practice for CHWs including the resources, supervision, monitoring, skills and training required, and to establish and deliver the CHW program.
  3. To evaluate the implementation and impact of the model of care on patient health, patient experience, health service use (inculding readmission) and evaluate its economic impact. 
  4. To identify the patient groups most likely to benefit from the model, and the facilitators and barriers for sustainability and scalability.



Project Design and Method

The project will be undertaken in three stages. 

Stage 1: Co-design of CHWs selection, training and activities. 

The first phase of the study is a co-design stage that involve the key stakeholders working together and contributing their different perspectives to come up with the best solution. This will define the training, supervision and support that the CHNs will need and how the project should be implemented in SLHD.  In this stage it is important that we have involvement of:

  • Key staff from the District especially hospital management and those involved in the discharge from hospital of patients with long term conditions.
  • Patients and their carers including those from Culturally and Linguistically Diverse backgrounds.
  • General practice and community pharmacists.
  • Community organisations especially from culturally and linguistically diverse communities and those involved in supporting patient after their discharge in the community.

The codesign phase will commence with interviews with participants.  This will be followed by workshops to review what has been found from the interviews and consultations.

Stage 2. Intervention trial

A pragmatic randomised controlled trial will include patients identified by the SLHD using their database of in-patients at four public hospitals. Research staff will approach eligible patients to invite them to join the study. The CHN will visit the patient at home, and will provide non- medical support for self-management, medicine reconciliation, and access to appropriate health and non-health services. Evaluation will be based on routinely collected hospitalisation, Medicare and Pharmaceutical Benefits scheme data, patient and provider surveys and qualitative interviews.

Phase 3. Translation

Based on the findings we will identify conditions for sustainability and translation to other Local Health Districts in NSW and in Australia and overseas.


Chief investigator: Mark Harris , phone +61 (2) 9385 8384

Trial Coordinator: Sharon Parker, phone +61 (2) 9065 6733

Research Officer: Sarah Wright, phone +61 (2) 9348 1784

Key Partners

Sydney Local Health District (SLHD), Agency for Clinical Innovation (ACI), Central and Eastern Sydney Primary Health Network (CESPHN), Health Consumer NSW (HCNSW) , University of Otago, New Zealand, University of Ottawa, Canada, Flinders University, Maastricht University, Netherlands





Project lead centre


Project stream

Prevention and Management of Long Term Conditions | Health System Integration and Primary Health Care Development