An ageing population and increasingly prevalent risk factors such as obesity means that more Australians are living with chronic health conditions for longer periods of time. According to the Productivity Commission approximately 38% of Australians have at least one physical chronic health condition. For the health sector this comes at a substantial cost, with $38 billion spent annually providing care to people with chronic conditions.

A recent Productivity Commission study has identified successful innovations implemented on a smaller scale which offer important, practical insights into ways to improve outcomes for people with chronic conditions. A few highlight case studies include;

  1. Nellie- Nellie is an automated SMS-based persona for promoting self-care for people with chronic conditions. When people opt-in to the Nellie system, they receive friendly text messages from Nellie with reminders about things that are important for managing their condition, and reply to Nellie with information about their health. Nellie is based on a similar system develop in the United Kingdom known as Florence. A 2015 study found that 94% of people who use Florence considered it helped them better manage their own health.
  2. Monash Watch - Patients at risk of repeated hospitalisations are identified by Monash Health using the Health Links algorithm. People who agree to participate in Monash Watch receive phone calls from a Care Guide and support from a Health Coach to reduce avoidable hospital admissions in a 12-month period. Interim results show that Monash Watch is achieving a 20-25% reduction in hospital acute emergency bed days compared to usual care.
  3. Lumos- Lumos is the largest collaboration between NSW Health and Private Health Networks and links consumer data across primary, ambulance, acute care, cancer registry and notifiable conditions registry data to enhance understanding of the consumer journey through the healthcare system. The purpose of Lumos is to capitalise on technology to identify significant gaps in care and identify and address conditions before they worsen and reach the hospital stage.

Despite the success of these local level innovations, the PC identified two fundamental challenges to scaling up digital solutions for chronic care: the need for increased collaboration and better knowledge diffusion, and funding reform. The PC’s downbeat assessment is that COVID-19 did not shift the dial – at least not on an enduring basis.


While there is recognition in the health sector that collaboration will improve service quality and the adaptability of the health system, the PC thought that medical professionals traditionally have been hesitant to engage in large scale collaborative projects due to outdated processing methods and time constraints.

Then along came COVID-19. Collaboration within and across hospitals, primary health networks and community health providers became – often literally overnight - a fundamental feature of the successful COVID-19 response in Australia. For example, Western Sydney Primary Health Network (WentWest) and Western Sydney Local Health District collaborated through rapidly setting up COVID-19 screening clinics and using CareMonitor software which enabled low-risk patients to be monitored by care teams remotely and facilitated a clinical handover to the patients' usual general practice.

So collaboration now should be not so hard? Not so: the PC expressed concerns that collaboration may remain an element solely present in crisis situations. It is not so much a case of ‘old habits die hard’, but in the PC’s view, it’s the lack of formalised approaches and clear governance and accountability mechanisms will impede upon innovative approaches to chronic health care. The pre-COVID-19 ‘red tape’ that impaired collaboration were only suspended during the crisis, not replaced or revised.

Embracing Funding Innovations

The PC also considered that the dominant funding arrangements in the health system are a barrier to providing integrated person-centred care to people with chronic conditions. Patients with complex and chronic diseases require long-term, proactive and systemic care approaches; however, current models of funding are largely designed to be responsive to episodic care for issues such as infectious disease and trauma.

Although governments have been attempting to support innovations in health care, federal and state government approaches largely seek to achieve this through short-term grants or activity-based funding. This funding model conflicts with the nature of AI and algorithmic-based models which require the provision of long-term testing, learning and trials.

The PC is encouraging governments to introducing blended funding models, which take advantage of the benefits of different payments will enable the health sector to implement AI related technologies on a larger scale.

The PC’s ‘cold towel’

Even if the barriers impeding innovation in the health sector could be overcome, the PC also suggested that the potential of AI in managing chronic health conditions may be overstated.

In a post-pandemic global environment, it is now certain that the possibilities of health care even for critical conditions no longer needs to be refined to the four walls of the hospital room.

Although technological solutions can significantly facilitate patient self-management and data sharing, such solutions are insufficient on their own. Chronic conditions necessarily will require a high level of human intervention, skill and judgment – and chronic care patients would benefit as much from better collaboration between humans in the chain of care as from the substitution of humans with snazzy apps.


Authors: Jasleen Kaur and Peter Waters

Read more: Innovations in care for chronic health conditions