Supporting Complex Dynamic Health Journeys Using Conversation to Avert Hospital Readmissions from the Community: An Ecological Perspective Incorporating Interoception

  • Carmel Martin
  • Joachim P. Sturmberg
  • Keith Stockman
  • Donald Campbell
  • Lucy Hederman
  • Carl Vogel
  • Kevin Smith


Hospital readmissions are the consequence of an individual unstable health journeys in the context of their local health services and community configurations. The Patient Journey Record System (PaJR) has developed a conversational approach with care guides and clinician coaches who support such health journeys irrespective of condition and location.

This chapter explores the pilot deployments of PaJR, that were initially validated in rural Ireland communities (IPCC), followed by MonashWatch (MW), a hospital-based readmission program in multicultural inner-city Melbourne, Australia. Despite differences in language, culture, community and health services settings, and recruitment strategies (GP invite vs cold calling) and uptakes rates (IPCC > 90% and MW 60%), self-rated health and rates of acute problems (red alerts) requiring prompt intervention were similar in both groups. Typical presentations were different in the two groups with IPCC presenting with age-related multimorbidity problems and MW with a cluster of pain, depression, and drug and alcohol problems in the context of psychosocial and environmental problems with many more instances of not coping (pink alerts). PaJR was well received with very low dropout rates in either group. This approach identified problems, generally amenable to intervention, but many psychosocial problems, particularly in MW, were challenging to solve within existing health service structures and resources.

In conclusion supporting complex health journeys through conversations using lay care guides and an adaptive systems approach is feasible in at least two very different settings and patient groups.



Deirdre Grady, Laurence Gaughan, Brendan O’Shea, John Kellett, Narelle Hinkley, Damian Byrne, John-Paul Smith, Michael Jaurigue, Basem Youry, and all the wonderful care guides in Ireland and Melbourne.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Carmel Martin
    • 1
  • Joachim P. Sturmberg
    • 2
    • 3
  • Keith Stockman
    • 1
  • Donald Campbell
    • 1
  • Lucy Hederman
    • 4
  • Carl Vogel
    • 5
  • Kevin Smith
    • 6
  1. 1.Monash Medical Centre, General Medicine OfficesClaytonAustralia
  2. 2.School of Medicine and Public HealthUniversity of NewcastleNewcastleAustralia
  3. 3.Foundation PresidentInternational Society for Systems and Complexity Sciences for HealthNewcastleAustralia
  4. 4.Centre for Health Informatics (CHI)Trinity College Dublin, The University of DublinDublin 2Ireland
  5. 5.Trinity Centre for Computing and Language StudiesTrinity College Dublin, The University of DublinDublin 2Ireland
  6. 6.Research Computing Centre Level 5The University of QueenslandSt LuciaAustralia

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