Community Assessment and Response Team Update

In a COVID-19 environment, development of a new model of community-based care has been accelerated to identify and prioritise care for patients most at risk for COVID-19 infection, morbidity or mortality. The Community Assessment Response Team (CART) model targets patients with complex/chronic conditions to avoid unnecessary emergency department presentations and hospital admissions/length of stay.

The team at Monash Health Community has developed an algorithm that accurately identifies this specific cohort of patients. A model of care has also been developed that includes risk stratification, ongoing monitoring and early intervention in the community by utilising existing MHC resources under the CART strategic framework. The aims are to disrupt the trajectory of the illness, potentially prevent avoidable hospital admissions and reduce length of stay

Current status

On 21 April, the Health Incident Command Team (HICT) approved a pilot of the CART model for rapid implementation. This model is seen as a key means of improving patient care and reducing avoidable health service utility across the network.


CART Model Development

The Community Assessment and Response Team (CART) model has been developed as part of the Monash Health’s Community Strategy as a way to manage people with complex/chronic conditions while avoiding emergency department (ED) and hospital admissions. In a COVID-19 context, MHC has accelerated the development of the CART model and framework. CART enables the identification of high-risk patients, stratifies their risk, prioritises their care, and monitors their progress in the community.

The framework is scalable to other programs, and is based on five key steps with clear escalation and de-escalation processes:

  1. Patient identification via algorithm and other services (ED, Ambulance Victoria, Community Health)
  2. Initial screening for risk stratification and resource allocation
  3. Ongoing active monitoring to identify early deterioration or changes in health
  4. Resources mobilised depending on current health status
  5. Data collection and evaluation to monitor the effectiveness of service delivery, patient experience, cost-effectiveness and future refinement.

CART Client Profile

CART prioritises interventions for people at most risk of serious infection, including:

  • Older people (65 years+)
  • People with chronic lung disease or moderate to severe asthma
  • People who have serious heart conditions
  • People who are immunocompromised including those undergoing cancer treatment
  • People with diagnosed chronic medical conditions (such as lung conditions and kidney failure)
  • People with multiple co-morbidities
  • People who have higher hospital utility (those who have had multiple ED or inpatient admissions) within the past 12 months.

At the beginning of April, a total of 3151 Monash Health patients were identified as eligible for the COVID-19 CART program based on patient priority and health risk scores. These scores were determined using the approved CART Model Parameters. Target health risk indicators for ED presentations and inpatients have also been identified for their association with COVID-19 and related complications.


Monash Health is currently in the final stages of planning the implementation of a three-month pilot. We look forward to sharing the results of the pilot and an outline of the next steps in the coming weeks.

The PaJR (Patient Journey Record) tool, a decision support system consisting of multiple patient self rated health questions, will be used as a screening mechanism to determine movement between CART packages once a level of support intensity has initially been assigned. This tool has been validated and is currently in use by the Monash Watch program.

Authorised by Julia Oxley, General Manager, Community on 29 April 2020
Signed off by HICT on 29 April 2020

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