Healthcare systems worldwide are under increasing pressure from growing patient numbers, complex chronic conditions, and rising readmission rates. These issues overburden resources and impact patient outcomes, making conventional hospital-based care less sustainable. One innovative solution is a hospital admission risk program (HARP), which seeks to provide care that is more customized, brought closer to home, and designed to avoid unnecessary hospital visits and enable quicker, safer healing.
By combining care coordination, patient education, remote monitoring, and virtual wards, HARP can help patients remain healthy in the community and reduce unnecessary hospital visits. This guide will explore the hospital admission risk program, its application at Victoria, Alfred, Bendigo, and Geelong, the use of technology to reduce readmissions, and best practices for implementing the program.
Key Takeaways
- Healthcare systems face challenges from increasing patient numbers and readmissions, prompting the need for customized care models.
- The Hospital Admission Risk Program (HARP) combines care coordination, education, and remote monitoring to reduce unnecessary hospital visits.
- HARP includes core components like integrated support, patient education, and virtual wards for better patient management.
- Programs like HARP show significant success in reducing emergency admissions and improving patient care in Victoria.
- Future developments focus on enhancing virtual care and proactive measures to prevent hospital readmissions.
Table of Contents
- What is the Hospital Admission Risk Program?
- The Core Components of a Hospital Admission Risk Program
- Who Benefits from These Programs
- How Virtual Wards and Remote Monitoring Fit In
- Case Study: Victoria’s Virtual Hospital Pilot
- Hospital Admission Risk Program Evaluation
- Hospital Admission Risk Program in Key Victorian Locations
- Special Focus: Reducing Risk for Elderly Patients
- Hospital Admission Risk Program Guidelines and Best Practice
- Looking Ahead: What Comes Next?
- Conclusion
- FAQs
What is the Hospital Admission Risk Program?
A hospital admission risk program (HARP) is a model of care focused on individuals who are frequent hospital customers or at risk of hospitalization. This includes long-term patients who have heart disease, respiratory disease, diabetes, and complex psychosocial needs.
These programs focus on:
- Facilitating hospital-community service coordination.
- Assistance in the self-management of the health of the people.
- Minimizing unnecessary hospitalization and inpatient readmission.
- Training patients and families on their conditions.
In Victoria, services delivered through the Australia Victoria Hospital Admission Risk Program (HARP) model include assessment, education, and care planning, connecting people to extended measures that assist them to remain well at home. These services also have formal hospital admission risk program guidelines that focus on integrated care and continuity between the hospital and the community.
The Core Components of a Hospital Admission Risk Program
A hospital admission risk program typically includes:
- Care Coordination and Integrated Support: HARP groups consist of nurses, allied health professionals, and care coordinators. They assist the patients with their conditions, inform them about their treatment plans, and assist them in using their services. Moreover, these groups discuss with GPs and other professionals a clear roadmap to be developed for each patient.
- Patient Education and Self-management: Programs focus on the education of patients on symptom interpretation, medication management, and chronic disease management. This gives individuals the strength to identify warning signs in time and act accordingly.
- Linking into Community Services: Well-planned programs enable patients to benefit from community health services, social support, and rehabilitation programs to maintain their wellness and minimize risk.
- Remote Monitoring and Virtual Wards: Recent models also offer on-board technology so that clinicians can remotely measure vital signs and symptoms of their patients and deliver home hospital-based care through virtual wards.
Who Benefits from These Programs
Risk hospital admission programs are particularly useful to individuals who:
- Experienced numerous preventable admissions or emergency room visits.
- Has chronic ailments (CHF, COPD, diabetes, renal disease)
- Individuals with complex care needs are older.
- Experiences psychosocial or coordination difficulties.
Most of the services also collaborate with families and carers to enhance home-based support structures.
How Virtual Wards and Remote Monitoring Fit In
One of the most promising developments for reducing readmissions is the use of virtual wards combined with remote patient monitoring.
What Are Virtual Wards?
A virtual ward is a replacement for an in-hospital stay with care at home. With this virtual model, patients remain in the status of admission, yet they receive daily clinical attention via telehealth check-ups, wearable devices, and specialist interventions as needed.
Under this model, patients who are already healed of illnesses like heart failure are able to go on with their treatment at home. Wearable devices measure vital signs (heart rate, oxygen levels) and send them to clinicians who can monitor the progress and intervene in case of necessity.
How Remote Monitoring Helps
Remote patient monitoring (RPM) is a technology that gathers health information of patients outside of the traditional clinical environment. It enables clinicians to track vital signs, chronic conditions, and the progress of the recovery in real-time, frequently averting complications that might result in readmission. RPM tools are used at Bendigo Health within the HARP framework to educate patients on self-management. They also alert clinicians when readings indicate a potential worsening of health.
Together with virtual wards, remote monitoring enables care teams to gain insight into the health of the patients in real-time, helping patients remain healthy at home and prevent readmission.
Case Study: Victoria’s Virtual Hospital Pilot
Victoria is also testing its first Virtual Hospital in a pilot project that uses virtual wards and remote monitoring to assist its patients back at home. It is operated by The Royal Melbourne Hospital and Austin Health and aims to assist over 250 patients who would otherwise have been admitted to the hospital. The first target is heart failure patients or those patients who need a cardiac procedure.
Moreover, clinicians track recovery progress using wearables and daily virtual check-ins, and intervene early if indicators of worsening are present. In mid-2026, the pilot will also undergo an evaluation to assess outcomes, including patient experience, technology usability, and equitable access.
Hospital Admission Risk Program Evaluation
The success of any hospital admission risk program depends on how it’s evaluated and guided. An effective hospital admission risk program evaluation looks at factors such as:
- Patient health outcomes and satisfaction
- Rates of emergency presentations and readmissions
- Uptake of community services and remote support
- Cost savings for the health system
Victoria has an official Hospital Admission Risk Program Monitoring and Evaluation Framework that outlines how services should be assessed, including what outcomes to track, how to measure patient satisfaction, clinical results, and effectiveness.
Here’s an overview of how these hospital admission risk program victoria have performed in reducing admissions and improving patient care:
| Outcome Measure | Result |
|---|---|
| Emergency Department attendances reduced | 35% fewer attendances |
| Emergency admissions reduced | 52% fewer emergency admissions |
| Days in hospital reduced | 41% fewer inpatient days |
| COPD-specific reductions | 63% fewer ED visits, 65% fewer admissions |
| Diabetes outcomes | 38% fewer ED, 73% fewer admissions |
| Virtual ward home completion rate | 92% of episodes completed at home |
These figures show that HARP and similar community care programs significantly improve service use through effective coordinated care.
Hospital Admission Risk Program in Key Victorian Locations
Across the state, the Victorian Hospital Admission Risk Program has been implemented across multiple health services, including regional and metropolitan areas.
1. Hospital Admission Risk Program Alfred
The hospital admission risk program Alfred serves the catchment area around Alfred Health, offering care coordination and short‑term intervention to help people manage complex health needs and reduce hospital use. Moreover, program participants receive multi‑disciplinary support and health education.
2. Hospital Admission Risk Program Bendigo
At Bendigo Health, HARP works with people living with chronic diseases and complex conditions to provide goal‑setting, education, and service referrals that help avoid unnecessary admissions. Also, remote monitoring is increasingly a part of this support.
3. Hospital Admission Risk Program Geelong
In Geelong and surrounding regions, HARP services connect people to community care, self‑management support, and health navigation to reduce reliance on hospitals. These services form part of the larger Victorian plan to create a balance between acute care and community health.
Special Focus: Reducing Risk for Elderly Patients
The elderly are usually the most susceptible to frequent hospitalization due to the presence of several chronic illnesses and complicated care requirements. Combined with HARP support, virtual wards, and remote monitoring, a hospital admission risk reduction program for the elderly will often combine to:
- Monitor and track changes to health.
- Deliver specific education regarding drugs and symptoms.
- Provide support through the family, carers, and health professionals.
These programs make older adults remain safely at home longer by personalizing care and integrating technology and human support.
Hospital Admission Risk Program Guidelines and Best Practice
An effective hospital admission risk program guideline helps standardise service provision and maintain quality and safety. The Health Independence Programs guidelines in Victoria outline the main elements of these services, the populations they serve, and the objectives they pursue.
Good guidelines cover:
- Who qualifies for the service
- How care plans are developed
- How teams coordinate with hospitals and GPs
- What remote monitoring looks like in practice
- How outcomes are tracked
Clear guidelines protect patients and help care teams deliver consistent, evidence‑informed support
Looking Ahead: What Comes Next?
Hospital admission risk programs are evolving. With improved coordination, technology, and emphasis on patient-centred care, these programs would become more effective.
In Victoria, further consideration of virtual wards and remote monitoring will facilitate the development of the role of health services to assist at-risk patients within the community. With their successful implementation, they may become part of the fundamental components of how hospitals address chronic illness and avoidable readmissions.
Overall, these programs represent a significant move towards a health system that values prevention and ensures that people remain in an environment they feel secure in, their homes.
Conclusion
In Australia Victoria hospital admission risk program is significant in helping individuals with complex and chronic medical conditions. These models, integrating care coordination, self-management support, virtual wards, and remote monitoring, help patients remain well in the community and reduce unnecessary hospitalizations.
In Victoria, Australia, the integration of virtual care into admission risk strategies reflects a broader shift toward person-centred, technology-enabled care. As evaluation of these programs continues, the evidence base will grow, improving care hospital admission risk programs and helping health systems make smarter decisions about care outside the hospital walls.
FAQs
A Hospital Admission Risk Program (HARP) is a coordinated care service to persons with chronic illness or complex needs with short-term care, education, and community care referral. It aims at maximizing health outcomes and reducing repeat hospitalization and emergency department visits.
Remote patient monitoring (RPM) involves the use of digital health devices to measure the vital signs and other health parameters of a patient at home. It also transmits the information safely to clinicians to review. Healthcare providers track these readings, trends, and intervene early when there is an indication of issues. Thus, saving the burden of physically visiting the patient.
HARP and virtual wards provide coordinated home-based care and early intervention. This can help reduce hospital readmissions for some patients, though results vary.
Guidelines provide HARP with a structure by outlining best practices for assessing the patient, planning care, and following up. They contribute to providing effective and consistent help and better results, and to decreasing unnecessary hospital visits.
Secure data transmission, encrypted data, limited access, and compliance with health privacy laws and regulations ensure the privacy of patients in remote monitoring. These measures allow only authorized clinicians to access sensitive health information.
