National Sepsis Program Extension 2023-2025: Coordination of Care and Post-Sepsis Support Model of Care Framework and Business Case

Sepsis is a life-threatening condition caused by an abnormal immune response to infection, affecting tissues and organs[1]. It is a major cause of mortality and morbidity in Australia and worldwide. The social, emotional and financial impacts of sepsis are high, but these do not stop when a patient is discharged from hospital or dies. It is common for the effects of sepsis to be felt by sepsis survivors[2], their families and carers, and people bereaved by sepsis for years after hospitalisation.[3]

In 2018 the Australian Sepsis Network and The George Institute for Global Health (TGI) launched the Stopping Sepsis National Action Plan to reduce the number of people who lose their lives each year to sepsis. This was supported by the Australian Commission on Safety and Quality in Health Care (the Commission) and many other stakeholders and people with lived experience[4].

In 2019, the then Department of Health and Aged Care (now Australian Government Department of Health, Disability and Ageing) appointed the Commission, working in partnership with TGI and Sepsis Australia to lead and coordinate the National Sepsis Program. This work included the development and launch of the Sepsis Clinical Care Standard. Further work was resourced in 2022 under the National Sepsis Program Extension. An aspect of this focused on improving coordination of care and post discharge support for sepsis survivors, families, carers and those bereaved by sepsis.

The Commission identified a need for further insights from the healthcare and consumer sector about the gaps in coordination of sepsis care and post-sepsis support to shape a model of care (a structured approach used in healthcare to outline how healthcare services can be designed, delivered and evaluated). Consultations were needed, to ensure the model of care was informed by the lived experiences of sepsis survivors and families of those who did not survive, and advice from the healthcare sector on the actions to take to address gaps.

ARTD was commissioned to undertake health stakeholder and consumer consultations and develop a Model of Care Framework for Sepsis Coordination and Post Sepsis Support, as well as a Business Case to support implementation.

ARTD worked with the Commission, The George Institute for Global Health (TGI), and Sepsis Australia to undertake exploratory research with health stakeholders and consumers.

The Coordination of Care and Post-Sepsis Support Model of Care Framework was developed following analysis, consultation and engagement to identify effective care coordination elements, systemic gaps, and explore aspirations for future sepsis care coordination and support.

The design phase included:

1. A review of existing literature on models of care for sepsis care coordination and post-sepsis support, other relevant integrated care models and evidence about the cost consequences of integrated models of care.
2. Surveys (n=390) focus groups (n=36) in 2024/2025. Respondents included health workers in hospital, governance, and community health-based roles. Results were summarised and discussed with the National Sepsis Program’s National Oversight Committee and Commonwealth, State and Territory Liaison Group.
3. Consumer consultation to share the findings of health stakeholder consultation and develop ideas for the model of care. This involved:

• • a survey completed by 44 consumers
  • two focus groups (n=13) to map the sepsis patient journey, identify service gaps and opportunities supports along the journey, and test a set of care principles developed from the survey of consumers
  • semi-structured interviews with 7 people bereaved by sepsis.

The draft model was presented to consumers at the April 2025 Sepsis Australia Consumer Forum, and the Commission’s National Sepsis Oversight Committee and Sepsis State and Territory Liaison Group, with further refinements made.

A Business Case was developed from existing data on the number and costs of sepsis admissions, ICU stays and readmissions (The George Institute), economic data from existing Australian and international sepsis coordinator programs, and the National Efficient Price Determination (IHACPA). This demonstrates the economic rationale for investing in coordination of care and post-sepsis support.

A companion Supporting Evidence and Implementation Ideas document was delivered, to provide more in-depth findings of the literature review, and the consultations with health stakeholders and consumers, which underpin the Model of Care Framework and Business Case.

The Model of Care Framework, Business Case and Supporting Evidence and Implementation Ideas documents are published on the Commission’s website. The intention is that these documents can be used by health services to:

• better understand the experiences of consumers and gaps in the healthcare system
• identify areas for improvement in the coordination of care and post-sepsis support in their local context
• utilise key components to support a case for funding for improvements to care coordination and post-sepsis support
• support the implementation of the Sepsis Clinical Care Standard.

Additionally, the project deliverables together with the consultation data will be used by the George Institute for Global Health as part of a National Health and Medical Research Council (NHMRC) funded research project to develop and test post-sepsis support models of care for adults and children over the next five years.