Northern Sydney (NS) and Central Coast Local Health District (CCLHD) undertook a pilot project with the Clinical Excellence Commission and eHealth in New South Wales (NSW). The project's primary aim was to integrate clinical risk screening for falls, pressure injuries, delirium, malnutrition, activity of daily living (ADL) assessment, smoking, and social status into a single care pathway rather than relying on separate assessment tools traditionally used by clinicians. This care pathway then recommends interventions for clinicians, who apply their clinical judgment to develop an individualised care plan based on identified risks and needs. One active care process remains in place throughout a patient's inpatient journey, to be completed upon admission and whenever there is a change in condition, rather than following a set frequency (e.g., daily). The project also introduces a patient dashboard, which includes ADL requirements, demographics, goals of care, and ordered nursing activities such as turning and skin assessment.

The project encountered various challenges from both clinical and technical perspectives, as well as the impact of the COVID-19 pandemic. It introduced significant changes to clinical workflows and required the adaptation of new concepts. A multi-professional approach, including Allied Health, was essential to utilise the exact technical solutions for continuity and clear visibility of risks and care planning. Throughout the project, technical limitations and the complexity of the digital healthcare record system were identified as key challenges, leading to some misalignment with the intricate clinical workflow and less-than-optimal clinician adoption. Additionally, measuring the outcomes of these changes was also challenging. Hospital-acquired Complications and patient satisfaction are deemed inappropriate as multiple factors influence project success measures. Despite these challenges, the system remains in place and provides a central point to document and view comprehensive care.