Developing transition planning processes to deliver sub-acute care closer to home

Miss  Kerri-Anne Von Deest1

1Queensland Health, Rockhampton, Australia

Aim and Background:

The Transition to Sub Acute project involves a Collaborative of allied health professionals across the central and north-west belt of Queensland with the aim of improving a person’s sub-acute journey. The Collaborative was formed in response to a commitment from Queensland Health to provide equitable access to safe, quality healthcare for all consumers. It also supports a growing trend to transfer clients to smaller facilities in the sub-acute period, to minimise displacement from home communities and to support system efficiency in large regional and metropolitan hospitals.

A literature review confirmed the need for greater standardisation of early, supported criteria-led transition planning but was not able to identify a tool that was fit for purpose.

The project’s aim is to develop, embed and evaluate an early transition process to facilitate consistent, predictable and evidence-informed decisions regarding transition of the sub-acute client.

Method:

  1. The Transition Planning Tool (TPT) was developed, piloted and evaluated
  2. The transition planning process, using the TPT, was trialled and evaluated for four months in the central and north-west belt of Queensland.
  3. The TPT was evaluated through rural and regional clinician feedback obtained through formal surveys, focus groups and patient feedback

Results:

  1. Clinician feedback showed that the TPT enhanced communication between regional and rural teams and assisted discharge planning to the rural site.
  2. A series of case studies have demonstrated positive feedback from staff and clients including: “I felt like I was in control of what was going on with my discharge plan to home.”

Conclusion:

Early implementation of the TPT is proving that the process needs to be embedded and further that allied health can be the lead for the transition of sub-acute clients. Early transition planning and communication between regional and rural sites is critical to providing seamless and integrated sub-acute care that is closer to home.


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