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

Miss  Kerri-Anne Von Deest1 Mr Robert Farquhar2

1Queensland Health, Rockhampton, Australia  2Queensland Health, Emerald, 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.


  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


  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.”


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.


Kerri-Anne Von Deest is a Clinical Educator in Occupational Therapy at Queensland Health

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