Navigating the challenges of introducing a sub-acute pathway to North West Queensland: Learning together

Ella Dunsford1, Katheryn  Farry2

1Mount Isa Centre For Rural And Remote Health, Mount Isa, Australia, 2North West Hospital and Health Service, Mount Isa, Australia, 3Gidgee Healing, Mount Isa, Australia, 4NWRH, Mount Isa, 4825

Background: Allied health service providers in North West Queensland (NWQ) have historically functioned independently of each other, with collaboration largely clinician dependent. This siloed approach to health care was contributing to fragmented care planning for residents transitioning from Townsville Hospital back to NWQ. The development of the Transition 2 Sub Acute Program across Central and North Queensland triggered the overhaul of our sub acute rehabilitation referral processes.

Aim: The North West Sub Acute Collaborative aimed to improve referral pathways, and in turn the patient journey between Government and Non-Government organisations across Queensland, in line with AHPOQ’s Transition 2 Sub Acute project.

Methods: The Transition to Sub Acute Collaborative identified key stakeholders delivering allied health sub-acute service across NWQ including Gidgee Healing, NWRH, North West Community Rehab and the North West Hospital and Health Service. The collaborative engaged key stakeholders in bi-monthly videoconferences with other sites in Queensland and facilitated two face to face workshops across a 24 month period. Key stakeholders from NWQ formed a region based collaborative to act on operational requirements for commitment to the Transition 2 Sub Acute project and on clinical requirements to translate research and recommendations into practice.

Results: NWQ’s region based collaborative has implemented weekly interagency case conferences between key stakeholders in NWQ, a clinical representative from The Townsville Hospital’s rehabilitation team and a research representative from the Sub Acute Collaborative. The inter-agency case conferences have facilitated more timely and appropriate referrals from The Townsville Hospital, early discharge planning, communication across Government and Non-Government organisations and increased collaboration between Allied Health professionals in NWQ. Clients are involved in care planning during their sub acute inpatient admission and, using the Transition Planning Tool, are able to meet their regional team and coordinate their regional based rehabilitation program before returning home leading to a streamlined transition from inpatient to community based services.

Conclusions/ Recommendations: A regional collaborative approach to sub-acute care planning has provided benefits across client, clinician and service levels within Allied Health organisations in NWQ – working together to face the challenges of introducing a standardised framework into a unique, complex environment.


Ella is the Project Manager and Clinical Lead of Occupational Therapy for North West Community Rehabilitation, based at Mount Isa’s Centre for Rural and Remote Health, James Cook University. Ella is a committed member of the Central and North-West Sub-acute Collaborative that is implementing the ‘Transition 2 Sub-Acute’ project; a project that aims to improve the sub-acute patients journey and expediting care closer to home. She is also a member of the project research team. Raised in regional South Australia, Ella has first-hand experience of the impact of centralisation of services and is committed to reducing inequity of access to health services and improving health outcomes for people living in rural and remote Australia.

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