Are you worried your patient may not manage in the community after they go home from hospital?

The Acute to Community Coordination Team (previously known as DPSS) are helping Northern Health patients on their ‘Staying Well’ pathway and will have a solution.

The team reviews patients in all areas of Northern Hospital, who have had unplanned admissions (three or more in the previous six months), are at risk of readmission or failed discharge, or who they worry may not be able to cope at home. These patients are referred to as Healthlinks patients, meaning the patient has had three or more recent unplanned admissions. Healthlinks patients are people with chronic and complex health needs, and are often frequent users of hospital inpatient services.

With extensive knowledge of the health service and community programs, the Acute to Community Coordination Team link patients to what they need, helping them transition from the hospital to the community, and continue to recover at home.

Lorinda McPherson, Manager – Acute to Community Coordination Team, says, “Our coordinators provide post discharge support in the form of a phone call within one to three days of going home. We check on the patient’s wellbeing and how their recovery is going – ensuring they are staying on track, improving their health, and referring them onto community programs such as the Hospital Admission Risk Program (HARP) if necessary.”

“We can help chronic disease patients to recognise if they are becoming unwell again, and assist them in ‘Staying Well’ and out of hospital. We provide support for the patient or carer with several phone calls in the weeks following discharge,” Lorinda continues.

Patients often struggle at home after discharge, as they aren’t clear on their discharge instructions. For example, medication changes, fluid restriction in heart failure patients, blood glucose management, and the importance of follow up care via their GP in the community.

“We are trying to prevent our patients from having to come back to hospital, as we know that frequent hospital admissions and being unwell leads to poor general health and reduced quality of life,” Lorinda says.

The Acute to Community Coordination Team also review any patient in the hospital with a length of stay (LOS) of five days and above, ensuring there is a clear plan for discharge.

The team are involved in referral to continuing care programs such as the Transition Care Program (TCP – both home-based and bed-based), GEM@Home and GEM@Resi.

If you are unsure if one of your patients would benefit from or be eligible for these programs, please contact your ward Acute to Community Coordinator.

To contact our coordinators, please click here or email lorinda.mcpherson@nh.org.au.

Featured Image (left to right): Acute to Community Coordination Team – Lorinda McPherson, Rebecca Moussa, Donna McVean, Melinda Roberts, Adeshewa Ajide, Natasha Vinci, Karina Barca, Sandra Rizzotto