An ABHI Partnership – Divisions working through the hospital to improve discharge processes in Sutherland
The Sutherland Division of General Practice has been working in partnership with South Eastern Sydney Illawarra Area Health Service to improve communication between hospital and community services, including the capture and sharing of information and discharge planning. Kate Bone (ABHI Regional Coordinator) is based part time at the Sutherland Division of General Practice and part time with the local hospital. Kate reports that, while challenging, being based in both settings has helped her develop relationships with staff across general practice and the Area Health Service.
Measuring the baseline for discharge planning in Sutherland:
To gain an evidence-based understanding of challenges and areas for improvement in discharge planning Kate started with a clinical notes audit both in the practice and at the hospital. The audit revealed lots of areas where discharge planning and the patient experience could be improved.
Identifying the issues:
Evidence gathered showed a lack of systematic process for discharges – especially chronic and complex patients. Community services were clearly stretched and packages of care not well set up or monitored. The time is right for systems change.
The solutions:
Kate has identified that as the Regional Coordinator, she is in an ideal position to take on a number of roles with both the hospital and General Practice teams including:
- Provision of advice on available services in the community on discharge.
- Assist in case management of complex care issues with relevant stakeholders (carers, family, providers, wards, and General practitioners) and follow up with the GP once complex patients have been transferred out of acute care
The outcomes:
In the long term the project hopes to reduce lengths of stay and improve the patient experience for patients over 65 through improved discharge planning systems. Some early wins for the program include:
- Hospital staff have a greater level of understanding of services available for patients on discharge
- Built relationships between the hospital staff and General Practice teams
- Better understanding of Kate’s role with the hospital team.
For more information about this project please contact katebone@shiregps.org.au
To tell us more about your ABHI Integration program or to find out more about ABHI Integration please contact jerrybacich@gpnsw.com.au