Discharge Planning

It’s more than a last minute thing…

Central Adelaide Local Health Network

Patient Centred

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Patient CentredTeam Work

RespectProfessionalism

> Diverse People groups: England, Italy, Vietnam, India, Greece, Sudan, Afghanistan

> 1.5% Aboriginal and Torres Strait Islander

> Slightly higher percentage of females: males

> Ageing population: > 65

Central Adelaide Local Health Network

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> Ageing population: > 65 years 17.5%, > 75 years 9.4%

> Western Adelaide has a 5.9% unemployment rate

> 31.6% Single person households in the west

Drivers for Change: Discharge Blockages

• Extended length of stay: patients decondition

• Bed block: decreased access to hospital

services

• Patients not admitted to home wards

• Emergency Department over capacity

• Unnecessary re-admissions

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• Unnecessary re-admissions

• Delayed planning: who to call?

• Lack of accommodation options

• Lack of discharge champions

• Lack of consensus between acute, sub-acute

and community sectors

• Poor communication

• Ownership: who’s responsibility is it?

Discharge Planning Goals

Patient Centred approach

Dignity in Care principles

Best Practice

Improved Outcomes for patientsImproved Outcomes for patients

Improved service access i.e.

the right patient, in the right place,

at the right time.

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10 Dignity in Care Principles> Zero tolerance of all forms of abuse

> Support people with the same respect you would want for yourself or a member of your family

> Treat each person as an individual by offering a personalised service

> Enable people to maintain the maximum possibly level of independence, choice, and control

> Listen and support people to express their needs and

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> Listen and support people to express their needs and wants

> Respect people’s privacy

> Ensure people feel able to complain without fear of retribution

> Engage with family members and carers as care partners

> Assist people to maintain confidence and a positive self esteem

> Act to alleviate people's loneliness and isolation.

In the beginning...

Local

TQEH/Community

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Regional

CALHN/CAHML

Community

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A Strategic and Operational Approach

> Outcomes shared with CALHN Executive

> Support to expand the Collaborative Membership

> Terms Of Reference Endorsed

> Reporting line established

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> Reporting line established

> Escalation pathways established

> Operationally Collaborative Action Group: shared goals and achievable outcomes

> Established key workgroups with Measurable Outcomes

Family

Allied Health

Team Approach: Who do We Call?

Medical Team Acute

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Health

Pharmacist

Nursing Acute and Community

Community Health

Providers

PATIENT

Acute and

Primary

Working Collaboratively: Changing Perspective?

> Developing the network & sharing with other services and providers

> Communicating across all sectors and services

> Conducting a gap analysis: what do we have, what do we need?

> Defining shared goals

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> Defining shared goals

> Breaking down the barriers and pre-conceived ideas

> Encouraging conversations, fresh ideas and initiatives

Ways of Working

> Patient centred: Consumer Engagement

> Terms of Reference

> Executive support

> Escalation pathway: Feedback mechanism

> Shared outcomes and goals

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> Shared outcomes and goals

> Equal partnerships

> Open communication

Outcomes

Workgroups: Aged Care, Disability, Hospital Avoidance,

Length of Stay, ED Frequent Presenters

Improved communication at all levels

Improved Education opportunities

Increased knowledge, confidence and communication

Improved pathways and networks

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Improved pathways and networks

Service agreements under development

Patient and Consumer engagement resources

Development of patient

information sheets, posters and brochures to encourage

active

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active participation in

care.

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What have learnt?

•Discharge Planning commences at the first patient

encounter: Acute/Sub Acute/Primary Care

•Staff need to be supported to commence the

planning and networking

•Staff should be resourced and have confidence to

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develop and communicate the plan: verbal and written

•Good and comprehensive clinical handover supports

discharge planning and avoids unnecessary

readmission.

•Discharge planning is everyone's responsibility

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