Hospital to home: an integrated approach to discharge planning in a rural South Australian town

Abstract

<h4>Objective</h4>To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings.<h4>Design</h4>Plan-Do-Study-Act framework using case-note audit and focus groups.<h4>Setting</h4>Central Yorke Peninsula Hospital in South Australia.<h4>Subjects</h4>All patients aged 65 years or older admitted between October 2001 and June 2002.<h4>Interventions</h4>Range of communication strategies designed to improve discharge planning practices.<h4>Main outcome measures</h4>Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge.<h4>Results</h4>There was a significant increase in the proportion of patients with a documented discharge plan for both non-Aboriginal (23%) and Aboriginal patients (52%). There was also a significant increase in the proportion of patients who received timely and informative risk screening (41% for non-Aboriginal and 58% for Aboriginal patients). Referrals to community health service providers also increased significantly from baseline to the intervention period (14% for non-Aboriginal and 33% for Aboriginal patients). The project also resulted in improved communication processes between hospital staff and community health service providers.<h4>Conclusions</h4>This National Demonstration Hospitals Program project has impacted on both hospital discharge planning and the hospital-community interface. Flow-on effects to other initiatives within the region are likely.