Improving the transition of care between hospitals and the community
Health Translation SA wants to better use the rich supply of healthcare data in South Australia to enhance and improve continuity of care and to ensure a coordinated and smooth progression of care as people transition between our hospitals and the community.
Background BriefJul 2020
Consumer ReportOct 2020
Situational AnalysisNov 2020
Project UpdateDec 2020
Clinician and Community SurveyMay 2021
Connected Care Workshop4 Jun 2021
Health Translation SA (HTSA) is working with our partners in education, research and healthcare services to address a significant health system challenge. To develop coordinated and smooth progression of care as people transition between our acute and primary care sectors (known as the ‘primary/acute care interface’).
As this is a significant and multi-faceted challenge to address our project will focus on one key aspect: access to and timely flow of accurate information between care providers and the patient. We are exploring how we can build on current digital health initiatives and health service reform to improve care as people transition between the hospital and community setting.
The Project is being driven by the Primary/Acute Care Interface Data Project Steering Committee comprising healthcare professionals, researchers and community members. This committee meets monthly and reports to the HTSA Board.
For more information on the project please read our Background Briefing Paper.
As the aim of this project is to develop a coordinated and smooth progression of care between the primary and acute care sectors, it is important that we encompass and understand the patient perspective in all aspects of the project.
In October we ran 2 focus groups where we invited patients and carers to share their experience of the healthcare as they transitioned in and out of hospital care. We were really interested in exploring what community members valued, what was working and what could be done better. Communication and coordination of healthcare were seen as critical to care as was the importance of knowing and understanding patients as a whole person and their specific life context.
The full Consumer Report can be downloaded below.
A situational analysis was conducted in Sep/Oct 2020 to:
• understand the problems associated with continuity of care across the interface from the perspective of consumers, clinicians and the health system, and
• identify relevant data assets, projects, and expertise that can contribute to the development of the solution.
It was conducted by HTSA project staff and was informed by a series of discussions with health service decision makers, primary and acute care clinicians, as well as patients and carers. The major findings are summarised in the figure below, and the full report is available for download.
If you would like to provide feedback on this report please email the Project Manager firstname.lastname@example.org. Feedback will be incorporated into an update in January 2021.
The findings of the Situational Analysis report were scheduled for discussion and broader feedback at a Stakeholder Forum planned for November 30th. The purpose was to discuss the findings and inform the next steps of the project. However due to COVID-19 the forum was cancelled. A project update is provided via the button below.
The Steering Committee has agreed on the following focus for this project.
We will seek to engage GPs, hospital clinicians and consumers in Feb 2021 to help determine the requirements of a technical solution to providing real time clinical information at point of care.
CONNECTED CARE: Working to join hospital and community care data systems
If you are a health professional or a member of the community – we want to understand your needs and concerns regarding the sharing of patient information between healthcare services.
The information collected from this anonymous survey, and a workshop to be held June will be analysed by Health Translation SA and the University of South Australia. The findings will be provided to SA Health as a report outlining the user requirements for a technical solution to connect hospital and community care data systems.
This survey will take about 10 minutes to complete online.
GP and Community Representatives Wanted!
Connecting General Practice and hospital Electronic Medical Record data has been identified as a pressing need. It is a high priority for patients, carers and clinicians alike.
We want to work with GPs, hospital clinicians, and patients/carers to identify and prioritise needs relating to the real-time transfer of clinical information.
Together with Digital Health SA we will be holding a forum on June 4th @ Adelaide Convention Centre. The ‘user requirements’ identified in the forum will be used to inform the technical solution developed or adopted.
If you are interested in representing GPs or patients/carers please send an expression of interest to email@example.com. Representatives will be reimbursed for their time.
We will be reaching out to connect with hospital clinicians through the Local Health Networks.
This project is supported by the Australian Government’s Medical Research Future Fund (MRFF) as part of the Rapid Applied Research Translation program. (MRF9100005).
Project Steering Committee
- Ali Krollig (Co-Chair)
Country SA Primary Health Network & Adelaide Primary Health Network
- Prof Susan Hillier (Co-Chair)
Dean of Research, Allied Health & Human Performance
University of SA
- Prof Tarun Bastiampillai
College of Medicine & Public Health
Flinders University, Southern Adelaide Health Network
- Dr Emily Kirkpatrick
Deputy Chief Public Health Officer
Medical Advisor for Primary Care/COVID-19 GP Liaison
Department for Health and Wellbeing
- Tina Hardin
Executive Director, Clinical Informatics
Commission on Excellence and Innovation in Health
- Adam Philips
Clinical Informatics Specialist
- Dr Santosh Verghese
Chief Medical Information Officer, Digital Health SA
Department of Health and Wellbeing
- Michele McKinnon
Executive Director, Commissioning and Performance
Department for Health and Wellbeing
- Chris Bollen
GP & Director BMP Healthcare Consulting
- Dr Gokhan Ayturk
Manager, Research and Ethics
Aboriginal Health Council of SA Ltd. (AHCSA)
- Lana Earle-Bandaralage
- Wendy Keech
Health Translation SA
Dr Ecushla Linedale
Health Translation SA