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.
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Background BriefJul 2020
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Consumer ReportOct 2020
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Situational AnalysisNov 2020
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User Survey & WorkshopMay – Jul 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.
The next step in the project was to develop the user requirements for a technical solution that provides real-time two-way transfer of patient medical information between general practice and hospitals.
To achieve this we:
- Conducted an SA wide survey of consumers and clinicians exploring
- At what points in the patient journey will real-time access to a patient’s complete medical record significantly improve care and patient outcomes
- What information (data) is most useful at these timepoints
- What issues or concerns need to be addressed?
- Ran a workshop – to co-develop the user requirements as informed by the survey results.
Survey results (illustrated below) showed that entry to the hospital via emergency department, outpatient referral or admission as an inpatient, as well as discharge from all these settings back to GP care were critical points in a patients’ journey where connected healthcare information would significantly improve care.
The most critical information required related to medications, medical and family history, investigations, allergies/intolerance and investigations.
These results were used as the basis for the user-requirement workshop held in June 2021. The outcomes of the workshop are available in the report below.
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)
Director-Health Policy
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
Allscripts Australia
- 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
Community Representative - Wendy Keech
CEO
Health Translation SA
Project Enquiries
Dr Ecushla Linedale
Health Translation SA
Ecushla.Linedale@healthtranslationsa.org.au
