Improving the pathway of care for older people being discharged from hospital in South Australia
SA hospitals are facing escalating demand from frail older people with multiple long-term conditions who have complex health and social care needs. Many hospital admissions are for ambulatory sensitive conditions and therefore potentially preventable (Banham et al., 2019). Australians aged 70 years and over represent 9% of the population yet account for 17% of ED attendances (Lowthian et al., 2012). Older frail patients are vulnerable to health crises and more likely to be hospitalised with extended lengths of stay (Theou et al., 2018) however once an admission has occurred, they remain at high risk for further admissions over the following 6 months. For this group, hospital admission is also associated with risk of adverse outcomes such as functional decline, falls, infection and increased confusion (Fogg et al., 2018).
No simple solution exists to reduce unplanned admissions of frail older people and current approaches in SA are fragmented. While there is evidence about strategies to improve older patients’ experiences of hospital discharge and reduce hospital readmissions, they are not implemented systematically across South Australia. Multiple approaches are needed which involve collaboration between the spectrum of care providers (hospital, aged care, primary care) (Hansen et al., 2011).
To improve the pathway of care for older people being discharged from hospital, in South Australia.
The governance structure for the STAAR-SA Project includes two key groups, the Project Team and Stakeholder Group. The Project Team is a small, hands-on group that met monthly during the active phase of the study, to oversee the Project and consists of clinicians, lead investigators from the 3 universities and ROSA (SAHMRI). The Stakeholder Advisory Group is a high-level group that provided guidance and advice to the STAAR-SA project and came together 3 x per year, over the course of the study. The STAAR-SA Advisory Group membership consists of relevant government and non-Gov agencies, Aged Care Providers, Primary Health Networks, GPs, clinicians, consumers, administrators, peak bodies and the 3 universities.
STAAR-SA Project Team
- Professor Maria Crotty
Professor of Rehabilitation Flinders University and Director Rehabilitation, Flinders Medical Centre
- Professor Gill Harvey
College of Nursing and Health Science, Flinders University
- A/Professor Craig Whitehead
Regional Clinical Director of Rehabilitation, Aged and Palliative Care, SALHN
- Dr Alice Bourke
Divisional Director Aged Care, Rehabilitation and Palliative Care (Medical) NALHN
- Dr John Maddison
Executive Director, Medical Services, NALHN
- Professor Maria Inacio
Director, Registry of Senior Australians, (ROSA) SAHMRI
- Professor Jon Karnon
Professor Health Economics, College of Medicine and Public Health Flinders University
- John Forward
Planning and Systems Director, Aged Care, Rehabilitation and Palliative Care Division, NALHN
- Dr Clare Pham
Research Fellow, College of Medicine and Public Health, Flinders University
- A/Professor Kate Laver
ARC Discovery Early Career Research Fellow, College of Medicine and Public Health, Flinders University
- Dr Elizabeth Lynch
Senior Research Fellow, College of Nursing and Health Science, Flinders University
- Dr Rob Jorissen
Senior Research Fellow, Registry of Senior Australians (ROSA) SAHMRI
- Dr Jesmin Rupa
Research Officer, College of Medicine and Public Health Flinders University
- Chrissie Isaksson
Network Manager, STAAR-SA Project, based in Wellbeing SA, SA Health
- Carmel McNamara
Senior Translational Project Officer, College of Nursing and Health Science Flinders University
The STAAR-SA project consists of 3 main programs of work or “work packages”.
Work Package 1
This work package involved analysing data in the Registry of Senior Australian’s (ROSA) to monitor whole of system outcomes for high-risk older people. Risk Profiling tools have been developed, that could be used to identify patients at high risk for unplanned hospitalisation by examining a number of identified predictive factors. These tools could be used at the point of ACAT or at entry into permanent residential care, to flag and prioritise patients who are at the highest risk of going to hospital within 90 days. This phase of STAAR-SA has been completed and further details can be found in the attached publications and resources.
Work Package 2
This work package will evaluate the cost and outcomes of a number of existing out-of-hospital care programs in South Australia. This evaluation will determine a) which types of programs work best for whom, where and when, and b) what standardized approach for monitoring and reporting would be useful. This phase of STAAR-SA is due to be completed by June 2023.
Work Package 3
This work package established a quality improvement collaborative (QIC) where local health network clinicians worked with other cross-sectorial stakeholders and came together to learn, share and benchmark outcomes with the goal of increasing the quality of care for older people at times of transition. This component of STAAR-SA has now been completed and further information can be found in the attached publications and resources.
An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan . Harvey G, Pham CT, Inacio MC, Laver K, Lynch EA, Jorrisen RN, Karnon J, Bourke A, Forward A, Maddison J, Whitehead C, Rupa J, McNamara C, Crotty M. 2021;2(1) Springer Science and Business Media LLC, doi:10.1186/s43058-021-00141-w
Work Package 1
Predictors of short-term hospitalization and emergency department presentations in aged care. Inacio MC, Jorissen RN, Khadka J, Whitehead C, Maddison J, Bourke A, Pham CT, Karnon J, Wesselingh SL, Lynch E, Harvey G, Caughey GE, Crotty M. J Am Geriatr Soc. 2021;69(11):3142-3156.
Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study. Inacio MC, Jorissen RN, Wesselingh S, Sluggett JK, Whitehead C, Maddison J, Forward J, Bourke A, Harvey G, Crotty M; STAAR-SA Study Collaborators. BMJ Open. 2021;11(11):e057247
Work Package 2
In addition to the health economic evaluation, the Council of the Ageing (COTA SA), through their Plug-in initiative, undertook a qualitative evaluation to explore the perceptions of older South Australians who have used the selected out-of-hospital services, to gain an understanding of the consumer and/or carer experience. The Plug-in is COTA SA’s specialist consumer engagement and insights consultancy. They give older people an influential voice and enable clients to innovate and improve products, services and policies for older Australians. Information about the evaluation and the main findings, can be found in the Key Insights Report, via the link below.
Work Package 3
Establishing and evaluating a quality improvement collaborative to address hospital to 3 home transitions for older people. Kate Laver, Elizabeth Lynch, Jesmin Rupa, Carmel McNamara, Maria Crotty, Gillian 5 Harvey, STAAR-SA Study Collaborators. BMJ Open Quality 2022;11: e001774. doi:10.1136/bmjoq-2021-001774
“A ‘plethora of services but a lack of consistency”: A qualitative study of service providers’ perspectives about transitioning from hospital to home for older South Australians. Jesmin Rupa; Kate Laver; Gillian Harvey; Carmel McNamara; Maria Crotty; Elizabeth A. Lynch. Australasian Journal on Ageing
Work Package 1 Infographic
Overall STAAR-SA Project Infographic
Video of the Quality Improvement Collaborative initiatives, undertaken through Work Package 3
COTA-SA video of the overall STAAR-SA project