Leads: Professor Maria Crotty, A/Professor Craig Whitehead, Professor Gillian Harvey, A/Professor Maria Inacio

This project focuses on improving Out of Hospital care for frail older people, ensuring that the care provided is timely, coordinated, high quality and meets the needs and expectations of older people themselves. It will improve the pathway of older people being discharged from hospital. While there is evidence about strategies to improve older patients’ experiences of hospital discharge and reduce readmissions, they are not implemented systematically across South Australia.

This project will establish a partnership with health providers, aged care nongovernment agencies (NGOs), general practices, consumers and researchers to guide the study, profile the older SA population at risk of multiple hospitalisations, develop an evaluation framework/matrix for health services and policy makers to evaluate all Out of Hospital programs for older people and establish a quality improvement collaborative with the goal of increasing the quality of care for older people at times of transition.

The outcomes include:

• provision of detailed information – on the characteristics and trajectories of older people who admit frequently in the different Local Health Networks (LHNs) using registry data from the Registry of Senior Australians (ROSA) to monitor whole of system outcomes for high risk older people and identify opportunities to reduce morbidity and utilisation
• provide information of high relevance to clinicians and managers for example ‘how do the out of hospital health programs compare in terms of risk adjusted cost-effectiveness?’ (cost per days out of hospital, cost per hospitalisation)
• Establishment of a network of people working in Out of Hospital Care in SA; linkages across LHNs, primary care settings and non-government aged care providers (to be measured via social network analysis); increase adherence to a core set of quality process indicators for transitions in care for older people (regardless of service provider); improve quality of transitions and increase capability for quality improvement