Transition and Continuity

Patients often express considerable anxiety about their ability to care for themselves after discharge. Meeting patient needs in this area requires staff to:

Provide understandable, detailed information regarding medications, physical limitations, dietary needs, etc.
Coordinate and plan ongoing treatment and services after discharge.
Provide information regarding access to clinical, social. physical and financial support on a continuing basis.

Below are some solutions to improve health services in this area.

Explained Medications / Medication Side Effects Understandably

Older Person Acute Care (OPAC) Model of Care - Hunter New England Area Health Service
Program to improve patient experiences and health outcomes for older people, whilst developing a workplace culture that values and embraces the care of older people.

Project RED - Boston University Medical Center
The Project RED (Re-Engineered Discharge) program recreates the discharge process to improve the process and post-discharge care.

Informed About Therapy Exercise Before Going Home

HIP HOP: Exercise class for adults following fractured neck of femur - Greater Western Area Health Service
This project aimed to review an exercise class for clients following a fractured NOF. The goals were to improve function post-op and address pre-morbid falls risk factors.

Move to Improve - Sydney South West Area Health Service
Implementation of a falls prevention and exercise promotion program for patients with neurological conditions.

Staff Arranged Follow-up Visit or Referral to Another Agency

Project RED - Boston University Medical Center
The Project RED (Re-Engineered Discharge) program recreates the discharge process to improve the process and post-discharge care.

Afghani Family Health Program - Greater Southern Area Health Service
The Trans-cultural Rural & Remote Outreach Project seeks to develop sustainable diversity-aware mental health services for culturally and linguistically diverse communities in Griffith.

Dr Who? Creation of an Area Health Services Provider Directory - Northern Sydney Central Coast Area Health Service
Project to collect, verify and maintain accurate provider and service information in a single Health Services Provider database for the population of clinical systems and as an online tool to assist in service referrals.

Dry as a Bone Solutions - Greater Western Area Health Service
The project identified and addressed the continence needs of our elderly and disabled clients in the community of Broken Hill.

Told What to Expect About Progress and Danger Signals to Watch For

Project RED - Boston University Medical Center
The Project RED (Re-Engineered Discharge) program recreates the discharge process to improve the process and post-discharge care.

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The NSW Health Patient and Carer Experience team would like to add your answer to improving patient care to their collection of solutions. Contact ARCHI to find out more.