Hospital to home: An integrated approach to discharge planning in a rural South Australian town

OBJECTIVE: To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings. DESIGN: Plan-Do-Study-Act framework using case-note audit and focus groups. SETTING: Central Yorke Peninsula Hospital in South Australia. SUBJECTS: All patients aged 65 years or older admitted between October 2001 and June 2002. INTERVENTIONS: Range of communication strategies designed to improve discharge planning practices. MAIN OUTCOME MEASURES: Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge. RESULTS: There was a significant increase in the proportion of patients with a documented discharge plan for both non-Aboriginal (23%) and Aboriginal patients (52%). There was also a significant increase in the proportion of patients who received timely and informative risk screening (41% for non-Aboriginal and 58% for Aboriginal patients). Referrals to community health service providers also increased significantly from baseline to the intervention period (14% for non-Aboriginal and 33% for Aboriginal patients). The project also resulted in improved communication processes between hospital staff and community health service providers. CONCLUSIONS: This National Demonstration Hospitals Program project has impacted on both hospital discharge planning and the hospital-community interface. Flow-on effects to other initiatives within the region are likely.