Providing post-acute care to improve health outcomes for Australians and reduce unplanned hospital readmissions.
In Australia, readmissions occur in 25% of acutely hospitalised older patients, contributing to over 600,000 potentially preventable hospitalisations per year. 7,8 CareComplete’s CareTransition program is a 30-day hospital discharge support program to help people make a smooth transition from hospital to home and reduce the chance that they’ll need to be readmitted to hospital.
The program is designed as an intervention to prevent unnecessary treatment, keeping people out of hospital and consequently reducing the associated costs. The program is for patients who have a medium to high risk of an avoidable readmission after discharge from hospital.
CareTransition is an evidence-based intervention led by a care coordinator. It features pre-hospital education and goal setting (where possible), and an individualised discharge ‘toolkit’ for the participant which is developed in close consultation with the hospital team.
After discharge, the care coordinator pays a home visit to review the discharge plan. There is also follow-up support via telephone to ensure the participant is following the plan and that they have reconnected with their GP.
Post-hospital support is an important intervention that reduces the chance of unplanned hospital readmission. It also provides education, support and coaching to the patient so they can learn how to manage their own care at home, on an ongoing basis.
Increased confidence and skills around self-management mean patients are less likely to encounter complications, and therefore achieve better long-term health outcomes.