A partnership has been established between a group of allied health professionals from across the central and north-west belt of Queensland to improve the patient’s sub-acute journey, particularly for those patients from rural and remote communities. The aim is to use a collaborative approach to provide a seamless and effective allied health sub-acute service and expedite care close to home.
Transition 2 Sub-acute
To provide a seamless and effective allied health sub-acute service and expedite care close to home across central and north-west Queensland
If successful we anticipate that:
- Patients will move to the right care quickly and home as soon as possible with the appropriate resources and infrastructure to support their care
- Patients and their family will be actively involved in care planning and have adequate health literacy to drive their journey.
- Care will transfer seamlessly between providers regardless of funding.
An allied health sub-acute collaborative was established that includes allied health representation from Hospital and Health Services (HHS) and non-government partners across the central and north-west belt of Queensland.
Process mapping using a retrospective chart audit followed patients who had presented into each partner organization with either a CVA or fractured neck of femur. On average, the audit found that a patient:
- spends 28 days in hospital
- has more than 80 individual handovers
- needs to be readmitted through the Emergency Department three times (from rural to regional and back to rural hospital/facility) and
- will have one day back at the rural facility prior to discharge
Queensland Health admitted patient data collection was also analysed to explore patterns of sub-acute care across the state using two tracer conditions: cerebrovascular accident and fractured neck of femur. (snapshot attached)
The Transition 2 Sub-acute project was subsequently established to address identified process and practice issues.
- An Allied health rural and remote sub-acute services framework has been developed and endorsed by both the Statewide Rehabilitation Clinical Network and Rural and Remote Clinical Network. The framework describes key components of allied health sub-acute service capabilities in rural facilities and guides rural health services to develop high quality and sustainable sub-acute service models using partnerships, telehealth, delegation and skill sharing approaches.
- An allied health criteria-led transition tool and companion discharge planning process have been developed and piloted to provide a predictable, consistent and evidence-based transition from intake into sub-acute care at the regional site and step down from sub-acute to the rural services. (User guide attached)
- Sub-acute care services are currently being mapped – including referral pathways and processes, current practices and the capacity of allied health workforce in health and primary health care services.
- New and enhanced sub-acute service plans are being developed for implementation in facilities across the Collaborative
Monitoring and evaluation framework has been developed and ethics approval gained to commence data collection.