The GEDI team can coordinate patient discharge by instigating referrals to allied health specialties, wound care specialists and discharge facilitation services to prompt the early actioning of concerns, according to local service requirements and the availability of a discharge planning service such as CHIP. Collaboration between the GEDI team and community health team (including community nursing, non-government organisations and community allied health), is important for patients returning home who require additional and/or increased support, for example; assistance with activities of daily living, transport, wound care, medication supervision, continence aid prescription. These measures may be short term to assist in return to baseline functioning or longer term to address a permanent function decline.
High risk patients may benefit from linkages with Nurse Navigator support with a view to providing ongoing coordinated care to better manage care and prevent representation. Additional linkages with primary health services particularly GPs is recommended to communicate changes and highlight new issues as a result of ED presentation.
