Gillian Harvey1, Clarabelle T Pham2, Maria C Inacio3, Kate Laver4, Elizabeth A Lynch1, Robert N Jorissen3, Jonathan Karnon2, Alice Bourke5, John Forward6, John Maddison7, Craig Whitehead4, Jesmin Rupa8, Carmel McNamara9, Maria Crotty4. 1. College of Nursing and Health Sciences, Flinders University, Adelaide, Australia. 2. Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia. 3. Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia. 4. Division of Rehabilitation, Aged and Palliative Care, College of Medicine and Public Health, Flinders Medical Centre, Flinders University, Adelaide, Australia. 5. Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Adelaide, Australia. 6. Aged Care, Rehabilitation and Palliative Care Division, Northern Adelaide Local Health Network, Adelaide, Australia. 7. Medical Services, Northern Adelaide Local Health Network, Adelaide, Australia. 8. Division of Rehabilitation, Aged and Palliative Care, College of Medicine and Public Health, Flinders Medical Centre, Flinders University, Adelaide, Australia. jesmin.rupa@flinders.edu.au. 9. Adelaide Nursing School, University of Adelaide, Adelaide, Australia.
Abstract
BACKGROUND: Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients' experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. METHODS: The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing 'out-of-hospital' programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people's care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. DISCUSSION: This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.
BACKGROUND: Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients' experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. METHODS: The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing 'out-of-hospital' programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people's care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. DISCUSSION: This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.
Authors: Sílvia López-Aguilà; Joan Carles Contel; Josep Farré; José Luis Campuzano; Luis Rajmil Journal: Am J Manag Care Date: 2011-09-01 Impact factor: 2.229
Authors: Sharon K Inouye; Ying Zhang; Richard N Jones; Peilin Shi; L Adrienne Cupples; Harold N Calderon; Edward R Marcantonio Journal: Med Care Date: 2008-07 Impact factor: 2.983
Authors: Jay G Berry; James C Gay; Karen Joynt Maddox; Eric A Coleman; Emily M Bucholz; Margaret R O'Neill; Kevin Blaine; Matthew Hall Journal: BMJ Date: 2018-02-27