A South Australian Study has found that fragmentation, lack of communication and problems accessing data is compromising the transition from hospital to home for older Australians.

Dr Elizabeth Lynch

Researchers surveyed 19 professionals from acute, post-acute, primary and community aged care settings about what influenced a successful transition from hospital to home.

The study. published in the Australasian Journal on Ageing, found that navigating service provision after hospital is difficult, increasing the risk of avoidable rehospitalisations.

“Across the board, everyone said it’s really tricky managing the transition in and out of hospital,”  Dr Elizabeth Lynch of the Caring Futures Institute at Flinders University told Community Care Review.

Community services under-utilised

A common theme was lack of access to patient data, partly because of privacy concerns, but also because of different medical record systems across services.

The study also found an over-reliance on the hospital sector, with primary care and community based services under-utilisated.

“When they put in programs to keep people out of hospital the money often goes into the acute hospitals, rather than on-the-ground community services,” Dr Lynch said.

“You’ve got one big hospital and lots of community organsisations so the argument is it makes sense to give the money to the hospital, but in terms of providing the service where it’s needed, the people we spoke to told us it’s counter intuitive.”

Services were also fragmented and poorly connected, compounded by the fact that similar services were often called by different names.

“The same programs in different local health networks are often called different names, so people don’t know what they are, for example .one service might call something ‘hospital in the home’ but another might call it ‘specialised home services,” Dr Lynch said.

 “There was a lot of fragmentation – that came through over and over again – particularly in relation to Commonwealth and state funding.

Dedicated liaison

Dr Lynch said one positive approach that emerged was having a dedicated aged care liaison person to navigate post-hospital care.

For example, if home care providers knew a client was going into hospital, a liaison officer could ring up ward staff and communicate about the individual’s needs, and touch base with the hospital when the person is being discharged.

“Without having that dedicated person it seems to be far too reliant and random chance,” Dr Lynch said.  “Having a decidated person to do that was consistently found to be positive,  but it’s not very often provided.”

Falling through the cracks

Dr Lynch also says there’s a need for system wide communication strategy, equitable services across different regions and flexibility in administration.

She says unless the shortcomings in the current system are addressed, vulnerable older people will continue to fall through the cracks without a ‘noisy family’ to advocate for them and ask questions.

The findings of the study were used to inform the establishment of a quality improvement collaborative tasked with identifying modifiable issues in the hospital to home transition. An evaluation of the collaborative was reported in the BMJ earlier this year.

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