New patient care facilitator program to help avoid hospital readmission

Darling Downs and West Moreton PHN and West Moreton Health are partnering with local general practices and Aboriginal Medical Service to implement a new Patient Care Facilitator program to assist patients from Ipswich Hospital’s general medical ward to avoid hospital readmissions.

The Queensland Department of Health has funded the program to improve health outcomes for patients following a hospital admission by linking them directly with their usual GP, or if they don’t have one, with a local general practice for follow up care.

To date, the PHN has recruited seven local practices to be a part of the program:

• Redbank Plaza Medical Centre
• Kambu Aboriginal and Torres Strait Islander Corporation for Health
• Limestone Medical Centre
• Winston Glades Family Practice
• Priority Health Medical Centre
• My Medical and Dental Springfield
• Z Plus Clinics

Redbank Plaza Medical Centre was the first general practice to sign up to the program, which is seeing improved communication channels between Ipswich Hospital and primary care.

“As a practice we embrace innovation, and with this program, we can see a tremendous opportunity to improve the barriers to successful transfer of care from the hospital to primary care,” Practice General Manager Shane Hutton said.

“Our Practice Nurse Team have taken on the role of Patient Care Facilitator, contacting any referred patients within four days of discharge to support them with understanding medical instructions and coordinating future care.”

West Moreton Health Executive Director Preventive and Prisoner Health, Therese Hayes, said the hospital was particularly keen to avoid respiratory readmissions over the current winter flu period.

“We know over the next few months we will see a surge in respiratory admissions, in particular. Through the Patient Care Facilitator program, the discharge coordinator at Ipswich Hospital will identify patients to be referred to their nominated general practice,” Ms Hayes said.

“Once a patient from the general ward is identified, the coordinator will refer via telephone directly and secure messaging to the participating practice and ensure a discharge summary is forwarded directly to the general practice.”

“The in-practice Patient Care Facilitator will then use the referral to ensure the patient is able to access the appropriate follow up care to enable them to fully recover at home.”

Darling Downs and West Moreton PHN CEO, Ms Lucille Chalmers, said the PHN’s role was to recruit practices to the program and provide ongoing funding and support.

“Through the Program, Queensland Health is funding the equivalent of a Registered Nurse as well as additional funding for the Practice to cover project and administration costs,” Ms Chalmers said.

“This is an important investment in enabling people to get the care they need closer to home and keeping hospital beds available for those who need them most.

“We commenced the program in May and currently have seven practices supporting patients.”