Ms Sarah Booth1, Ms Fiona Holland1, Dr Bernadette Saunders2, Mr Benjamin Orams1
1Western Health, Melbourne, Australia, 2Victoria University, Melbourne, Australia
Biography:
Fiona Holland is the Social Work Clinical Operations Lead at Western Health, Victoria. With a MBA, Fiona has extensive experience in in clinical leadership and quality improvement. Fiona is a passionate advocate for evidence-based practice within the allied health field and optimising health equity in the community.
Abstract:
Prolonged hospitalisation in Australia is increasingly associated with complex physical and psychosocial issues and inequitable access to services which requires multi-faceted, multi-disciplinary interventions. However, hospitals do not typically collect robust, uniform data identifying the external and intersecting factors impacting patients’ discharge.
In response, Social Work (SW) led the development of the ‘Complex Discharge Pathways Case Rounding’ (CoDPaR) framework, which aimed to enhance understanding of and responses to patients with complex physical and psychosocial issues hospitalised for a long time in a large tertiary health service, located in Melbourne’s west.
The project team applied the Model for Improvement (MFI) framework which enabled : (i) the early identification of patients with complex psychosocial needs, (ii) the development of formalised communication and escalation pathways, (iii) the evidence of support barriers to discharge, and (iv) the development of a comprehensive manual dashboard for patients on the National Disability Insurance Scheme, Victorian Civil and Administrative Tribunal, and Residential Aged Care Facility pathways and (v) quantified weekly complexity reports shared with Allied Health Director, Managers and Hospital Executive (HE). Data-driven operational planning regarding rostering, professional mentoring and targeted education emanated from using the CoDPaR framework, as areas of high demand and professional knowledge gaps were highlighted.
The CoDPaR framework provides previously undocumented insights into the psycho-social and external factors that impact patients’ discharge and quantifies the intersecting, complex issues that require ongoing innovative responses. Data stemming from the CoDPaR framework motivates significant improvements in discharge pathways, reducing unnecessary, prolonged admissions, and identifying factors impacting discharge.