Mrs Jade Gomez1
1NSHNS, Primary and Community Health, Northern Sydney Local Health District,
Biography:
Jade holds a dual degree in Social Work and Development Studies from the University of New South Wales and is currently undertaking a Masters in Creative Writing and Literature at Western Sydney University. She is a Senior Social Worker in the Emergency Department to Community (EDC) Program across Northern Sydney Local Health District, with over 9 years of experience working with complex patients in Emergency, acute, rehabilitation, and community settings across rural and metropolitan areas. Additionally, Jade has experience working as a case manager in Traumatic Injury and complex care needs, providing comprehensive support to individuals with significant comorbidities.
Abstract:
Background:
Ministry of Health (MOH) defines ‘Frequent Presenters’ as individuals who present 10 or more to ED in a 12-month period. FP have some of the lowest social determinants of health and are known to fall through the gaps, despite utilising a disproportionate amount of health services, length of stay, and time. EDC often works with FP within the Northern Sydney Local Health District (NSLHD) who require their complex needs to be addressed through person-centered, intensive case management and care coordination. By offering holistic, community-based support through regular home visits and in-reach collaboration with ED staff, the program seeks to build rapport, offer proactive intervention, and reduce unnecessary ED presentations.
Aim:
To proactively identify FP and deliver targeted clinical support and interventions aimed at reducing unnecessary ED presentations.
Method:
EDC incorporates a range of outcome measures and evaluation data, including ED presentation trends, implementation of Emergency Department Management Plans (EDMP), and feedback from clients, stakeholders, and clinicians.
Results:
Results indicate a reduction in ED presentations whilst simultaneously improving the social determinants of health for frequent presenters. EDC has successfully strengthened connections within NSLHD, across other districts, breaking down silos through information sharing, collaborative practice, and person-centered goals that empower individuals to better manage their health in the community reducing ED presentations.
Conclusion:
EDC program has demonstrated success in reducing ED presentations whilst improving client outcomes. By fostering collaboration with stakeholders and providing proactive, person-centered care, EDC continues to enhance the efficiency and effectiveness of health service delivery for complex individuals.