Health-Funded Transitional Care Team/Post-Acute Packages for Under 65's (and Over 65's).

The establishment of health-funded transitional care team/post-acute packages for persons under 65. These short term, time-limited packages will give patients access to allied health services and personal care supports from hospital as per the recommendations of the acute inpatient teams. A similar service "Rapid Response" has been provided to patients over the age of 65.

This model will help expedite a discharge into community, with patients being able to be further assessed in their own environment, of which most patients are likely to do better emotionally and functionally. It also ties into the need to provide assessments as evidence of functional need within the home, which is what the NDIS requires for a patient to receive adequate funding.

Ultimately, this model will help support patients to feel comfortable in discharging to their own residence, as well as allow clinicians to feel that their patients are adequately supported at home.

The ability to see into the life of a patient within their own environment will springboard early interventions and provide early referrals into lengthy processes (i.e. NDIS). It will also catch persons who "fall through the gap", who are not diagnosed with a disability, however are diagnosed with a health condition that may improve (i.e. a fracture). It will also help transition patients who must wait for funding sources into the community, rather than keep them in hospital.

The proposed packages/team would look at closing the gap from discharge to the implementation of community services, as opposed to patients remaining in hospital or waiting at home without support for the services to be established, risking a re-admission.

Members of this team may include one or more;

- Allied Health (Social Workers, Occupational Therapists, Physiotherapists)
- Nurses (of all levels)

The aim of the team may be to;

  • Provide the postacute support required for discharge (i.e. hygiene assistance)
  • Conduct assessments for patients within the home that may have different recommendations or outcomes
  • Organize and establish equipment in the home and training for use
  • Provide training to family or carers to provide care safely and adequately in the home
  • Provide shortterm case management for longer term supports (i.e. NDIS)
  • Train family or carers to provide care safely and adequately in the home
  • Monitor of patients who are at high risk of representation due to fragility or poor psychosocial supports
  • Refer and establish of links to other community supports to enhance quality of life which take time (i.e. Community Access Point or other health services)

If this team can engage with over 65’s, they can potentially;

  • Help transition families and patients into Residential Aged Care, including processes associated with this, such as applications to the Queensland Civil and Administration Tribunal and a discharge to a respite facility

The interventions in this team can potentially;

  • Increase quality of life and carer stress
  • Provide early intervention supports/assessments for lengthy processes (NDIS)
  • Decrease length of stay and quicken discharges to home
  • Decrease inpatient staff workloads and increase efficiency
  • Prevent readmissions due to accidents/falls
  • Overall decrease financial impact due to a shortened length of stay
  • Provide insight into the patient’s community setting for better inpatient interventions.
  • Prevent lifethreatening or unsafe events from occurring post-discharge

Why the contribution is important

Systematically, the provision of post-acute services has not been well supported for those under 65 in the community. Prior to the NDIS, if a patient (with or without a disability) requires hygiene support, rails or an allied health provider, they will be referred to “Community Access Point”, where they will link patients to a service for their needs. Unfortunately, this service has a waitlist of approximately 4-12 weeks post first contact.

It is not a crisis or post-acute service; hence patients may need to either discharge without the essential support required, rely on informal supports or remain in hospital until services can be organized. Skipping the referral hub process has been tried in the past, however with the roll-out of the NDIS, the uptake of community providers to take on new clients is also significantly lower, with service providers only accepting Community Access Point referrals.

With NDIS, the process to have support from the NDIS is extremely lengthy, with access to the scheme taking approximately 5 weeks and implementation taking significantly more after this. Patients with chronic illnesses who do not meet criteria for NDIS will also need to go through the NDIS application process to gain access to other support systems, which is also significantly lengthy.

Adequate case management supports are also significantly under-resourced in community, which unfortunately leads to compounding and complex scenarios when support in the first instance may prevent complexity from occurring in the first place.

Accommodation solutions and housing solutions will be difficult to implement quickly and is out of Health’s control. Brick and mortar houses take time to build and so will interim care facilities, or upgrades to hospitals to include specialized GEM units for sub-acute patients.

Ultimately, health remains impacted due to significant systematic wait-times and a lack of investment in early intervention supports. It can be argued that crisis intervention is more difficult to manage and lead to worsening economic and health outcomes, than preventative services. Hence this team can act as a bridge between the two, ultimately leading to healthier persons and a more efficient and economically viable health system.

by okunoy on May 20, 2019 at 03:07PM

Current Rating

Average score : 4.8
Based on : 9 votes


  • Posted by jodiemichelle May 23, 2019 at 09:17

    I think this idea is viable and has the potential to be implemented quickly. Can I suggest adding community pharmacist/pharmacy to the allied health team list. I feel efficient access and delivery of medications and support aids organised by their case manager as part of the client care plan may eliminate stress after discharge.
  • Posted by JOGFFL May 27, 2019 at 18:30

    I like this idea and also think it is viable. I think that this idea has been trialled in a limited fashion in a program called Surgery Connect. The public health system used private practices to deliver physiotherapy services to rehab patients with a total knee replacement. It helped reduce the waiting lists and gave patients much needed care throughout their recuperation. It didn't fund mobile visits, but the bureaucracy wasn't overwhelming and the payment was reasonable if you were already a bulk billing practice - although still below market rates.

    Medibank Private has also been running a rehab at home service for their members which might provide an example to model from.
  • Posted by kathyk May 27, 2019 at 20:49

    A strength of this idea is that the funding is aimed at a gap-point in current services (some transition-care services do exist in Metro South but I believe they are mainly focused on post-acute rehab clients rather than health-related or chronic conditions?) and potentially adds funds and expertise to the over-stretched public community health sector. Perhaps a model of specifically-trained allied health assistants and ENs, managed by qualified professionals could provide particular care within well-defined boundaries?
Log in or register to add comments and rate ideas