title: Hospital to home: an integrated approach to discharge planning in a rural South Australian town.
abstract: OBJECTIVE
  To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings.
  
  
  METHODS
  Plan-Do-Study-Act framework using case-note audit and focus groups.
  
  
  METHODS
  Central Yorke Peninsula Hospital in South Australia.
  
  
  METHODS
  All patients aged 65 years or older admitted between October 2001 and June 2002.
  
  
  METHODS
  Range of communication strategies designed to improve discharge planning practices.
  
  
  METHODS
  Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge.
  
  
  RESULTS
  There was a significant increase in the proportion of patients with a documented discharge plan for both non-Aboriginal (23%) and Aboriginal patients (52%). There was also a significant increase in the proportion of patients who received timely and informative risk screening (41% for non-Aboriginal and 58% for Aboriginal patients). Referrals to community health service providers also increased significantly from baseline to the intervention period (14% for non-Aboriginal and 33% for Aboriginal patients). The project also resulted in improved communication processes between hospital staff and community health service providers.
  
  
  CONCLUSIONS
  This National Demonstration Hospitals Program project has impacted on both hospital discharge planning and the hospital-community interface. Flow-on effects to other initiatives within the region are likely.
authors.affiliation: Department of Rehabilitation and Aged Care, Flinders University, Adelaide, South Australia, Australia.
authors.forename: Denise
authors.initials: D
authors.lastname: Bolch
authors.forename: Julie B
authors.initials: JB
authors.lastname: Johnston
authors.forename: Lynne C
authors.initials: LC
authors.lastname: Giles
authors.forename: Craig
authors.initials: C
authors.lastname: Whitehead
authors.forename: Paddy
authors.initials: P
authors.lastname: Phillips
authors.forename: Maria
authors.initials: M
authors.lastname: Crotty
mesh_terms: D000368:Aged; D003142:Communication; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D017144:Focus Groups; D006780:Hospitals, Rural / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D017146:Models, Organizational; D010351:Patient Discharge; D017060:Patient Satisfaction; D016730:Program Development / Q000379:methods*; D015397:Program Evaluation; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data; D013021:South Australia