In Queensland one region is working on a way of following up patients after discharge to prevent readmission.
Darling Downs and West Moreton PHN and West Moreton Health are partnering with local general practices and the Aboriginal Medical Service to start a patient care facilitator program to assist patients avoid hospital readmissions.
Queensland Health has funded the program to improve health outcomes for patients following a hospital admission at Ipswich Hospital 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, and Z Plus Clinics.
The program is already seeing improved communication channels between Ipswich Hospital and primary care.
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“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,” said Redback Plaza’s practice general manager Shane Hutton.
“Our practice nurse team has 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 of 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 PCF 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 PCF 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 an RN 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.”
Country SA PHN
Country SA PHN has partnered with MindFit at Work to offer an online wellbeing training session to all care finders across country South Australia, focused on compassion fatigue, setting boundaries, and resilient thinking, with positive participant feedback provided.
After starting with a few sites, the support is now being extended to all workers right across country South Australian general practices and residential aged care homes.
“I am thrilled … we will be providing this face-to-face and online education and support in recognition of the fact that today’s healthcare environment is demanding and the mental well-being of our healthcare workforce is more vital than ever,” said CEO Mark Hartigan.
“The pressures of the profession, especially in rural and remote areas, can lead to significant stress and burnout.
“The MindFit at Work program is specifically crafted to address these challenges, offering practical strategies that help healthcare professionals build resilience, manage stress, and maintain their mental health.
“The program aims not only to improve individual well-being but also to enhance team cohesion and overall workplace morale.”
Error message in PRODA
Several PHNs have reported this week on a new error message causing issues in PRODA when attempting to link the provider to a GPACI patient in HPOS.
An example of this error can be viewed here.
The DoHAC has received confirmation from Services Australia that this is a new error. It has come to their attention through the help desk as well as through PHNs, and they say they are working with the systems team on a fix.
The bad news is the fix can’t happen before December.
In the interim, the explanation is:
- The 0831 warning displays when a provider is not eligible for the full period that the incentive indicator is assigned to the patient. Please note, this is not an error and does not restrict the ability for a practice to add an incentive indicator or assign a responsible provider.
- As this is only a warning message, the user can continue by selecting ‘confirm’ again after the message appears to proceed with linking/adding the responsible provider.
- Operators may also have to select “save” twice.
- Updated wording for the 0831 warning message will help alleviate confusion.
Any further advice from Services Australia will be circulated once received.
