The Community Hospital Interface Program is a state wide framework focusing on the transition between the hospital and the community enhancing a safe continuum of care for the client. Gaps are identified and addressed with multiple approaches.
The Cairns program targets the elderly, young disabled and those with complex care needs. Risk screening, assessment and complex care coordination is provided by a team of clinical Nurses. Their skills and knowledge improve access to appropriate community care outside the acute care setting. A comprehensive assessment, identification and facilitation of the co-ordination of care for community services that support the patient journey are fundamental to the programs’ success.
The program aims to:
- Prevent avoidable hospital admissions and unnecessary re-presentation.
- Improve access to appropriate services at the patients place of residence
- Improve communication and care coordination between the hospital and the patients care provider’s at their place of residence.
The program provides:
- Discharge planning support
- Complex community care coordination
- Clinical care co-ordination and provision of resources and education
- MASS application
sfor Home Oxygen requirements co-ordination.
The program is conducted by a team based at Cairns Hospital. The team includes a Nurse Manager and Clinical Nurses (Community Care Coordination). Collaborative links with the multidisciplinary team across the patient journey underpins the model.
- Access and co-ordination of community services
- Frequent and Avoidable Admissions
- Screened as at risk from Firstnet
and meets a Discharge Risk Factor
- Lives alone
- Being cared for or is a carer
- History of community services
- Self-care problems