The Aboriginal Transfer of Care model (the Model) aims to reduce unplanned readmissions through ensuring that a multidisciplinary team meeting is held before the discharge of an Aboriginal patient to identify service needs and make the appropriate links between services. The model was developed at Campbelltown Hospital in 2016 to respond to data that showed significant growth in Aboriginal patient numbers, a higher re-admission rate for Aboriginal patients and multiple reports from Aboriginal patients through 48-hour follow-up phone-calls made by ALOs that showed patients were being discharged from hospital without receiving scripts, medications and without having a GP follow-up appointment organised.
The model empowers Aboriginal health staff to use their expertise through bringing together ALOs, Transfer of Care nurses, the Aboriginal Chronic Care Clinical Nurse Consultant and other staff as needed, including AHWs, Hospital clinicians and Community based health and social services staff. The model incorporates a multidisciplinary transfer of care planning process that is patient-centred and holistic and is aligned with the Aboriginal concept of health.
The model has been demonstrated through a pilot study at Campbelltown Hospital and an evaluation of the program to reduce unplanned readmission for Aboriginal patients, improve the patient experience for Aboriginal people and improve hospital systems and processes by embedding NSW Aboriginal health staff, Aboriginal health expertise and a multidisciplinary approach. The model has developed a toolkit to systematise ways of working and support consistency of practice, sustainability of model and adoption of the model at other health facilities.
Patient, carer, family and community Principle 2
