An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan

Abstract

Background Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients’ experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. Methods The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. Discussion This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.

Health initiatives to reduce the potentially preventable hospitalisation of older people in rural and regional Australia

“…The program, ‘Keeping Australians Out of Hospital’, involved significant financial investment ($11.7 million) into implementing evidence‐based, scalable preventive measures 60 . Research projects funded included the development of an early detection program to prevent unnecessary hospital admission in aged care residents, 61 and a study currently underway which is investigating reducing PPH of older people throughout South Australia 62 . The Keeping Australians Out of Hospital program has since been consolidated into the Preventive and Public Health Research initiative under the Medical Research Future Fund 10‐year plan 63…”

A ‘plethora of services’ but a lack of consistency: A qualitative study of service providers' perspectives about transitioning from hospital to home for older South Australians

“…This qualitative study is contained within the State Action on Avoidable Rehospitalisations and Unplanned Admissions across SA (STAAR‐SA) program 11 …”

Establishing and evaluating a quality improvement collaborative to address hospital to home transitions for older people

“…14 The work described in this paper was part of a larger programme of work, the State Action on Avoidable Rehospitalisations and Unplanned Admissions (STAAR-SA) project, which aimed to address avoidable admissions for older people in South Australia. 15 A network of people involved in hospital admissions and transitions was established comprising healthcare professionals from primary, acute and community care, researchers, aged care and community care organisations, consumers and consumer advocacy groups. The STAAR-SA programme of work is described elsewhere 15 but in brief involved (1) using registry data to profile individuals at risk of admissions, (2) evaluating the effectiveness of existing out-of-hospital programmes within the state and (3) implementing a state-wide quality improvement collaborative (QIC) to improve care for hospitalised older people.…”

“…15 A network of people involved in hospital admissions and transitions was established comprising healthcare professionals from primary, acute and community care, researchers, aged care and community care organisations, consumers and consumer advocacy groups. The STAAR-SA programme of work is described elsewhere 15 but in brief involved (1) using registry data to profile individuals at risk of admissions, (2) evaluating the effectiveness of existing out-of-hospital programmes within the state and (3) implementing a state-wide quality improvement collaborative (QIC) to improve care for hospitalised older people. This paper describes the process and outcomes of the STAAR-SA QIC.…”

“…The work described in this paper was part of a larger programme of work, the State Action on Avoidable Rehospitalisations and Unplanned Admissions (STAAR-SA) project, which aimed to address avoidable admissions for older people in South Australia 15. A network of people involved in hospital admissions and transitions was established comprising healthcare professionals from primary, acute and community care, researchers, aged care and community care organisations, consumers and consumer advocacy groups.…”