The three-stage assessment to support hospital–home care coordination in Tshwane, South Africa

Abstract

Background In complex health settings, care coordination is required to link patients to appropriate and effective care. Although articulated as system and professional values, coordination and cooperation are often absent within and across levels of service, between facilities and across sectors, with negative consequences for clinical outcomes as well as service load. Aim This article presents the results of an applied research initiative to facilitate the coordination of patient care. Setting The study took place at three hospitals in the sub-district 3 public health complex (Tshwane district). Method Using a novel capability approach to learning, interdisciplinary, clinician-led teams made weekly coordination-of-care ward rounds to develop patient-centred plans and facilitate care pathways for patients identified as being stuck in the system. Notes taken during three-stage assessments were analysed thematically to gain insight into down referral and discharge. Results The coordination-of-care team assessed 94 patients over a period of six months. Clinical assessments yielded essential details about patients’ varied and multimorbid conditions, while personal and contextual assessments highlighted issues that put patients’ care needs and possibilities into perspective. The team used the combined assessments to make patient-tailored action plans and apply them by facilitating cooperation through interprofessional and intersectoral networks. Conclusion Effective patient care-coordination involves a set of referral practices and processes that are intentionally organised by clinically led, interprofessional teams. Empowered by richly informed plans, the teams foster cooperation among people, organisations and institutions in networks that extend from and to patients. In so doing, they embed care coordination into the discharge process and make referral to a link-to-care service.

Three-Stage Assessment as Reverse Innovation in Interprofessional Student Clinical Rotations

“…The 3-stage assessment is a fundamental component of the South African medical system, and its impact on care and care coordination in South Africa is being studied. 12,15 Concordia University Wisconsin's 4 years' experience with PA clinical year rotations in South Africa suggests additional lines of research. Study on this topic could include both ongoing review of SWOT analyses of future PA students traveling to South Africa, especially their attitudes toward 3-stage assessment, as well as assessment of PA graduates' ability to implement in US practice settings the social aspects of care they were exposed to in South Africa, with a particular focus on the challenges they experience in implementation.…”

“…The 3 distinct sections of the assessment pertain to the clinical, personal, and contextual characteristics of a patient, thereby enabling the clinician to create a comprehensive summary. 12 The purpose of the summary is to facilitate collaborative, interprofessional, multisectoral management of patients, in particular at times of referral and discharge. 12 During the rotation, the entire 3-stage assessment was clinician led, including the personal and contextual sections, and was a regular focus during the morning clinical meetings when care of the patients in the wards was discussed.…”

“…12 The purpose of the summary is to facilitate collaborative, interprofessional, multisectoral management of patients, in particular at times of referral and discharge. 12 During the rotation, the entire 3-stage assessment was clinician led, including the personal and contextual sections, and was a regular focus during the morning clinical meetings when care of the patients in the wards was discussed. It is this deliberate clinician focus on patients' perspectives on their illness and treatment-as well as patients' living arrangements, livelihood, and dependents-that was remarkable to the visiting PA students.…”

The impact of substance use disorders on families and carers: A scoping review

“…Kraus et al, 2009;Li et al, 2013;Maharaj et al, 2017;Ray et al, 2009). It also requires that all interven ons are organized in a way that enables inter-professional coopera on and pa ent/ family-centered care coordina on (Hugo et al, 2020). There is also a need to iden fy or create harm reduc on interven ons that concretely address the SUD burden of care for family members and carers.…”