Home for Christmas: out-of-hospital services

For many patients, recovery and ongoing wellbeing is better supported in care settings outside of hospital.

Each year, Central Adelaide promotes a ‘Home for Christmas’ campaign to staff and patients to encourage patients to be ready for discharge in time to spend with family.

To support this around the holidays – and all year round – we have a range of out-of-hospital care and hospital avoidance initiatives to help support patients in alternative care settings.

Right care, right place, right time

“Providing out of hospital care options for older people has a significant benefit to their health and wellbeing. There is a higher burden on older patient’s health the longer they remain in hospital,” Ellen Mills, Acting Executive Director Allied Health, Strategic Integration & Partnerships, said.

“In fact 35 per cent of elderly patient’s experience decline in their health during their admission.

“Ten days in hospital leads to 10 years of muscle ageing for people who are most at risk.

“So where possible and safe to do so, we look to out-of-hospital care options so patients can be supported outside of an acute setting on their road to recovery.”

Bryony’s story

Less than a week before Christmas, 52-year-old Bryony Gallyer was hospitalised after experiencing a severe headache which turned out to be a blood clot on her brain.

After several days as an inpatient, she was able to return home in time for Christmas with ongoing care from the Hospital in the Home team.

“It’s such a great service. I’d much rather be home than in a hospital bed, although in saying that I had excellent care in hospital” Bryony said.

“After I felt so sick on Monday, by Tuesday I was really hoping I’d be home for Christmas.

The twice daily visits for medication and checks from the Hospital in the Home team mean that Bryony can have Christmas Day with her family and friends at her sister’s house.

Hospital & Rehab in the Home

Hospital in the Home service provides acute nursing and medical care to patients as a substitute for treatment in hospital, meaning people can return home sooner or, in some instances, avoid a hospital admission altogether.

Likewise Rehab in the Home provides people who have been in hospital with access to rehabilitation therapies and nursing in their home, instead of in hospital.

CALHN Integrated Care Coordinator (CICC)

The 24/7 CALHN Integrated Care Coordinator (CICC) bridges the gap between hospital and community based care, providing a point of contact for GPs, SA Ambulance Service and other providers when seeking alternative care and rapid assessment options for patients who don’t need emergency care, but who would otherwise present to the Emergency Department.

The CICC also works alongside ward and ED clinicians to advocate and advise on contemporary care options in the community to facilitate a timely return home for patients.

For GPs, our GP Liaison Unit is available to assist bridge the gap and navigate the system to ensure the best care and outcomes for collective patients.

Care for older patients

Our Community Geriatric Services can assist with falls prevention, memory clinic and aged care assessment. This also includes the Transition Care Program which provides a range of short-term care services to eligible older people following a hospital stay to help them regain as much independence as possible. The 12 week program can be delivered at home or in a residential care setting.

The Specialist Dementia Care Program was established for people experiencing severe behavioural and psychological symptoms of dementia and who require care beyond a traditional residential care facility, but don’t need to be in hospital. The aim is to improve a person’s quality of life and stabilise their symptoms to enable them to transition to a less intensive setting.

Mental health

There has been an increasing focus on providing mental health care in more appropriate settings. Often an ED environment isn’t the best place for someone with mental health related needs.

Our eastern and western community mental health teams provide a range of services to consumers out-of-hospital.

For those in crisis, the Mental Health SAAS Co-Responder program has enabled us to respond to hundreds of consumers and divert them to more appropriate care in a community setting. It’s a joint initiative with SA Ambulance Service. A similar initiative with SA Police, partnering mental health clinicians with police is also having positive outcomes.

We are partnering with Anglicare to provide access to The Way Back Support Service for ongoing out-of-hospital for consumers who have experienced suicidal crisis.

Hospital Avoidance

The Hospital Avoidance and Supported Discharge Service started in July at Sefton Park to allow more people with complex needs to avoid unnecessary visits to the ED.

It provides multidisciplinary care to people who have not had their needs met by GPs, Priority Care Centres or paramedics in patients’ homes. That includes those with restricted mobility, bariatric conditions, aged care residents and the homeless.

The service has with three rapid assessment bays, with additional procedure and treatment rooms.

*Pictured are Hospital in the Home nurse Damien Staunton and Bryony Gallyer.