College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
Australas J Ageing. 2022 Dec;41(4):e371-e378. doi: 10.1111/ajag.13080. Epub 2022 May 3.
We explored the perspectives of professionals working in health and aged care services in South Australia about factors that influenced successful transitions from hospital to home or residential aged care home for older people. We examined successful and recommended strategies that could support safe transitions following hospital discharge and reduce avoidable hospital admissions in South Australia.
Nineteen professionals from acute, post-acute, primary, community and aged care settings in South Australia participated in semi-structured interviews. Qualitative content analysis was conducted.
Participants reported that navigating service provision could be difficult, compounded by different funding arrangements for hospitals, community, primary care and aged care services. Some participants felt that there was an over-reliance on the hospital sector, leaving primary care and community-based services under-utilised to support hospital transitions. The importance of good communication between services and sectors was highlighted. Participants described different categories of services that supported safe transitions by supporting older people immediately post-discharge; services that provided support to stay at home in the weeks and months following discharge; and services that helped the person receive health care at locations other than hospitals or emergency departments when they were unwell. Participants noted that successful programs were not always maintained.
Division of responsibility of aged and health-care services between state and national governance contributes to fragmentation of care in South Australia. Careful planning of transitions and coordination of services across sectors is required to ensure older people are supported in the months following discharge from hospital to reduce avoidable rehospitalisations.
我们探讨了南澳大利亚州卫生和老年护理服务专业人员对影响老年人从医院顺利过渡到家庭或养老院的因素的看法。我们研究了成功的和推荐的策略，这些策略可以支持出院后的安全过渡，并减少南澳大利亚州可避免的住院。
南澳大利亚州 19 名来自急性、康复后、初级、社区和老年护理机构的专业人员参加了半结构式访谈。采用定性内容分析法。
参与者报告说，医院、社区、初级保健和老年护理服务的资金安排不同，导致服务提供的协调可能很困难。一些参与者认为，对医院部门的过度依赖，使得初级保健和社区为支持医院过渡的服务利用不足。强调了服务和部门之间良好沟通的重要性。参与者描述了不同类别的服务，这些服务通过在出院后立即为老年人提供支持来支持安全过渡；为出院后数周和数月提供在家支持的服务；以及在人们身体不适时帮助他们在医院或急诊部门以外的地方获得医疗保健的服务。参与者注意到，成功的项目并不总是能够持续。
州和国家治理层面上的老年和医疗保健服务的责任划分导致了南澳大利亚州的护理服务分散。需要精心规划过渡和跨部门服务的协调，以确保在老年人出院后几个月内得到支持，从而减少可避免的再住院。
