As part of the multistage State Action on Avoidable Rehospitalisations and Unplanned Admissions (STAAR-SA) project, The Plug-in worked alongside University of Adelaide Nursing School, Adelaide PHN and Central Adelaide Local Health Network, to understand the needs of older people following a hospital stay. The aim of the project was to reduce multiple avoidable admissions to hospital, so older people can remain independent and living well at home.

Watch the video detailing project outcomes below.

The challenge

As people age and become more frail, they are likely to become vulnerable to health crises and more likely to be hospitalised with extended lengths of stay, thereby increasing demand on hospitals.

For an older, frail person, hospital admission also comes with an associated risk of hospital related complications such as functional decline, falls, infection and increased confusion. Once an admission has occurred, there is also a high risk of further admissions over the next six months.

However, many hospital admissions are potentially preventable which means many can avoid such risks and adverse outcomes.

About the STAAR-SA project

To better understand the needs of older people aged over 75 years during transition from hospital care to the community, and to develop and test a solution for a more effective and person-centred approach to integrated care, the STAAR-SA project engaged with and heard from health professionals and service providers.

The Plug-in also engaged directly with older people and their family members or carers who had both positive and negative hospital discharge experiences, as well as those who had trialled new hospital outreach services to support their transition from hospital back to home.

The outcomes

The Plug-in was able to support the project team to identify and achieve a range of improvements that support older people to transition from a hospital stay back to home, while reducing the risks that would result in rehospitalisation, including improvements in medication provisions at discharge and connections and communications between hospitals and residential aged care facilities. Watch the below video for more information about the project, the research and outcomes.

The State Action on Avoidable Rehospitalisations and Unplanned Admissions Project (STAAR-SA) is an Integrated Knowledge Translation project across South Australia.

The project is funded by a Medical Research Future Fund Rapid Applied Research Translation Grant, administered by the South Australian Health and Medical Research Institute (SAHMRI) on behalf of Health Translation South Australia.