The Plug-in, University of Adelaide Nursing School, Adelaide PHN and Central Adelaide Local Health Network worked together to improve the provision of integrated care for older people. Following previous consultation with older people, health professionals and service providers, we learned that when it comes to returning home after a hospital admission, ‘There is something missing in the middle’.

This stage of the project — which is supported by funding from The Hospital Research Foundation — looked to address this problem, and ultimately reduce multiple admissions to hospital and to help older people remain independent and living well at home.

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, we engaged with and heard from health professionals and service providers.

The project helped the project stakeholders to determine what type of person/position would help provide continuity of care for an older person when moving between care at hospital, GPs and at home.

For further information please contact us on 08 8224 5526 or email