The support of a Care Transition Coordinator for older people and their families as they transition from hospital to home can significantly reduce readmissions, a research study has found.
Navigating the system can be problematic for some older people, but a study lead by Flinders University’s Professor Gillian Harvey found the coordinator role to be “critical” in providing support.
“The Care Transition Coordinator role helped to bridge the gap for older people by providing support, advice and help to navigate the system,” Prof Harvey said.
The coordinator’s followup care continued for about a month and included phone calls, visits and transport, plus correspondence with family members, carers and services.
As a result, the study group had 42 per cent fewer readmissions to hospital compared to standard geriatric outpatients
The role was trialled at the Royal Adelaide Hospital and supported by The Hospital Research Foundation Group’s “Your Choice” donor-led grant round in 2019.
Prof Harvey is now taking her findings to the hospital Geriatric team and will seek more opportunities to introduce the Care Transition Coordinator role into care.