February 29, 2024

UOW researcher to examine how best to support older people returning home after hospital

Study aims to develop ways to best transition patients between health care setting

University of Wollongong (UOW) Liverpool Campus PhD candidate Kirsten Parker has been awarded $50,000 by the Western Sydney Local Health District (WSLHD) Research & Education Network to examine the feasibility and acceptability of a transitional care intervention.

Ms Parker is a member of the Centre for Chronic and Complex Care Research at Blacktown Hospital (WSLHD) and is supported with a full-time industry PhD scholarship program based at UOW Liverpool.

Transitional care is about the continuity of care between different healthcare settings. Good transitional care happens when patients are provided with a plan that connects community-based health care services upon discharge from hospital with the goal of preventing readmissions and increasing the time spent at home for frail older people.

Older people living with multiple health conditions are more likely to go to hospital. Once they are in the hospital system understanding the return to home and services available to them in the community can be complex and the information fragmented. 

The Australian Commission on Safety and Quality in Health Care has identified transitions in care as a priority and important to healthcare quality and safety. There is an increased risk to the person if they are not supported home safely from hospital - increased risk of returning to hospital, mortality and future institutionalisation. For example, more than 50 per cent of medication errors occur when people move from one healthcare setting to another.

Research published by the Australian Institute of Health and Welfare found that nearly half (46 per cent) of potentially preventable hospitalisations – where hospital admissions could have been avoided with timely and adequate health care in the community -- were for people aged 65 and over.

Ms Parker said the research project was prompted by challenges she saw while working in hospitals.

"Seeing the negative effects that multiple readmissions have on vulnerable populations has been the true catalyst for the design and development of this project. We ultimately hope to improve patients' experience and safety in the high-risk journey from hospital to home," Ms Parker said.

"This funding from the Research and Education Network within WSLHD will enable me to undertake this important research project in improving care continuity when patients discharge from hospital. I am so grateful for the funding and support of the network as we test this nurse navigator model of care."

Ms Parker’s project will connect with frail, older people who have been admitted to Blacktown and Mount Druitt Hospitals and are returning to their homes.

During the trial a specially trained nurse navigator will meet with patients in hospital before they are discharged and discuss the plan for home and make appropriate referrals.

Once discharged, the nurse navigator will contact the patient within a few days to provide support and answer questions about the discharge summary and follow up plan. During this contact the nurse will make referrals, facilitate GP review when needed, and provide education and resources.

The project will aim to transition patients home safely from hospital and to increase time spent at home. The provision of a clinician as a patient advocate on their return home will help to improve patient experience and quality of life during this transfer.

Ms Parker’s project will be supervised through a unique collaboration between UOW Liverpool academics and industry professionals - Professor Louise Hickman, Pro Vice Chancellor of Health at UOW Sydney campuses; Professor Caleb Ferguson, Director for the Centre for Chronic and Complex Care Research at Blacktown Hospital (WSLHD); Senior Research Fellow Julee McDonagh and Professor Richard Lindley (WSLHD). 

Professor Hickman says Ms Parker’s industry-led PhD is an excellent example of UOW's commitment to advancing health and care in the region through practical doctoral research programs.

“UOW Liverpool is dedicated to advancing health and medical research alongside our goal of training the best medical workforce of the future. Kirsten's research will be embedded in the community she’s hoping to serve, and create a lasting impact to quality of life for older patients living with frailty.”

UOW is committed to addressing the United Nations Sustainable Development Goals, which provide a shared blueprint to achieve a better and more sustainable future for everyone. This project addresses Goal 3: Good Health and Wellbeing, which aims to ensure healthy lives and well-being at all ages.