An integrated knowledge translation approach to address avoidable rehospitalisations and unplanned admissions for older people in South Australia: implementation and evaluation program plan

Gill Harvey, Clarabelle Pham, Maria C. Inacio, Kate Laver, Elizabeth Lynch, Robert Jorissen, Jon Karnon, Alice Bourke, John Forward, John Maddison, Craig Whitehead, Jesmin Rupa, Carmel McNamara, Maria Crotty

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Abstract

Background
Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients’ experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers.

Methods
The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced.

Discussion
This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.
Original languageEnglish
Article number36
Number of pages7
JournalImplementation Science Communications
Volume2
DOIs
Publication statusPublished - 7 Apr 2021

Keywords

  • Hospitalisations
  • unplanned hospitalisations
  • emergency department encounters
  • Older people
  • Implementation
  • Evaluation
  • Integrated knowledge translation
  • Quality improvement

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