The Aboriginal Transfer of Care model extends traditional discharge planning to provide a new structured multidisciplinary planning process for Aboriginal patients being discharged from hospital. A pilot of the Aboriginal Transfer of Care model in Campbelltown Hospital demonstrated a decrease in unplanned readmissions for Aboriginal patients
The project will refine, document and evaluate the Aboriginal Transfer of Care model for Aboriginal patients aged 15 years and over with chronic conditions admitted to selected South Western Sydney Local Health District hospitals. The study will use a before and after design using linked administrative health data and qualitative research.
The study aims to determine to what extent implementing Aboriginal Transfer of Care decreases rates of unplanned hospital readmissions, emergency department presentations, and rates of discharge against medical advice, among Aboriginal patients.
Collaborators: Office of the Chief Health Officer, Centre for Epidemiology and Evidence, Tharawal Aboriginal Medical Service, Western Sydney Local Health District, Nepean Blue Mountains Local Health District