STAAR-SA. State Action On Avoidable Rehospitalisations And Unplanned Admission: An Integrated Knowledge Translation Project Across SA

SA hospitals are facing escalating demand from frail older people with multiple long-term conditions who have complex health and social care needs.  Older frail people are vulnerable to health crises and are more likely to be hospitalised with extended lengths of stay. However, many hospital admissions are potentially preventable. This is an important issue to address, as hospital admission for the frail older person is associated with a risk of adverse outcomes, including functional decline, falls, infection and increased confusion. Once an admission has occurred, there is also a high risk of further admissions over the next six months.

Current approaches to avoidable hospital admissions/readmissions in SA are fragmented. While there is evidence about strategies to improve older patients’ experiences of hospital discharge and reduce readmissions, they are not implemented systematically across South Australia.

The STAAR-SA research project aims to improve the pathways of care for older people aged 65 years and over after discharge from hospital. The project focuses on improving Out of Hospital care for frail older people, ensuring that the care provided is timely, coordinated, high quality and meets the needs and expectations of older people themselves.

The project will establish a partnership with Local Health Networks, Primary Health Networks, aged care non-government agencies (NGOs), general practices, consumers and researchers from the 3 SA universities.

STAAR-SA consists of three work packages:

Work Package 1 involves analysing data in the Registry of Senior Australian’s (ROSA) to monitor whole of system outcomes for high risk older people. A Risk Profiling tool has been developed, that could be used to identify patients at high risk for unplanned hospitalisation by examining a number of identified predictive factors.

Work Package 2 – evaluating the cost and outcomes of a number of existing out-of-hospital care programs in South Australia. This evaluation will determine a) which types of program works best for whom, where and when, and b) what standardized approach for monitoring and reporting would be useful.

Work Package 3 – establishing a quality improvement collaborative where front-line clinicians and their service managers come together to learn, share and benchmark outcomes with the goal of increasing the quality of care for older people at times of transition.

This project is supported by the Australian Government’s Medical Research Future Fund (MRFF) as part of the Rapid Applied Research Translation program. This Project is part of the work being undertaken by Health Translation SA.

Further information about the STAAR-SA project can be found on the Health Translation SA website