The Transition2sub-acute Project (T2SA)

About the Project

Updated 28 February, 2023

The Transition2sub-acute Project (T2SA) is an allied health sub-acute collaborative project (HREC/2018/QMS/48160)

About:

The sub-acute pathway represents an important transition of care, and the need for effective and reliable transition protocols – both into and out of the sub-acute care environment – is critical for effective and equitable care. Sub-acute care programs have been shown to support greater functional outcomes for patients through access to rehabilitation services, regular follow-up and support networks, multi-disciplinary engagement, and individualised care planning. Despite the benefits offered via the sub-acute pathway, enduring issues with system constraints, inconsistent access to services post-discharge and patient and familial involvement, and breakdowns in continuity of care, communication, and patient information sharing, often hinder optimal delivery. These challenges are often considered to be more pronounced for individuals living in rural and remote locations. Expediating the transfer of patients to care closer to home during their sub-acute period is anticipated to minimise displacement from communities and contribute to system efficiency in large regional and metropolitan hospitals.

Aim and objective:

Queensland Health is committed to equitable access to safe, quality healthcare (including sub-acute or rehabilitation care) for Queenslanders.  Phase one of the T2SA evaluation identified key areas of focus which were subsequently explored in a second and third phase in a joint collaboration between the Hopkins Centre and the Allied Health Professions’ Office of Queensland (AHPOQ).

The aim of the second phase was to examine patients’ sub-acute transition journeys following acute hospital admission. This was a qualitative evaluation seeking to provide more patient-centred and seamless care for patients receiving sub-acute and rehabilitation care in regional centres (i.e., providing sub-acute or rehabilitation care closer to the patient’s home, usually in a smaller local hospital).   The study used chart audit data from 97 rehabilitation and GEM patients, and data from 37 in-depth semi-structured interviews conducted with a sub-group of these patients. Quantitative chart audit data and qualitative interview data were analysed to explore and describe sub-acute transition experiences from the perspectives of these sub-acute patients. By describing rural and remote based patients’ experiences in relation to the client-centredness of transitions, continuity of care, and the challenges associated with sub-acute and rehabilitation transitions, the objective was to better inform the provision of these services for a vulnerable sub-acute population.

The aim of the third phase was to conduct a scoping review of the literature, for translation and dissemination through both peer review publication and presentation to clinical rehabilitation networks. The scoping review sought to describe the scope of the existing literature examining the models and mechanisms currently being used to facilitate TOC of older sub-acute patients and synthesise and evaluate how different TOC models and mechanisms differentially influence TOC of these patients. The intention was also to identify the processes or conditions that function as barriers to and/or enablers of effective TOC for older sub-acute patients, and the ways in which these are considered within existing TOC practices. Describing, synthesising, and critically comparing models and mechanisms that facilitate more effective transitions into, out of, and within sub-acute care will help to highlight new directions for supplementing the care complexities that leave older patients more vulnerable to poor transition experiences and outcomes. In addition, identifying high-quality TOC protocols and translating this information into research and practice has the potential to support more positive and personalised patient experiences, ‘humanising’ the experience of health care engagement for patients, including for older patients, that may be particularly vulnerable to adverse experiences.

Expected outcomes:

A mix of outputs appropriate to the field have been shared, including 1:3:25 page reports and a publication. In addition, throughout the project there have been presentations and discussions between the research team, AHPOQ and clinicians in the field to ensure engagement with the findings, development of policy and practice messages, and identification of next steps. The findings of phases 2 and 3 were disseminated through research presentations at the Hopkins Centre Symposium: Bold Ideas, Better Solutions in November 2022, and at the Queensland Clinical Rehabilitation Network Steering Committee meeting in February 2023.

Expected impact/ goal:

The findings of the first phase highlighted multiple professional, procedural, organisational, and patient-related benefits associated with the T2SA initiative, as well as several structural, governance, and professional culture barriers, and the need for on-going procedural and practical supports to sustain its continuation. The findings of the second phase represented a concentrated, ground-level effort to advocate for, represent, and champion the preferences, perspectives, and voices of end-users (i.e., the vulnerable sub-acute patients themselves) within the health care literature, highlighting unique differences in the way that continuity of care is experienced and conceptualised by rural and remote patients, and important insights into the characteristics of interpersonal interactions and care planning that contribute to better transition experiences. In the third a final phase, a scoping review of the models and mechanisms being used to facilitate TOC of older patients with on-going sub-acute needs highlighted processes and conditions that function as the barriers to and enablers of effective TOC for older sub-acute patients, and mechanisms that support the most effective TOC, considering patient complexity and vulnerability.

Collectively, dissemination of these findings via industry reports, peer-reviewed publications, and presentations and discussions between the research team, AHPOQ and clinicians in the field continues to inform the development of policy and practice messages, and identification of next steps to improve TOC within clinical rehabilitation networks in Queensland.

Results: 

By describing patient experiences of care transitions, the primary contribution of phase 2 of the T2SA project is showing where policy and practice improvements can be made at the patient level to ensure effective and equitable transitions particularly for rural and remote patients who often experience multiple and lengthy transitions. Importantly, the study findings contribute to better outcomes for older people with complex needs by:

• Eliciting how continuity of care is uniquely conceptualised by patients in the context of rural health care. For rural and remote Australians in this study, continuity was viewed in terms of continuity of both physical care and family and community supports.
• Directing clinicians and organisations to prioritise family and social support systems in transition planning and as part of maintaining continuity of access for rural and remote patients.
• Providing much needed evidence for the introduction of new protocols that enable continuity of care across transitions, including recommendations drawn from the perspectives of the patients for improving care continuity and patient satisfaction across the sub-acute care continuum (i.e., the utility of telehealth and communicative technology services in sub-acute environments to increase patient connectedness with family and community supports, especially when receiving care far from home; transparency and forward-planning for discharge).

The findings from phase 3 of the T2SA project highlight the degree to which enabling effective transitions is contingent upon complex, complimentary interactions between systems, health care staff, and patients and their caregivers. By scoping and describing models and mechanisms that facilitate effective movement through different levels, systems, and locations of sub-acute health care, the primary contribution of this project is showing where policy and practice improvements can be made to at the system-, service-, and patient-levels to inform the provision of more consistent, seamless, and effective TOC for vulnerable sub-acute patients. Importantly, the findings of the scoping review contribute to better outcomes for older people with complex needs by:

• Eliciting the key individual factors which appear critical to facilitating effective TOC of older sub-acute patients, including multidisciplinary cooperation and coordination, information continuity, patient-centred care practices, dedicated care coordination and continuity, post-discharge follow-up, and health care education and training.
• Offering novel directions for sub-acute organisations, health care staff, and policy contributors to evolve TOC mechanisms at each the system-, service-, and patient-levels to facilitate a cohesive best practice TOC model for older sub-acute patients (e.g., enabling continuity with primary care, and primary health care services; prioritising therapeutic partnerships between providers and patients and caregivers; supporting greater patient education and self-management).

People/organisations involved:

The Hopkins Centre: Jessica O’Loghlen (née Bowley); Professor Michele Foster

Allied Health Professions’ Office of Queensland: Jennifer Finch; Dr Belinda Gavaghan

Funding:

This project was funded by the Allied Health Professions’ Office of Queensland, Clinical Excellence Queensland.

Project status and timeframe:

Phases 2 and 3 of the T2SA project, undertaken by the Hopkins Centre, commenced in August 2021 and concluded in December 2022.