1. Does readmission equate to a “failed discharge”?
Helen Zisos & Kaushalya Samaraweera
Social Work Department
HSWDG Research Symposium 2016

2. Project Background Ageing Population – impact of baby boomers
GEM patients are discharged home with risk
Increased rate of readmission
GEM LOS and patient flow

3. Drivers Travis Review (2015) Victorian Auditor-General’s Report (2016)
Statement of Priorities ( )
Health Round Table
Productive Ward/Lean Redesign

4. SVHM Strategic Direction - enVision 2025
Seamless continuum of care
Person centred care
Innovative and best practice models of delivery

5. Project Aims
To identify the risk factors that may contribute to readmission
Strengthen how SW can profile contribution to patient flow
Inform areas of practice change to reduce rate of readmission

6. Evidence
Demand for public hospital services is expected to increase at a faster rate than funding for capacity (Travis, 2015) Older patients aged over 65 have significantly higher rates of hospital admission and readmission and account for 52% of hospital readmissions in Australia (Courtney et al, 2009) Older Australian’s have more health conditions, more hospital separations and stay longer than younger age groups (Brown, Abello & Thurecht, 2011) The burden of ill health among older people can be reduced or prevented by adequately addressing specific risk factors (WHO, 2016)

7. Risk factors for older people
Multiple comorbidities including chronic illnesses
Multiple previous hospital admissions in the year leading up to readmission
Cognitive impairment/dementia
Polypharmacy
Poor mobility/falls

8. Methodology (n = 25) Ritchie & Spencer Framework (2001)
Retrospective data analysis - quantitative and qualitative
Sample included patients readmitted to hospital within 28 days of being discharged home during a 6 month period from July to December 2014
Low risk ethics approval
Engagement with key stakeholders

9. Data mining approach (Epstein 2011)
Data mining tool consisted of 35 elements:
Demographics
Psychosocial attributes
Medical issues/cognition/function
Reason for readmission
LOS and length of time between discharge and readmission
Risk factors identified by health professionals during admission

10. Evaluative & Diagnostic
Results (n = 25)
80% were 76 years or older
68% were CALD
44% were male
56% were female
48% lived alone
52% lived with family
44% had a carer
50% had cognitive impairment
80% had 5 + comorbidities
Clear contextual information about risk factors
Clinicians are working with high levels of risk
Patient-centred, multi-disciplinary approach to care planning
SW are exploring the least restrictive discharge plan
Readmission within 28 days in not necessarily a negative thing
Evaluative & Diagnostic
Contextual
Strategic
76% had between 1-3 previous admissions
52% had 10 days or less at home between discharge and readmission
72% had a GEM admission of 15 days or less
92% were readmitted because of an acute medical illness
100% of the time, SW completed a comprehensive assessment and d/c plan

11. Qualitative Results Lack of insight
Cognitive impairment impacting on function
Impulsivity
Social isolation
Refusing formal supports

12. Case Example 87 year old female CALD background
Lives with son who has mental health issues
No formal supports
Deemed to have capacity - (emerging) cognitive impairment
History of falls
At risk of elder abuse

13. Social Work Intervention
Suspected elder abuse – physical, financial, verbal
Refusal of formal supports
Acceptance of her own limitations and risk
Poor home environment/hoarding/staff safety
Social isolation
Non-compliant with medical treatment and recommendations
Longstanding family conflict
Multiple presentations to ED & GEM (18+ in 2014)
Least restrictive vs patient autonomy

14. Future Directions Further analysis of data – how can we improve?
Is there a correlation between reason for admission and readmission?
Readmission tool to avoid duplication of social work assessment