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We’re getting them home and keeping them home 

2 July 2024

A new program at Grampians Health Edenhope is helping older patients get home from hospital quicker and ensure they have all the support needed to prevent a return visit.

The ‘Transition Care Program (TCP)’ recognises that well-being and health outcomes are improved when patients can avoid inappropriate, extended hospital stays.

It is a notion Don Symonds heartily agrees with; after four weeks in hospital, he was desperate to get home.

“At the start I was grateful to be in there and get the pain under control, but I was definitely more grateful to get out,” he said.

“I come from a farm so I like the freedom of being home. If I didn’t get help from all the nurses and other staff I would’ve been stuck for a while.”

The 12-week intensive TCP program involves coordinated care, delivered in the home, by district nursing staff, allied health assistants, physiotherapists, a dietician and a social worker.

For Don, it also meant coming home to a new walker, shower chair and raised toilet seat.

“I had nurses coming in every day to check my blood pressure and help me shower,” he said.

“Someone else organised Meals on Wheels and I get picked up for appointments if I need to be somewhere. It means I can do exercise classes and get all the bills and things sorted at home.”

Holistic approach brings ‘remarkable gains’

Three patients have completed Edenhope’s program, following an acute hospital stay, and three more are in the process. District Nurse Kallie Howard always agreed with the theory behind TCP but was shocked at just how much patients improved.

“We do regular assessments to keep track of patients’ progress and the gains have been remarkable,” she said.

“Their ability to complete daily activities improves and, most importantly, they’ve all been able to stay home. We’re getting them home and keeping them home.”

Because TCP staff are linked to a plethora of health services, from podiatry to dietitians and mental health support, they can identify patients’ needs and facilitate appointments.

“We book the appointment, pick them up and then debrief afterwards, to make sure they are implementing programs,” Ms Howard said.

“It means we’ve got a holistic picture of their needs and they also don’t need to depend on a loved one to keep track of things.”

All health professionals involved in the program are based in the Health and Wellbeing HUB, which enables a coordinated approach.

“It’s really unique to have so many services in one spot and that’s the perk of a small town,” Ms Howard said.

“We all work in together, recognising and addressing patients’ individual needs. It’s much more than a clinical approach, we want them to be thriving and getting back into life.”

Don isn’t quite back on his feet but, now that he’s out of hospital, he has the support of a community behind him.

“Even just being able to go down the street and have lunch with someone, it makes a big difference,” he said.

“All these appointments are nearly a full-time job but at least I can socialise and get out a bit. I’m very fortunate to have so much help while I sort myself out.”