Hospital Avoidance and Earlier Supported Discharge at Southern Adelaide LHN
Complex Care Team
Social workers and nurses provide an intensive time limited case management approach to better support people in the community who are at risk of avoidable admissions to hospital as a result of their complex chronic condition(s) or combined health and psychosocial needs. The team actively focuses support on individuals who have had three or more avoidable ED visits or unplanned hospital admissions in the last 12 months.
For further information see Complex Care Team
Multidisciplinary Community Response Team
Consisting of social workers, occupational therapists, physiotherapists, psychologists and dietitians providing allied health services to prevent unnecessary admissions and support earlier safe discharge for individuals at high risk. Services are short term and goal oriented to stabilise factors contributing to hospitalisation risk.
- Care coordination and linkage to longer term services to support independence in the community
- Assessment and intervention to address function, mobility and environmental issues contributing to hospitalisation risk.
- Falls assessment and falls prevention interventions for patients at high risk of a falls related to hospital presentation
- Psychosocial assessment and intervention where the patients’ psychosocial needs are significantly impacting on health/function and hospitalisation risk
- Nutrition assessment and support for individuals at risk of admission due to a nutrition related issue
- Country Liaison Service -The role provides a central point of contact to support the health journey for country patients requiring care in SALHN hospitals
For further information see Country Liaison Service
Phone: (08) 7117 0728
Mobile: 0466 503 363
Fax: (08) 7117 0724