Hospital Avoidance and Earlier Supported Discharge at SALHN

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. 

Examples include:

  • 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

Contact details

Telephone: (08) 7117 0728
Mobile: 0466 503 363
Fax: (08) 7117 0724