The three-stage assessment to support hospital–home care coordination in Tshwane, South Africa
African Journal of Primary Health Care & Family Medicine
| Field | Value | |
| Title | The three-stage assessment to support hospital–home care coordination in Tshwane, South Africa | |
| Creator | Hugo, Jannie F.M. Maimela, Tshegofatso C.R. Janse van Rensburg, Michelle N.S. Heese, Jan Nakazwa, Chitalu E. Marcus, Tessa S. | |
| Description | Background: In complex health settings, care coordination is required to link patients to appropriate and effective care. Although articulated as system and professional values, coordination and cooperation are often absent within and across levels of service, between facilities and across sectors, with negative consequences for clinical outcomes as well as service load.Aim: This article presents the results of an applied research initiative to facilitate the coordination of patient care.Setting: The study took place at three hospitals in the sub-district 3 public health complex (Tshwane district).Method: Using a novel capability approach to learning, interdisciplinary, clinician-led teams made weekly coordination-of-care ward rounds to develop patient-centred plans and facilitate care pathways for patients identified as being stuck in the system. Notes taken during three-stage assessments were analysed thematically to gain insight into down referral and discharge.Results: The coordination-of-care team assessed 94 patients over a period of six months. Clinical assessments yielded essential details about patients’ varied and multimorbid conditions, while personal and contextual assessments highlighted issues that put patients’ care needs and possibilities into perspective. The team used the combined assessments to make patient-tailored action plans and apply them by facilitating cooperation through interprofessional and intersectoral networks.Conclusion: Effective patient care-coordination involves a set of referral practices and processes that are intentionally organised by clinically led, interprofessional teams. Empowered by richly informed plans, the teams foster cooperation among people, organisations and institutions in networks that extend from and to patients. In so doing, they embed care coordination into the discharge process and make referral to a link-to-care service. | |
| Publisher | AOSIS | |
| Date | 2020-07-07 | |
| Identifier | 10.4102/phcfm.v12i1.2385 | |
| Source | African Journal of Primary Health Care & Family Medicine; Vol 12, No 1 (2020); 10 pages 2071-2936 2071-2928 | |
| Language | eng | |
| Relation |
The following web links (URLs) may trigger a file download or direct you to an alternative webpage to gain access to a publication file format of the published article:
https://phcfm.org/index.php/phcfm/article/view/2385/4022
https://phcfm.org/index.php/phcfm/article/view/2385/4021
https://phcfm.org/index.php/phcfm/article/view/2385/4023
https://phcfm.org/index.php/phcfm/article/view/2385/4020
|
|
ADVERTISEMENT
