AIM
The aim of this project is to reduce futile cycles of ED utilisation and improve outcomes for patients with complex psychosocial and health needs using individualised case support to integrate care across the health-social service interface.
INCLUSION CRITERIA
A person who has attended any NT Hospital ED on 6 or more occasions over the previous 6 months AND has one or more of the following complex psychosocial co-morbidities
- Unstable accommodation and/or
- Substance use disorder and/or
- Repeat attendances with injuries related to assaults and/or
- Repeat attendances related to a deterioration in a chronic disease in a person not linked with a primary or secondary health care provider for chronic disease management.
EXCLUSION CRITERIA
- under the age of 18 years
- decline to participate in the programme
- under guardianship
- receiving palliative care in the last 12 months of life
- receiving antenatal care
- suffering acute conditions likely to need time limited interventions
- the person has established and strong connections with a community support team who are currently co-ordinating care
WHAT WE REQUIRE FROM YOU
The ED team (inclusive of medical, nursing and allied health) will identify and refer patients meeting the inclusion criteria to Darren (AHP) for assessment.
Darren will provide an advocacy role, educational role and support streamlined access to follow-up community care to address immediate discharge care needs and schedule follow-up meetings with the participant.
CONTACT
Darren Braun - Aboriginal Health Practitioner
Ext 27974
Mobile 0455 828 322
Email
FURTHER QUESTIONS
- Dr Sandra Brownlea (
This email address is being protected from spambots. You need JavaScript enabled to view it. ) via switch 8922 8888 - Megan Duck; Research Coordinator (
This email address is being protected from spambots. You need JavaScript enabled to view it. ) 8922 8608 - Hanna Bjoern; Research nurse (
This email address is being protected from spambots. You need JavaScript enabled to view it. ) 8922 7969