What matters to patients in transitional aged care

The Mid North Coast Local Health District (MNCLHD) Transitional Aged Care Program (TACP) is aligned with the national program that aims to optimise the functioning and independence of older people after a hospital stay.

With the care of a multidisciplinary team of clinicians, TACP is a 12-week home-based therapy program that aims to restore function and improve quality of life and health outcomes.

The MNCLHD TACP team chose to adopt patient-reported measures (PRMs) to help understand what matters to their patients and to inform the shared planning of goals-of-care. The team started using patient-reported measures in November 2023.

Patient-reported measures workflow

• Patients are enrolled in the TACP program within 48 hours of discharge from hospital admission.

• Team members register patients in the Health Outcomes and Patient Experience (HOPE) platform and assign the PROMIS-29 survey.

• During the initial clinical assessment visit, the patient completes the PROMIS-29 survey, and results are discussed.

• PROMIS-29 is repeated close to discharge from TACP. Clinician discusses progress and ongoing goals with patient, then transcribes into HOPE.

• Results, trends and outcomes are visible in the electronic medical record (eMR) and can be included in ongoing and shared care planning with other healthcare providers, including primary care.

• Clinicians, team leaders and managers have access to aggregated data to inform service level improvements.

Consumer story

Mrs Page enrolled in the TACP program after being hospitalised with a stroke in 2023 at age 76. During her initial TACP assessment appointment, Mrs Page completed the PROMIS-29 survey.

The results indicated a loss of ability to participate in social activities, increased depression and poor physical function. The survey results assisted the team to understand and plan together with Mrs Page.

Towards the end of the program, Mrs Page completed the PROMIS-29 again and had improved in almost all domains. She had been able to return to some of the activities that were important to her. Areas of concern, including declining results with depression, were acknowledged and supported in both care with the TACP team and referral to her GP for ongoing management.

* Name has been changed for patient privacy.

Benefits of patient-reported measures

• Patient
• Service
• Organisation

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Clinical engagement approach

The PRMs team took a district-wide approach and engaged the local TACP teams to learn about the opportunity and benefit of using quality-of-life PROMs.

They also engaged the broader team by mapping and scoping the TACP model of care, and exploring how the team could use and reflect on the survey results with their patients.

As a large team, the TACP team benefited from a train-the-trainer model for staff education on the use of the PROMIS-29 and HOPE.

Governance

• Within MNCLHD, the PRMs team reports to the District Manager Health Reforms, Opportunities and Transition within Integrated Care, Allied Health and Community Services (ICAHCS) Directorate.
• Monthly monitoring reports including risks and issues of PRMs go-lives are presented to the Director of ICAHCS for tabling at Leadership Team Committee meetings.
• Patient Reported Measures are promoted locally through bi-monthly MNCLHD PRMs Community of Practice meetings, where all clinicians and managers who are using HOPE are invited to share their implementation experiences.
• Local leads for PRMs provide updates on enhancements and additions of new surveys and cohorts. In addition, key milestones and successes are celebrated in the MNCLHD newsletter The Pulse.
• Further local PRMs awareness occurs through active rounding with MNCLHD staff members.