As part of our Winter Strategy, the team have been looking at different ways to support patients in their transition from hospital to home.
That is how the targeted, population-specific Supported Transition to Assist Recovery (STAR) program was born and launched yesterday.
Dr Katharine See, Director of Respiratory Medicine, said the team identified the age group over 70 with a few common conditions were representing to hospital within 72 hours.
“Those conditions include Chronic Obstructive Pulmonary Disease (COPD), pneumonia and heart failure. When we explored the reasons for this, we found that these people were often coming back to hospital not because they got sicker, but because they didn’t understand their follow-up plan and felt anxious and nervous being at home,” she said.
The STAR program is an initiative aimed at providing some clarity to those patients and reassuring them regarding the recovery process.
“To be able to do that, patients will get a phone call from Andrew Lang – our STAR nurse, within 24-48 hours from discharge to check in and answer any questions they might have and to help link them to their GP and the community. In case they require a hospital contact, we can link them to our HOT clinics or Hospital in the Home Service,” she said.
Andrew has been a ward-based nurse for more than 20 years and sees this program as a great opportunity to get involved in the follow-up care.
“As happy as we are to see the patients, we agree they could be better managed at home, where they are more comfortable and familiar and we know patients want to be at home. I am looking forward to being involved from admission all the way to discharge and beyond and keeping people at home,” he said.
As these illnesses are unfortunately chronic, Andrew is ready to answer numerous questions and give the patients the reassurance they need.
“The STAR program and the calls will help patients feel safe, knowing that home is where they should be.”
Referrals for the STAR program can be made through MedTasker and the program will run until the end of October, when the evaluation will be conducted.