Older people with multiple chronic conditions are at high risk of being readmitted to hospital within a short time from discharge, making their care costly.
Without systems in place to help people with multiple chronic conditions safely transfer from hospital back to the community, they are likely to experience fragmented care and gaps in services.
The RBRC tested the feasibility of a nurse-led telehealth transition care coordination service for people with multiple chronic conditions at the Central Adelaide Local Health Network (CALHN).
We found that there was value in integrating a readmission risk assessment within 48 hours of admission, and subsequent transition plans where indicated.
