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South Australia Divisions of General Practice
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Southern Division

Discharge Planning

Coordinated Care Trial
 
  • Division has an established mental health program and a mental health officer
  • Division identified 2 GPs with a high mental health case load and established GP psych-liaison with Morier Ward (Psych unit) at Noarlunga Health Service
  • Now developed into discharge case conferences when the patients of these GPs are discharged from Morier Ward
  • Division has provided advice on which EPC numbers to use
  • This model is now standing on its own

 

Mental health
Community linkages

  GPs are being called for a multidisciplinary discharge planning meeting from the Cardiac Surgical Ward at Flinders Medical Centre on a regular basis. Hospitals
  Case conferencing and care planning have been added to the standard model of discharge planning for patients from the Orthopaedic Ward at Flinders Medical Centre. A lot of the background development for this was due to the NDHP3 project. Hospitals
  Mental Health Services Mental health
Allied health
  The Division lobbied MHS's to modify their procedures to include GPs contribution in care planning by faxing the care plan. A trial with 15 GPs quelled initial fears with allied health workers and the model is now working.  
  Supported Residential Facilities Residential Aged Care Facilities
Mental health
Community linkages
  Victor Harbour has 5 Supported Residential Facilities - hostels. Since many residents have mental health problems this has been a problem when new arrivals need care from local services. A case management plan has been developed between GPs, Glenside Hospital, local hospital and community mental health so discharge notes are sent down for each person discharged from Glenside to the SRFs. A care planning meeting is held, with the GP funded to attend this at the local hospital. Location of case notes, care plan etc is now determined in advance of an emergency.
  The Division is conducting an Innovations project: a randomized controlled trial in residential care facilities with emphasis on managing challenging behaviours and performing medication reviews. Case conferencing is the key tool in this project.

Medication reviews
Randomised controlled trial
Mental health

 

Contact: sdgp@health.on.net

Urban Division

keywords: Coordinated Care Trial, Mental health, Community linkages, Hospitals, Mental health, Allied health, Residential Aged Care Facilities, Mental health, Medication reviews, Randomised controlled trial, Mental health, Urban Division, Community linkages

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