Discharge Referral Services Expanded to prevent Avoidable Hospitalisation for the Elderly

The two Commissioned Discharge Referral Programs ‘REMEMBER ME’ by Kincare and STAY at HOME by Just Better Care have now been expanded to be available to work with a range of community and primary health providers, where short term management and support could be beneficial for elderly people at risk of hospitalisation.

Patient eligibility criteria for the discharge service includes:

  • People who have suspected or diagnosed dementia
  • A person with a chronic or complex health condition
  • A person who is not receiving adequate support, and would significantly benefit from post-discharge follow-up at home within 24 hours
  • Would significantly benefit from short-term follow-up support
  • Are not currently enrolled in TACP/TRANSPAC
  • Exhibit other characteristics to be agreed

Referral eligibility of clients at risk of hospitalisation will be determined using one or more of the following tools:

  • Harp ≥24
  • AUSDRISK Tool Score ≥12
  • AACVD risk ≥15
  • 3 or more chronic conditions / comorbidities
  • Frailty screening score ≥3
  • Hospitalised in the previous 12 months

The services will be provided to clients from within the indicated Local Coordinated Networks (LCNs). See map below.

Cluster Map LCN