This is a study in Sydney Local Health District of Community Health Navigators (CHNs) providing follow up care for patients as they move hospital to the community. The first phase of the study is a co-design stage that involve the key stakeholders working together to identify training and supervision needs. The second phase is a randomised trial evaluating the impact of CHN follow up following discharge from hospital.
Emeritus Prof Mark Harris (UNSW), Prof Parisa Aslani (USyd) A/Prof Jean-Frederic Levesque (ACI), A/Prof Margo Barr (UNSW), Dr Anurag Sharma (UNSW), A/Prof Ben Harris-Roxas (UNSW), Dr Michael Wright (UTS), Prof Richard Osborne (Swinburn)
Dr Fiona Doolan Noble (University of Otago), Dr. Simone Dahrouge, (University of Ottawa), Dr Sara Javanparast (Flinders University) Dr. Pim Valentijn (Maastricht University)
Ms Lou-Anne Blunden (SLHD), Dr John Cullen (SLHD), Deb Donnelly (SLHD), Ms Julie Finch (SLHD), Dr Brendan Goodger (CESPHN), A/Prof Fiona Haigh, A/Prof Elizabeth Harris, Ms Regina Osten (ACI), Dr Anthony Brown (HCNSW), Dr Sara Javanparast (Flinders University)
Ms Sharon Parker
This study addresses a major challenge of the health system in dealing with people with multiple long-term conditions and vulnerabilities. As well as suffering limitation to their own quality of life, these patients are at risk of hospitalisation and re-hospitalisation due to a range of
problems including medication errors, poor self-management and limited access to care. This places a significant burden on the health system.
To develop, implement and evaluate the impact of a CHN delivered model of care supporting transition of care from hospital to community for patients who are aged or have chronic condition.
The project will be undertaken in three stages.
Stage 1: Co-design of CHWs selection, training and activities.
The first phase of the study is a co-design stage that involve the key stakeholders working together and contributing their different perspectives to come up with the best solution. This will define the training, supervision and support that the CHNs will need and how the project should be implemented in SLHD. In this stage it is important that we have involvement of:
The codesign phase will commence with interviews with participants. This will be followed by workshops to review what has been found from the interviews and consultations.
Stage 2. Intervention trial
A pragmatic randomised controlled trial will include patients identiﬁed by the SLHD using their database of in-patients at four public hospitals. Research staff will approach eligible patients to invite them to join the study. The CHN will visit the patient at home, and will provide non- medical support for self-management, medicine reconciliation, and access to appropriate health and non-health services. Evaluation will be based on routinely collected hospitalisation, Medicare and Pharmaceutical Beneﬁts scheme data, patient and provider surveys and qualitative interviews.
Phase 3. Translation
Based on the findings we will identify conditions for sustainability and translation to other Local Health Districts in NSW and in Australia and overseas.
Chief investigator: Mark Harris , phone +61 (2) 9385 8384
Trial Coordinator: Sharon Parker, phone +61 (2) 9065 6733
Research Oﬃcer: Sarah Wright, phone +61 (2) 9348 1784
Sydney Local Health District (SLHD), Agency for Clinical Innovation (ACI), Central and Eastern Sydney Primary Health Network (CESPHN), Health Consumer NSW (HCNSW) , University of Otago, New Zealand, University of Ottawa, Canada, Flinders University, Maastricht University, Netherlands