State Action on Avoidable Re-hospitalisations and Unplanned Admissions: an Integrated Knowledge Translation project across SA (STAAR-SA)

“In the project we brought various groups together…academic and clinical. We brought together clinicians from the coalface... together with very experienced research groups… translational researchers, people from SAHMRI and health economists, and they all worked together with consumers to try and solve problems.”

- Professor Maria Crotty

Australian aged 70+ represent 9% of the population, yet account for 17% of ED attendances. Older frail patients are more likely to be re-hospitalised in 6 months following discharge. No simple solution exists to reduce these unplanned admissions and current approaches in SA are fragmented. While there is evidence about strategies to improve older patients' experiences of hospital discharge and reduce hospital readmissions, they are not implemented systematically across South Australia.

Goal

To improve the pathway of care for older people being discharged from hospital, in South Australia.

Aims

To analyse data in the Registry of Senior Australian’s (ROSA) to monitor whole of system outcomes for high-risk older people. Includes older people living in the community, including residential care, who have had an aged care eligibility assessment.
To evaluate the cost and outcomes of several existing out-of-hospital care programs in South Australia.
To establish a quality improvement collaborative (QIC) where local health network clinicians work with other cross-sectoral stakeholders, to test ideas using a 'proof of concept' approach.

Researchers

From Flinders
Professor Maria Crotty
Professor Gill Harvey
Associate Professor Craig Whitehead
Professor Jon Karnon
Dr Clare Pham
Associate Professor Kate Laver
Dr Elizabeth Lynch
Dr Jesmin Rupa
Carmel McNamara

Research collaborators
Professor Maria Inacio
Dr Rob Jorissen
Dr John Maddison
John Forward
Dr Alice Bourke
Chrissie Isaksson

Grant Details

Medical Research Future Fund (MRFF) Rapid Applied Research Translation Grant and administered by Health Translation SA: $790,000

Chief Investigator:
Professor Maria Crotty

Commenced:
2019

Completion Due: June 2023

Tools and Resources

Tools and resources developed through STAAR-SA, including infographics and videos can be found on the Health Translation SA website.

Work Package 1
Hospitalizations Before and After Entry Into Long-Term Care. Jorissen RN, Crotty M, Caughey GE, Harvey G, Inacio MC. J Am Med Dir Assoc. 2022;S1525-8610(21)01108-7.

Predictors of short-term hospitalization and emergency department presentations in aged care. Inacio MC, Jorissen RN, Khadka J, Whitehead C, Maddison J, Bourke A, Pham CT, Karnon J, Wesselingh SL, Lynch E, Harvey G, Caughey GE, Crotty M. J Am Geriatr Soc. 2021;69(11):3142-3156.

Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study. Inacio MC, Jorissen RN, Wesselingh S, Sluggett JK, Whitehead C, Maddison J, Forward J, Bourke A, Harvey G, Crotty M; STAAR-SA Study Collaborators. BMJ Open. 2021;11(11):e057247

Work Package 2
The Council of the Ageing (COTA SA), through their Plug-in initiative, undertook a qualitative evaluation to explore the perceptions of older South Australians who have used selected out-of-hospital services, to gain an understanding of the consumer and/or carer experience. Information about the evaluation and the main findings, can be found in the Key Insights Report.

Work Package 3
Establishing and evaluating a quality improvement collaborative to address hospital to 3 home transitions for older people. Kate Laver, Elizabeth Lynch, Jesmin Rupa, Carmel McNamara, Maria Crotty, Gillian 5 Harvey, STAAR-SA Study Collaborators. BMJ Open Quality 2022;11: e001774. doi:10.1136/bmjoq-2021-001774

"A ‘plethora of services but a lack of consistency”: A qualitative study of service providers’ perspectives about transitioning from hospital to home for older South Australians. Jesmin Rupa; Kate Laver; Gillian Harvey; Carmel McNamara; Maria Crotty; Elizabeth A. Lynch. Australasian Journal on Ageing