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Poster Abstracts

Development of an integrated care role to actively support our most vulnerable client groups being discharged from a public hospital.


Laura O'Shea

Inner Melbourne Post Acute Care, North Richmond Community Health, Richmond, Melbourne, VIC., AU
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Introduction: Inner Melbourne Post Acute Care (IMPAC) is a state funded health program which supports people following discharge from a public hospital with a diverse range of clinical and non-clinical services, delivered by a team of clinicians, generally over the telephone.

Evidence supports contact with a community worker upon or soon after discharge to improve access to primary health care.

We identified an increasingly vulnerable cohort of clients which mainstream services were not able to support adequately in the immediate post discharge period. To respond to this, the role of the Discharge Support Worker (DSW) was created.

Short description of practice changes implemented: IMPAC developed the role of DSW in 2014, in consultation with St Vincent’s Hospital, to support discharges of our most vulnerable clients.

Aim and theory of change: The aim of the role is to engage meaningfully with clients to allow the provision of intensive, practical support to vulnerable clients, to assist in achieving better health and social outcomes.

Targeted population and stakeholders: The targeted population is vulnerable and at risk of readmission due to isolation, low socio-economic status, mental illness, homelessness, multiple chronic health conditions, reduced confidence in their health management and self-care, and/or a history of poor engagement with services.

All agencies who refer to IMPAC, including hospitals and any other health agency who is involved with a client who has presented to a public hospital in the past 28 days are key stakeholders.


Timeline: The role was created in August 2014.

Highlights: The role has proven to be responsive, flexible, dynamic and collaborative, and has achieved significant outcomes for clients. Referrers are very engaged with IMPAC, which allows us to work collaboratively to achieve better outcomes.

Sustainability and transferability: The role requires a highly skilled worker as they are required to work autonomously and react quickly, with client behaviours or environments which are very challenging. The DSW is very well supported by the IMPAC Program Manager and other clinical staff, who help to formulate a care plan for each client.

The role was initially offered to clients who were discharged from STV, but the model has proven to be transferable across all hospital and community settings.

Conclusions: The DSW role has successfully supported upwards of 100 client contacts each year (2018=193) through meaningful engagement and practical support. Our stakeholders have provided very positive feedback on this innovative approach to integrated care.

Discussions: By providing a highly skilled welfare worker to work directly with the program's most vulnerable clients, we have successfully reduced hospital re-admissions, improved well-being of clients, and redirected our senior clinical staff to focus on more complex clinical issues that often present in the post discharge period.

Lessons learned: Since creation, demand has increased significantly, with significant program budget spent on material aid and industrial cleans. Boundaries around what is reasonable and unreasonable must be clarified, in order to protect future program budget, and to protect the primary purpose of the DSW.

How to Cite: O'Shea L. Development of an integrated care role to actively support our most vulnerable client groups being discharged from a public hospital.. International Journal of Integrated Care. 2021;20(S1):163. DOI:
Published on 26 Feb 2021.


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