Older, complex and multimorbid patients are frequent users of hospital services. Preliminary evidence suggests that care navigation, in which a suitably qualified health professional is deployed to coordinate the care of the patient between multiple providers, may reduce unwarranted hospital presentations in this group. This project involves the retrospective evaluation of a care navigation model to reduce hospital readmissions in patients identified as being at risk of readmissions according to a DHS derived risk algorithm (HealthLinks score). Evaluation was performed using a cohort study design with propensity score matching, in which those who received the care navigation were matched to controls based on the probability of receiving the intervention. A process evaluation was performed using qualitative methods to identify barriers and facilitators to broader implementation of this type of care model. Future work will involve further development and testing of the readmission risk algorithm with the addition of Peninsula Health Electronic Health Record data.
For further information please contact Nadine Andrew – firstname.lastname@example.org