In response to mounting difficulties, from 1998 onwards, in meeting the demand for hospital services ("access block") and increasing ambulance bypass,1 the Victorian Department of Human Services (DHS) allocated funds to major metropolitan hospitals in 2000 for a review of patient management in emergency departments.2 In April 2000, a multidisciplinary steering committee was convened at the Royal Melbourne Hospital, a major metropolitan tertiary referral hospital, to review the post-acute-care needs of emergency department patients and to develop a model of care coordination. The committee comprised hospital staff and community service providers, including post-acute-care facilitation and hospital-in-the-home services.

As a first step, the committee audited the needs of a convenience sample of 76 emergency department patients. Fifty-one patients (67.1%) were deemed eligible for post-acute care. The 25 ineligible patients (32.9%) had needs related to long-term care. All but one of the 19 patients discharged from the emergency department had post-acute-care needs. The committee identified the primary contributors to "access block" to be a shortage of aged-care places and the need to admit elderly patients with minor injuries or illnesses, because of social issues or lack of home support.

A literature search demonstrated the value of risk identification and emergency department or hospital discharge planning, especially in the elderly (Box 1). The committee drew on this evidence, the audit results and focus group experience to activate a Care Coordination Team (CCT) to ensure that emergency department patients were provided with services to facilitate their return to, or maintenance in, the community, specifically by:

• preventing unnecessary and/or inappropriate hospital admissions;

• minimising repeat presentations of patients; and

• providing safe and effective discharge from the ED.

The CCT commenced at the end of July 2000. The DHS allocated $200 000 for equipment and four CCT staff in the first year. The care coordinators comprised nursing and allied health personnel. Continuing Department of Health Services (DHS) funding is available as part of the DHS Emergency Demand Strategy.2

The care coordinators undertake a comprehensive discharge risk assessment of suitable patients. Priority is given firstly to patients for whom unnecessary or inappropriate admission could be prevented, and then patients awaiting admission who require complex discharge planning. The risk assessment involves documentation of expected discharge date and destination, existing services and supports, and includes prompts for referral to internal and external health professionals.

The patient assessment and management algorithm is shown in Box 2.

The CCT service was assessed 12 months after its commencement. The assessment was mainly analysed descriptively. The Royal Melbourne Hospital Human Research Ethics Committee exempted the assessment from formal review as it was a quality assurance exercise.

Between August 2000 and July 2001, 43 405 patients presented to the emergency department. Box 3 gives the diagnoses and disposition of the 2532 patients (5.8%; 95% CI, 5.6–6.0) seen by the CCT. In total, 1199 referrals to community service providers were made (Box 4). Most (81.5%) referrals were made for the 1254 patients who were discharged home; 881 discharged patients were provided with a total of 977 referrals (some received multiple referrals). To optimise continuity of care, patients discharged home without a referral to a community service provider were telephoned within seven days.

A comparison of admissions to the emergency department in the 12 months before and after the CCT service is given in Box 5. Overall, only 53 patients (2.1%; 95% CI, 1.6–2.8) seen by the CCT had an unplanned re-presentation. To our knowledge, no patient died or suffered an adverse event after CCT review and discharge home.

An audit of medical histories in the four-month period (1 August – 24 November 2000) assessed medical staff intention to admit patients before care coordinator intervention. Of 673 histories audited, there were 31 (4.6%; 95% CI, 3.2–6.5) with documentation clearly stating an intention to admit the patient. However, after CCT involvement, these patients were discharged home with the support of community service providers.

Overall, the CCT achieved its aims. Significantly fewer patients required admission after the service commenced.

Many factors affect admission rates, including industrial action, bed availability, ambulance bypass, and improved access to hospital-in-the-home and homeless persons services. However, it is likely that the CCT prevented some unnecessary admissions by utilising community support. The results of the medical history audit and the low rate of repeat presentation of patients after CCT intervention support this conclusion.

The overall number of repeat presentations to the emergency department showed a downwards trend after the service commenced, consistent with the findings of others.3,8,12 These numbers include both unplanned and planned repeat presentations (eg, delayed investigation or review). It is encouraging that the re-presentation rate of patients reviewed by the CCT was much lower than the overall re-presentation rate. This suggests that community support and follow-up was, in most cases, adequate. However, care is required in comparing these rates, as the re-presentation rates of CCT patients excluded planned re-presentations.

The findings indicate that discharge after CCT review was safe and effective. This is supported by the low re-presentation rate, the positive responses from the patient and carer satisfaction survey, and the lack of adverse events identified by community service providers and the care coordinators' telephone follow-up.

Variations in staffing levels as a result of resource allocation and annual leave have occasionally had an adverse effect on service provision. Time constraints have necessitated patient prioritisation when a large number of patients need timely management. Resource limitations of community services, including limited after-hours services, and inadequate places in aged-care facilities, rehabilitation units or geriatric evaluation and management units, have also restricted the service. Other services have variable waiting lists (eg, council and home nursing services, and crisis accommodation). Finally, eligibility criteria have limited patient access (eg, geographical location, age, diagnosis, and availability of carers).

After one year of service, the CCT has successfully integrated into the emergency department, and there is evidence of a high degree of staff satisfaction with the team, improved discharge planning practices, and the establishment of referral systems, links and relationships with internal and external service providers. We recommend this model, and the extension of community support services, to assist in the disposition of patients after acute care in emergency departments.

2: Algorithm of Care Coordination Team referral and assessment process