SPECIAL SESSION: Transitional Care Using Telehealth: Fewer Emergency Unplanned Admissions and Improved Quality of Life and Functional Ability

Description/Overview: Prof Courtney’s research program involves the development, trial and evaluation of innovative discharge planning and transitional care models that span across hospital and community health sectors and include hospital and in-home assessment, exercise strategies and telephone follow-up interventions with ‘at-risk’ community-living older adults (1,2,3,4) This presentation focuses on results of her previous clinical trials in ‘general hospitalised medical patients’ and presents findings published in Journal of American Geriatric Society (JAGS) and PlusOne which demonstrate significantly few emergency hospital readmissions (22% intervention, 47% control, P = .007) and emergency GP visits (25% intervention, 67% control, P<.001). The intervention group reported significantly greater improvements in Q of L, exercise endurance and functionality than control group. Cost-effectiveness analysis demonstrated cost savings to the Australian health service of $8,000/patient (2)Findings are influencing health services delivery seeing the introducing of exercise interventions and rehabilitation for frail ‘at-risk’ older people prior to discharge to reduce hospital re-admissions. Given cardiac disease and type 2 diabetes are significant global health problems causing increasing mortality and increased healthcare costs(5), her research program has moved to investigate transitional care models in the high-risk ‘dual diagnosis’ cardiac disease and diabetes population in order to reduce unplanned hospital re-admissions and improved quality of life(6,7,8). Given the major knowledge gap concerning evidence on the effect of tele-health and intervention delivery modes in this ‘dual-diagnosis’ population together with the lack of evidence of theory-based behavioural interventions demonstrating consistent results, this study is evaluating a tailored self-efficacy theoretically based self-management transitional care program involving tele-health (Cardiac/Diabetes TRANS-CARE) to reduce hospital re-admissions and improve quality of life and reduce costs. Pilot study work results will be presented(7)