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Work needed to smooth path of patients in and out of hospital


Lives could be put at risk unless there is increased support for GPs and hospital staff in organising the transfer of patients into and out of hospital, the AMA has warned.

The AMA said hospital readmissions were reduced and adverse events minimised when effective arrangements were in place to make the movement of patients to and from hospital as seamless as possible.

AMA President Dr Steve Hambleton said that patients were increasingly relying on GPs to coordinate their care, particularly when it involved admission to hospital.

Dr Hambleton said that, in order to provide the best possible care, doctors and hospitals needed to ensure there was good communication between them, so that patients received consistent and continuous care.

“When best practice transfer of care arrangements between GPs and hospitals are in place, and adhered to, hospital readmissions are reduced, adverse events are minimised, and patients and care providers have a more satisfactory and positive experience,” he said.

The AMA Council of General Practice has developed a Position Statement on General Practice/Hospitals Transfer of Care Arrangements 2013 which details the steps GPs, hospitals, governments and other organisations should take to ensure that the experience of patients moving into and out of acute or sub-acute care was virtually seamless.

“Continuity is a key tenet of quality care,” the Position Statement said.

It advised that when a GP initiates referral to a hospital, he or she had a responsibility to provide comprehensive and legible referral letters containing up-to-date summaries and sufficient information to enable the appropriate assessment of management of the patient while in hospital.

This should include the main presenting problem and past interventions; other medical conditions and treatments that might have a bearing on hospital care; details of medications; the results of recent investigations; and family and social circumstances.

The Position Statement said GPs should also contact the hospital to get progress reports on their patient, and to anticipate when they might need a post-discharge appointment.

For their part, hospitals needed to ensure that referring GPs were promptly notified of an unanticipated treatments, or where the patient required urgent follow-up care upon discharge.

In addition, the Position Statement said, hospitals needed to ensure comprehensive and accurate summaries – including details of all treatments and medications provided and the results of all tests conducted – were given to the referring GP within 24 hours of discharge, and that the patient had sufficient medication to last until the first post-discharge appointment with their doctor.

The AMA said organisations such as the Local Hospital Networks (LHNs) and Medicare Locals (MLs) should support good transfer or care arrangements.

It said MLs had been set up, in part, to ensure the primary health care services and hospitals worked effectively together, and more needed to be done to build “collaborative pathways” for the transfer of care.

“While some MLs [and] LHNs have commenced work on improving care pathways across various parts of the health system in their areas, this is not happening consistently across Australia, and there is scope for this to be applied across the country,” the Position Statement said.

The role and function of Medicare Locals is currently under review by the Abbott Government, and the Australia Medicare Local Alliance seized on the AMA’s comments as recognition of the value of its member organisations.

“This is coordination at its best from a quality of care, efficiency and productivity point of view, and increasingly, as the relationships and partnerships between LHNs and MLs develop, communities will receive real health benefits from improvements in the patient journey,” AML Alliance Chair Dr Arn Sprogis said.

“We also agree there is an urgent need to explore a nationally consistent approach to care pathways between LHNs and MLs, and that there is enough flexibility to ensure care pathways are suitable for local circumstances.”

The AMA suggested another health initiative of the former Government currently under review, the Personally Controlled Electronic Health Record System, had the potential to improve transfer of care arrangements.

“A well-developed and clinician-friendly e-health system would go a long way to improving the communication between the various parts of the health system,” the Position Statement said.

However, it reinforced concerns that, in its present format, the clinical usefulness of the PCEHR had been undermined by the emphasis on personal control.

“It is paramount that the content of e-health records is accurate, reliable and meets clinical needs, otherwise the e-health records will not be used, and potential benefits from a well-developed system will be lost,” the Statement said. “To this end, e-health records must be restructured to engender trust.”

Dr Hambleton is part of a three-member panel appointed by the Abbott Government to review the PCEHR and recommend changes to improve its clinical usefulness and adoption by both medical practitioners and patients.

The AMA said the Government also needed to revise the Medicare Benefits Schedule fee structure to provide better support for quality transfer of care arrangements.

It said there needed to be recognition of the time and effort GPs and other practitioners had to devote to organising and coordinating transfers of care, and hospitals had to give their staff sufficient time to produce high quality and timely discharge summaries.

It also recommended that GPs be represented on hospital management committees to ensure the issues and concerns of general practitioners were presented and addressed.

The Position Statement can be viewed at:


Adrian Rollins