The three-stage assessment to support hospital-home care coordination in Tshwane- South Africa

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dc.contributor.author Hugo, J.F.M. (Jannie)
dc.contributor.author Maimela, T.C.R. (Tshegofatso)
dc.contributor.author Janse van Rensburg, Michelle N.S.
dc.contributor.author Heese, Jan
dc.contributor.author Nakazwa, C.E. (Chitalu)
dc.contributor.author Marcus, Tessa S.
dc.date.accessioned 2020-10-17T05:06:20Z
dc.date.available 2020-10-17T05:06:20Z
dc.date.issued 2020-07
dc.description.abstract BACKGROUND: In complex health settings, care coordination is required to link patients to appropriate and effective care. Although articulated as system and professional values, coordination and cooperation are often absent within and across levels of service, between facilities and across sectors, with negative consequences for clinical outcomes as well as serviceload.Aim: This article presents the results of an applied research initiative to facilitate the coordination of patient care. SETTING: The study took place at three hospitals in the sub-district 3 public health complex (Tshwane district). METHOD: Using a novel capability approach to learning, interdisciplinary, clinician-led teams made weekly coordination-of-care ward rounds to develop patient-centred plans and facilitate care pathways for patients identified as being stuck in the system. Notes taken during three-stage assessments were analysed thematically to gain insight into down referral and discharge. RESULTS: The coordination-of-care team assessed 94 patients over a period of six months. Clinical assessments yielded essential details about patients’ varied and multimorbid conditions, while personal and contextual assessments highlighted issues that put patients’ care needs and possibilities into perspective. The team used the combined assessments to make patient-tailored action plans and apply them by facilitating cooperation through interprofessional and intersectoral networks. CONCLUSION: Effective patient care-coordination involves a set of referral practices and processes that are intentionally organised by clinically led, interprofessional teams. Empowered by richly informed plans, the teams foster cooperation among people, organisations and institutions in networks that extend from and to patients. In so doing, they embed care coordination into the discharge process and make referral to a link-to-care service. en_ZA
dc.description.department Family Medicine en_ZA
dc.description.librarian pm2020 en_ZA
dc.description.sponsorship Department of Family Medicine, University of Pretoria en_ZA
dc.description.uri http://www.phcfm.org en_ZA
dc.identifier.citation Hugo JFM, Maimela TCR, Janse van Rensburg MNS, Heese J, Nakazwa CE, Marcus TS. The three-stage assessment to support hospital–home care coordination in Tshwane, South Africa. African Journal of Primary Health Care and Family Medicine 2020;12(1), a2385. https://doi.org/10.4102/phcfm.v12i1.2385. en_ZA
dc.identifier.issn 2071-2928 (print)
dc.identifier.issn 2071-2936 (online)
dc.identifier.issn 10.4102/phcfm.v12i1.2385
dc.identifier.uri http://hdl.handle.net/2263/76517
dc.language.iso en en_ZA
dc.publisher AOSIS Open Journals en_ZA
dc.rights © 2020. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. en_ZA
dc.subject Care coordination en_ZA
dc.subject Three-stage assessment en_ZA
dc.subject Collaborative care en_ZA
dc.subject Down referral en_ZA
dc.subject Patient discharge en_ZA
dc.subject Interprofessional network en_ZA
dc.subject Intersectoral network en_ZA
dc.title The three-stage assessment to support hospital-home care coordination in Tshwane- South Africa en_ZA
dc.type Article en_ZA


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