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Refining a nursing and allied health discharge and transfer care plan to enhance discharge communication

Interviews with elderly patients, their family carers and health care workers were held to explore the reasons for early re-presentation to the Acute Assessment Unit at Sir Charles Gairdner Hospital. These interviews revealed that a clearer health plan was needed to be communicated to patients and families. A new Nursing and Allied Health Discharge Care Plan was developed that added to information provided to the patient/patient’s family/residential care staff on discharge. This new form was piloted. No changes were found in patient/family carer/aged care staff satisfaction, perceived care continuity and preparedness for discharge after introduction of the new form. However, feedback suggested that adjustments to the discharge care plan could enhance its usefulness and feasibility. This project is the second phase of the project which uses the action research method which aims to develop and pilot a revised discharge care plan.


Curtin University, Associate Professor Chris Toye
Associate Professor Anne Williams
Sir Charles Gairdner Hospital, Ms Dee Whitty
Ms Susan Slatyer
Sir Charles Gairdner Hospital, Ms Katrina Fyfe

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