Transition of Care

Key Priorities

NCPHN and MNCLHD have undertaken a joint person-centred health system strategy to support advances of integration between acute services and primary care. One of the key priorities within this strategy is to improve transition of care.

NCPHN Coffs Harbour Clinical Council also highlighted safe transition of care as one of the top priorities for action within the MNC.

The Safe Transition of Care (SToC) is a three phase project aimed at improving patient related electronic communication between MNCLHD and Primary Care Providers.

Phase 1 focused on increasing the number of discharge summaries received by primary care. Pre implementation data collected from LHD and Pilot site GP practices, process mapping completed, gap analysis completed, consultation with LHD and Primary Care Stakeholders undertaken. Identified opportunities for improvement include, now live; systematic approach to receiving GP contact detail updates (via the MNCLHD public website) and strengthening rigor around confirming regular GP with all patients.

Phase 2 focused on initiation of Admission and Discharge Notifications (ADN), early consultation meetings have been held with IT, e-health and General Practice.A survey was distributed to clarify demand across General Practitioners and 82% of General Practitioners expressed the need for ADNs.-  in the design stage.

Phase 3 focused on quality of patient related electronic communication this will included discharge summaries and referrals. A survey was distributed to ascertain critical information that could be targeted for improvement. To great success 43% of General Practitioners completed the survey and provided data that Safe transition of Care could utilise to determine the project approach.

Read our story:

Mid North Coast Safe Transition of Care Project click here.