Care coordination and Post-Acute Surgical Services: An integrated approach for complex surgical patients to improve healthcare delivery and outcomes

The PASS model of care is an end-to-end service for complex surgical patients, that is adaptable and transferrable model of care, led by a Care Coordination Nurse (CCN)

We have:

• Developed a nurse led model to support safe, structured discharges for each patient
• Scaled the CCN role across another surgical ward successfully
• Created an integrated care approach with our community GP’s

The CCN role has:

• Reduced length of stay for several complex diagnostic related group’s (DRG)
• Released more to time to care for the primary nurses at the bedside
• Established a successful succession program
• Allowed nurses (both hospital and community) to work to top of scope
• Ensured every patient has a discharge plan
• Created discharge education and provided on the floor support for nursing, medical and allied health staff
• Increased in patient and staff satisfaction

We aim to:

• Establish an online discharge portal
• Develop a discharge network for all ‘discharge’ nurses
• Strengthen partnerships with the primary care sector, to sustain improvements in the patient care continuum with more connected community pathways
• Establish a community home visiting service that would cater for the complex needs of surgical patients within the community, that has surgical governance
• Establish Satellite Clinics