Overview

Effective care pathways are explored in this topic by reflecting on the systems of community and hospital-based care and patient journeys. You’ll build an understanding of the roles and responsibilities in the systems including complexities of discharge processes, patient perspectives, and common clinical pitfalls in care transfer through practical placements.

Intended Learning Outcomes

  • Discuss the evidence base underpinning effective care transition and identify areas of possible future research.
  • Outline programs that attempt to limit avoidable hospital admissions (including re-admissions).
  • Describe a range of journeys of patients who transition between different clinical settings and subsequent health outcomes.
  • Demonstrate an understanding of experience of care between home-based and hospital-based environments by liaising with patients and their advocates.
  • Explain the role and responsibilities of health practitioners in referrals and discharge planning within a complex health system.
  • Reflect on systems underpinning transitions between community and hospital-based care including range of stakeholders, common pitfalls, and effective future strategies through placement experiences.