Improved discharge planning through a community & ambulatory in-reach model

Mrs Haria Lambrou1, Mr David Harrower1, Mr  John  Ashfield1, Ms Ilanit Whitemnan1

1Alfred Health, Caulfield , Australia


A model was developed for community and ambulatory services to routinely in-reach into sub-acute wards with the aim of improving discharge planning.

A quality improvement activity was undertaken on two sub-acute inpatient wards to determine the effect of introducing an in-reach model on discharge planning. An intake worker from the community and ambulatory team attended journey board meetings on two pilot wards to act as a resource for clinicians and assist in discharge planning. The model was implemented for 6 months and outcome measures included length of stay, unplanned readmission rates and impact on the timeliness and quality of referrals from inpatient wards to community & ambulatory services. Staff satisfaction with the in-reach model was also measured.

In comparison to the non-trial wards, the in-reach model demonstrated a 25% – 39% reduction in unplanned readmissions on the trial wards but did not reduce length of stay. Improved timeliness and appropriateness of referrals from the trial wards to community and ambulatory services was also seen.

Significance of findings to Allied health:
The in-reach model can help reduce unplanned hospital readmissions through improved discharge planning, which can result in improved efficiency within the hospital and increased availability of hospital beds. Length of stay was not reduced, but the trial was able to demonstrate an improved awareness of discharge resources in clinicians, as well as an improvement in the quality and timeliness in referrals to community and ambulatory services.


Haria has a clinical background in Physiotherapy and has worked in public health for 21 years, mostly as a musculoskeletal physiotherapist. Her role over the last 2 years has been as a team leader as part of the Caulfield Community Health Service, where she leads a team of clinicians responsible for the intake of referrals to community & ambulatory services.