Question

How can we improve the hospital – outpatient continuity, and with which  organisational measures?

Problem description

Currently, we don’t have organisational and concrete measures at our disposal, supported by several tools, in order to ensure the best transition between hospital and ambulatory care.  This can produce a worsening of symptoms of a patient.  Here, there’s a risk that an individual team member (or case manager) sits working on his own in his corner, without taking contact with the patient and his primary network during hospitalisation, without a planning such a transition. If we look back to our experiences in Lausanne, and the dedication spent on this transition, then we realise that this is something very useful for us because currently completely neglected

Impact - effect

Without such a transition procedure it is difficult, as a member of a mobile team (or case manager) to build a relationship of trust and an alliance with the patient. Moreover, it is a lost opportunity to learn to know the patient better, to target his problems and needs, his internal and external resources. Research shows that, without a specific accompanying measure, about 50 % from the patients will not show up at the first appointment (whether this is with a psychiatrist, psychologist, home based nurse) after a period of hospitalisation.  And those missing this first appointment, are twice more likely to be re-admitted to hospital during the same year than those who showed up at the first appointment

To do

To do : spend careful attention to the transition hospital/external to hospital : contact patient and his network during hospitalisation, elaborate a discharge plan and a joint care project, develop daily life concrete projects for the patient, and all this previous to any intervention of the mobile team

Theme

Starting up and further development/deployment of mobile teams

Topic

critical success factors for starting up and further development/deployment

Reference -  contact

Olivier Ciarlan, psychologue, EM d’Henri Chapelle

Mobile team

2B

Project

RéSME

Intership abroad - place

Lausanne (CMT)

Date

February 2014