Complex Hospital Discharge Program in Melbourne

SeenCare provides hospitals and NDIS participants a streamlined pathway to a safe discharge and ongoing comprehensive care in Melbourne

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Hospital Discharge Services in Melbourne

As a doctor and nurse led NDIS service, we understand the challenges involved in discharge planning for patients with complex care requirements.

Our Complex Hospital Discharge Program gives hospitals a streamlined pathway to discharge NDIS participants into a safe environment where their ongoing social and medical needs are met.

As part of our service, a GP, registered nurse and support worker will be available to assist with discharge planning and complete a full clinical handover, including assuming medical governance where appropriate.

To find out more or to make a referral, please contact us today.

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What is the Complex Hospital Discharge Program?

SeenCare is a specialist registered NDIS provider for participants with complex care requirements and high medical needs.

With experienced doctors and nurses as part of our core care teams, we deliver a unique model of integrated disability and healthcare supports to people living in Melbourne.

Our Complex Hospital Discharge Program is a system we designed to facilitate the efficient discharge of NDIS participants with high medical needs into the community.

The program is based on close collaboration between the provider and hospital clinical team, with a focus on creating sustainable ongoing care arrangements that reduce hospital readmissions and lead to better long term outcomes for people with disability.

Key Features of the Program

Our approach varies according to the needs of each clinical team and patient. However, key tasks undertaken usually include:

Assessment and Recommendations

Upon receiving a referral, we conduct a preliminary assessment, including recommendations on potential approaches to discharge and ongoing community care. These initial plans can be presented to the patient and/or Guardian before progressing further.

Accommodation Assistance

We operate several SIL homes that are also suitable for short and medium term accommodation (STA & MTA). If these are not available, we can assist with locating another accommodation provider through our networks.

Development of a Transitional Care Plan

Our doctors, nurses and disability support workers will collaborate with individual clinicians and full teams to develop a robust plan to achieve a safe discharge. This includes pre-discharge tasks related to community supports and an overview of ongoing care requirements for the transitional post-discharge phase.

Full Clinical Handover

Our team can attend planning and handover meetings to ensure a smooth transition of care from hospital into the community. Where appropriate, one of our GPs can assume medical governance upon discharge.

Continued Collaborative Care

Most participants with complex care needs require ongoing input from hospital or community based specialists. We provide high-level collaborative care, including shared-care arrangements if required. We will also provide detailed handover whenever a patient is readmitted to hospital.

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Medical Tasks We Can Assist With

Some of the common healthcare tasks SeenCare can assist with are:

  • Wound and pressure ulcer care
  • High-risk meds (eg., insulin and warfarin)
  • Chronic disease management
  • Continence (including IDC & stoma)
  • PEG feeding & swallowing
  • Care coordination
  • Tracheostomy care
  • Rehabilitation programs

In addition to the above, we can craft individualised care plans for rare conditions and complex situations.

Benefits for Hospital Teams and Patients

SeenCare’s Complex Hospital Discharge Program helps hospital teams by:

Expediting discharge: With our comprehensive community medical support, patients can be discharged faster than if they were supported by a regular NDIS provider.

Reducing workload: SeenCare can shoulder some of the burden involved in discharge planning, freeing your staff up to focus on other tasks.

Minimising readmissions: Our doctors and nurses can handle many medical situations in the community that would otherwise result in hospital admission.

Improving outcomes: SeenCare’s unique model of integrated healthcare and disability support helps patients achieve new levels of independence and wellbeing.

Referral Criteria

SeenCare is committed to expanding the options available to NDIS participants with complex care requirements and high medical needs. Therefore, our referral criteria are intentionally broad and flexible.

In short, as long as we can safely provide ongoing care in a community setting (within the funding available), there is a good chance we will accept your referral.

Please Note: To maintain our capacity to service clients with higher needs, we are unlikely to accept referrals for patients with low support requirements.

Better Outcomes for Everyone

With a combined 54 years of experience in the disability and healthcare sectors, SeenCare understands the challenges in accessing high-quality community support for people with complex care requirements and high medical needs.

Our Complex Hospital Discharge Program is designed to overcome the barriers that keep NDIS participants in hospital longer than required. It also helps ease some of the burden involved in discharge planning for already overloaded hospital teams.

Finally, by taking a long-term and holistic view of healthcare, we help NDIS participants with high medical needs achieve a level of independence, freedom and wellbeing they never thought possible.

To find out more or to make a referral, please contact us today.

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