1. Case Report: Discharging the complex, long-stay patient Dr David Skalicky Dr John Estell Department of Rehabilitation Medicine, St George Hospital, SESIAHS. 29/10/2010 HIMAA, Sydney

2. Rehabilitation Medicine “brings about recovery following loss of function and ability” “management of disability” “prevention and reduction of functional loss, activity limitation, and participation restriction”

3. Table 1: Length of stay for inpatient rehabilitation patients at St George Hospital, Kogarah, Sydney. Mean RehabilitationMean Tot HospitalMax Hospital YearLength of Stay (days) Length of Stay 200521.741.6239 200623.846.5278 200722.643.8179 200825.147.5405 200925.642.3193 201026.445.2123

4. Case Study MB 65 yo female Admitted to Sutherland hospital on 20/9/2008 Discharged from St George hospital on 1/6/2010 Total Length of Stay: 615 days HospitalLoSWard Sutherland10 monthsHDU St George4 monthsRespiratory St Vincent's3 daysTracheal Stent St George6 monthsRehabilitation

5. Case Study MB 65 yo female Multidisciplinary intensive inpatient rehabilitation Goals To walk short distances independently To discharge to sister's home on Central Coast

6. Discharge 615 days in hospitals >1000 pages of clinical notes Accumulated results on eMR Moving out of area Diagnoses Specialists Hospitals Other health issues Treatments

8. Objectives Discharge Summary communicates with Health Professionals New GP on the Central Coast Clinical coding department Patient Aims to summarise Clinical and functional information Many hours of work from many people Significant financial expense

9. Discharge Medication summary Short interview  one month before discharge Patient driven Discharge interview Longer interview  three weeks before discharge Overall perspective on dates and location Personal perspective on her 'journey'

10. Discharge Review of clinical records Discharge summaries from each hospital admission, and from each episode of care “Systems Review” template Preferred to chronological reporting Draft reviewed by rehabilitation team Verbal handover to GP

11. Discharge Clinical coding and classification 7 episodes of care at St George Hospital, 1 episode at Sutherland 1 episode at St Vincent’s 125 ICD-10-AM diagnoses 48 ACHI interventions

12. Guidelines Allow time Plan with the patient Have a good knowledge of the patient's admission Seek feedback from the team Make periodic summaries (every 3-6 months) Liase with medical record department

13. Acknowledgements Rehabilitation Team, Ward 6W, St George.