A multidisciplinary Care Coordination Team improves emergency department discharge planning practice

Joanne E Moss, Liza M Houghton, Carolyn L Flower, Danielle L Moss, David A Nielsen and David McD Taylor
Med J Aust 2002; 177 (8): 435-439. || doi: 10.5694/j.1326-5377.2002.tb04884.x
Published online: 21 October 2002


  • In response to difficulties meeting the demand for hospital services ("access block") at Royal Melbourne Hospital, a major metropolitan tertiary referral hospital, an audit of patient needs revealed a shortage of aged-care beds and a need for post-acute care.

  • A multidisciplinary Care Coordination Team (CCT) was formed at the end of July 2000 to ensure that emergency department patients were provided with services that would facilitate their return to, or maintenance in, the community.

  • The target population included the frail elderly, those living alone, the homeless, frequent emergency department attenders, and those with complex medical or drug and alcohol problems. As part of routine emergency department care, a risk screen was implemented to determine referral to the CCT.

  • In the first 12 months, the CCT saw 2532 patients (5.8% of all emergency department attendances). Nearly half of these patients were discharged home with referrals to community service providers.

  • The rate of hospital admission from the emergency department fell significantly compared with the 12-month period before implementation of the CCT (13 420 patients, 30.9% [95% CI, 30.5–31.3] v 14 217 patients, 32.6% [95% CI, 32.2–33.0]; P < 0.001).

  • Surveys of staff, patients and carers, as well as community service providers, showed a high level of satisfaction with the CCT.

In response to mounting difficulties, from 1998 onwards, in meeting the demand for hospital services ("access block") and increasing ambulance bypass,1 the Victorian Department of Human Services (DHS) allocated funds to major metropolitan hospitals in 2000 for a review of patient management in emergency departments.2 In April 2000, a multidisciplinary steering committee was convened at the Royal Melbourne Hospital, a major metropolitan tertiary referral hospital, to review the post-acute-care needs of emergency department patients and to develop a model of care coordination. The committee comprised hospital staff and community service providers, including post-acute-care facilitation and hospital-in-the-home services.

As a first step, the committee audited the needs of a convenience sample of 76 emergency department patients. Fifty-one patients (67.1%) were deemed eligible for post-acute care. The 25 ineligible patients (32.9%) had needs related to long-term care. All but one of the 19 patients discharged from the emergency department had post-acute-care needs. The committee identified the primary contributors to "access block" to be a shortage of aged-care places and the need to admit elderly patients with minor injuries or illnesses, because of social issues or lack of home support.

A literature search demonstrated the value of risk identification and emergency department or hospital discharge planning, especially in the elderly (Box 1). The committee drew on this evidence, the audit results and focus group experience to activate a Care Coordination Team (CCT) to ensure that emergency department patients were provided with services to facilitate their return to, or maintenance in, the community, specifically by:

  • preventing unnecessary and/or inappropriate hospital admissions;

  • minimising repeat presentations of patients; and

  • providing safe and effective discharge from the ED.

The care coordinators undertake a comprehensive discharge risk assessment of suitable patients. Priority is given firstly to patients for whom unnecessary or inappropriate admission could be prevented, and then patients awaiting admission who require complex discharge planning. The risk assessment involves documentation of expected discharge date and destination, existing services and supports, and includes prompts for referral to internal and external health professionals.

The patient assessment and management algorithm is shown in Box 2.

Results of CCT service evaluation

The CCT service was assessed 12 months after its commencement. The assessment was mainly analysed descriptively. The Royal Melbourne Hospital Human Research Ethics Committee exempted the assessment from formal review as it was a quality assurance exercise.

Between August 2000 and July 2001, 43 405 patients presented to the emergency department. Box 3 gives the diagnoses and disposition of the 2532 patients (5.8%; 95% CI, 5.6–6.0) seen by the CCT. In total, 1199 referrals to community service providers were made (Box 4). Most (81.5%) referrals were made for the 1254 patients who were discharged home; 881 discharged patients were provided with a total of 977 referrals (some received multiple referrals). To optimise continuity of care, patients discharged home without a referral to a community service provider were telephoned within seven days.

A comparison of admissions to the emergency department in the 12 months before and after the CCT service is given in Box 5. Overall, only 53 patients (2.1%; 95% CI, 1.6–2.8) seen by the CCT had an unplanned re-presentation. To our knowledge, no patient died or suffered an adverse event after CCT review and discharge home.

An audit of medical histories in the four-month period (1 August – 24 November 2000) assessed medical staff intention to admit patients before care coordinator intervention. Of 673 histories audited, there were 31 (4.6%; 95% CI, 3.2–6.5) with documentation clearly stating an intention to admit the patient. However, after CCT involvement, these patients were discharged home with the support of community service providers.

Satisfaction surveys

Three satisfaction surveys were undertaken. Each was voluntary and employed a questionnaire with "tick box" ordinal or categorical response options, supplemented by written comments. All questionnaires were developed by the CCT and examined for readability and face validity by the CCT steering committee and emergency department research personnel.

Community service providers

Sixteen key community service providers, whose services are regularly accessed by the CCT, were surveyed by mail in August 2001. Most are listed in Box 4. All surveys (100%) were returned. The CCT was reported as:

  • always or sometimes easily accessible (eight [50.0%] and three [18.8%] respondents, respectively; five respondents had not referred to the CCT);

  • always or sometimes having a positive impact on patient outcomes (seven [43.8%] and five [31.3%] respondents, respectively; four failed to answer); and

  • a model worth recommending to other emergency departments (14 respondents [87.5%]; two respondents failed to answer).

Overall, the response was positive, with many respondents requesting additional information about the team. Two key issues reported were an appreciation of an emergency department contact person and the social and clinical information received about patients discharged.

Little criticism of the service was evident from the surveys. However, suggestions were made for the inclusion of bilingual care coordinators, an expansion of the disciplines within the service, and extending its availability to 24 hours a day.


Overall, the CCT achieved its aims. Significantly fewer patients required admission after the service commenced.

Many factors affect admission rates, including industrial action, bed availability, ambulance bypass, and improved access to hospital-in-the-home and homeless persons services. However, it is likely that the CCT prevented some unnecessary admissions by utilising community support. The results of the medical history audit and the low rate of repeat presentation of patients after CCT intervention support this conclusion.

The overall number of repeat presentations to the emergency department showed a downwards trend after the service commenced, consistent with the findings of others.3,8,12 These numbers include both unplanned and planned repeat presentations (eg, delayed investigation or review). It is encouraging that the re-presentation rate of patients reviewed by the CCT was much lower than the overall re-presentation rate. This suggests that community support and follow-up was, in most cases, adequate. However, care is required in comparing these rates, as the re-presentation rates of CCT patients excluded planned re-presentations.

The findings indicate that discharge after CCT review was safe and effective. This is supported by the low re-presentation rate, the positive responses from the patient and carer satisfaction survey, and the lack of adverse events identified by community service providers and the care coordinators' telephone follow-up.

Variations in staffing levels as a result of resource allocation and annual leave have occasionally had an adverse effect on service provision. Time constraints have necessitated patient prioritisation when a large number of patients need timely management. Resource limitations of community services, including limited after-hours services, and inadequate places in aged-care facilities, rehabilitation units or geriatric evaluation and management units, have also restricted the service. Other services have variable waiting lists (eg, council and home nursing services, and crisis accommodation). Finally, eligibility criteria have limited patient access (eg, geographical location, age, diagnosis, and availability of carers).


After one year of service, the CCT has successfully integrated into the emergency department, and there is evidence of a high degree of staff satisfaction with the team, improved discharge planning practices, and the establishment of referral systems, links and relationships with internal and external service providers. We recommend this model, and the extension of community support services, to assist in the disposition of patients after acute care in emergency departments.

1: Evidence that emergency department discharge planning can improve the identification and community support of patients at risk*

* Levels of evidence are based on the grading system of the National Health and Medical Research Council.13

  • Joanne E Moss1
  • Liza M Houghton2
  • Carolyn L Flower
  • Danielle L Moss4
  • David A Nielsen5
  • David McD Taylor6

  • 1 Peter MacCallum Cancer Institute, East Melbourne, VIC.
  • 2 Emergency Department, Royal Melbourne Hospital, Melbourne, VIC.



The authors wish to acknowledge Miss Elizabeth Virtue, Nurse Manager Emergency Services, and Professor Peter Cameron, Director of Emergency Medicine, for their assistance and support in establishment of this discharge planning initiative. We also acknowledge the valuable contribution of both Mrs Nicole Amsing from the Post-Acute Care Facilitation Unit and Ms Katherine Hirst who was an original team member.

Competing interests:

None identified.

  • 1. Victorian Department of Human Services. Public Hospitals Policy and Funding Guidelines. Melbourne: DHS, 2001.
  • 2. Victorian Department of Human Services. Emergency demand management – a new approach. Melbourne: DHS, 2001.
  • 3. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalised elders. A randomised clinical trial. JAMA 1999; 281: 613-620.
  • 4. Weir R, Browne G, Byrne C, et al. The efficacy and efficiency of the quick response program: a randomised controlled trial. Can J Aging 1998; 17: 272-295.
  • 5. McCusker J, Verdon J, Tousignant P, et al. Rapid emergency department intervention for older people reduces risk of functional decline: results of a multicentre randomised trial. J Am Geriatr Soc 2001; 49: 1272-1281.
  • 6. Caplan GA, Brown A, Croker WD, Doolan J. Risk of admission within four weeks of discharge of elderly patients from the emergency department — the DEED study. Age Ageing 1998; 27: 697-702.
  • 7. Friedman PD, Jin L, Karrison TG, et al. Early revisit, hospitalisation, or death among older persons discharged from the ED. Am J Emerg Med 2001; 19: 125-129.
  • 8. Scott IA. Care of older people in acute care hospitals: do we know how? Med J Aust 1999; 171: 485-488.
  • 9. Caplan GA, Croker WD, Brown A. Recognition of deficits of physical and cognitive function in the elderly by medical staff in the emergency department. Emerg Med 1998; 10: 19-24.
  • 10. Thomas and Associates. Final report of the development of a risk-screening tool for service needs following discharge from acute care project. Melbourne: Department of Human Services, 1998.
  • 11. Runciman P, Currie C, McNicol M, et al. Discharge of elderly people from an accident and emergency department: evaluation of health visitor follow-up. J Adv Nursing 1996; 24: 711-718.
  • 12. Miller DK, Lewis LM, Nork MJ, Morley JE. Controlled trial of a geriatric case finding and liaison service in an emergency department. Am Geriatric Soc 1996; 44: 513-519.
  • 13. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, AusInfo, 1999.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.