Community Health Navigator (CHN) (Community Health Worker) assisted transition of care from hospital to community.

Not Applicable

Recruiting

• Conditions: chronic respiratory disease; diabetes; chronic neurological cancer conditions; chronic renal disease; chronic musculoskeletal conditions; Respiratory - Chronic obstructive pulmonary disease; Metabolic and Endocrine - Diabetes; Cancer - Any cancer; Renal and Urogenital - Kidney disease; Musculoskeletal - Other muscular and skeletal disorders

• Registration Number: ACTRN12622000659707
• Lead Sponsor: SW Sydney

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Study Start: 2022-05-05
• Last Update Posted: 19 August 2024

Recruitment & Eligibility

• Status: Recruiting
• Sex: All
• Target Recruitment: 460

Inclusion Criteria

Inclusion criteria
Patients will be identified via the Patient Flow Portal (PFP) contained within the Sydney Local Health District (SLHD).
1.Aged 40 years and over
2.Living within Sydney Local Health District boundaries
3.Admitted for a chronic condition or under the aged care service as recorded under reason for admission in the patient flow portal based (coded using ICD10)
4.Speaks English or any of the top five languages (Arabic, Cantonese, Mandarin, Greek or Italian)

Exclusion Criteria

Exclusion criteria
1.Selected for follow-up by any other chronic care program offered by the SLHD
2.Planned discharge to hostel, Residential Aged Care Facilities (RACF), rehabilitation facilities, transferred to another SLHD facility or transferred to another hospital or may be too unwell to participate in the study
3.Admitted primarily for COVID-19 diagnosis
4.Receiving community palliative care services
5.Receiving 7-day post discharge follow up from Mental Health services
6.Mild to moderate cognitive impairment (based on Rowland Universal Dementia Assessment Scale (RUDAS) score, able to give verbal assent and has a carer/informant as their primary carer available for an interview. People diagnosed with severe cognitive impairment unable to give verbal assent will be excluded
7.Patient or their primary carer does not have a landline or a mobile phone contact number available

Study & Design

• Study Type: Interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
The primary outcome is hospital readmissions. and this will be assessed by data linkage. [ During 60 days post discharge]