Discharge coordination project expands across West Moreton

Since 2024, Darling Downs and West Moreton PHN has supported the Queensland Health Patient Care Facilitator project to improve patient continuity of care and reduce avoidable hospital presentations, admissions and readmissions by strengthening integration between Ipswich hospitals and primary care.  

The pilot has demonstrated the value of clearer communication between hospital and general practice, particularly in supporting continuity of care and timely follow-up after an unplanned hospital admission.

The PHN is pleased to announce that funding has been secured to extend the project for the remainder of 2026. As part of the extension, the Discharge Coordination Officer (DCO) service will expand to support all general practices across the West Moreton region.

West Moreton DCO, Tendai Makaripe (pictured), will continue working with hospital teams to improve the quality and timeliness of discharge summaries and strengthen communication between hospital and primary care.

“From what I see in my day-to-day work, having a DCO provides an important link between the hospital, the patient and their GP.  

We can identify gaps in communication or follow-up after discharge and work with patients, hospital staff and GP practices to address these early.

This gives patients greater confidence that their care does not stop when they leave hospital and helps GPs receive the information, they need to continue their care.

Expanding the program across West Moreton will extend this support to more patients and practices and further strengthen the connection between hospital and primary care,” said Ms Makaripe.

Ms Makaripe also reflected on the importance of hospitals having accurate information about a patient’s nominated regular GP.

“Accurate GP information is fundamental to ensuring continuity of care.

When we know who a patient’s regular GP is, we can ensure the right practice receives the relevant discharge information and can follow up with the patient appropriately.

I have seen how having the correct GP information can make the transition from hospital to the community much smoother.

It reduces communication gaps, supports timely follow-up and gives the GP a clearer picture of what has occurred during the patient’s hospital stay,” said Ms Makaripe.

Darling Downs and West Moreton PHN CEO, Ms Lucille Chalmers, said the project is an investment in enabling the community to access the care they need, and easing pressure for local hospital and health services.  

“We’re pleased to be extending the project across the West Moreton region, building on what we have learned through the pilot to support more patients and practices through greater continuity of care,” said Ms Chalmers.

The PHN is also encouraging patients to nominate a usual GP and practices to keep these details accurate and up to date to support the transition from hospital to primary care.