Right care, first time: Decision support for post-discharge pathways in general medicine

Unplanned readmissions in General Medicine at the RMH have risen from 12.7% to 16.8%, coinciding with a reduction in average length of stay from 7 to 5.7 days. This suggests discharge planning is not keeping pace with the speed patients are moving through the system. There is an increasing number of after discharge services for clinicians to remember leading to variation in care.

My project will use routinely collected Electronic Medical Record (EMR) data to identify which post-discharge services reduce unplanned readmission and for which patient cohorts. This will guide clinicians toward the right post-discharge pathway earlier, ensuring patients receive targeted care and remain at home after discharge.

The MacHSR Future Leaders Fellowship will support me by consolidating experiences in clinical practice and continuous improvement into independent health service research, providing the mentorship and peer network I need to grow as a researcher and translate this work into practice. For RMH, the fellowship creates the protected time needed to address challenging quality indicators and has the potential to improve resource allocation and reduce pressure on hospital capacity.