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Stanthorpe resident Doreen Shardlow is defying the odds – despite turning 98 years old this week, she still lives at home and hasn’t had a hospital presentation since Christmas of 2023.
It’s a feat of independence she puts down to the Darling Downs Health Rural Community Integrated Care (CIC) service – a new and innovative service designed to provide continuous healthcare and support, while keeping residents out of hospital where possible.
The Rural CIC is a collaboration between nursing and pharmacy staff to identify patients and consumers in hospital who may require more support accessing or managing their medications once they leave hospital to go home.
Through regular home visits, Darling Downs Health nurses and pharmacists can then ensure residents are continuing to take their medications, while providing important face-to-face wellness checks, long after they’ve been discharged from hospital.
Ms Shardlow said her weekly interactions with Stanthorpe Hospital Advanced Practice Pharmacist, Kay Knight, and Clinical Nurse Consultant, Marsha Clark, had been vital to her continued good health.
“My family lives away and I wouldn’t be here without these ladies coming every week,” Ms Shardlow said.
“I’ve had sore legs and they’ve been coming here twice a week to dress my legs and check my blood pressure and everything else, and it gives me that peace of mind.
“I haven’t been to hospital since I got Covid at Christmas last year (in 2023), and before that, I was in and out of hospital all the time. But that’s all stopped now, thanks to this service.
“I’m 98 years old and I would not be here without them.”
Advanced Practice Pharmacist Kay Knight said the Rural CIC allowed different teams within the hospital service to join forces to deliver community-based care to the consumers who needed it most.
“To me, that community-based care should be care delivered post-discharge, or to people in their homes, to try and keep people at home,” Ms Knight said.
“We also have a great relationship with the local GPs and Medical Officers at the hospital who are already familiar with the patients and have cared for them acutely, so often they will tell us if there’s someone we should keep an eye on, or something to monitor in their post-discharge plan.”
The service is already having a real impact on hospital readmissions in Stanthorpe, with a 34 per cent reduction in hospital readmissions over a 12-month period for people with complex discharge needs like Ms Shardlow.
During that same 12-month period, Stanthorpe Hospital avoided more than 330 hospital admissions and more than 240 emergency department presentations as a direct result of Rural CIC interventions at home.
Stanthorpe Hospital Clinical Nurse Consultant, Marsha Clark, said the service’s key focus was on ensuring continuous health care could be delivered at home, or as close to the home, as possible.
“There’s such satisfaction in keeping people out of the institutionalised environment of a hospital and be able to see them stay in their home environment,”
Clinical Nurse Consultant, Marsha Clark
“Because a home might not be completely perfect, but at the end of the day, it’s home.”
Ms Knight said the community feedback from the Rural CIC surveying had been overwhelmingly positive.
“We’ve done surveys with people and they’re saying, ‘now I understand my medication better’, or ‘now I feel more in control of my health’,” she said.
“That feedback is what really makes a difference.”
The Darling Downs Health Rural CIC team is currently looking to expand the service to Inglewood, Millmerran and Texas, and is also working in partnership with the South West Hospital and Health Service to expand this model of care to other rural communities.