Implementation and Evaluation of an Aboriginal Transfer of Care (ATOC) Model: Final Report

Transfer of care initiatives aim to improve transfer of care for patients to and from acute settings and back to primary care, i.e. GP and community. Aboriginal people with chronic conditions are more likely to leave hospital with incomplete transfer of care arrangements and to be readmitted after a recent hospitalisation. The South Western Sydney Local Health District (SWSLHD) Aboriginal Transfer of Care (ATOC) model extends traditional discharge planning to provide structured transfer of care for Aboriginal patients. A pilot of the ATOC model in Campbelltown Hospital decreased unplanned readmissions for Aboriginal patients with from 15.6% in January 2016 to 5.7% in April 2016. Following these promising findings, ATOC was also adopted at Liverpool Hospital.