Liaison nurses support transition from hospital to home

Regaining independence at home after a hospital stay can be difficult for older people, with the period after a hospital admission representing increased risk of falls and other health issues.

Bolton Clarke’s District Liaison Nurse Anja works within The Alfred Hospital – one of 17 hospitals supported by on-site Bolton Clarke teams – to link patients with the right support to make the transition back to independent living.

“Being a liaison here allows me to assist in discharges with people requiring more assistance at home,” Anja said.

“There are a lot of people who are vulnerable in our communities, including older people who require that extra support and care after coming from hospital.

“It could be anything from cognition, mobility, wound or other types of care need that they can’t manage themselves and still require that nursing support at home,” she said.

Anja’s unique role as a District Liaison Nurse is one that has been around since the 1960s in The Alfred Hospital in Melbourne when aged care needs were becoming apparent within our communities.

“When I was in university, we knew then there was going to be a massive need for our aged care services to be well-armed with nurses.

“When I was working in rehabilitation aged care I saw a District Nurse Liaison working with families.

“I saw her work, heard her speak and thought ‘yes, I want to be like you’ and here I am.

“My role has fulfilled all my reason as to why I wanted to become a nurse.”

Anja said Bolton Clarke’s focus on step-down and transition care also included key research projects to reduce frailty and improve social connection for people after discharge from hospital.

“There are two projects running at the moment - Connecting Communities to Care, which involves designing a community-wide social connection model of care and sits in our local district of Glen Iris, and Being Your Best which involved targeted interventions to address frailty and recruits from the hospital with the Bolton Clarke Research Institute.

“Wellness and reablement is the key for these projects.”

This week is Nursing in the Community Week (September 12 – 18) and celebrates the roles nurses take in coordinating and connecting our communities.