243. Straight Home: An initiative to reduce the number of discharge ready patients
Invited abstract in session HF-5: Innovation 4, stream Sessions.
Thursday, 15:30-17:00Room: St Olavs, Kunnskapssenteret KA11
Authors (first author is the speaker)
| 1. | Tone Beate Svee
|
| Trondheim Municipality | |
| 2. | Ida Rasmussen Bjerke
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| Trondheim Municipality | |
| 3. | Joe Viana
|
| Department of Industrial Economics and Technology Management (IØT), Norwegian University of Science and Technology (NTNU) |
Abstract
The South Trøndelag Health Partnership faces persistent challenges with high numbers of patients deemed ready for discharge, especially at St. Olavs Hospital, which reports up to 11,500 such days annually—the highest in Norway. Many of these patients could go directly home with enhanced follow-up, avoiding short-term municipal care. The “Rett hjem – forsterket utskriving” (Straight Home – Enhanced Discharge) initiative introduces an interdisciplinary discharge team to bridge hospital and municipal services. Its goals are to speed up discharges, increase direct-to-home transitions, and optimize municipal care use. In 2024, 1,318 patients from St. Olavs Hospital in Trondheim were classified as discharge ready—a number expected to grow due to aging demographics and seasonal pressures. Trondheim’s home care services, divided into 12 geographic zones, operate with small, fixed-schedule teams. Weekly interdisciplinary meetings support coordination, but safe hospital-to-home transitions require adequate staffing and competencies, especially for frail elderly patients. The project explores how municipalities can sustainably scale this model to manage fluctuating patient volumes while ensuring safe, high-quality care transitions. We invite the ORAHS community to contribute insights to improve the initiative’s delivery.
Keywords
- Integrated planning of health services
- Modelling and simulation
- Patient flow
Status: accepted
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