PROACT – A Journey of Integration& Collaboration of Health Services into Residential Aged Care

Abstract

Introduction: Residential Aged Care Facilities (RACFs) play an important role in the care of a group of older Australians who are rapidly increasing in numbers. They are often frail, dependent and are of high acuity. Demand for clinical care of RACF residents has increased, and there has been a shift in the characteristics of staff who care for them. It is now common practice in High Care facilities that the majority of direct care is provided by Assistants in Nursing and/or Personal Carers, who have little formal training. Sydney Local Health District (SLHD) in Sydney Australia has 77 Residential Aged Care Facilities (RACFs), with 4,576 beds. Description: In 2008 a telephone triage service, Aged Care Triage (ACT), was introduced to assist RACF’s to provide care to residents in the most appropriate setting. The service is staffed by experienced registered nurses. During the period July 2009 - June 2010 this service saved 2427 emergency department presentations across the District. The Access Care Team aims to provide the best care for residents of RACFs in the most appropriate setting by offering clinical advice and arranging services to support resident's care within the RACFs. It offers a partnership between RACFs, GPs and services of SLHD, by linking medical specialists and expert hospital nurses with GPs, ACAT/MAC, Sydney District Nursing and Palliative Care, with GPs and RACF staff.  The Access Care Team can arrange outreach or outpatient services for clinical issues such as ambulatory care appointments, behavioural issues, continence issues, IV antibiotic therapy, Palliative care, Wound care management.  The Access Care Team also has the capacity to facilitate and coordinate transfers to the most appropriate health services, such as appropriate emergency department if required. In 2010, funding was sourced to commence an RACF Outreach service. This compliments the ACT service. The outreach model was developed to improve access to primary health care for older people residing in RACFs and for the provision of face-to-face clinical nursing services to residential aged care facilities (RACFs) during the business hours period. Three senior nurses with extensive aged health experience are employed to provide a rapid and mobile outreach service to RACFs within SLHD catchment. They attend RACFs during business hours to resolve problems and prevent transfers or facilitate transfers to the Emergency Department. Aim, Theory, Targeted Population & Stakeholders: Together with relevant stakeholders the service and promotes an outreach model into residential care that: Builds on the existing ACT  Service which is a central point of contact, resource for all RACF within SLHD Utilises an existing care manual for  use within facilities to support RACF staff with evidence based algorithms for clinical care Provides regular targeted and group education for RACF staff Provide clinical coaching to RACF staff with all consultations. Promote collaborative work between acute care staff, RACF staff, GPs, Allied Health staff, families      and significant others across primary and secondary settings. Establish goals of care and  management plan for residents seen by the RACF outreach which facilitated efficiency of review in ED Enable the management of complex residents within the RACF Promote early intervention for highly complex residents Impacts: During the period June 2016 – January 2017 the RACF outreach team provided 777 occasions of service seeing 193 residents. 166 interventions ranging from care planning, medication review, complex wound management, comprehensive geriatric assessment, behaviour management, tube management and end of life planning Facilitation of geriatrician review. These residents would otherwise been transferred to one of the Districts ED’s. This small team of nurses have been able to sustain the model over a number of years while imparting clinical education to RACF staff to empower them to provide high quality care to frail aged residents. The right care, in the right place at the right time.