Residential Aged Care Facilities Staff Research Articles

Comparison of end-of-life care for people living in home settings versus residential aged care facilities: A nationwide study among Australian general practitioners.

We have little knowledge of differences in end-of-life care between home settings and residential aged care facilities (RACFs) where people spend most of their last year of life. This study aimed to compare end-of-life care between home settings and RACFs from the perspective of Australian general practitioners (GPs). A descriptive study was conducted with 62 GPs from Western Australia, Queensland and Victoria. Participants were asked to provide reports on end-of-life care of decedents in their practice using a validated clinic-based data collection process developed by our team between September 2018 and August 2019. Of the 213 reported expected deaths, 66.2% mainly lived at home in the last year of life. People living at home were more likely to die at a younger age (median 77 vs. 88, p<0.001), to be male (51.1% vs. 33.3%, p=0.01) and to die of cancer (53.9% vs. 4.2%, p<0.001) compared to those in RACFs. There were no significant differences between the two patient groups for seven out of the eight assessed symptoms, except nausea. GPs' perceived roles in caring for patients and levels of their involvement in provision of common palliative care services were comparable between the two groups. The usual accommodation setting was most frequently considered the preferred place of death in both groups. However, more home residents ended up dying in hospital compared to RACF residents. There were significantly higher frequencies of end-of-life discussions (ORs ranged 5.46-9.82 for all topic comparisons) with GPs associated with people living at home versus RACFs. One opportunity for improved care is through promoting greater involvement of GPs in end-of-life discussions with RACF residents and staff. In general, more Australians could potentially remain at home until death if provided with greater access to essential specialist palliative care services and supportive services in home settings.

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19.

Resource assessment in trials undertaken in residential care homes: Experiences from the Australian MIDDEL cluster randomised controlled trial research team

BackgroundThe resources involved in delivering a clinical trial in residential aged care facilities (RACFs) are significant and the success of a trial is dependent upon adequate planning, including appropriate timelines for each component of the study and the required budget. This paper describes process and resource assessment during recruitment, collection of outcome measures and intervention delivery, and presents learnings and considerations for conducting trials in RACFs with people living with dementia. MethodsData were collected across 24 clusters in 12 RACFs over 18 months during a cluster randomised controlled trial which was testing the effectiveness of music interventions in people living with dementia. Data were collected on resources required for recruitment and assessment of baseline data, as well as reasons for participant non-attendance at the interventions. ResultsTime between contacting next of kin and receiving formal consent often exceeded 45 days. The ratio of time between direct and indirect research activity was approximately 1:2. Participant intervention adherence is at risk from unplanned RACF lockdowns and reasons for non-attendance include those both related directly to the participant and to staff resources, scheduling or other practical considerations. ConclusionsResearch planning should focus on building relationships with RACF staff and resident families, factor in adequate time for recruitment in the study timeline and consider budgeting for backfill of RACF staff during data collection phases to expedite the process and ensure adherence to study protocol timelines. Trial registration Australian and New Zealand Clinical Trial Registry: ANZCTR12618000156280, 1/02/2018, http://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618000156280A

Preliminary Research: Virtual Reality in Residential Aged Care to Reduce Apathy and Improve Mood

This study determines the feasibility of using virtual reality (VR) for residents with and without dementia in the residential aged care (RAC) environment (also referred to as nursing homes or long-term care). A mixed-methods study was conducted with 13 residents of varying cognitive capacity in a residential aged care facility (RACF) operated by a not-for-profit organization in Brisbane, Australia. Residents participated in one facilitated VR session, either as a group or individual session. Residents' mood and apathy were measured by the Observed Emotion Rating Scale (OERS) and the Person-Environment Apathy Rating Scale. Residents also completed a structured interview to provide their feedback after the VR session. In addition, four RACF staff members were interviewed about their experience of using the VR in residents and the ongoing feasibility. The experience of VR administered by a researcher and leisure and lifestyle coordinator as a leisure activity, significantly reduced apathy in residents (Z = -2.818, p = 0.005) through observations of increased facial expression, eye contact, physical engagement, verbal tone, and expression. The study did not find a VR impact on the OERS measures; no significant increase in fear/anxiety was observed. Reminiscence was clearly observed in six of the nine residents with the ability to verbally communicate. VR was found not to be helpful in residents during episodes of acute neuropsychiatric and behavioral symptoms. This study suggested feasibility of using fully immersive VR delivered by mobile phone technologies. It provides preliminary data for a controlled trial presently underway examining the effectiveness of VR as a group activity in RAC to improve mood states, behavioral symptoms, and pro re nata psychotropic medication use. Residents indicated that VR was enjoyable with low levels of physical and emotional discomfort reported or observed.

Teaching strategies and activities used for students' clinical placement in residential aged care facilities: a scoping review protocol.

The objective of this scoping review is to examine and map current knowledge of teaching strategies and activities used with nursing students during clinical placements in residential aged care facilities. Residential aged care facilities provide opportunities for nursing students to develop skills and interest in caring for older adults. Studies that address students' clinical placements in these settings highlight the benefits of and concerns with their experiences. Insight into the state of knowledge regarding teaching strategies used in residential aged care facilities could benefit nursing education programs and help to ensure student learning is maximized. This scoping review will consider research and narrative reports on teaching activities and strategies used by nursing faculty and residential aged care facility staff in teaching nursing students. The concepts of interest include planned and intentional activities and strategies used to facilitate student learning and student clinical experiences. A clinical experience is defined as when a student enters a residential aged care facility and is assigned an individual or individuals to care for. This scoping review will aim to locate published and unpublished literature employing a three-step search strategy. Only papers published in English from 1992 onward will be included. Data extracted from eligible papers will include details on the participants, context, strategy, activity and outcomes. Extracted data will be reported in a tabular form and presented narratively to address the review objective.

Evaluating the use of interactive virtual reality technology with older adults living in residential aged care

Background and objectivesAs technologies gain traction within the aged care community, better understanding their impact becomes vital. This paper reports on a study that explored the deployment of virtual reality (VR) as a tool to engage older adults in Residential Aged Care Facilities (RACF). The paper has two aims: 1) to identify the benefits and challenges associated with using VR with residents in aged care settings, and 2) to gather the views of older adult residents in RACF about the potential uses of VR in aged care. Research design and methodsFive RACF residents and five RACF staff members took part in an intensive two-week evaluation of a VR system. Qualitative data was collected from multiple interviews and via researcher notes and video recordings made during the VR sessions. ResultsResults highlight the usability issues that impacted on the aged care residents' ability to use interactive VR technology and the potential negative impact head mounted displays can have on those living with dementia; the role that VR can play in engaging residents who might otherwise self-isolate, and how this can extend to increased engagement with family and friends. Discussion and implicationsWe discuss the design challenges that will need to be met in order to ensure that interactive VR technology can be used by residents living in aged care, and the potential for VR to be used as a tool to improve the quality of life of some older residents, particularly those for whom traditional social activities do not appeal.

Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

ObjectivesThe “Goals of Patient Care” (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF). DesignThe study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences. Setting and participantsThe study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained. MeasuresThe primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates. ResultsMore than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016). Conclusions and implicationsIn the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Cost-effectiveness of professional oral health care in Australian residential aged care facilities.

To conduct a model-based cost-effectiveness analysis, from a health care system perspective, of using oral health professionals to provide oral hygiene services at residential aged care facilities (RACFs) in Victoria, Australia, compared to current practice (CP). Increasingly dentate cohorts of older adults are entering RACFs, making urgent the need of further development and provision of oral health programmes in ageing dentitions. The model was based on 47624 RACFs' places in Victoria over one year. The main outcome measured was "cost per pneumonia case averted." Four different scenarios of oral hygiene provision were compared to CP. Costs included were RACF staff training, professional salaries, programme coordinator office expenses, dental equipment and hospitalisation costs. Effectiveness assumptions for each scenario were based on systematic reviews and randomised control trials. All four scenarios were dominant strategies. The magnitude of negative incremental cost-effectiveness ratio was not informative; therefore, incremental costs and incremental effectiveness were used to present results. "Professional oral health care (POHC) provision once every two weeks and current provision of oral health care the other days" was the most cost-saving alternative (AU $896 per resident saved). The most effective alternative was "POHC provision once a week and non-POHC provision by trained Nurse aids twice per day the other days" (6779 pneumonia cases averted). One-way sensitivity analyses confirmed the robustness of results. The four scenarios were highly cost-effective compared to CP. These results could be a strong basis to implement new oral health programmes in Australian RACFs.

Understanding barriers to effective management of influenza outbreaks by residential aged care facilities.

ObjectiveTo identify the perceived barriers to the implementation of the Australian national guidelines on influenza outbreak management with Sydney Local Health District (SLHD) residential aged care facility (RACF) staff.MethodsAll SLHD RACFs were invited to participate in a telephone interview. The questionnaire collected information about demographic characteristics and participants' level of agreement with statements regarding perceived barriers to implementing the national guidelines for influenza outbreak management.ResultsTwenty‐eight of 61 RACFs (46%) participated in the study. The three most common barriers identified were as follows: scepticism towards staff influenza vaccination (n = 13, 46%); the effort required to read the national guidelines (n = 11, 39%); and lack of infrastructure to physically separate residents during an outbreak (n = 10, 36%).ConclusionsWe recommend implementing and evaluating programmes which address misconceptions about influenza vaccination amongst RACF staff. Further, all RACF staff, including care staff, should receive targeted education on the role of infection control in influenza outbreak management.

An integrated oral health program for rural residential aged care facilities: a mixed methods comparative study

BackgroundPeople in residential aged care facilities (RACF) are at very high risk of developing complex oral diseases and dental problems. A multidisciplinary approach incorporating oral health professionals and RACF staff is important for improving and sustaining oral health in RACFs. However, difficulties exist with access to oral health services for RACFs, particularly those in regional and rural areas. This study investigated the impact and experience of an integrated oral health program utilising tele-dentistry and Oral Health Therapists (OHT) in RACFs in a rural setting within Australia.MethodsA mixed method comparison study was undertaken. Two hundred fifty-two clinical audits were completed across nine facilities with and without access to the integrated oral health program. Twenty-seven oral health quality of life surveys were completed with eligible residents. One focus group discussions (FGD) and eight interviews were completed with RACF staff. Thematic analysis was conducted on the transcribed FGDs and IDIs. Quantitative data were analysed using descriptive statistics.ResultsAudits showed an improved compliance to Australian Aged Care Quality Accreditation Standards for oral health in the facilities with access to the integrated program compared to those without the program. Thematic analysis revealed that facilities with the integrated program reported improvements in importance placed on OH, better access to OH services and training, and decreased disruption of residents, particularly those with high care needs.ConclusionsThe integrated oral health program incorporating OHTs and tele-dentistry shows potential to improve the oral health outcomes of residents of RACFs. Improvements for managing oral health of residents with high care needs were observed. RACFs without easy access to an oral health service will also likely benefit from the increased support and training opportunities that the program enables.

Factors influencing decision-making processes for unwell residents in residential aged care: Hospital transfer or Residential InReach referral?

To investigate decision-making around hospital transfer and/or referral of residents to a Residential InReach (RiR) service in north-eastern metropolitan Melbourne, Australia, from the perspectives of residential aged care facility (RACF) staff, general practitioners (GPs) and RiR registered nurses (RNs). Thirty-one staff from eight RACFs, five GPs and four RiR RNs participated in individual or group interviews. Residential aged care facility staff and GPs valued and relied upon RiR to manage unwell residents. Thematic analysis identified RiR utilisation was driven by the following: (i) complexity of decision-making processes in RACFs; (ii) variability in facility-based medical and nursing care; and (iii) impact of RiR service outcomes on patients and referrers. Availability of timely and appropriate medical and nursing care in RACFs was reported to influence transfers to the hospital and/or referrals to RiR. RiR was used to complement or substitute usual care available to residents. Further research and improvements in RACF and RiR resources are required.

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

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.

Person-centered care and engagement via technology of residents with dementia in aged care facilities.

Touchscreen technology (TT) is a resource that can improve the quality of life of residents with dementia, and care staff, in residential aged care facilities (RACF) through a person-centered care approach. To enable the use of TTs to engage and benefit people with dementia in RACFs, education is needed to explore how these devices may be used, what facilitates use, and how to address barriers. We sought to provide education and explore RACF staff views and barriers on using TT to engage their residents with dementia. An educational session on using TT with residents with dementia was given to staff from three long-term RACFs in Melbourne, Australia. A cross-sectional convenience sample of 17 staff members (personal care attendants, registered nurses, enrolled nurses, allied health clinicians, and domestic staff) who attended were administered questionnaires pre- and post-sessions. As a result of the education seminar, they were significantly more confident in their ability to use TT devices with residents. TT, and education to staff about its use with residents with dementia, is a useful strategy to enhance RACF staff knowledge and confidence, thereby enhancing the use of technology in RACFs in order to improve care standards in people with dementia.

"Bringing the outside world in": Enriching social connection through health student placements in a teaching aged care facility.

BackgroundOlder adults living in residential aged care facilities (RACFs) often experience limited opportunities for social connection despite close proximity to peers, which has implications for mental health and quality of life (QoL). The introduction of large‐scale undergraduate health student placements in RACFs may enhance opportunities for meaningful engagement through social connection, although this remains unexplored.ObjectiveThis research explores whether interpersonal encounters between health students and RACF residents influence residents’ opportunities for social connection and QoL.MethodsA mixed methods design was employed which included questionnaire data from residents, and qualitative interview data from residents, family members and RACF staff. Data were collected during and after student placements to allow for an in‐depth exploration of residents, family members and staff perspectives.ResultsForty‐three participants (28 residents, 10 staff and five family members) were recruited during 2014. Overall, many residents had clinical levels of depression, mild cognitive impairment and multiple morbidities, however reported moderate‐to‐good QoL. Thematic analysis was undertaken on interview transcripts, and three themes emerged: (i) social isolation and loneliness fostered by residents’ age‐related conditions, (ii) students expand socially supportive connections beyond the RACF and (iii) meaning making by sharing health experiences, which was found to help renegotiate older adults’ pervasive narrative of vulnerability.ConclusionSupported and structured health student placements in RACFs enable older adults to participate in meaningful encounters with younger people. These encounters focus on sharing health experiences and address long‐standing issues of isolation and loneliness by providing opportunities for social connection.

Using action research to build mentor capacity to improve orientation and quality of nursing students' aged care placements: what to do when the phone rings.

To describe whether an action research approach can be used to build capacity of residential aged care facility staff to support undergraduate nursing students' clinical placements in residential aged care facilities, using development of an orientation programme as an exemplar. Aged care facilities are unpopular sites for nursing students' clinical placements. A contributing factor is the limited capacity of staff to provide students with a positive placement experience. Strategies to build mentor capability to shape student placements and support learning and teaching are critical if nursing students are to have positive placements that attract them to aged care after graduation, an imperative given the increasing care needs of the ageing population worldwide. Action research approach employing mixed-methods data collection (primarily qualitative with a quantitative component). Aged care facility staff (n=32) formed a mentor group at each of two Tasmanian facilities and met regularly to support undergraduate nursing students (n=40) during placements. Group members planned, enacted, reviewed and reflected on orientation procedures to welcome students, familiarise them with the facility and prepare them for their placement. Data comprised transcripts from these and parallel student meetings, and orientation data from student questionnaires from two successive placement periods (2011/2012). Problems were identified in the orientation processes for the initial student placements. Mentors implemented a revised orientation programme. Evaluation demonstrated improved programme outcomes for students regarding knowledge of facility operations, their responsibilities and emergency procedures. Action research provides an effective approach to engage aged care facility staff to build their capacity to support clinical placements. Building capacity in the aged care workforce is vital to provide appropriate care for residents with increasing care needs.

Role of information and communication technology in promoting oral health at residential aged care facilities

Information and communication technology (ICT) can provide knowledge and clinical support to those working in residential aged care facilities (RACFs). This paper aims to: (1) review literature on ICT targeted at residents, staff and external providers in RACFs including general practitioners, dental and allied health professionals on improving residents' oral health; (2) identify barriers and enablers to using ICT in promoting oral health at RACFs; and (3) investigate evidence of effectiveness of these approaches in promoting oral health. Findings from this narrative literature review indicate that ICT is not widely used in RACFs, with barriers to usage identified as limited training for staff, difficulties accessing the Internet, limited computer literacy particularly in older staff, cost and competing work demands. Residents also faced barriers including impaired cognitive and psychosocial functioning, limited computer literacy and Internet use. Findings suggest that more education and training in ICT to upskill staff and residents is needed to effectively promote oral health through this medium.

Investigating the current methods of assessing behavioral and psychological symptoms in residential aged care facilities in a metropolitan city.

Up to 90% of people with dementia living in residential aged care facilities (RACFs) display behavioral and psychological symptoms of dementia (BPSD), and these are associated with poorer quality of life and increased morbidity and mortality. In order to implement appropriate interventions, it is important to understand the symptoms in more detail. Despite the availability of BPSD assessment tools, it is unknown what the current practice of monitoring of BPSD in RACFs. We sought to investigate the current BPSD assessment tools being used in RACFs and explore different stakeholders' views on current practices. A cross-sectional convenience sample of 21 clinicians were identified and administered a questionnaire. Old age psychiatrists, aged psychiatry clinicians, behavior management teams and RACF staff completed the questionnaires. Clinicians reported that objective consistent information about BPSD were important for recommending and implementing pharmacological and non-pharmacological strategies for BPSD; however, the use of validated BPSD assessments in RACFs was not a usual part of clinical practice. RACF staff stated the major barrier to assessment of BPSD was lack of time. Alternate methods of assessing BPSD which consider preferences from clinicians and RACF staff should be further investigated. Modern technology which can allow "real time" assessment may be a solution.

Optimising healthcare ICT support for the care and management of elderly adults with mental illness in residential aged care facilities

The global increase of adult mental illness (Dementia and Alzheimer) in the 65 years and older age group, pose unique treatment challenges to residential aged care facility staff. Current residential aged care mental illness treatment plans for elderly adults are not customised according to individual personal needs. Such customization requires inputs from multiple stakeholders i.e. mentally ill adults, carers, medical professionals and clinicians, community mental healthcare service providers, family/relatives and friends. This research aims to develop an integrated ICT framework that supports customised treatment plans for adults with mental illness in residential aged care facilities. This research-in-progress outlines initial stages of a novel methodology to better support and enable individual care and treatment of adults with mental illness in residential aged care facilities. Application of this methodology will 1) identify key information needs for individualised mental illness treatment plans, 2) integrate and consolidate multiple information sources, 3) enhance aged care facility carers’ experience and understanding of the impact of mental illness on human behaviour, and 4) implement innovative ICT solutions that support individualised care and treatment plans.

Developing networks between residential aged care facilities as a result of engagement in a falls prevention project: an action research study

Background: Residential aged care facility (RACF) staff often operate in isolation. Research is lacking on networking between facilities. Aims: To explore outcomes associated with network formation between two RACFs as part of an action research approach to reducing falls. Design: Action research approach with qualitative data collected. Methods: Twelve RACF staff from two facilities in regional Tasmania, Australia, formed a falls prevention action research group. Thematic analysis was undertaken of 22 audio-recorded fortnightly group meetings. Results: This was the first opportunity for participants to meet colleagues from another facility in a professional context. The formation of an inter-facility network enabled the sharing of ideas and systems related to evidence-based falls prevention activities and other issues and galvanised a collaborative focus for action. Conclusions: An action research process can be used to create an inter-facility network. Such networks can decrease staff isolation and facilitate best resident care.

Exploring the Ambulatory Transitional Care Experience from Residential Aged Care Facilities (RACF) to Ambulatory Care Services

Abstract Objective(s): To explore the transitional care journey through Ambulatory care Services (ACS) for older residents from Residential Aged Care Facilities (RACF). To develop a clearer understanding of older residents needs and any gaps in current services provided; and to inform the development of a model of care to improve the resident’s transitional care journey. Study Design: A qualitative project design using extensive stakeholder engagement Method: The Ambulatory Care (AC) experience was explored through semi-structured interviews with residents and their carers to determine gaps in transitional care continuity. Focus groups with RACF and ACS staff were also utilized. Journey mapping was used to support anecdotal evidence. Results: Three residents and 2 carers were interviewed and a total of 40 RACF and ACS staff attended 5 focus groups. Principal Findings: Qualitative data analysis identified four main themes across the transition journey: Inconsistent and adhoc communication; Just waiting around; Is it doing more harm than good?; and Unmet expectations. Conclusion: The results of this study have highlighted shortcomings in the provision of quality care in this transitional care group of older clients. A collaborative approach across organizational boundaries is necessary to ensure the development of an integrated person centered model to ensure the best transition to ambulatory care for RACF residents exists.