Out of Hours Support for RACHs

Enhanced out of hours support for residential aged care project

Background 

The Royal Commission into Aged Care Quality and Safety examined the complex issues being faced by Senior Australians at the interface of the primary health care and aged care systems. A lack of awareness and utilisation of available after-hours services, coupled with residential aged care home (RACH) staff who work after-hours often having a lower sense of confidence and skill, has resulted in potentially inappropriate and unnecessary transfers of residents to Gold Coast Emergency Departments (EDs) after-hours. This not only increases pressure on the health system, but also contributes to poorer health outcomes for this patient population. In response to this, the Gold Coast Primary Health Network (GCPHN) was funded by the Department of Health and Aged Care (DoHAC) to address this within the Gold Coast region. GCPHN engaged the Gold Coast Health Residential Aged Care Acute Support Service (RaSS Team) to lead the project, acknowledging their existing well-established working relationships with RACHs and other local primary care providers. 

Aims and Objectives 

The aims and objectives of this project include: 

• RACHs will have improved confidence to provide high quality after-hours care to residents through comprehensive facilities and GP after hours care plans, end of life and advance care plans.  
• Increased health professional and RACH staff confidence in referring outside of the ED when after-hours care is required with clearly defined after hours referral pathways  
• Increased access to timely information to RACH residents’ medical information, through comprehensive after hour plans and use of digital health tools.  

Outcomes 

The expected outcomes of this project include: 

• Participating RACHs will have developed and implemented individualised after-hours management plans, in line with residents’ wishes with the capability to maintain these plans where required.  
• RACHs will be mentored to better understand after-hours health care options and referral pathways and how to utilise these when appropriate.  
• RACHs will be supported to develop and embed procedures to ensure residents’ digital medical records are kept up to date, particularly where an after-hours episode of care occurs to support appropriate clinical handover and continuity of care.  
• RACHs will be supported to work collaboratively with their residents, GPs, and other health care professionals, to develop/review and update after-hours action plans as required.  

Project Activities 

Numerous successful activities were completed with the first participating RACH cohort, including training on use of The Viewer, Catheter Skills Refresh Workshops, two larger format events which separately focused on Palliative and End-of-Life Care and Dementia Behaviour Management, as well as individual capacity-building activities conducted onsite at RACHs.

An additional year of funding has enabled the RaSS team to continue their work on this project. Discharge of appropriate facilities from intensive support to a monitoring phase, allowed capacity to identify and onboard a new cohort RACHs in need of additional support.