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Post-hospital care approach sees resident ED visits plummet


The team behind a successful intervention to reduce hospital readmission among aged care residents is looking at ways to facilitate its widespread adoption as a new standard of care.

A collaborative study between researchers at UNSW Medicine’s Centre for Healthy Brain Ageing (CHeBA), St George Hospital in Sydney and Calvary Health Care developed and tested the Regular Early Assessment Post-Discharge (REAP) intervention for aged care residents at 21 facilities in the local catchment area.

It involved a specialist geriatrician and nurse practitioner monitoring the care of residents through seven regular monthly visits at their facilities.

A lack of specialist clinical input within facilities is a key factor in aged care residents being re-hospitalised, an outcome that is frequent, costly, potentially avoidable and associated with poor survival and diminished quality of life, said lead researcher Dr Nicholas Cordato.

The study demonstrated REAP’s effectiveness and is now being used to advocate for broad implementation of the model, said Dr Cordato, senior lecturer at UNSW and senior staff specialist at St George and Calvary Hospitals.

“REAP is associated with almost two-thirds fewer hospital readmissions and half as many emergency department visits compared with usual care of nursing home residents after hospital admission,” Dr Cordato told AAA.

“Importantly, the intervention is cost-effective with total costs 50 per cent lower in residents receiving the REAP intervention compared with matched controls.”

While there is clear justification for REAP to be more widely implemented from a financial perspective, access to sufficient numbers of appropriately trained specialist staff was likely to be prohibitive for many health services, said Dr Cordato.

“We are now looking at ways to facilitate the broader adoption of this model of care, in particular with man-power constraints in mind.

“Our group is looking to streamline these processes by focusing on aspects of the REAP intervention which appeared to be most effective in our analyses.”

The research team is planning to undertake a follow-up randomised-controlled study examining the effectiveness of this streamlined approach.

“If proven beneficial, we plan to use our findings as a platform to advocate for implementation of this intervention as standard clinical practice across all health districts,” he said.

The findings of the randomised-controlled study examining the effectiveness of REAP are published in the March issue of JAMDA, the Journal of Post-Acute and Long-Term Care Medicine.

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