The ACT primary health network has joined other PHNs around Australia initiating programs to provide expert, coordinated and collaborative health care to aged care facility residents.
On 25 October it began the trial of its Geriatric Rapid Acute Care Evaluation (GRACE) program, which aims to improve the healthcare journey and avoid presentations to the Calvary Public Hospital’s emergency department (ED) when other options are available.
In the first week of operation, GRACE organised alternative arrangements for the following three potential ED admissions:
- an ambulance service referral to a nurse rather than resident pick up;
- organisation of a syringe pump for a resident requiring palliative care; and
- a nurse going into the facility to provide treatment for a resident.
The ED also saw two to three patients a day with a nurse on hand to fast track the residents’ treatment to enable a speedy and safe discharge back to their residential care facility.
“We developed GRACE after conducting a needs assessment of our older population to identify service gaps, as required by the Commonwealth health department funding arrangements,” Julie Porritt, ACT PHN’s innovation and improvement general manager told Australian Ageing Agenda.
“The GRACE pilot program recognises that many aged care residents experience significant difficulty and avoidable anxiety seeking treatment for non-life threatening, acute care needs.”
She said the program fostered collaboration between a resident’s general practitioner, the five participating facilities and nursing and medical staff at Calvary Public Hospital.
“It offers all parties and family an alternative process that is designed to have a patient’s assessment and treatment undertaken in the patient’s residential care setting,” Ms Porritt said.
She said they were confident the GRACE pilot would provide multiple benefits to residents and their various care providers.
“At this early stage we have already seen the different care providers collaborating to provide patient-centred care for a number of residents. Residents benefit from less disruption and anxiety by being treated in their residence.
“If a patient’s condition is serious enough to warrant a hospital admission, this is also coordinated between the GRACE team and the Calvary Public Hospital Emergency Department,” Ms Porritt said.
The resident’s GP and family together with the facility staff and Calvary clinicians create a care plan with an agreed goal for the resident, she said.
Similar schemes are occurring around Australia, with the Brisbane North PHN detailing its (GOAS) trial in July (read our story here).
GRACE differs from GOAS in that it is driven by Calvary’s ED rather than GOAS’ geriatrician-led model – similar to some Victorian PHN programs – as the driver.
GRACE was developed taking into account other PHN programs and pilots, including the Metro North Hospital and Health Service’s (MNHHS) residential care liaison service from Redcliffe Hospital (read our story here).
It also references Rapid Assessment of the Deteriorating Aged at Risk (RADAR), which is directed at older people in community settings.
GOAS was outlined at the recent Leading Age Services Australia conference, where Michele Smith from Brisbane North PHN described the success of the 12-month pilot phase.
GOAS has hit its six-month target three months ahead of schedule. Three aged care residents per day are accessing the GOAS and by the end of September this year it had provided 225 specialist outreach services to facilities along with 31 training sessions on the GOAS clinical pathways to 281 facility staff, she said.
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This will be very interesting to watch unfold. Maybe TCH (canberra hospital) will come on board.
It will be interesting to see the outcomes and effectiveness of this program especially for residents with a diagnosis of dementia when a hospital transfer can be very unsettling for all involved. If a resident can stay in their familiar environment the end result should be better. I am sure facilities without RN/EEN coverage will benefit greatly.
We had a very positive experience with the Grace Team in November when my husband suffered a seizure when in residential aged care. The Grace team saw us while he was in A & E, continued to see him while he was in hospital, and made follow up visits once he was back in care. It was reassuring to have such continuity of professional care, for us and for the Care staff.
I sincerely hope that this is a service that is implemented widely.
My mother who is 94,in aged care, has Dementia and multiple other health concerns, has been treated by the GRACE team members from Canberra Calvary, on several occasions.
It is a fantastic service which I was nervous about being discontinued.I am delighted that the service will continue. The team are caring and professional and will always contact me to keep me in the loop regarding Mum’s treatment and progress.WELL DONE GUYS..KEEP UP THE FANTASTIC WORK THAT YOU DO FOR OUR ELDERLY!!!Pauline
What a fantastic idea.
How do we become involved as Registered Aged Care Nurses