RACF residents have disproportionately high demands for acute medical services, frequently presenting to emergency departments, with many requiring hospital admission.4,5 Unnecessary admissions to emergency departments and hospitals, owing to relatively minor and repeated health problems, or lack of appropriate end-of-life care plans,6 can be prevented with timely provision of primary care. This is particularly important given unnecessary hospital attendances can expose residents to potential complications (eg hospital-acquired infections, falls, disorientation).7
To succeed in this way in the after-hours period, resident care must be coordinated between RACF staff and GPs or other medical practitioners providing care (refer to Part B. Collaboration and multidisciplinary team-based care ). This coordination should include the documentation of GP preferences for resident care, including processes to follow up with the GP, in appropriate circumstances, prior to arranging an ambulance transfer (which may in fact be unnecessary).
Collaborative care models between nurse practitioners and GPs increase the former’s ability and availability, allowing them to provide more primary care services in RACFs.8 Under the guidance of a GP, with initial training and ongoing support and collaboration, nurse practitioners are able to provide comprehensive assessment, communicate acute care needs to the GP and facilitate care within the RACF.
In turn, increased primary care within the RACF addresses many of the factors that lead to unnecessary emergency department and hospital admissions. In order to succeed in such a collaborative care model, there needs to be buy-in from all stakeholders, including key clinical staff and health service management/executive. Greater buy-in for GPs may require encouragement; for example, funding to support the provision of after-hours care.
Collaborative and coordinated care
Because of the complexity of multidisciplinary care needs and multiple care providers, systems of care and collaborative arrangements need to be clearly defined and documented to ensure access to safe and timely comprehensive and high-quality care. Collaborative arrangements between the RACF and GP:
- strengthen the relationship between RACFs and GPs 9,10,11,12
- ensure residents can access appropriate care 24 hours a day
- help maintain continuity of care for residents13,14
- potentially prevent avoidable hospital presentations and admissions.8,15
Care coordination between the RACF, primary care and acute health services influences the quality of care in RACFs. Communication and information sharing between services are seen as vital to providing high-quality care to residents.16 Coordination needs to extend into the after-hours period in order to maintain continuous and comprehensive care.
Effective clinical handover of care of RACF residents is critical in the after-hours period. This includes access to current health information and qualified RACF staff involved in the ongoing care of residents. Clinical handover of resident care to other members of the RACF and external care providers occurs frequently (refer to Part B. Medical records at residential aged care facilities ). Lack of, or inadequate, transfer of care is a major risk to resident safety. It can result in serious adverse patient outcomes, including:
- unnecessary hospitalisation
- delayed treatment
- delayed follow-up of significant test results
- unnecessary repeats of tests
- medication errors.
As such, RACFs need to ensure GPs providing after-hours care have access to staff and clinical handover material that supports continuous care to all residents. This may come in the form of, or combination of:
- GP and staff briefings
- handover notes
- access to facilities and equipment
- on-call and emergency contact details.
GPs working in the after-hours period must have access to appropriate handover contacts and can request to have access to the RACF’s information technology systems, software (including residents’ shared health summary/record or event summary) and secure messaging used by other RACF staff. Wherever possible, GPs could also take part in face-to-face handover.
Effective infrastructure and supports can help to ensure the same level of care can be provided to RACF residents in the after-hours period as during usual consulting hours.
GPs and other members of the RACF care teams need to have timely access to advice around the management of all RACF residents. This is a particular concern in the after-hours period when key personnel may not be available in person. For some residents, such as difficult psychogeriatric patients, advice may need to be immediate. Investment in online technologies and telehealth will give care teams at rural and remote RACFs greater access to timely specialist advice (refer to Part B. Older people in rural and remote communities ). It also provides GPs working in these facilities with a peer-to-peer education and collaboration platform.
RACFs, particularly in rural areas, need increased investment across a broad range of infrastructure and supports (eg built infrastructure and bed capacity). Built infrastructure in the form of a treatment room in RACFs would ensure a more cost-effective service solution by avoiding unnecessary transfer to hospitals and other facilities.