Professor Gillian Harvey, Knowledge Translation, Caring Futures Institute, Flinders University
Acute hospitals face ongoing problems with ambulance ramping, waiting times, bed shortages and delayed discharges, all impacting patient flow through the system. Whilst many initiatives aim at solving ‘front door’ problems, for example by finding ways to by-pass the Accident and Emergency department, equal problems exist at the ‘back door’, in terms of timely and effective discharge and transitions out of hospital. This is particularly a problem for older people, especially those awaiting an aged care package and/or placement in a residential care home. Through our transdisciplinary research projects at Flinders University in South Australia, we are working in collaboration with older people, and the health and aged care services that care for them, to co-design and evaluate workable solutions.
In an initial exploratory study, we partnered with Council on the Ageing SA to seek the views and experiences of older people who had experienced multiple unplanned hospital presentations over the course of a year. Older people described the fragmentation of care they experienced and the sense that there was ‘Something Missing in the Middle’.[1] This informed the development of a statewide project, ‘STAAR-SA’: State Action on Avoidable Rehospitalisations and Unplanned Admissions across South Australia, where researchers at the Registry Of Senior Australians (ROSA) developed a profile of older people who present frequently at hospital and an algorithm to predict the risk of re-presentation and hospitalisation. These analyses indicated that after an initial aged care assessment, over one-fifth of older people had an unplanned hospitalisation within 90 days and a similar proportion had an Emergency Department (ED) presentation.[2] For older people entering residential aged care for the first time, the 90-day incidence rates of unplanned hospitalisation and ED presentation were 18% and 22.6% respectively.[3] To address this challenge, we established a Quality Improvement Collaborative, bringing teams from metropolitan and regional local health networks together to design and test local solutions to reduce avoidable hospital presentations.[4]
This program of work has helped to establish a statewide network of individuals, teams and organisations across the health and aged care sectors committed to improving the care of older people, particularly at points of transitions across the different systems. We are now working with network members to test a nurse-led transitional care intervention when older people make a first-time transfer from hospital to residential aged care. This MRFF funded trial – OPTIMAL (Optimising older People’s Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison) – is implementing and evaluating a combination of digital and relational interventions aimed at improving the transition out of hospital and into residential aged care. Another, recently completed, MRFF study titled ‘There must be a better way’ involved partnering with consumers to implement a digitally enabled geriatric urgent care unit to improve hospital flow.[5]
Critical to building this ongoing program of research has been the recognition that solutions cannot come from one part of the system alone. Older people’s care pathways typically cross hospital, primary and aged care – sectors with different governance arrangements and different economic drivers, and a good illustration of the complexity of translating research evidence into policy and practice.[6] Investing in relationship building and bridging boundaries between different stakeholder groups takes time but is a critical step to finding and implementing sustainable solutions to acute hospital avoidance and improving experiences and outcomes of care for older people.
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[1] Marshall A, Zaluski S, Rawlings K, Harvey G (2021) What do older people want from integrated care? Experiences from a South Australian co-design case study. Australasian Journal on Ageing. 40:406-412.
[2] Inacio M, Jorissen R, Khadka J, et al. (2021) Predictors of short-term hospitalization and emergency department presentations in aged care. Journal of the American Geriatrics Society, 69(11):3142-3156.
[3] Inacio MC, Jorissen RN, Wesselingh S, et al. (2021) Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study. BMJ Open, 11:e057247.
[4] Laver K, Lynch E, Rupa J, et al. (2022). Establishing a Quality Improvement Collaborative to address hospital to home transitions for older people. BMJ Open Quality, 11:e001774.
[5] Greene L, Crotty M, Whitehead C, et al. (2024) Assessing the reach and safety of an innovative urgent care service tailored to older adults. Australasian Journal on Ageing.43:387-393.
[6] Kitson A, Brook A, Harvey G, et al. (2018) Using complexity and network concepts to inform healthcare knowledge translation. International Journal of Health Policy and Management, 7(3): 231-243.
