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Aged Care After Hours Program

Southern NSW Medicare Local
Project Added:
26 August 2015
Last updated:
13 May 2021

The Aged Care After Hours Program


The Aged Care After Hours Program (ACAHP) aimed to improve the quality of care in residential aged care facilities (RACFs) after hours, through the development of an Emergency Decision Guidelines Tool and staff training package.


To reduce avoidable transfers to the emergency department (ED) and unnecessary transportation of frail elderly people from (RACFs) after hours.


  • Trains staff to appropriately respond to urgent situations and feel confident in managing situations.
  • Improves relay of important clinical information to general practitioners (GPs) or NSW Ambulance.
  • Creates a more sustainable after-hours GP workforce, as GPs are potentially more willing to engage in after-hours rosters if calls are more targeted.
  • Reduces avoidable transfers to hospital.
  • Improves linkages and care options for residents and aged care providers.
  • Ensures end of life issues are managed with dignity and assurance.
  • Reduces impact of high staff turnover on after-hours care.
  • Ensures new graduates are familiar with the system prior to entering the workforce.
  • Provides a standardised approach across the aged care sector.

Project status

Project dates

Project start: February 2013
Project implementation: July 2013
Regional rollout: March 2015

Project status

Implementation - the initiative is currently being implemented, piloted or tested.


In February 2013, Southern NSW Medicare Local (SNSWML) completed an after-hours needs assessment across the region. A number of concerning trends were identified in the aged care area, as follows.

  • Some aged care facilities reported having no available after-hours medical cover. These facilities reported using ambulance services to access the local ED for problems arising after hours.
  • Facilities described issues with medication management and supply, often during the transfer from hospital to home.
  • Advanced care directives were not widely available or referred to after hours.
  • Recruiting and retaining skilled and knowledgeable staff in RACFs was reported to be difficult. Variable skill levels and high turnover of facility staff had consequences after hours. GPs received calls from distressed staff who provided little clinical information. As such, GPs were unable to determine an appropriate response.
  • Lack of eHealth uptake in RACFs limited possible avenues of communication.


  • Employed an after-hours project coordinator within SNSWML to undertake the diagnostic phase of project, instigate negotiations and build relationships with GPs and RACFs in the region.
  • Created an after-hours advisory group to oversee the project and engage stakeholders. Membership included local GPs and practice nurses, Southern NSW Local Health District, RACFs, NSW Ambulance, consumers and SNSWML project staff.
  • Engaged an aged care registered nurse to work with interested facilities to:
    • undertake a skills gap analysis in the Goulburn region, to identify staffing levels, qualifications and training requirements
    • deliver Emergency Decision Guideline and Identify, Situation, Background, Assessment and Recommendation (ISBAR) training to facility staff
    • promote the inclusion of Emergency Decision Guideline training in industry training courses
    • review discharge medication issues to improve systems and communication flow between the hospital, GPs, community pharmacy and facility
    • assist the facility to become eHealth ready
    • support the uptake and use of advanced care directives.
  • Provided an incentive program for GPs to provide an after-hours on-call service to RACFs in the first year of the project. The aim of the incentive program was to form collaborative rosters and reduce the call burden on individual GPs, increasing after-hours cover at RACFs.
  • Created resources for the training package:
    • ISBAR Communication and Assessment Information Form for GPs, in partnership with Southern NSW Local Health District. This form combines the ISBAR methodology and basic clinical assessment information onto one page. It’s on a tear-off pad that can be completed quickly and sent via fax to the GP or after-hours care service provider
    • Emergency Decision Guidelines: This tool and model of care was originally developed by the Tasmanian Medicare Local and the Hornsby Ku-ring-gai Health Service. SNSWML developed it further by printing the guidelines as a flip chart with 13 colour-coded tabs
    • key and lanyard tags outlining the ISBAR mnemonic
    • PowerPoint presentation
    • trainer notes and participant handouts
    • case scenarios with role-play activities
    • competency assessment and training evaluation feedback forms
    • protocol and procedure forms
    • attendance sheets and certificates of completion
    • a Train the Trainer education package.


The pilot project was implemented in four RACFs and Goulburn Base Hospital. It has now been rolled out in all RACFs in Eurobodalla, Bega Valley, Queanbeyan, Goulburn, Yass and Cooma-Monaro. It has also been implemented by the Medicare Local - Age and Palliative Care team.


  • Goulburn Base Hospital, Southern NSW Local Health District
  • 34 RACFs in Southern NSW
  • Tasmanian Medicare Local


Stage One: Development of ISBAR / Emergency Decision Guidelines Tool

Collated emergency presentation baseline data at Goulburn Base Hospital over a three-month period, between June and August 2013. The data was used to support the development and implementation of the training package and model of care, to guide RACF staff in managing unwell residents. Data collated included:

  • total number of presentations to EDs at Goulburn Base Hospital over 65 years, total number of presentations over 65 years from RACFs, percentage of presentations over 65 years from RACFs
  • admission and discharge rates for residents of RACFs
  • number of presentations to EDs after hours
  • most common medical complaints requiring presentation to the ED.

Stage One outcomes

Admission data identified a reduction in ED presentations. However, a number of confounding variables existed, so it was difficult to definitively attribute the change to the intervention. Anecdotal evidence describes appropriate use of the communication tool. This is supported by reported occasions of ambulance officers requesting the completed form for transfer and GPs requesting the completed form to inform care.

Most importantly, there is evidence to suggest improved communication pathways between a number of service providers as a positive (and initially unplanned) flow-on effect. This process appears to have created a functional communication pathway that has been used to address other shared problems, including medication management and discharge planning.

Stage Two: Training Package Pilot

  • Training was undertaken in four RACFs over a three-week period, in four-hour blocks of face-to-face sessions. A total of seven sessions were organised to allow flexibility in attendance.
  • A set of key learning objectives were identified for the implementation of the training package. It was approved by the Australian Practice Nurses Association (APNA) for four hours of continuous professional development points.
  • The success of the training was evaluated by pre- and post-training questionnaires. Pre-training data collected included the:
    • participant’s role in the RACF (care manager, registered nurse, enrolled nurse, care assistant)
    • number of staff trained
    • RACF name
    • prior knowledge of, training in or use of either the ISBAR or Emergency Decision Guidelines
    • participant’s confidence with making calls to other health professionals regarding a resident’s care, such as a GP
    • participant’s confidence with assessing the unwell resident
    • participant’s understanding of the relevant clinical information required.
  • Post training data collected included:
    • has the training on Emergency Decision Guidelines been relevant and worthwhile?
    • has the training on the ISBAR communication tool been relevant and worthwhile?
    • will the Emergency Decision Guidelines flip chart increase your confidence with guiding and assessing the unwell resident?
    • will the ISBAR communication tool increase your confidence when communicating to other health professionals?
    • does the Communication and Assessment Information Form guide you in communicating relevant information to the GP?
    • are you confident in using the Emergency Decision Guidelines and ISBAR in your workplace?
    • will anything about the way you work change? If so, what and how?
    • what follow-up education or support do you think you need in using the Emergency Decision Guidelines and/or ISBAR?

Stage Two Outcomes

  • 75 staff were trained.
  • Pre- and post-session training evaluations had a 100% participation rate.
  • The pre-training evaluations highlighted the following points:
    • 17.8% had heard about ISBAR and 5.5 % of participants had used it
    • 23.3% had heard about the Emergency Decision Guidelines and 12.3% of participants had used it
    • 89% were confident with calling the GP
    • 82.2% were confident with assessing the resident
    • 39.7% had difficulty determining the required relevant clinical information.
  • The post-training evaluation sessions identified the following information:
    • 100% reported training on ISBAR and the Emergency Decision Guidelines worthwhile and relevant
    • 100% had increased confidence in using ISBAR and the Emergency Decision Guidelines
    • 100% liked the Communication and Assessment Information Form as a useful tool for providing relevant information to GPs and other health professionals
    • 98.6% reported the training and tools provided would change their way of working.
  • The post-training evaluation also provided the following anecdotal feedback:
    • ‘easy to understand, easy to follow, really useful’
    • ‘well presented, enjoyed the training’
    • ‘correctly assess residents, better prepared, more organised, great prompts’
    • ‘greater confidence with assessing and phoning GPs, providing relevant clinical information, being more precise’
    • 'confidence to deliver more complete and accurate care for residents
    • 'able to identify urgent from non-urgent, timely observations and assessment’
    • ‘review training every six to 12 months as a refresher course’
    • ‘recommended – all staff should attend the training’.

Lessons learnt

  • Ensure there is high-level representation in governance structures to champion and promote the initiative. The Goulburn pilot succeeded by having a senior person with an aged care background from respected organisation on board.
  • There may be political will to embrace the initiative at the local RACF level, but it is often difficult to gain the support of corporate head office.
  • Corporate groups have different structures. This has implications for leveraging the solution.  Training had to be tailored to suit each organisation. For example, it wasn’t feasible to rollout a four-hour training program at sites outside of Goulburn. Staff could not be released for a four-hour period.  Hence, the training was modified and delivered as a negotiated 1:1 training plan with the staff member.
  • Ensure that ongoing monitoring is written into the project plan. You are likely to get good feedback immediately following training. However, how are you going to evaluate how well things are working six months down the track?
  • Identify avenues for formal endorsement of the initiative, so should its evaluation prove favourable, the initiative becomes part of a systematic review.
  • Information technology infrastructure and capability can be a barrier to arriving at the best solution.  For example, we wanted to produce an electronic version of the Emergency Decision Guidelines to be transmitted by RACFs via Argus to GPs.  Information technology capacity in some smaller RACFs could not support such a system; larger (corporate) RACFs had concerns regarding system integrity and policy.
  • Exposure to alternative communication strategies can be a barrier, i.e. moving away from ‘what we have always done’.
  • Ensure that all materials receive formal approval from participating organisations.

Further reading

  1. Curtis K, Tzannes A and Rudge T.  How to talk to doctors – a guide for effective communication. International Nursing Review 2011; 58: 13-20.
  2. ISBAR Northern Territory Education & Training. ISBAR for Clear Communication. Northern Territory Australia; 2011. Retrieved 26 February 2013 from
  3. VMIA Risk Management and Insurance. ISBAR for clear communication: Clinical communication for health employees. Southern Health; 2010. Retrieved 26 February 2013 from
  4. West Coast District Health Board. ISBAR Communication Tool for Health Professionals. Department of Health New Zealand; 2010.
  5. Kurrle S, Yasdani N. Geriatric Rapid Acute Care Evaluation (GRACE) Model of Care. The NSW Agency for Clinical Innovation; 2013.
  6. Southern Tasmania Area Health Service. Emergency Decision Guidelines: A guide for the acutely unwell, deteriorating resident. Hobart: Medicare Local Tasmania; 2011.


Jo Risk Regional Director, Engagement and Coordination
COORDINARE - South Eastern NSW Primary Health Network
Phone: 1300 069 002

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