Community Older Persons Intervention and Liaison Outreach Team (COPILOT)

South West Sydney's population is projected to grow by a third by 2031, from just under one million to around 1.3 million. The population is also rapidly ageing, with a projected 74% increase in people aged 65 and over, and a 92% increase in those 85 and over. This growth, along with rising disease burdens, will impact hospitals and community services in the South Western Sydney Local Health District (SWSLHD).

In SWSLHD, there are no emergency department (ED) alternatives that provide urgent assessment and treatment in the community for older people. This has resulted in older people spending on average 15 hours waiting in ED for treatment for low acuity conditions. There is often poor care coordination between primary and acute health services, and urgent care services are limited to Residential Aged Care Facility (RACF) geriatric outreach teams. These facility-based services operate in silos with differing processes, causing service gaps during staff absences and a lack of district-wide coordination.

Providing care closer to home

The project team conducted a retrospective analysis of 2022 SWSLHD ED presentations (n=160,000) and found 22.2% (n=35,520) were people aged 65 year or older. Of this cohort 36.5% (n=12,964) were not admitted, suggesting they likely could have avoided ED and received treated in the community.

During the COVID-19 pandemic, the RACF hospital avoidance Community Outreach Geriatric Service (COGS) was established at four of the hospitals across the district. In 2023, SWSLHD secured funding to establish an urgent care service. The funding opportunity led to the development and implementation of a district-wide service, the Community Older Person Intervention and Liaison Outreach Team (COPILOT), incorporating the four services and expanding to older people in the community. The benefits of this service are:

• Care is provided in a supportive manner which addresses the health and psycho-social needs of the whole family, and is provided closer to home and is more accessible.
• Efficient, connected and coordinated healthcare that links acute care with general practitioners and community service providers.
• Patients participate in escalation plans should their health deteriorate.
• Reduced presentations and facilitated discharges to decrease the pressure on ED and better utilisation of hospital resources.

Standardising outreach processes and centralising intake

To establish an integrated multidisciplinary community service four changes where required.

1. Establish a new Urgent Care Service for community dwelling patients (not RACF) commenced January 2024. A multidisciplinary outreach team that includes a geriatrician, nursing, physiotherapist, occupational therapist, social worker and dietitian was established to provide urgent care across SWSLHD for older people living at home or supportive accommodation.
2. Standardise the Community Outreach Geriatric Service processes across SWSLHD that deliver urgent care to residents of RACF commenced February 2024. One common process incorporating virtual care across all services and ensuring equity to all areas of South West Sydney was developed and implemented.
3. Transition governance of RACF outreach service under Primary and Community Health January 2024. Medical and nursing positions employed throughout the RACF outreach service transitioned from hospital-based employment to Primary and Community Health.
4. Centralise intake for all community services from August 2024. An intake pathway was established through Triple I (central district intake hub) for all COPILOT referrals, enabling accurate activity tracking, timely prioritisation, and response. This also extended operating hours to 12 hours a day, 7 days a week.