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Hand in Hand: Connecting Acute Aged Care Services with Residential Aged Care Facilities

Nepean Blue Mountains Local Health District
Project Added:
4 December 2014
Last updated:
8 December 2014

Hand in Hand: Connecting Acute Aged Care Services with Residential Aged Care Facilities

Nepean Hospital, Nepean Blue Mountains Local Health District


This project aims to provide care to patients in their home for patients who are living in Residential Aged Care Facilities (RACF). This will be through either face to face consultations or consultations using Telehealth (video conferencing). This project will also smooth the process for those patients who do need to go to hospital, avoiding lengthy stays in busy Emergency Departments (EDs). 

Download a poster about this project from the Centre for Healthcare Redesign graduation, December 2014.  


The aim is to connect Residential Aged Care Facilities (RACF) with specialty Acute Aged Care Services to establish an appropriate episode of care, promote a smooth transition between services and improve the patient journey.


  • Improved access to specialist Acute Aged Care Services for patients
  • Improved patient satisfaction
  • Improved relationships between hospitals and RACFs
  • Reduced readmission rate for this group of patients
  • Increased number of direct admissions as opposed to emergency department presentations therefore reducing the impact on busy emergency departments and the ability to use specialty resources more efficiently. 


The ageing population across Nepean Blue Mountains Local Health District (NBMLHD) has shown to be increasing more rapidly than that of NSW. The estimated resident population percentage growth for the 70+ age group between 2011 and 2026 is 112% for NBMLHD compared to 63% for NSW

In 2013 there were over 1100 presentations to the Nepean Hospital Emergency Department by patients located in RACFs. Increased complications associated with hospital admissions result in poorer patient outcomes, patient dissatisfaction and an increased length of stay. The readmission rate for this group of patients (19%) is much higher then the hospital Key Performance Indicator (6%) and patients were frequently breaching the 4 hour National Emergency Access Target (NEAT) target despite the Emergency Department Medical Assessment Unit (EDMAU) model of care aimed to address this issue. 


This project followed the Redesign Method. Several data sources were evaluated focusing on patients from RACFs. The data looked at 28 day hospital readmission rates, ED presentations and length of stay in the ED. This was compared to hospital key performance indicators. 

The Virtual Aged Care Service (VACS) was identified as a successful method of patient care and assessment, however, limited resources restricted timely accessibility to this service. Staff from both Nepean Hospital and RACFs were interviewed. Patient/carer stories were conducted.

A Literature search was conducted on “Lessons Learnt” in Telehealth.

There were four solutions developed to address the issues identified.

  1. Improve accessibility and efficiency of patient care pre and post hospitalisation (using Telehealth). This involved setting up Telehealth to allow video conferencing between RACF and Acute Aged Care Services. This means patients can be reviewed in a timely manner within their home.
  2. Clear communication processes between RACFs, VACS, EDMAU registrar and ED. This involves developing flowcharts and business rules to clarify the communication process. It will also encourage strong relationships between RACFs and Nepean Hospital and a smoother journey for patients requiring specialised Aged Care Services.
  3. Inform and educate RACFs on the purpose of VACS through face-to-face education sessions and brochures. This provides information to RACFs that can be distributed to staff members, General Practitioners, patients and families.
  4. Permanent fulltime VACS Clinical Nurse Consultant. A proposal will be put forward for this position with a purpose to build strong relationships, provide clinical support to RACFs and facilitate the admission and discharge of patients presenting to hospital.

Implementation sites 

This initiative has been implemented in two local RACFs and Nepean Hospital by the Acute Aged Care Services, VACS team and Telehealth team.


This initiative will look at the 28 day readmission rate, time spent in the ED and VACS activity including phone calls, patient visits and Telehealth consultations. 

It is expected that through timely reviews, enhanced by the use of Telehealth, readmission rates will fall. A smoother process for those patients presenting to hospital will result in a reduction in the time spent in the ED and an increase in the number of direct admissions thus patients will bypass the ED completely.

To date Telehealth consultations have occurred for follow up appointments for patients following discharge at Nepean Hospital. These have been successful with only small technical issues identified. Patients and staff at the RACFs are satisfied with this process and through the various stages of implementation this will be expanded to include referrals by General Practitioners.


This initiative worked closely with two Residential Aged Care Facilities - Uniting Care Edinglasse Village (Emu Plains) and Emmaus Residential Aged Care (Kemps Creek). 

The project was undertaken via the Agency for Clinical Innovation’s Centre for Healthcare Redesign program.

Lessons Learnt

It is essential to engage all stakeholders and allow opinions and ideas to be heard. This in turn supports the implementation of solutions. Given that the RACFs are not governed by the Nepean Blue Mountains Local Health District it was vital to build strong relationships to support implementation and ensure the RACFs were willing to participate in the initiative. 


  1. Ouslander, J.G, Lamb G, Tappen R., et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc, 2011. 59(4): p. 745-53.
  2. Nikolaus, T; Specht-Leible N; Bach M., et al. A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing, 1999. 28(6): p. 543-50.
  3. Richards, S.H., et al. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. Br Med J, 1998. 316(7147): p. 1796-801.
  4. Creditor, M.C. Hazards of hospitalization of the elderly. Ann Intern Med, 1993. 118(3): p. 219-23.
  5. NSW State and Local Government Area Population Projections: 2014 Final. Strategic Analysis and Investment Unit, Health System Planning and Investment Branch, NSW Ministry of Health.


Tanya Baldacchino
Telehealth Nurse Manager
Nepean Hospital
Nepean Blue Mountains Local Health District
Phone: 0448 994 953

Dr Mohammed Kakkat
Senior Hospitalist Geriatric Services
Nepean Hospital
Nepean Blue Mountains Local Health District

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