Back to accessibility links

Nurse Practitioner for Outreach Rapid Response Acute Aged Care Service

Mid North Coast Local Health District
Project Added:
29 February 2016
Last updated:
14 March 2016

Nurse Practitioner for Outreach Rapid Response Acute Aged Care Service


This project implemented a nurse practitioner (NP) led service that delivers care to older people in the community within residential aged care facilities (RACFs) or at home.

View a poster of this project.


This project was a finalist in the Integrated Care category of the 2015 NSW Health Awards.
Watch a video on this project (opens in a new tab).


To reduce avoidable hospital presentations and/or re-presentations from RACFs and the community.


  • Reduces the number of co-morbidities and avoidable presentations to the emergency department (ED).
  • Improves timely access to physical assessment and treatment for older people.
  • Reduces costs and delays associated with patient transfers from RACFs to and from hospital.
  • Improves the continuity of care for older people in RACFs , through a holistic and person-centred approach.
  • Enhances collaboration between RACFs , EDs and general practitioners (GPs).
  • Increases the nursing skills of RACF staff through knowledge-sharing and collaboration.
  • Improves patient satisfaction and experience with healthcare services.
  • Promotes end of life care planning.


The NSW Ministry of Health has identified a number of conditions that contribute to avoidable hospital presentations in NSW EDs . These include geriatric syndrome, which has symptoms including confusion, constipation, dehydration, delirium, falls, gastroenteritis, skin tears and urinary catheter changes in older people. Prior to the project, up to 17% of ED presentations at Coffs Harbour Health Campus were people aged 70+ years who showed symptoms of geriatric syndrome. To reduce ED presentations and achieve NSW Ministry of Health hospital avoidance targets, a new approach was required.


  • A new model of care was developed, which allows care to be delivered to patients within the RACF or at home.
  • The service is available on weekdays and based in the ED at CHHC . It is delivered by a NP , who is a registered nurse with additional education and experience. NPs can autonomously diagnose patients, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within their legislated scope of practice.
  • RACF staff were trained in intravenous medication and intravenous and subcutaneous fluid administration, complex wound management and other common treatments, under the direction of the NP . They use tools including detecting Deterioration, Evaluation, Treatment, Escalation and Communicating in Teams (DETECT) and Identify, Situation, Background, Assessment and Recommendation ( ISBAR ).
  • The project is to be expanded to include a Telehealth service that will support RACFs and make the program more accessible.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • Project Start: January 2013
  • Project finish: December 2014

Implementation sites

  • Coffs Harbour Health Campus, MNCLHD
  • GPs from North Coast Primary Health Network (Mid-North Coast Medicare Local)
  • Autumn Lodge, Nambucca Valley Care
  • Bellorana Masonic Village
  • Coffs Coast Legacy
  • Coffs Harbour Nursing Centre
  • Coffs Haven Residential Care Service
  • Masonic Village
  • Mater Christi, Sawtell Catholic Care of the Aged
  • Opal Coffs Harbour
  • Pacifica Residential  Aged Care
  • Raleigh Urunga Masonic Village
  • Riverside Garden, Nambucca Valley Care
  • St Augustine’s Aged Care
  • St Joseph’s Aged Care
  • Woolgoolga and District Retirement Village


  • GPs from North Coast Primary Health Network (Mid-North Coast Medicare Local)
  • RACFs as outlined above.


  • 85% of RACF residents received their medical care and end-of-life care from the NP in their home during 2013, which increased to 74% in 2014.
  • There were 900 occasions of service of hospital avoidance in 2013, out of a total of 1046. In 2014, there were 791 occasions of service of hospital avoidance out of 1067.
  • Medical and nursing staff in ED anecdotally reported a significant reduction in older persons presenting to the ED from RACFs .
  • 77% of patients in RACFs were seen by the NP , reducing the need for hospital transfers.
  • During the project, there were no incidence of pressure ulcers requiring lengthy hospitalisation due to the increased skillset of RACF staff.
  • Medical, surgical and ED staff used the service to expedite the discharge of older people and ensure continuity of care is delivered, reducing the risk of re-presentations.
  • RACF staff are now able to perform procedures usually only undertaken in the acute care setting, with six RACFs capable of administering intravenous antibiotics.
  • Hospital transfers for catheter changes, stitches for skin lacerations, intravenous antibiotics, vacuum-assisted and negative pressure dressings for complex wound management have been eliminated, as these services are delivered by the NP in collaboration with nursing staff in RACFs .
  • GPs use the service to collaborate with the NP to manage the health of patients in RACFs , rather than transferring them to a hospital.
  • The NP -led outreach service is now being considered in Toowoomba, Grafton, and Goulburn, as well as Bankstown-Lidcombe Hospital.


  • 2015 NSW Health  Awards Finalist – Integrated Care
  • 2015 MNCLHD Quality Awards Winner – Integrated Care

Lessons learnt

  • The success of this NP -led service is dependent upon collaboration between the NP , RACFs and GPs , who must implement the program with a patient-centred care approach.
  • Maintaining appropriate and timely communication and respect for each other are essential for success.
  • The NP -led service is efficient and easily transferable to other health services.
  • Expanding the days and hours of the service would further increase its efficiency.
  • The role is yet to be backfilled during the NP's absence, so succession planning is recommended where possible for long-term sustainability.

Further reading

  • Forero R, Hillman K. Access block and overcrowding: a literature review. Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales; 2008.
  • Caplan GA, Sulaiman NS, Mangin DA et al. A meta-analysis of hospital in the home. Medical Journal of Australia 2012; 197(9): 512-519.
  • NSW Department of Health. Avoidable Admission – Preamble. North Sydney: NSW Health.
  • NSW Department of Health. Future Directions for Health in NSW – Towards 2025. North Sydney: NSW Health; 2007.
  • Ouslander J, Berenson R. Reducing unnecessary hospitalizations of nursing home residents. New England Journal of Medicine 2011; 365: 1165-1167.
  • Clinical Epidemiology and Health Service Evaluation Unit. Potentially preventable hospitalisations: a review of the literature and Australian policies – final report. Victoria: Royal Melbourne Hospital; 2009.
  • Stefanacci R, Haimowitz D. The perfect interactions to reduce hospitalizations. Geriatric Nursing 2014; 35: 466-470.


Shin Hwa Kang-Breen
Nurse Practitioner for Acute Aged Care
Coffs Harbour Health Campus
Mid North Coast Local Health District
Phone: 02 6656 5824

Search Projects

Browse Projects

Submit your local innovation
and improvement project