Back to accessibility links

Providing Appropriate Care for Residents in Aged Care (PAC4RAC)

NSW AmbulanceNorthern Sydney Local Health DistrictTwilight Aged Care
Project Added:
7 December 2016
Last updated:
16 December 2016

Providing Appropriate Care for Residents in Aged Care (PAC4RAC)


This project aims to reduce the number of unnecessary ambulance transfers of aged care residents, by developing a patient-centred care model. This model will determine the most appropriate care pathway, allow clinicians to deliver timely healthcare services and provide the patient with appropriate care in their home.

View a poster from the Centre for Healthcare Graduation, December 2016.


To reduce the number of Twilight Aged Care (TAC) residents who require transport by NSW Ambulance to emergency departments (EDs) in Northern Sydney Local Health District (NSLHD) by 25%, by June 2017.


  • Reduces ambulance transfers from aged care facilities to hospital EDs.
  • Allows aged care residents to be appropriately treated in their own home.
  • Improves health outcomes and reduces the risk of adverse events.
  • Reduces ED presentations and hospital bed days for aged care residents.
  • Increases staff capacity in assessing residents’ acute care needs within aged care facilities.
  • Increases staff knowledge of available resources for aged care residents.
  • Develops strong working relationships between healthcare teams, to support an integrated approach to service delivery.


NSW Ambulance receives an average of 5800 calls to residential aged care facilities each year. 4000 of these are admitted to a NSLHD facility for an average of 6.6 days, resulting in 26,400 bed days at a cost of $38.94 million per year.

An audit conducted in April 2016, found that some of these patients could be treated in their home, reducing the discomfort and disorientation caused by going to hospital in an ambulance, presenting to the ED and staying in hospital. It was also recognised that some conditions do require treatment in the hospital environment.

In 2015, TAC sent a total of 141 residents to NSLHD EDs, with 114 of these residents admitted to hospital at a cost of over $1.1 million in bed days. It was determined that reducing the number of unnecessary ambulance transfers and ED presentations would improve the health outcomes of aged care residents and improve the efficiency of the healthcare system.  


  • A tick box was added in August 2016 to the TAC electronic records system and transfer form, to indicate whether a resident has an Advanced Care Plan or Advance Care Directive. This will support the management of the patient and ensure relevant information is sent to hospital with the resident.
  • An after-hours medical service was identified and used by TAC facilities, to enable consistent information sharing and provide a single point for general practice after-hours access.
  • Education for TAC staff commenced, on the topic of Acute Post Acute Care (APAC) charts, which guide staff through healthcare assessments of aged care residents. This allows staff to be familiar with and confident in managing residents’ acute care needs. Quarterly training sessions are scheduled as a continuous improvement strategy.
  • The Identification Situation Background Assessment Notification Documentation (ISBAND) tool was implemented in all TAC facilities in August 2016.
  • A service directory has been developed, to ensure the after-hours medical service and TAC staff are aware of services that are available as an alternative to hospital-based care.

Project status

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

Key dates

February 2016 – June 2017

Implementation sites

  • Twilight Aged Care
  • NSW Ambulance – North Sydney Zone
  • Northern Sydney Local Health District
  • Northern Sydney Primary Health Network



  • A full evaluation will be undertaken in June 2017, with measurement of the following outcomes:
    • number of transfers from TAC facilities via NSW Ambulance to NSLHD EDs (target is 25% reduction)
    • number of ‘000’ calls to NSW Ambulance by TAC (target is 25% reduction)
    • number of agreed, identified and treatable conditions managed within TAC (target is 50%).
  • Results will be collected using resident, family, staff and paramedic surveys, as well as analyses of NSLHD and NSW Ambulance data.  

Lessons learnt

  • It can be challenging to work with different organisations that each have their own business model and frames of reference.
  • It’s important to maintain constant communication and manage the project around team members’ availability.
  • Staying committed to the success of the project is integral to its success.
  • It can be challenging to deal with time constraints and differing expectations.
  • The Centre for Healthcare Redesign methodology of developing and implementing a project, as well as seeking project sponsorship, has great value.

Related reading

  • Griffiths D, Morphet J, Innes K et al. Communication between residential aged care facilities and the emergency department: a review of the literature. International Journal Of Nursing Studies 2014; 51(11): 1517-1523.
  • O'Connell B, Hawkins M et al. Referrals to hospital emergency departments from residential aged care facilities: stuck in a time warp. Contemporary Nurse 2013; 45(2): 228-233.
  • Waird A, Crisp E. The role of advance care planning in end-of-life care for residents of aged care facilities. Australian Journal of Advanced Nursing 2016; 33(4): 26-34.


Claire Banister-Jones
Facility Manager, Jamieson House
Twilight Aged Care
Phone: 0409 460 429

Jonathan Tunhavasana
Health Relationship Manager
NSW Ambulance
Phone: 0414 917 972

Jacqui Edgley
Director of Nursing and Midwifery
Mona Vale Hospital
Northern Sydney Local Health District
Phone: 0434 323 418

Search Projects

Browse Projects

Submit your local innovation
and improvement project