Southcare Outreach Service (SOS)

Published 19 February 2016. Last updated 28 October 2021.

NSW Health Award finalist – 2015

The Southcare Outreach Service (SOS) is a new model of care that delivers a rapid response, multidisciplinary team to clients aged over 65 years in their home to prevent presentations to the emergency department (ED).

This project was a finalist in the Integrated Health Care category in the 2015 NSW Health Awards. Watch a video on this project.


To reduce ED presentations in aged care clients over 65 years of age, by providing safe and effective clinical interventions in the client’s home.


  • Improves access to timely, safe and effective clinical care.
  • Promotes teamwork and collaboration among healthcare providers.
  • Empowers clients and families to participate in healthcare planning.
  • Provides an integrated healthcare model that delivers the right care, at the right place (their home), at the right time.
  • Improves health literacy.
  • Reduces presentations to the ED and unplanned hospitalisations.
  • Delivers rapid response and emergency care in the home environment.
  • Reduces duplication of community services.
  • Increases the productivity and efficiency of Sutherland Hospital and increases the capacity of the ED to care for emergency patients.


Population forecasts for 2011-2021 suggest the fastest growing age groups in SESLHD are people aged 70-74 years (+36%), 75-79 years (+30%) and 85 years and over (+18%). There is evidence to suggest that health outcomes are improved for these people if they are treated in their own home by a specialist geriatric nurse, to reduce avoidable presentations to the ED.

Prior to the project, all community services at Sutherland Hospital had waiting lists with urgent referral waiting times of 1-2 weeks. While rapid response models of care did exist at other hospitals, there were no services in the Sutherland Shire that could intervene quickly and prevent aged care clients from presenting or re-presenting to the ED . This meant there were no referral pathways for vulnerable clients that could be used by general practitioners (GPs), NSW Ambulance, residential aged care facilities (RACFs), community services and other primary healthcare providers.

In January 2014, funding was received from an ‘Innovation in Integrated Care’ grant, for the purpose of pursuing an integrated approach across services, to provide better care in the community.


  • The SOS is a community-based, rapid response multidisciplinary team for clients aged over 65 years in the Sutherland Shire.
  • Clients are seen within 1-48 hours of referral and provided with clinical interventions by nurses, physiotherapists, occupational therapists, social workers and Geriatricians for a period of up to six weeks.
  • The SOS only takes referrals for clients who are residing in their own homes in the community or discharged from Sutherland Hospital ED and are at risk of re-presenting.
  • There are 8 referral pathways that are inclusive of The Sutherland Hospital plus our local GPs, Geriatricians, NSW Police, NSW Ambulance, clients and carers.
  • Care is coordinated and executed in collaboration with the client’s GP .
  • If the client can’t be cared for in their home, direct admission protocols have been developed with Kareena Private Hospital, President Private Hospital and local Residential Aged Care Facilities to allow for fast and seamless admission to these facilities. This allows clients to bypass Sutherland Hospital.
  • The trial project began on 10 February 2014, with a view to measuring efficiency and effectiveness, to determine if the model was sustainable across the district. Due to the success of the project, the SOS was sustained at the end of the grant period.

Key dates

  • Project Start: February 2014
  • Project Finish: June 2015
  • Project Sustained: From July 2015

Project status

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

Implementation sites

  • The Sutherland Hospital
  • NSW Ambulance Service
  • Kareena Private Hospital
  • President Private Hospital
  • NSW Police
  • Central and Eastern Sydney PHN
  • South Eastern Sydney Local Health District
  • Homes of SOS clients
  • Local Residential aged care facilities


  • NSW Ambulance Service
  • Kareena Private Hospital
  • President Private Hospital
  • NSW Police
  • Residential aged care Facilities
  • South Eastern Sydney Medicare Local
  • South Eastern Sydney Local Health District


  • There have been over 1500 clients assessed to date.
  • 99% of SOS clients remain out of hospital at the 28-day follow-up.
  • ED presentations were shown to decrease by more than 90% in the pre and post 28-day follow-up.
  • Hospital admissions reduced by 69% in the pre and post 28-day follow-up.
  • 100% of clients indicated a high level of satisfaction with the SOS, with 95% reporting that they would have gone into hospital were it not for the service. One client stated: “I was alone and without the team’s help, hospital was the only option I would have been left with.”
  • During the 16-month trial, waiting times for existing community services decreased. Community occupational therapy decreased its wait time from five weeks at 24/9/13 to three weeks at 30/6/15, while community physiotherapy reduced its waiting time from seven weeks at 24/9/13 to one week at 30/6/15.
  • GP, Ambulance and Police engagement is high.
  • The service can be replicated in other local health districts, or tailored to other groups who are at risk of presenting to the ED .
  • The SOS has been sustained internally within Southcare, Division of Aged and Extended Care and has been redesigned to ensure sustainability over the long term.


  • 2015 NSW Health Innovation Awards – Integrated Health Care, Finalist.


Lessons Learnt

We found that is was vital to understand the regional support and project sponsors prior to launching this type of model, to ensure local engagement. Integration with local GPs , community services and hospitals was also essential to the success of the project.

Further Reading

  • Naylor M, Brooten D, Jones R et al. Comprehensive discharge planning for the hospitalised elderly. Annals of Internal Medicine 1994; 120: 999-1006.
  • Voss R, Gardner R, Baier R et al. The care transitions intervention: Translating from efficacy to effectiveness. Archives of Internal Medicine 2011; 171: 1232- 1237.


Kylie Ditton
Clinical Nurse Consultant
Sutherland Hospital
South Eastern Sydney Local Health District
Phone: 02 9540 7047


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Aged healthIntegrated careSouth Eastern SydneyMetropolitanEmergencyNSW Health Award
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