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Acute shared care models / pathways

What is it

Acute shared care models refer to the joint clinical care of a patient by two specialists.

The models identified at site included:

  • Pre-operative – where the preoperative medical care and risk assessments of admitted older person surgical patients were managed by both the geriatrician and the surgeon on the surgical ward (such as in the orthogeriatrics model of care at Nepean) and then specific risk prevention pathways commenced.
  • Post-operative – where the post-operative medical care of the admitted older surgical patient was managed predominantly by the geriatrician and the surgical outcomes by the surgeon on the surgical ward (e.g. in Sutherland, Nepean and Hornsby). Specific wound care and osteoporotic prevention pathways then commenced.
  • Complex health needs – where the day-to-day medical care of the admitted older person with one or more comorbidities was managed predominantly by the geriatrician in a specialised aged health ward with parallel care from specialists of various disciplines (e.g. cardiovascular and respiratory).

The key benefits reported include the reduced deterioration of older surgical patients, appropriate risk assessment and management prior to surgery, improved management of behavioural issues through management by experienced aged early discharge planning, and fast-track rehabilitation resulting in an overall shorter length of stay.

Consultative/liaison models were observed but reported to be far less effective than a structured referral based on criteria.

Those with post-operative models expressed a pre-operative and post-operative model would be ideal if resources did not limit this.

How it works

Patients are admitted under a primary speciality and supported by the secondary speciality. Often a single specialty will take over the care of the older person once the other speciality has completed their management plan. For example, an older person with a fracture of the neck of femur (NOF) is admitted under the orthopaedic surgeon and supported by the geriatrician. The orthopaedic surgeon will undertake all care related to the NOF fracture and the geriatrician will take responsibility for managing all other health, social and behavioural issues. Once the older person no longer requires management of the NOF fracture, all responsibilities will be handed over to the geriatrician. 

Resourcing

The primary admitting specialists vary between hospitals. Often, the primary complaint of the older person is who the person is they will be admitted under. For example, a patient with cardiac complaints will be admitted under the cardiologist and supported by the geriatrician. Alternatively, patients can be admitted under the geriatrician and supported by a specialist such as a cardiologist. These arrangements are determined by the facility. The model generally has experienced nurses and allied health staff to support this model.

Success factors

  • Collaborative surgical team/absence of silos
  • Clear administrative procedures that support shared care
  • Clear delineation of roles between two specialists
  • Good communication between specialists – not through the patient
  • Often reported to be more successful where the geriatrician assumes full medical care and the other specialty provides a ‘consultant’ role.

Models in operation

  • Ortho-geriatric model – Sutherland, Hornsby, Nepean, Concord (Pre- and post-operative)
  • Surgi-geriatric model – Nepean (Post-op only)
  • Complex health needs – Sutherland, Nepean