NSW Health clinicians and patient-reported measures (PRMs) experts share their insights and experiences in this spotlight based on an ACI-hosted roundtable discussion. Learn how they embed PRMs into daily practice to support goal-setting, meaningful conversations, and person-centred care for older people.
Care for older people in NSW
Older people in NSW receive care through a range of services designed to support health, independence and wellbeing. While services vary across settings, the following programs have embedded the collection and use of PRMs as a routine part of clinical care:
- Transitional aged care programs (TACP) provide short-term restorative care support following hospital discharge, helping older people regain function and avoid premature entry into residential care.
- Residential aged care services deliver long-term care for older people who can no longer live in their own home. It includes accommodation, personal care 24 hours a day, as well as access to nursing and general health care services.
- Community-based chronic care programs support older people living with chronic conditions, with a focus on proactive management and quality of life.
Across these services, care is increasingly person-centred, goal-oriented and focused on empowering older people to actively participate in their health journey.
Embedding PRMs in older people’s care
In particular, Patient Reported Outcome Measures (PROMs) are now embedded into everyday practice for the care of older people in many services in NSW Health. PROMs help identify what matters most to the individual—whether it’s managing anxiety, maintaining independence or feeling heard. In programs such as TACPs, PROMs have proven effective in tailoring care to individual goals, supporting the development of an personalised Care and Services plan and prompting meaningful reflection.
Embedding PROMs into daily huddles, staff meetings and routine conversations has helped to normalise their use and ensure sustainability. Integration into the model of care is supported by standardised education resources and governance structures, allowing PROMs to become a core part of service delivery rather than a standalone initiative.
Digital platforms have further enabled implementation, with real-time data entry and visual tools like tablets enhancing point-of-care conversations. PROMs show patients and carers that their experiences are valued, and they provide a strategic lens to promote independence and reduce hospital admissions.
Ray's story
This consumer story provides a real-life example of how PROMs can benefit patients, as Ray’s journey through the Transitional Aged Care Program (TACP) was enhanced by the feedback he shared.
Benefits of PROMs
PROMs amplify consumer voices, particularly in settings where patients may feel less heard. Presenting aggregate data back to clinical teams has strengthened engagement and highlighted the tangible impact of care. This feedback loop continues to drive improvement and motivation across services. PRMs deliver benefits at the patient, service and system levels.
Benefits for the patient
- Supports expression of goals and concerns
- Reduces anxiety through meaningful discussion
- Promotes ownership of health and care decisions
- Enables vulnerable patients to communicate needs clearly
Benefits for the service
- Enhances team-based learning and reflective practice
- Strengthens goal-based care models
- Enables agile service delivery through feedback loops
- Supports benchmarking and service review
Benefits for the organisation
- Informs future models of care through aggregated data analysis
- Identifies trends and clinical risks for proactive support and tailored education
- Embeds PRMs into governance and decision-making structures
- Encourages collaboration across the healthcare continuum
- Enables health services to align with community needs through the collective patient voice
Helpful tips for other services
Set accountability drivers and targets from the outset
Embedding PROMs into routine conversations, team huddles and staff meetings helps ensure they are seen as integral to care, not an additional task. When PROMs are part of the model of care and clinical workflows, they become sustainable and meaningful.
Design for sustainability, not dependency
Long-term success relies on standardised education resources, clear processes and visible data reporting structures. This reduces reliance on individual staff and supports continuity across teams. Embedding PROMs into governance frameworks and clinical functions reinforces their value and ensures they remain central to service identity.
Engage patients and carers meaningfully
Older people are often comfortable using digital tools when supported appropriately. Ensure accessibility by offering flexible options such as SMS, email or tablet, and involving patients and carers in co-designing PROMs delivery. Adapting workflows based on feedback and recognising individual needs is key to person-centred care. When patients see their voices reflected in decisions, it reinforces the message: "Nothing about us without us."
Contributors
Thank you to the following people who contributed to the ACI Roundtable discussion that formed the basis of this spotlight. The conversation was guided by the 5D Cycle of Appreciative Inquiry, a cyclical process for change and problem-solving that focuses on strengths and positive experience.
- Jill Reyment, Director Clinical Governance, MLHD
- Ally Mundey, PRM Lead, SVHS
- John Paul Troiani, PRM Lead, ISLHD
- Angeline Vogel, HSM Balranald, FWLHD
- Lisa Bailey, RACF Clinician, Older Persons Mental Health, CCLHD
- Toby Booby, TACP Manager, WNSWLHD
- Alexis Cox, TACP Manager, SVHS
- Glade Vyslysel, Team Leader, Occupational Therapist, Westlakes Community Rehabilitation Team, HNELHD
- Kelly Hopkins, TACP Physiotherapist, SESLHD
- Melissa Tinsley, Associate Director, Integrated Digital Enablement Accelerator (IDEA), ACI
- Glen Pang, Aged Health Network Manager, ACI
- Kirsten Brighten, Project Officer, Patient Reported Measures, ACI
- Tilly Armstrong, Program Manager, Patient Reported Measures, ACI
- Katelyn Crean-La Rance, Project Officer, Patient Reported Measures, ACI
- Anka Radmanovich, TACP Principal Policy Officer, MoH