Optimising care coordination in residential aged care

GPs play an integral role in supporting the end of life and palliative care needs of residents living in residential aged care homes (RACHs) and enabling choice at end of life. 

To improve access to support, WA Primary Health Alliance (WAPHA) began a pilot project in January 2023 for aged care organisations to employ four dedicated clinical coordinators to implement key initiatives across eight sites in Western Australia.

The pilot was established following a consultation forum where GPs identified the need for a dedicated role within RACHs for them to liaise with, co-ordinate case conferencing and engage in RACF quality improvement initiatives. 

The pilot intends to improve proactive care of RACH residents with complex and/or chronic conditions at end of life, as well as improve primary care to ensure residents receive the right care at the right time in the right place. It also provides clear pathways to reduce avoidable hospitalisations. 

To support implementation, WAPHA established an orientation program and monthly community of practice (CoP) meetings focused on quality improvement and building capacity and capability of all staff across the eight pilot sites. 

The pilot also provided an opportunity to collaborate with the University of Wollongong to implement a suite of standardised palliative care assessment tools and outcome measures known as the Palliative Aged Care Outcomes Program (PACOP). 

Feedback from GPs involved in the pilot has been positive, with one GP commenting that it helped streamline processes and improve resident care. 

“It’s been easier to coordinate end of life care for the residents and their families. 

The case coordinator has always provided us with report of the outcome of meetings as soon as they are completed. 

We have had less complaints from residents’ families and it’s made the process very easy for all parties. Case coordinators have made significant contribution in streamlining the process”. 

Within six months of the program starting, 144 Residential Goals of Patient Care, 491 advanced care plans, and 1,195 PACOP assessments have been completed. 353 case conferences have also been held, with 35 involving a GP and 40 involving members of specialist palliative care services and/or other services. 

In addition to these outcomes, case coordinators have undertaken quality improvement activities, including linking PACOP assessments to clinical decision-making and referral to the Metropolitan Palliative Care Consultancy Service, implementing a multicultural version of the Symptom Assessment Scale, After Death Audit, Palliative Care Champion or Link Nurse Role, Training Needs Analysis Survey and My Health Record, and developed a 12-month palliative care education plan and an early-hospital discharge pathway. 

The Optimising Primary Care Coordination for People Living in RACFs pilot is funded by the WA Department of Health through the National Partnership Agreement: Comprehensive Palliative Care in Aged Care until 30 June 2024.