WA Primary Health Alliance (WAPHA), in partnership with the WA Department of Health, is making notable progress in enhancing primary care for residents in aged care homes.
The Optimising Primary Care Coordination for People Living in Residential Aged Care Homes project, funded through the National Partnership Agreement, has entered its second phase. This work aims to build internal aged care capacity to deliver quality primary, end-of-life and palliative care and to reduce administrative burden from GPs.
In phase one, the project funded four aged care organisations across the metropolitan area. Each organisation employed a dedicated nurse case coordinator who worked across two of their residential aged care homes (RACHs). The purpose of the nurse case coordinator was to improve coordination of primary care, implement a system of clinical assessment tools which supported the identification of unmet palliative care needs, increase the uptake of advance care planning and build capacity within the RACH workforce to provide generalist palliative care.
Phase one resulted in:
- Increased numbers of family meetings facilitated across all eight RACH’s and an improved screening process to identify complexity. This led to a reduced but more targeted approach to identifying the need for case conferencing, therefore reducing the load on GPs.
- Improved utilisation of specialist palliative care services, resulting in a more targeted approach to referrals to the Metropolitan Palliative Care Consultancy Service.
- Increased uptake of advance care planning.
- Increased completion rates of the Residential Goals of Care.
- Reduced numbers of residents transferred to the emergency department.
- 100% of residents had their preference relating to place of care/place of death recorded.
- 100% of residents who died during the final four months of this project, had their preference for place of death respected.
- Each organisation involved in the project has adopted the system of palliative care assessment tools as business as usual.
- Funding to expand this project into a second phase was granted.
The second phase aims to replicate the success of phase one. Four new aged care organisations have been recruited to participate in this project.
Each organisation will be funded to recruit a dedicated registered nurse to act as a case coordinator. There will be a stronger focus on facilitating primary care coordination and reducing administration burden on GPs who attend these RACHs as well as reporting relating to reduction in preventable presentations to hospitals. The case coordinators will play a pivotal role in building capacity and capability within the teams at each RACH and across the aged care organisations through their role in quality improvement.
WAPHA would like to thank the aged care organisations who participated in phase one and to warmly welcome our four new services to phase two. For more information about this project and the other work that WAPHA is undertaking under its Aged Care Program, visit our website.