Addressing Potentially Avoidable ED Visits Among Residents of Aged Care Facilities

Walkabout Medical Homes with Mary Takach: A 10-month Study of Australia
December 2014 
There are many reasons residents in aged care facilities end up in emergency departments (EDs), but a significant number of these visits, between 40 and 67 percent according to research, are potentially avoidable (NCHS, 2004; Ouslander, 2010). One reason for many unnecessary ED visits is the fact that some staff at an aged care facility may lack the basic skills for assessing and addressing conditions that could be otherwise managed there.
To address this issue one primary health care organization located in Newcastle, New South Wales has implemented a program expanding on efforts previously piloted by a local hospital. The Hunter Medicare Local, in partnership with local hospitals, launched the Aged Care Emergency (ACE) Service in 2012. A first of its kind in Australia, ACE has achieved national awards and is one of CEO John Baille’s proudest achievements. The development and expansion of the model was in response to identifying the lack of coordination between the aged care facilities and EDs; recognizing the changing capacity of aged care facility workforce that are not comfortable with assessing and treating non-life threatening problems at the facility; and realizing that a whole system approach would be needed to address this issue. Features of the ACE program include:

• Designating and training ED nurses to be a ready “phone a friend” resource for aged care facility staff during business hours helping them work through the complicated and difficult processes of assessing the right care and the right place of care for frail residents. During afterhours, aged care facilities are able to access the General Practice Afterhours call center to receive similar support.
• Improving communication between aged care facility staff and ED departments
• Raising the level of competency and empowerment among aged care facility staff through training and resources
• Improving the quality of care delivered to elderly residents including establishing the resident’s goals of care prior to transfer to the ED
• Improving the experience of the resident’s care at the ED

Building the case for this kind of program requires strong relationships across sectors that traditionally have not communicated well including residential aged care facilities, hospitals, and primary care. Hunter Medicare Local, with its hospital partners, provided leadership at the executive level to support development and ongoing oversight of the program. Hunter Medicare Local also provides:

• Financial support for a new full-time position, a Clinical Nurse Consultant, to oversee the hospital implementation of the ACE program
• Emergency training manuals that includes flowcharts and evidence-based algorithms as well as other resources to be used by aged care facility staff when assessing various medical conditions (Click here to see prototype)
• Training and education for aged care facility staff and ED nurses that include in-person “Train the Trainer” workshops, Manager Forums, and web resources. Trainings not only walk the aged care facility staff through care guidelines, but also how to do proactive planning with residents and their families establishing their preferences for end of life care. This means advance planning about decisions such as whether the resident wants treatment in an ED or intensive care unit and/or interventions that include surgery, use of intravenous antibiotics, etc.
• Quarterly interagency meetings that provide an interactive, open forum that reviews what’s working and what’s not working

In addition to providing executive leadership support, the hospitals have agreed to support the redesign of processes and roles in the EDs to accommodate the model (via a memorandum of understanding with the Hunter Medicare Local) that includes:

• Enabling ED nurses to become trained and established as a resource to aged care facility staff.
• Case managing frail, elderly residents when they present to the ED including assigning clinicians that are experienced with care of the geriatric patient . For instance, a resident presenting in the ED with an arm fracture would not necessarily need to be worked up for their chronic congestive heart failure.
• Creating a fast track in the ED that gets residents back to the aged care facility as soon as possible in order to minimize the effects of an otherwise stressful environment.

Hunter Medicare Local also has collaborated with the local ambulance service to redesign their processes for transport.
Penetration of the ACE program has now reached 78 out of the 100 aged care facilities and six hospitals across the Hunter Medicare Local’s large geographic footprint. While an evaluation is underway, preliminary analysis shows that when an ACE call occurs up to 75 percent of residents were managed within their aged care facility, and avoided a transfer to hospital. ACE is a fine example of the strength of partnerships and collaboration on an issue that can improve quality, costs, and satisfaction goals for some of the frailest members of our societies.

MORE ON CREATURES IN AUSTRALIA, PART III, “THE CUTE KIND”

My past blogs have focused on encountering dangerous creatures in Australia, but this one turns to the kind of creatures that evoke smiles rather than fear. As I have traveled around Australia interviewing people for this fellowship research project, I have had the opportunity to see many beautiful beaches and vineyards.
Although the U.S. also has an abundance of beaches and vineyards, what we don’t have are koalas and kangaroos that may show up at any of these locations. Imagine being in wine country, opening your blinds in the morning and being greeted by a “mob” of kangaroos nibbling on grass.
Or walking down a white sand beach to take a swim only to find a koala emerging from the surf from its swim. These are the kind images that will be live in my memory for years to come!