HOW IT WORKS
This consultation service, which serves frail older adults during emergency department (ED) visits or hospital admissions and the transition back home, works with general practitioners (GPs) and other community providers involved in the continuity of care. Fundamental to all OPCCT processes is ongoing, shared responsibility for care. Program eligibility is based on a range of characteristics, including presence of geriatric syndromes, social isolation, care environment, hospitalization frequency, cognition, and age. Eligibility criteria reflect quality and safety issues and are based on priorities set by international research into rapid identification of common frailty markers. The patient intake process, which uses the Rockwood Clinical Frailty Scale, is a comprehensive assessment of health and social needs that determines patient care goals, discharge disposition, and referrals to appropriate allied health professionals for care in the hospital or at home. The OPCCT nurse acts as a navigator in the ED once a referral is made. The formal referral pathway is the ED’s health information system, though referrals are also made informally in the ED.
Originally this program started with a 12-month pilot in 2014. The program was designed and implemented by the local health care network to support seamless care transitions between primary and tertiary care settings for aged care facility residents. The pilot program cared for more than 1,000 patients before transitioning to an expanded program that encompasses patients living at home. The program routinely collects data on program activities and is being evaluated externally.
For providers. Although most team members are colocated in hospitals, the health and social care providers involved in OPCCT collaborate across multiple settings: within hospital departments, community care, subacute facilities (rehabilitation, geriatric evaluation and management units, hospice), home palliative care, GPs, and Aged Care Facilities. OPCCT nurses can self-refer in the ED, which ensures prompt intervention and avoids the wait for a referral from general ED clinicians, who generally are not as focused in identifying frailty as the OPCCT nurse. Smooth transitions are coordinated and monitored through communication tools and standardized handover prompts.
For patients/caregivers. The OPCCT team works closely with the patient, family, and GP to plan care, using two advanced care planning documents (the Statement of Choices Form and the Adult Resuscitation Plan). Family and caregivers are involved in all aspects of care before and during transfer from the hospital, engaging them so that care planning is goal-driven and facilitates medical interventions. Caregivers are offered interventions such as ongoing social work support in the community to assist with the prevention of or early identification of caregiver fatigue. End-of-life care planning is also addressed with caregivers, providing them with planning resources and bereavement support.
This program is different from others because of its new collaborative partnerships, but there is no new governance structure. Prior to launch, a series of meetings were held with internal and external members, including GPs, a patient representative, and local network staff. The program is unique in that external stakeholders help drive policy. The board is responsible for adopting international best practice guidelines and for using local data to monitor outcomes.
OPCCT is based on an integrated, population-focused model of care to serve all older people who presented at the Mater Health’s ED department with geriatric syndromes. There was no additional funding, but existing resources were used in a more efficient and integrated manner.