Associate Professor Susan Kurrle Curran Chair in Health Care of Older People Faculty of Medicine, University of Sydney Director, Rehabilitation and Aged Care Service Hornsby Ku-ring-gai Health Service Geriatric Rapid Acute Care Evaluation Jenny Houston GRACE Project Leader/CNC Anne Bruce GRACE Clinical Nurse Consultant (CNC)

ACEAged Care Liaison Nurse EMU & ASET Ortho geriatric service GRACE ED Nurse Practitioner

Rehabilitation and Aged Care Service GRACE commences

GRACE Aims  To reduce hospital access block by supporting General Practitioners (GPs) and Residential Aged Care Facilities (RACFs) with enhanced hospital resources to avoid an unnecessary hospital admission (pre- hospital)  To reduce the ALOS in the ED when the nursing home and hostel pts presents to hospital  To reduce the ALOS of admitted nursing home and hostel pts

GRACE Aims  To collaborate with the GPs and RACFs to develop a model of care that: - provides a decision support system - provides hospital resources to assist with assessment & care provision -provides coordinated management plans  Increases the uptake of Advanced Care Directives in the Residential Aged Care Facilities

GRACE Geriatric Rapid Acute Care Evaluation  Commenced on 5th August 2005  Criterion for inclusion: all residents from nursing homes are eligible (hostels “by arrangement”)  Through out the pt journey the GRACE Team liaise with the RACFs and GPs

(GRACE) Nursing Home & hostel pathway to standardise care

Arrival/reception  RACFs contact the GRACE nurse (phone) to assist with decision of whether to transfer a pt to ED  GRACE nurses who have aged care assessment skills advise re the course of action (can also access ED staff specialists)  enquires if Advanced Care Directive or plan is in place - indicates level of intervention required  may discuss early symptom relieve such as pain relief or subcutaneous fluids (RACF liase with GP)

Arrival/reception II Fast track patients:  If contacted by phone then GRACE triage sheet is completed. If the pt is being transferred to hospital pre- admission information is written in the notes  pt notes flagged with a green GRACE sticker  pt put in EDIS “pt expects”  Triage nurse will notify GRACE nurse when pt arrives  GRACE nurse regularly checks EDIS/ED/EMU for nursing home patients not identified on admission

Triage, treat & process GRACE Nurses:  if GRACE is not contacted prior to presentation GRACE nurses contact RACFs to gain baseline information eg function, behaviours etc (only one phone call for ED and RACF to cope with)  work with ED nurses and medical staff to establish a discharge time than 4 hours.  document a preferred plan from an aged care perspective  access to rapid geriatric support (GRACE dedicated geriatrician (.5) starts April)

Triage, treat & process If the GRACE patient remains in the community :  RACF liases with GPs - GRACE does not take over care, increases capacity of the RACFs to maintain their residents  may provide access to hospital staff eg clinical nurse consultant, geriatrician etc  may provide consumables to prevent an ED presentation eg subcutaneous fluids  may refer to Northern Sydney Home Nursing Service or Acute Post Acute Care to support the RACFs

EMU is GRACE’s short stay ward  4 quarantined short stay GRACE Beds, classified as EMU X- GRACE team remain involved in care  GRACE pts may stay longer than 48 hours  EMU provides a comfortable safe environment to assess and observe older patients  EMU staff have a “Fast Track” philosophy  the ratio of nursing staff is flexible to match fluctuating numbers and acuity of GRACE pts

GRACE Geriatric Rapid Acute Care Evaluation Total of bed days used is 2,268 Note: ALOS 2003/04 was 6 days

Process  Executive support essential - EMU Admission and Discharge Policy states that GRACE pts requiring admission must be assessed in EMU  ED & EMU NUMs and Staff Specialists and Bed Manager are GRACE “champions”  GRACE CNC works closely with ASET CNC - GRACE/ASET “after hours nurses” are ED nurses with an aged care interest. GRACE & ASET CNCs preceptor “out of hours nurses” which builds aged care capacity in ED  Outcomes monitored and feedback given to staff and RACFs eg GRACE newsletter

Getting started with “GRACE”?  create a tension for change - review your RACF pts journeys, process map it - Is it optimal?  discuss the idea of GRACE with Executive, GPs and RACFs located in your area  express interest in the GRACE Model of Care workshop that Angela Littleford from NSW DoH will be convening later this year