Acutely unwell residents living in residential aged care facilities (RACF) have specific care needs that may, at times, exceed the capability of the general practitioner (GP) and RACF to manage independently. We are increasing the support available for residents to receive care in the RACF where it is safe to do so and the resident agrees to it.
Residential Aged Care Facility Support Service (RaSS)
The RaSS model provides care in partnership with GPs and RACFs to improve patient choice of care setting and the quality and safety of care provided across the care continuum.
The RaSS is a single point of contact for RACF staff and GPs with residents who have acute health care needs beyond existing capabilities. When needed, experienced clinicians are available to provide:
- Telephone triage – telephone assessment of acute care needs and matching the care need to the most appropriate care delivery service
- ED substitutive care (where resources allow) – acute assessment or care in the RACF environment as an alternative to ED transfer; the types of care able to be delivered will be determined by the scope of practice of individual RaSS staffing models
- Gerontic nursing assessment for RACF residents presenting to ED or admitted to hospital
- Discharge planning, co-ordination and transitional communication for RACF residents presenting to ED or with an acute admission, including for residents who have presented to and been discharged from ED after-hours
- Follow-up of all RACF residents at 7 days (earlier if clinical need requires) to ensure fulfillment of referrals, resolution of care need
- Specialist consultative services for RACF residents via telehealth or in-person visits (where resources allow).
- Implementation toolkit for RACF support service
Assists facilities in implementing the RaSS
- Management of acute care needs of RACF residents
This suite of collaborative pathways for general practitioners and registered nurses are intended as clinical support tools for management of acutely unwell residents living in aged care facilities