The demography of the Australian population is changing resulting in a greater need for the health care system to develop innovative models of care that will meet the complex needs of frail, older adults in a community setting
[1, 2]. The correlation between increasing age and reduction in functional ability means that older adults are large consumers of acute hospital care
[3, 4] and commonly have longer lengths of stay than younger persons
. Evidence suggests that when admitted frail older adults are at an increased risk of adverse effects, such as physical deconditioning, functional decline, pressure injuries, malnutrition, falls and acute delirium
[6–8]. Changing health care policies, together with closure of hospital beds and shortened length of stay have seen a trend towards providing older people with more specialised care in a community setting
[1, 5]. Services that provide comprehensive geriatric assessment and subsequent care in the community are one alternative to sending older adults to hospital
. This approach has been demonstrated to be highly effective for community-dwelling older adults
, however there is less evidence surrounding its effectiveness for those in long-term residential care facilities (RCF).
As more people enter long-term institutional care; innovative models of medical service delivery will be imperative, to promote best practice for residents whilst containing healthcare costs
. There is considerable international interest in alternative models of care for long-term RCF residents
[10, 11]. The Netherlands has successfully trialled the use of RCF physicians with specialist training in nursing home medicine and have demonstrated improvements in the quality of care provided within RCF
. In the US interventions to up-skill RCF staff in the assessment and management of acute inter-current illness have reduced acute care transfers from RCF facilities
. These successes demonstrate that medical management of RCF patients can be improved, placing the challenge on local health care administrators to develop models of care that are efficacious and applicable to their local context.
The proportion of adults dying within residential aged care facilities (RCF) is also rising. In the United States (US) it is estimated that 67% of residents will die within their facility
. These trends highlight the need to promote Advance Care Planning (ACP) and documentation of Advance directives (AD) within RCF and to up-skill residential care staff in the provision of palliative care
[13–16]. When ACP discussions are backed up by formal documentation of AD this can facilitate decision making at a future crisis point, easing the burden on family, and care providers
. Despite the willingness of older adults to discuss their preferences for end-of-life care and the benefits of formally documented AD, its uptake in RCF has been relatively low
The Residential Care Intervention Program in the Elderly (RECIPE) service is based in outer metropolitan Melbourne, Australia and provides expert comprehensive assessment and management by geriatricians and aged care nurse specialists to individuals living in RCF who are at imminent risk of requiring acute care management. In 2002 the hospital aged care unit established the service and promoted it to RCFs and general practitioners (GPs) in their catchment area. At this time, local RCFs had limited access to primary care physicians, ACP was not widely promoted in RCF and there were few alternatives to ED attendance for management of acute illness outside standard office hours. Prior to commencement of the service RCF staff reported that approximately 13% of residents had formal AD and that there was no formal system for documenting or communicating this amongst care providers.
The aims of the RECIPE service are to improve residents’ quality of life by providing them with optimal medical care within the facility, increase opportunities to discuss ACP and document ADs, promote greater consumer engagement in their care, and to improve communication between RCF and acute care clinicians. It was anticipated that if these aims were achieved then emergency department attendances would also be decreased. When the service was established, a comprehensive health service evaluation was undertaken to evaluate the feasibility, acceptability to consumers, and the potential of this model of care to decrease acute health care utilisation. This paper presents the findings of a preliminary study which evaluated both the feasibility of the geriatrician-led, in-reach service and of conducting a randomised controlled trial (RCT) to evaluate this model of care