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Supporting older residents in the Fraser Coast with rapid time-limited care

Wednesday 8 June 2022


Wide Bay Hospital and Health Service (WBHHS) has piloted a new interdisciplinary model of care to support older residents in the Fraser Coast region.

The Rapid Interdisciplinary Senior Engagement (RISE) model of care enhances access to allied health, nursing, and geriatrician services to rapidly support older residents in the community.

It helps support the safe return to their homes after presentation to the emergency department or a hospitalisation and provides an opportunity to receive time-limited care in their home.

The RISE pilot was soft launched in March 2022, with the team fortunate to have the expertise of allied health and nursing representatives working collaboratively with the patients to provide short-term support.

Support could include mobility assessments in the home environment, organising equipment needed for recovery, providing wound care, linking a patient to appropriate community-based services, assisting with My Aged Care navigation and reconnecting with established services for longer term care needs.

Principal project officer Claire Kelly said research had shown that rapid support of individuals, in the first two weeks following discharge from hospital, reduced the risk of representation.

“Our RISE service looks to support vulnerable patients who have non-complex conditions and are unable to access other services in a timely manner, which may mean a need for admission or a longer stay in the emergency department or acute wards,” Claire said.

“This helps keep members of our community outside of hospital where clinically appropriate and eases the demand on our facilities and supports patient flow.

“The RISE service also enables other services such as the Geriatric Emergency Department Intervention, Hospital in the Home and acute wards, to focus their efforts on providing care to our patients with more complex health needs.”

Claire said the development and rollout of the RISE service grew from extensive work undertaken by the Fraser Coast Healthy Ageing Collaborative.

“WBHHS is a proud partner of the collaborative, which is made up of public and private health services, community organisations, general practitioners, consumers, residential aged care facilities and supportive living arrangement providers,” she said.

“We all have the common goal of assisting the Fraser Coast community to age well and provide the right care, in the right place, at the right time.

“Our RISE service aims to make steps towards addressing key needs identified by the Healthy Ageing Collaborative, including providing access to multidisciplinary specialist services, evidenced-based knowledge and service navigation.

“It was fortunate to have the amazing ideas and thoughts developed by the collaborative to guide the development of this service.”

Claire said the pilot had already proved successful with referral reasons ranging from short term service provision due to a resolving condition, establishing skills and confidence for self-management and connecting patients with community service providers for longer term care.

“This has enabled earlier and safe discharge from emergency departments without the need for admission to the clinical decision unit and from wards following an acute episode of care,” she said.

“Initial contact with consumers on the same day of referral was 53%, with 66% receiving initial contact within 24 hours referral, which was a key deliverable of the project.

“The time to initial contact has also been decreasing as the ability to match staffing levels to the proposed model of care has been increasing.”

“While RISE aimed to improve older community members access to services, it has also improved staff satisfaction.

“Emergency staff have reported having peace of mind discharging directly from the emergency department more quickly, knowing that the RISE team will follow up on the consumers at their home.

“We thank the consumers, the integrated care team, allied health and assistants, nursing, infrastructure, the steering committee and all who were part of the pilot, and we look forward to the next phase to make the valuable service a permanent part of integrated care services.”

Who to refer:

  • Patients who reside within the Fraser Coast region
  • Require short-term and non-complex interventions to facilitate early discharge or prevent hospitalisation
  • Non-Indigenous community members over the age of 65 who have markers of frailty
  • Aboriginal and Torres Strait Islander community members over 55 who have markers of frailty.

How to refer

WBHHS staff are to email the RISE team at FC-RISE-ICS@health.qld.gov.au for more information.

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Last updated: 8 June 2022