clinical focus
Also, nursing home residents have relatively little access to
specialist geriatrician or nurse practitioner input within their
nursing homes. All these factors combine to hinder effective
communication between different clinicians, and they leave
little time to focus on important management tools, such as
medication reviews or formulation of advance care directives.
The research team said the follow-through care of residents
after hospital discharge is generally neglected, so what does
good follow-through care involve?
For most people who live in the community, after they’re
discharged from hospital, out-patient follow-up is offered to
them by their treating hospital clinicians. This usually happens in
a hospital out-patient clinic or in the specialist private rooms, and
this serves various functions.
Firstly, it can often identify problems early before they evolve
into bigger issues. It can also allow practitioners to focus on
chronic ailments. It allows medication review, and it also allows for
formulation of long-term management plans, including advance
care directives.
By comparison, there’s very little that’s on offer for nursing
home residents. Hospital out-patient clinics really aren’t made for
nursing home residents. It’s really difficult to access, not just the
rooms, but also in terms of transportation, and it’s also far more
feasible for patients to be reviewed by a specialist within nursing
homes, but in general this doesn’t happen.
With all of those issues in mind, the team developed the
Regular Early Assessment Post-Discharge intervention. Can
you walk us through the key elements of REAP?
REAP is actually quite simple, and it really does emphasise this
post-discharge care. Through the intervention, nursing home
residents receive monthly coordinated specialist geriatrician and
nurse practitioner assistance within the resident’s nursing home
for six months following hospital discharge.
Residents continue to receive the usual care from their general
practitioner and nursing home staff throughout the course of
the intervention. Indeed, when we were formulating REAP, we
recognised the central role of the general practitioner, and so the
general practitioner retains ultimate medical decision-making
responsibility for their patient.
REAP also encourages direct communication between all
the different parties, not just the REAP clinicians, but also the
general practitioners and the nursing home staff. It’s left to
the discretion of the geriatrician and the nurse practitioner to
arrange appropriate investigations and treatments as they deem
necessary, but this is usually in concert with the treating general
practitioner and the nursing home staff.
Recommendations can include things like alteration of
medication prescriptions, changes to medicine management and
the formulation of advance care directives. By incorporating nurse
practitioner input, more invasive investigations are also potentially
available in nursing homes, including intravenous cannulation for
intravenous fluids and antibiotics.
You looked into the effectiveness of the REAP intervention
and found it was associated with almost two-thirds
fewer hospital readmissions and half as many emergency
department visits, compared with controls. What do you put
that success down to?
Really, it’s quite simple. REAP firstly provides more clinical care.
It also provides care that’s appropriate to the patient’s needs,
and the care is provided at an appropriate time with the focus on
the period immediately following acute hospitalisations, when
patients are more likely to be re-hospitalised.
What’s next for the project? Would you like to see the
REAP intervention rolled out across all aged care facilities
in Australia?
That would be wonderful. Our recent study shows that
REAP is cost effective, with total costs around 50 per cent
lower in patients receiving REAP, compared with matched
controls. Therefore, from a financial perspective, there is clear
justification for REAP to be broadly implemented.
However, we’re also realistic. Pragmatically, from a manpower
point of view, it’s difficult to find sufficient numbers of
appropriately trained specialist staff in many health services.
REAP is relatively labour intensive. It requires six specialist
geriatrician and nurse practitioner nursing home reviews over a
six-month period.
We’re now looking at ways to facilitate the broader adoption
of this model of care, with manpower constraints particularly in
mind. We’re looking at streamlining these processes by focusing
on aspects of the REAP intervention which appear to be most
effective in our analyses.
We’re also planning to undertake a follow-up randomised
controlled study examining the effectiveness of this streamlined
approach. If this proves beneficial, then we plan to use our
findings as a platform to advocate for implementation of REAP as
standard clinical practice across all health districts.
What went into getting all stakeholders on board with the
intervention, and who would be the drivers of the partnership
should REAP spread more widely?
It actually involves numerous stakeholders. We were lucky
enough to get the support of a number of different groups,
so the nursing home residents themselves were enthusiastic,
or the families of the residents who weren’t able to advocate
for themselves.
Also almost all of the nursing homes within the St George
district came on board. The local general practitioners were quite
interested and they were also supportive of the study. We had all
of our aged care department at St George Hospital on board with
specialist geriatricians as well as nursing staff. The South Sydney
and Illawarra Health Service and the Dementia Centre for Research
Collaboration at UNSW were also very supportive, and they
provided personnel and infrastructure support.
Then we were also able to access funding through the
St George and Sutherland Medical Research Foundation through
an establishment grant. It was actually very encouraging. All these
groups were very supportive, and it really didn’t require a lot of
effort to have them come on board.
Looking into the future, I think it’s actually essential that all of
the different groups continue to be involved, and I don’t think
any one particular group will be driving it. I think obviously the
residential aged care facilities and the hospitals have to be central
to this, but we need a partnership approach with the nursing
home residents and their families, as well as general practitioners
also being intricately involved. Each stakeholder has their own
unique contribution, and the success of this intervention really
hinges on all of the individual stakeholders coming on board and
driving it into the future. ■
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