1. 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 skurrle@nsccahs.health.nsw.gov.au GRACE@Hornsby Geriatric Rapid Acute Care Evaluation Jenny Houston GRACE Project Leader/CNC jhouston@nsccahs.health.nsw.gov.au Anne Bruce GRACE Clinical Nurse Consultant (CNC) abruce@nsccahs.health.nsw.gov.au

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

3. Rehabilitation and Aged Care Service GRACE commences

4. 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

5. 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

6. 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

7. (GRACE) Nursing Home & hostel pathway to standardise care

8. 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)

9. 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

10. Triage, treat & 3-2-1 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)

11. Triage, treat & 3-2-1 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

12. 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

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

15. 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

16. 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