Factors influencing health service utilisation in the care of acutely unwell residential aged care facility residents
Background: Australians are living longer, with more complex healthcare needs and multiple morbidities, leading to greater health care utilisation and costs. Residential aged care facility (RACF) residents are frailer and more vulnerable, with more complex health needs than the wider community. Acutely unwell residents are at risk of unnecessary hospitalisation and treatment, with associated poor outcomes. Safe and effective health care for unwell residents can potentially be delivered outside of a hospital environment with appropriate interventions.
Rationale: Hospital avoidance programs for acutely unwell residents aim to provide early recognition and response to health deterioration and prevent hospitalisation. International studies of hospital avoidance programs have shown mixed and inconclusive results. An examination of the impact of a hospital avoidance program for acutely unwell residents in Australia is therefore warranted.
Objective: The overall objective of this research is to evaluate the effectiveness of an existing hospital avoidance program and identify factors impacting health service utilisation in the care of acutely unwell residents.
Methods and participants: The research evaluated a New South Wales (NSW), Australia based hospital avoidance program provided by an Aged Care Rapid Response Team (ARRT). ARRT is staffed by a geriatrician, an aged care community registrar and two Clinical Nurse Consultants (CNCs) who provide support to acutely unwell residents living within 43 RACFs. The evaluation involved a four-site retrospective quasi-experimental study of ARRT, a retrospective group-based trajectory analysis of residents, and six semi-structured interviews with two Geriatricians, two ARRT CNCs, an Emergency Department (ED)-based Clinical Nurse Specialist, and an Extended Care Paramedic.
Research articles: This thesis contains four articles. Article I is an integrative review investigating models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Article II is a comparison of health system utilisation and health outcomes of RACF residents reviewed by ARRT to RACF residents receiving usual care. Article III is a comparison of health service use trajectories of RACF residents reviewed by ARRT to RACF residents who received usual care. Article IV explores health professional perspectives on the factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care residents.
Research findings: Findings revealed that ARRT successfully managed 85% of residents they reviewed within the RACF. Hospital avoidance potentially occurred as a result of ARRT intervention on 48.1% of occasions. ARRT reviewed residents requiring hospitalisation spent an average of 9-10 fewer days in hospital, with AUD$2,091 to $8,014 lower associated hospital treatment costs, compared to residents who received usual care. Patient factors (i.e., age, comorbid health conditions and dementia) and service factors (i.e., service design, service barriers, and adaptability and responsiveness of service) impact health service utilisation in the care of acutely unwell residents.
Contributions of the thesis: The current research provides evidence for improved resident health outcomes and improved health service utilisation patterns associated with ARRT. A revised theoretical model of hospital avoidance for acutely unwell RACF residents has been developed. This model can be used and adapted for future hospital avoidance program evaluations. Important design considerations for future hospital avoidance programs were also identified, such as team skill mix and relationship building between services.
