CAREPACT

Residential Aged Care Clinical Pathways

The Queensland Health suite of clinical pathways, developed to support decision making by Registered Nurses and General Practitioners (GPs) caring for residents of aged care facilities and to guide referral to Queensland Health Residential Aged Care Facility (RACF) acute care Support Services (RaSS).

Please use the link below to access the suite of pathways and also read the “How to use the pathways” and “Conditions of use and copyright” prior to implementing.

Residential Aged Care Clinical Pathways (Queensland Health)

Referral for RACF Clinicians

CAREPACT is available for clinical support and advice

7 days a week, 364 days a year, from 0730-1600

Referral process for RACF Clinicians

CAREPACT Emergency Triage Service

For all referrals to our Mobile Emergency Team (MET), please call the Triage line with a recent set of vitals:
0427 026 319

Referral for General Practitioners

Referral process for General Practitioners

CAREPACT Specialist Consult Line

Direct line to an Emergency Physician or Geriatrician for support, guidance and referral:
Hours: During the COVID Pandemic the GP and Paramedic Referral line is now available 24 hours a day.
Mobile: 0437 252 746

General Practitioners are encouraged to speak directly with a CAREPACT Specialist. Referrals in writing have resulted in delays to emergent care for patients and are discouraged. Further information like recent investigations, previous specialist involvement, and concurrent referrals will be discussed.

Referral for Paramedics

Referral process for Paramedics

CAREPACT Specialist Consult Line

Direct line to an Emergency Physician or Geriatrician for support, guidance and referral:
Hours: During the COVID Pandemic the GP and Paramedic Referral line is now available 24 hours a day.
0437 252 746

Things to consider prior to calling:

• Patient lives in Residential Aged Care in Metro South HHS
• NOT independent living, disability, or private accommodation
• Patient has a condition that could be managed by Mobile Emergency Team
• NOT new abdominal pain, chest pain, ALOC, or focal neurology
• Vital signs and examination findings
• Who called QAS? Is GP/Family aware?
• Advance care planning
• If clinical history is uncertain - phone us

CAREPACT Model of Care

There are seven main components to the CAREPACT model of care:

1. Telephone Triage and Clinical Care Planning

• Triage is the first point of contact for RACF staff and GP’s and provides a dedicated single point of contact to discuss and refer acutely unwell RACF residents to specialist care.
• Triage provides an assessment of the RACF resident and ensures the acute care needs of the resident are met by referring to the most appropriate clinical care delivery service.
• On contacting CAREPACT, the CNC will conduct a focused clinical assessment, in consultation with the CAREPACT Consultant, which allows the resident to be treated either within the RACF, community setting or, if needed, the emergency department. 
• Follow up of all RACF residents presenting and discharging from ED after hours.
• Follow up at 7 days (earlier if clinical need requires) to ensure fulfillment of referrals, resolution of care needs.

2. Mobile Emergency Team

• MET aims to improve the quality of emergency healthcare to this vulnerable geriatric population.
• MET provides an emergency department-equivalent assessment for residents with an acute deterioration.
• As an alternative to transferring to emergency departments across the Metro South region, residents can be assessed in the care facility by Emergency Specialists, Geriatricians or Nurse Practitioners.
• Resident suitability is assessed via triage in consultation with the CAREPACT Consultant, and after discussion with the residents GP and substitute decision maker.
• MET can perform point of care tests including iSTAT and ECGs and utilise telehealth facilities.

3. Nurse Navigator

• The NN streamlines and enhances the care pathway for the frail elderly resident to reduce unnecessary hospital stays and improve resident outcomes.
• Mediated case management for residents or RACFs with high ED presentations and/or identified need for engagement with CAREPACT services.

4. Inreach Clinical Nursing Team

• An emergency department and inpatient resource, with early discharge planning by specially trained Clinical Nurses, located at 4 hospitals in MSH.
• Discharge planning, co-ordination, and transitional communication for RACF residents presenting to ED or admitted to hospital.
• The CNs liaise with the RACF to gather information regarding the resident’s baseline and acute needs, as well as ensuring a comprehensive gerontic nursing assessment is completed.
• The CNs will liaise with the RACF, GP and other community services to ensure that continued care can be provided on return, and that an adequate clinical handover is performed.

5. Hospital acute care substitution

• CAREPACT can provide inpatient hospital standard acute care substitution within residential aged-care facilities to patients who meet the criteria of Queensland Health’s Hospital in the Home guidelines, but first point of referral for ongoing care will be to the current Acute Care at home team (HITH).

6. Clinical education and support for RACF staff

• CAREPACT has partnered with GPs, RACFs and inpatient specialist staff to develop a best practice management manual for acute health concerns (RaSS Clinical Handbook) which has now been rolled out state-wide under the Health Improvement Unit (HIU).
• The Handbook provides guidance on when to refer to the CAREPACT service or to alternate existing services and starts at the point of illness rather than the point of referral.
• It aims to improve both clinical assessment and handover of clinical information to other care providers.
• CAREPACT is also partnering with aged care facilities to help improve their staff skill mix and resources through providing education in the facility as well as education days.
• We are also working with GPs in the aged care setting to determine the least distressing intervention for the resident or expediting emergency care for the deteriorating patient.

7. GP and Paramedic Direct Referral Line

• GP and Paramedics can refer eligible patients directly to the CAREPACT Consultant.
• Provides an alternative to hospital presentation where consistent with patients and family wishes, as well as the best practice approach to providing care.

Why is CAREPACT important?

The Metro South Health (MSH) catchment has a rapidly growing number of RACF beds, the high care bed numbers have increased by over 28% since 2008. The CAREPACT model of care provides a creative solution to continuing to provide high quality care despite this growth. There are currently 94 RACF's in the catchment with over 9,400 beds and more facilities are being approved every few months. Similar demand pressures are being faced in all Queensland metropolitan areas. Reported rates of presentation of RACF patients to emergency departments range from 0.1 to 1.5 ED transfers per RACF resident bed per year, with admission rates of these patients varying from 40 to 60 per cent of ED presentations. Both RACF Bed numbers and ED presentations will continue to increase unless alternative management methods are implemented.

CAREPACT recognises the unique, accredited professional environment of RACFs. We are focussed on addressing the complex array of factors that influence RACF staff to transfer patients to hospital, including the RACF staff skill mix and reources, perceived risk, and patient functional and cognitive impairment.

Patients and their families consistently express a desire to receive acute treatment in their home environments and increasing demand is expected with the aging population. Further, it is well-known that the transfer of an elderly patient can be distressing and place them at risk of iatrogenic complications.

CAREPACT aims to fill the need to improve service delivery to this cohort of patients, by providing alternative methods for assessment and management. This will provide improved care and choice for this growing population. For further information, please contact the team on CAREPACT@health.qld.gov.au