Optimising care transitions for older South Australians


To address the growing challenges in South Australian hospitals due to increased admissions of frail older individuals with complex health and social care needs, Caring Futures Institute’s Professor Gill Harvey and Carmel McNamara are working with Flinders University’s Professor of Rehabilitation, Aged and Extended Care, Maria Crotty who is leading the ‘OPTIMAL (Optimising older People’s Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison)’ project.  

Professor Gill Harvey

The project aims to improve collaboration among care providers, including hospitals, residential aged care homes, and primary care providers. The goal is to standardise strategies that improve the experiences of older people receiving care while also reducing hospitalisations when a person enters residential aged care for the first time. 

“SA hospitals are facing increasing demand from frail older people with complex health and social care needs, who are vulnerable to declining health and more likely to be hospitalised for extended periods.” Professor Harvey explained.  

This problem affects people every day, with frail older people experiencing challenges when transitioning to residential aged care. Divides between the hospital system, primary care and aged care can further complicate matters, creating a need for effective intervention. 

“Individuals are entering into permanent residential aged care at a later age often with several chronic health conditions. They are likely to be frail and may no longer have access to their usual GP or practice.” Professor Harvey said. “This is often a distressing time for the older person and their family, hence the importance of working to ensure a smooth transition.”  

The OPTIMAL project is funded as part of an MRFF grant and involves health and aged care stakeholders across South Australia. Initial work will involve the development of a real-time dashboard through partnership with the Commission of Excellence and Innovation (CEIH). This dashboard will provide a tool for identifying individuals at high risk of re-hospitalisation before they are transitioned to permanent residential aged care for the first time. This will then enable the implementation of timely interventions to enhance care coordination and reduce the risk of readmission. 

Professor Harvey explained that the OPTIMAL project builds upon the success of a previous study, the ‘State Action on Avoidable Rehospitalisation and Unplanned Admissions (STAAR-SA) Project which was led by Professor Crotty, with involvement of CFI researchers Professor Gill Harvey, Professor Kate Laver and Dr  Elizabeth Lynch.  

“Focused on improving the pathways of care for people aged 65 years and over after discharge from the hospital, the STAAR-SA project demonstrated that the prevention of readmissions relied on collaborative efforts and sustainable relationships across health and aged care services,” Professor Harvey explained.

The project will involve the three metropolitan Local Health Networks and focus on improving integration between the acute care sector and residential aged care homes. Transitional care interventions will be initiated based on patient risk stratification, for example, ranging from enhanced communication pathways to intensive case management. 

Leveraging the relationships developed through the STAAR-SA project, the project involves various sectors, including clinicians, aged care service providers, government agencies, and consumers, particularly encompassing stakeholders.

Focusing on building strong industry research engagement, maintaining relevance, and enhancing research impact through interdisciplinary relationships, are mutual goals of the project and the Caring Futures Institute

Improving care for older South Australians, informing policy, and strengthening networks and partnerships are the primary goals of this initiative. Through its endeavours, significant impacts on service design and policy reform will be achieved, specifically targeting the enhancement of care for frail older individuals transitioning to reside in residential aged care homes. 



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Care Ambition 2030 Quality Aged Care Uncategorised