Saint Arnaud

Researchers are evaluating a Residential In-Reach (RIR) program designed to provide prompt care to residents in aged care homes in the Grampians region of Victoria, Australia. This program aims to reduce unnecessary hospital transfers by delivering medical consultation services directly to aged care facilities, especially in rural and regional settings where evidence for such programs is limited. The study uses a stepped-wedge trial design to gradually introduce the program across different facilities, allowing comparison of outcomes over time and between sites. The RIR program offers a telehealth consultation service from a central hospital, where aged care staff can refer residents to a nurse practitioner for triage and recommendations. These may include monitoring the resident's condition, comprehensive assessments, collaborating with general practitioners on diagnosis and treatment plans, providing education to staff, or making further referrals such as to geriatricians or emergency services. All participating aged care homes in the region will have access to this intervention as it is rolled out. Participants will include health services with emergency departments or care centers admitting residents from aged care homes, staff involved in the RIR program setup and delivery, residents who have received care through the program or their family members able to provide consent, and general practitioners managing these residents. Researchers will collect data over 14 months, focusing on the rate of hospital presentations from aged care homes and other clinical outcomes. They will also explore barriers and facilitators to implementing the program in rural and regional health settings.