Access to after-hours primary care is a particular concern for people living in residential aged care facilities. While residential aged care facilities (RACFs) tend to be high and increasing users of after hours primary care services, a significant portion of this use is unnecessary and/or inappropriate.
People living in RACF can often lack appropriate access to GPs during business hours which further impacts challenges with continuity of care. The problem is two-fold. While on the one hand we need to improve access to timely and appropriate care for some of our most vulnerable members of the community, on the other the imperative is to reduce system burden: to reduce unnecessary emergency department (ED) presentations, hospital admissions and ambulance transfers. There is a need to reduce presentations of category 5 (minimal acuity) presentations to ED, and reduce presentations to ED during the after hours period.

The increased demand on after hours services from RACF settings is often used as an exemplar of broader systematic failures in after hours care. The causes of the increased demand are many and varied, and depend on the local service system context, but usually include a combination of the following:

• lack of access to appropriate clinical data to inform decision-making including integrated medical data or ehealth (further exacerbated by high turnover of staff)
• poor primary care service coverage during the after-hours period
• lack of established health pathways or processes that result in fragmentation of the local health system
• over-reliance on deputising services which can have long wait times
• problematic after-hours medication management and supply, and/or polypharmacy
• low use of advanced care directives and deficits in confidence and capacity of staff to provide adequate and/or quality palliative care.

At facility level, issues specific to the residential aged sector which impact the way that after hours services are used include high turnover of nursing staff, high RN-resident ratios, lack of adequate GP cover during leave, and family/carer expectations. Issues can be further exacerbated by regional and rural locations, poor transport access, poor access to allied services, and internet accessibility issues.
Residential aged care staff need to be better supported to make informed decisions relating to accessing primary care during the after-hours period. Common presentations to ED which are avoidable include exacerbation or acute presentation of chronic disease; sequellae from preventable injury such as falls, and deficits in providing adequate palliative care.

After hours models of care must be developed locally and innovatively. They should be flexible, responsive and tailored to local and regional circumstance and make efficient and effective use of local the broader health workforce. At their heart they must be driven by more efficient use of data and collaborative communication.

Innovations to watch

Examples of innovative approaches being trialled and implemented in various Australian settings that we are keenly keeping an eye on at Larter include varieties of GP-led models, nurse-led models and collaborative system approaches:

• nurse-led models include telephone triage and internet-supported triage models; telehealth arrangements between RACF and Nurse Practitioners at Urgent Care Centres
• GP-led models include co-located GP clinics in hospitals, local GPs to create a roster system that provided after-hours support to RACFs, in addition to practice-based after-hours GPs and medical deputising services
• collaborative approaches to reduce polypharmacy
• collaborative telehealth pilots linking aged care providers, the on-call GP, Ambulance and the Emergency Department
• collaborative education: in-reach providers providing training to RACF staff, GPs and locum services on early recognition, escalation and assessment of a deteriorating resident and an awareness of the options for facility-based acute care
• targeted education: after hours nurse triage provider is building health literacy of RACF staff to support decision-making

We know that to effect changes in this space we need to address: practice change, policy change, behaviour change and systems change – for staff, consumers and services. Overcoming these challenges requires improved collaboration, coordination and continuity of care – among sectors, agencies, residents, carers. A whole-of-system approach that is adapted for particular local contexts.
Solutions musts aim for improved sector capacity and empowerment, improved community and provider health literacy, and better quality care. Above all, improved health outcomes for our vulnerable populations.

Contact us if you would like to learn more about our work in and understanding of the after hours primary care system.