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Using an integrated, team-based model of care involving RACF staff, GPs, Nurses, Allied Health and Carers to empower residents, and improve confidence in care choices and health services

The Challenge

Ageing is a natural process.  As we get older, we move from a focus on health improvement and health intervention, to a focus on health maintenance and quality of life.  Health maintenance requires a more collaborative team based approach to the provision of care that typically exists at other stages of the life course as patient sometimes struggle with the complexity of self-navigating access to health services, and varying degrees of support and coordination are required to ensure residents get the right care at the right time.  The provision of primary health care to residents of aged care facilities (RACF) remains fragmented.  While RACF do an exceptional job coordinating services and activities around the needs of residents, an additional layer of health care coordination is often required to ensure clarity around the needs and goals of residents, and that the type of health care they receive is effectively organised across multiple health providers and professionals to achieve the life goals of the patient.

Theory of Change

A more coordinated approach to team-based health care and health maintenance, supporting the life goals set by residents in a structured health maintenance plan, will improve resident quality of life, health outcomes and confidence as they age.

Anticipated Outcomes

Short-Intermediate Term

  1. Number of residents with an annual health maintenance plan.

  2. Number of different service types (e.g. nursing, medical, allied health, social) coordinated per resident.

  3. Self-reported resident confidence in the quality of care.

Long Term Outcomes

Improve quality of life in place.

Progress

Better Quality

-
Number of residents with an annual health maintenance plan.

Better Access

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Number of different service types (e.g. nursing, medical, allied health, social) coordinated per resident.

Greater Confidence

-
Self-reported resident confidence in the quality of care.
LAST UPDATED: 
NOTES:

29 July 2024

Contact:

Jamie Pisani, Clinical Services Manager, Home Care (homecare@thcfa.org.au)

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