Empowering the elderly through Integrated Care

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

To enhance choice of care setting for older patients whilst preventing functional decline and promoting recovery. Overall aiming to improve the quality of life for older persons living on the Fraser Coast.

Dates: 1 September 2024 - 30 June 2025

Implementation sites: Hervey Bay Hospital

Partnerships: Queensland Ambulance Service and several internal stakeholders

Aim

To complement existing Integrated Care Services by providing person-centered hospital substitutive care to patients aged over 65 years or over 50 years for Aboriginal and Torres Strait Islander peoples.

Outcomes

  • 10 bed GEM/GEMR HITH establishment following successful change process at Fraser Coast.
  • Since the soft launch in February 2025, 30 patients received hospital equivalent care in their choice of setting.
  • All patients provided overwhelmingly positive feedback.
  • The average inpatient length of stay for the target patient cohort is 21 days whereas GEM/R HITH comparative admission data for 30 patients:
    o  average LOS = 7.72 days
    o  27 via Gem HITH, average LOS = 7.56 days
    o  3 via GEM/R HTH average LOS = 9.16 days

Background

Fraser Coast is experiencing population growth coupled with a higher proportion of older people in the community.  While the Fraser Coast has a well-established acute HITH service, which focuses on the needs of an acute patient cohort, the need for a geriatric sub-acute service was identified to enhance care for the ageing population.

Fraser Coast, Wide Bay Hospital and Health Services has approximately 30% of the local population currently aged over 65 years compared to the Queensland State average of approximately 17%. Overall population growth in the region of more than 8 % over the last 2 years has exacerbated demand challenges. This growth is evidenced by the scale of local developments including multiple over 50s lifestyle resorts and retirement villages.

Older patient presentations accounted for over 52% of all Emergency Department presentations on the Fraser Coast in 2023-2024. In addition, the >65 year cohort made up 49% of all medical and rehabilitation admissions during that timeframe. Recent data shows that the average length of stay for the target patient cohort exceeds 21 days.

Methods

This initiative successfully introduced a new GEM/ GEMR HITH service into an existing well established HITH Integrated Care service.

All stakeholders were engaged in the change management process and the HITH team empowered to recognise the benefits for the target patient cohort. Strategies for success included staff meetings and information sessions being held within the existing HITH service and wider Integrated care teams. Proactive stakeholder engagement occurred with medical and allied health teams across the Fraser Coast hospitals, and the GEDI teams in ED.

Following the preliminary consultations, a business case for change was developed and presented to all stakeholders and their trade unions. All relevant personnel were provided opportunity to feedback, and responses were considered in the development of the model of care for GEM /GEMR HITH.

Integrated Care staff and stakeholders were introduced to the model, referral pathways and admission processes. Our efforts were met with overwhelming positivity from all services given the consumer centred, value-based care of this initiative. This successful integration highlights the wider Integrated Care ethos.

Education opportunities were promoted for existing Integrated care staff to become credentialled as Functional Independence Measure assessors and an education plan established. Professional development needs and opportunities continue to be explored to ensure workforce capability for service sustainability.

We were in the fortunate position to have funds available for the purchase of resources and equipment to establish the new service. Staff were engaged to identify specific resource needs. This resulted in the requisition of items which the project team hadn't initially considered and in a very well-resourced GEM/ GEMR HITH service. This strategy undoubtedly assisted in the change management process given the evidence of tangible benefits.

The implementation plan followed Change management methodology whereby we used a structured approach to minimise resistance whilst achieving the desired outcome of establishing a much-needed service for the local community.

Discussion

The success of the project was largely dependent on integration of the new GEM/GEMR HITH service into an existing and well-established acute HITH service. Prior to the implementation phase the project team worked with staff to identify transferable skills and knowledge gaps. The project team attended weekly HITH staff meetings to provide opportunity for engagement. This allayed fears and clarified any misconceptions about the impact the new service would have on the existing HITH team.

The project team was faced with the challenge of finding suitable physical space for the new GEM/GEMR HITH team members. Local need has outgrown Hervey Bay hospital floorspace with current developments presenting a challenge in terms of Gem/GEMR HITH office and storage space.

During the service establishment phase Hervey Bay experienced a major flooding event which caused significant disruption to our service, and that of other Integrated Care teams. During the flood we were unable to access many GEM/GEMR HITH patients due to safety concerns related to travel.  These challenges provided opportunity to strengthen links with the wider Integrated Care teams, collaboratively sharing resources to ensure that patient safety was maintained.

Another challenge was vehicle access. This was also compounded by the flood event which resulted in the loss of 8 fleet cars. During this time an audit was undertaken resulting in Executive approval for the purchase of an additional fleet car.

Early results indicate GEM/GEMR HITH is making a positive difference for the Elderly at Fraser Coast, Wide Bay. Next steps include strategies to optimise weekend service delivery, embedding referral pathways, and ensuring ongoing service sustainability. Ongoing collaboration with the acute HITH service remains vital. Proactively responding to feedback will enable a consumer driven service.

In conclusion, establishment of the multi-disciplinary GEM/GEMR HITH service, has strengthened collaboration between Integrated Care Services to enhance care of our Elderly population at Fraser Coast, Wide Bay.

References

Fraser Coast Regional Council, Five year age groups
Five year age groups | Fraser Coast Regional Council | Community profile (id.com.au)

Fraser Coast Regional Council, Population and AGE STRUCTURE
Population and age structure | Fraser Coast Regional Council | Population forecast (id.com.au)

Key contact

Rachel Parry and Dot Nicholson

CNC Project Officer -Geriatric Evaluation and Management / NUM - Integrated Care Services, Fraser Coast

Wide Bay Hospital and Health Service

Email: Rachel.parry@health.qld.gov.au

Last updated: June 2025

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