Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Provision of off-site collaborative (The Prince Charles Hospital/Anglicare) transitional care for TPCH patients who no longer require acute hospital care but are unable to return to their home: as a sequalae improving TPCH acute bed capacity.
Dates: January 2025 - ongoing
Implementation sites: The Prince Charles Hospital
Partnerships: Anglicare Southern Queensland
This project was presented as a Poster at CEQ Showcase 2026 (PDF 301KB).
Aim
- Provide a person-centric care through an older person focused multidisciplinary team in a Residential Aged Care Home (RACH) environment that promotes ongoing health/wellbeing for discharge ready older adults who are on a residential aged care pathway.
- Optimise TPCH hospital resources by releasing acute care bed capacity.
Outcomes
- We have been operational for 103-days 12/11/2025-23/02/2026) with 71 referrals, 34 admissions, 26 discharges. We have more referrals than we can accept
- Discharges: 10 to St Martins RACH, one discharged home, the remainder to other RACHs
- Median LOS was 27 days (mean: 29 days)
- During the reporting period, St Martins interim care has returned 1111 bed days to TPCH for delivery of acute care. TPCH Internal medicine inpatients have a mean LOS of three days; 1111 returned acute bed days equates to 370 additional patients able be cared for at TPCH
- EuroQoL5D data is collected on admission/discharge Mean scoring increases demonstrate measurable improvement across several domains, indicating that the interim care environment supports both functional stability and enhanced wellbeing
Background
Challenges in delivering healthcare with an aging population nationwide - aging and future healthcare demands
In 2013, 14% of Australia's population was over 65years. Based on medium-level growth assumptions, by 2053 more than 20% will be greater than 65years, and nearly 5% will be greater than 85years.[1] These demographic shifts are driving substantial increases in healthcare utilisation. The health system faces growing pressure to provide appropriate, models of care that support older people safely, and more efficiently across the care continuum.
In 2023-24 in Australia, there were 75,600 admissions to permanent residential care homes (RACH).[2] A recent Southern Australian population-based study found 80% of RACH placements were via hospital or respite.[3] An Australian Productivity Commission Report found the "proportion of separations for 'aged care type' patients waiting 35 days or longer was 15.5% nationally in 2023-24, the highest proportion in ten years".[4] This will be an escalating challenge with a recent QLD Health Report predicting from 2023 to 2033, the largest increase in hospitalisations will be ‘dementia' (81.5%), followed by 'waiting for RACH placement' (74.4%).[5]
Hospital inpatient services are focused on providing acute care for shorter periods; they are not structured to provide extended periods of maintenance care for older patients, and this contributes to enduring daily bed supply and demand imbalances. Patients who do not require acute care but remain ‘waiting' in acute care beds for RACH placement negatively impact patient flow and bed capacity. This forward flow to RACH placement is complicated by the competing demand for RACH beds. A recent Queensland qualitative study exploring solutions to patient flow identified transitions to maintenance care would contribute to reducing bottlenecks and resource efficiency.[6]
Directorate Level - Providing High Quality Care and Meeting Bed Capacity Demands
At an organisational level, enduring daily bed supply and demand imbalances must be managed. Patients who do not require acute care but remain 'waiting' in acute care beds for a RACH placement negatively impact patient flow and bed capacity. This forward flow to RACH placement is complicated by the competing demand for RACH beds. A recent qualitative study conducted in Queensland exploring solutions to patient flow identified transitions to maintenance care would contribute to reducing bottlenecks and resource efficiency [6]
On average, TPCH have upwards of 30 patients per week waiting for RACH placement.
Patient Level - Aging with Autonomy, Dignity and Respect
Long stay in an acute care environment is known to be unsuitable for elderly vulnerable patients.[7] The inability to progress with their lives and the uncertainty of their future destination, is known to result a range of negative emotions, including loneliness, sadness, fear, confusion, rejection, isolation, and grief, as well as physical deconditioning [8]. The transition to a permanent RACH can result in life changing events including loss of a home, personal items, privacy, identity, relationships, choice, independence and decision-making capacity. This combination of physical deconditioning, psychological deterioration and life altering events, can result in a critical reduction in an individual's sense of autonomy, reducing successful transition to RACHs.
Methods
On the 12 November 2025, TPCH and Anglicare Southern Queensland commenced the provision of an Interim Care Service for 14-patients within the Wilson-Henry wing of St Martin's RACH, at Taigum. The collaborative model of interim care supports older sub-acute maintenance type patients who are clinically ready to be discharged from hospital and are on the pathway for permanent RACH placement.
St Martin's staff provide nursing/personal care services, accommodation, meals, hotel services, consumables, standardised equipment, and the provision of all foods/fluids. TPCH provides overarching governance for clinical care with a Geriatrician, onsite Nurse Practitioner (NP), social worker, occupational therapist and assistance, and pharmacist. Additional medical support is provided by the original treating team when the St Martins Geriatrician is not available. An escalation procedure has been developed to support after hours care through the NPs and the TPCH Medical Registrar on call. Referrals are made to allied health (podiatry, mental health, SPACE etc.) as required.
Implementation of the new model of care commenced in June 2025. An NP was employed and commenced identifying and facilitating engagement of stakeholders. This included those who would be directly involved in care, contribute to the service and those who could influence the success of service across both organisations. An ‘Implementation Readiness Assessment' was performed to evaluate the TPCH capability, resources, and risks to provision of the new service. Evolving from the review, an Action Plan was developed outlining the actionable steps and tasks, with realistic timelines and a schedule for implementation roll out.
The NPs, along with numerous small working groups (TPCH and Anglicare) were developed to address and implement the action items with examples below:
Recruitment and workforce; onboarding for geriatrician, social worker, occupational therapist, pharmacist, allied health assistant, electronic training access for St Martins clinical documentation, training for NP, geriatrician, pharmacist on electronic prescribing system
Patient Flow; admission screening criteria, admission discharge pathways, clinical escalation pathway with clinical assessment template, collection and transport of specimens,
Clinical Documentation; guidelines for transporting and reconciling TPCH clinical documentation with Anglicare clinical documentation into the TPCH chart, records, entering admission, transfer and discharge data into Hbsic, PFM, QAS, orientation manual, deceased patient procedure, missing patient procedure
Pharmacy Requirements; medication cupboards (S8 and general imprest), medication refrigeration, script printing, after hours prescribing and supply
Quality and Safety; guideline for incident system reporting across both sites, mapping of standards across National Safety and Quality Care Standards and Aged Quality Care, audit requirements, minimum observation standards (i.e., vitals, bowels, weight), falls pathway
Communication/Education; new service communication across TPCH (i.e., emails, in-service, newsletter, operational/service/consultant meetings), patient/NOK pamphlets
Key performance indicators and evaluation; a Redcap database was created to collect data including patients referred/assessed for suitability, days from assessment to transfer, mean/median LOS, total admissions/discharges, clinical frailty score, average age, gender, post code on admission/RACH discharge, no. of reportable adverse events and deaths, EQ-5D-5LHealth Questionnaire on admission/discharge and Prems survey.
Equipment and resources; laptops, mobile phone, shared email account and remote access.
Discussion
Hospitals and residential aged care services operate with distinct priorities, processes, levels of staffing, and care models. Hospitals are focused on the provision of short-term, acute medical care for immediate, complex, or unstable health issues in busy, noisy, strained environments. In contrast, residential aged care services provide long term, home like environments with dining rooms, communal lounges, activity spaces, outdoor areas, and programs that support social, physical, and cognitive engagement.
The transition from hospital to a permanent RACH forms a peak period of risk for instability and vulnerability for older adults with heightened risks to both physical and mental health. A major contributor to the project's success has been the ability to offer patients an interim-care period within a RACH, giving patients, families, and carers the opportunity to better understand what residential aged care involves Outside the constraints of the hospital environment, individuals can re-establish familiar routines, develop new ones, participate in meaningful activities, and resume living with greater autonomy and purpose.
Success of this collaborative service has been underpinned by the strong communication and collaborative partnership between TPCH and St Martins staff. Shared goals around resident health and wellbeing have enabled greater flexibility in care delivery across both organisations.
A weekly Clinical Review Team meeting supports two-way communication between frontline clinicians, allowing for coordinated review, planning, and support for current patients, new admissions, and those transitioning to permanent care. These meetings also provide opportunities for monitoring clinical practice, delivering education, identifying continuous improvement initiatives, and following up on critical incidents.
In addition, a quarterly Clinical Advisory Committee provides governance and oversight of the model of care. This committee ensures that all partners remain aligned with the program's objectives and committed to achieving high quality outcomes for residents.
Over the next six to 12 months we aim to:
- explore increasing bed capacity
- explore the use of an onsite radiology, and infusion service to minimise resident movements and disruption to decrease the risk of delirium
- develop a Power BI reporting tool to facilitate up-to-date data to support patient flow of maintenance patients to St Matins, and identify new needs and areas for improvement,
- develop a consistent handover minimum data set in collaboration with RACH staff, ensuring it can be used across all facilities-not only St Martins-to support accurate and timely information transfer from hospital to RACH.
- explore opportunities to release Nurse Practitioner time to enable ongoing staff education and strengthen capability to manage patients with complex needs.
- deliver targeted clinical skills training for RACH staff to enhance confidence and competence in caring for higher acuity residents.
- conduct a comprehensive six-month review of the interim care model, incorporating more patient-centred outcome measures such as weight trends, quality of life indicators (EuroQoL-5), and PREMs.
- increase benchmarking activities with other interim care units to identify best practices and opportunities for improvement.
All hospitals face the challenge of appropriately caring for older vulnerable patients who do not require acute care but remain ‘waiting' in for RACH placement acute care beds. This model of collaborative care will be generalisable for many healthcare organisations.
References
1. Australian Institiute of Health and Welfare. Older Australians. 2024 20 February 2026]; Available from: https://www.aihw.gov.au/reports/older-people/older-australians/contents/about.
2.Australian Institiute of Health and Welfare. Admissions into aged care. 2025; Available from: https://www.gen-agedcaredata.gov.au/topics/admissions-into-aged-care.
3.Hughes, G.A., et al., Transitions of Care Among Older People Entering Residential Aged Care Homes. Australas J Ageing, 2025. 44(4): p. e70116.
4.Australian Productivity Commission. Steering committee for the Review of Government Service Provision. Pg 24. 2026; Available from: https://assets.pc.gov.au/2026-01/rogs-2026-partf-overview-and-sections.pdf?VersionId=bWh24vhbLBJ9XSdufNrPLDyZyRLepb6H.
5.Queensland Health. Ageing and future health care demand,. 2025; Available from: https://www.choreport.health.qld.gov.au/from-the-cho/ageing-and-future-healthcare-demand#section__ageingofthepopulation.
6.Samadbeik, M., et al., "A banana in the tailpipe": a qualitative study of patient flow in the healthcare system. BMC Health Serv Res, 2025. 25(1): p. 745.
7.Fernando, R.L., et al., Optimising older People's Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison (OPTIMAL): protocol for a stepped wedge cluster randomised controlled trial with embedded process evaluation. BMC Geriatr, 2025. 25(1): p. 550.
8.Scott, S.M., et al., The importance of aged care policies in assisting older adults transition from home to permanent residential aged care: a focused ethnographic study. BMC Geriatr, 2025. 25(1): p. 975.
Key contact
Bronwyn Pearse
Nurse Practitioner
Metro North Hospital and Health Service