Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
Designed to improve clinical decision-making and escalation during deterioration by building confidence, shared understanding, and communication between residential aged care homes and hospital clinicians.
Dates: January 2025 - June 2025
Implementation sites: Princess Alexandra Hospital CAREPACT – Geriatric Emergency
Partnerships: Brisbane South Primary Health Network
Aim
To examine changes in RACH clinicians’ confidence managing challenging situations immediately before, immediately after, and six-months following completion of the exchange.
Background
Residential Aged Care Homes (RACHs) in Australia support older adults with multimorbidity, frailty, and cognitive impairment who frequently experience acute clinical deterioration requiring timely and complex decision-making. Transfers from RACHs to emergency departments (EDs) are common; in 2018–2019, approximately one-third of residents experienced at least one ED transfer, with up to 55% considered potentially avoidable.
- Such transfers are associated with increased distress for residents and families, risk of non-goal concordant care, and iatrogenic harms. Potentially avoidable transfers are often linked to gaps in clinical assessment, communication, and escalation pathways, as well as reduced staff confidence, particularly during after-hours deterioration events.
- RACH clinicians operate within multifaceted clinical and organisational pressures, which can increase role complexity and hinder timely, person-centred escalation of care. Strengthening capability at the aged care–hospital interface is therefore critical. Educational and work-integrated learning approaches, including shadowing and exchange programs, have been shown to enhance clinician confidence, interprofessional understanding, and collaboration.
- Immersion in another clinical setting can demystify professional roles, foster shared expectations, and build respectful relationships that underpin effective cross-sector communication during clinical deterioration.
- Comprehensive Aged Residents Emergency Partners in Assessment, Care and Treatment (CAREPACT) is a specialist gerontic nursing service supporting RACH residents across the aged care–hospital interface in Brisbane South.
- CAREPACT clinicians work across metropolitan EDs and inpatient wards, partnering with RACHs to enhance clinical assessment, escalation pathways, and alternatives to ED transfer, including telehealth consultation and specialist gerontic nursing review. In collaboration with Brisbane South Primary Health Network (BSPHN), CAREPACT developed an innovative, bursary-supported, three-day clinical exchange program for RACH clinicians. Participants shadowed CAREPACT gerontic nurses in EDs across four metropolitan hospitals, gaining firsthand exposure to ED workflows, assessment processes, and decision-making related to older adults with complex needs.
The program aimed to strengthen clinical confidence, improve understanding of escalation options, and support more nuanced decision-making regarding when to seek telehealth advice, specialist CAREPACT input, or ED transfer. This exchange represents a novel, scalable strategy to strengthen capability, collaboration, and system integration at the aged care–hospital interface. By building shared clinical language and trusted professional relationships, the program has the potential to improve the quality of clinical escalation and handover, support alternatives to ED transfer, and ultimately enhance outcomes and experiences for older residents and their families.
Outcomes
- Improve RACH clinicians’ confidence and self-efficacy in events of deterioration
- Strengthen cross-sector communication
- Strengthen aged care–hospital interface workforce
- Clear, timely, and appropriate escalation of care
- Marked improvement of clinician confidence in acute deterioration and escalation-related domains
- Valuable for future evaluations linking exchange participation to RACH resident outcomes, service utilisation, and economic impact
- Surveys completion 42/45 (93.3%) at baseline, 38/45 (84.4%) post-exchange, and 19/45 (42.2%) at six months
- CMCS scores increased from a median of 4.02 (IQR 3.68-4.38) to 4.69 (4.00-5.00), with a median change of +0.36 (0.15-0.80) (p<0.001)
- Confidence increased post-exchange and remained high at six months (Friedman, p<0.001)
Methods
This descriptive pilot evaluation of the CAREPACT–RACH Exchange Program, used a mixed-methods, repeated-measures design. The evaluation examined changes in participant confidence and experiences through surveys at three time points: baseline (pre-exchange), immediately post-exchange, and six months post-exchange. Quantitative confidence measures were accompanied by qualitative free-text reflections.
The CAREPACT–RACH Exchange Program was developed as a targeted workforce capability initiative to strengthen clinical decision-making and communication across the aged care–hospital interface. Program design and evaluation methods were co-developed through consultation with consumer representatives and key stakeholders, including RACH clinical leaders, ED nursing leadership, consumer representatives, and research advisors. Stakeholder input informed participant materials, exchange structure, and evaluation focus, with emphasis placed on low participant burden, confidentiality, and relevance to real-world practice. CAREPACT is a specialist gerontic nursing service within Metro South Hospital and Health Service, Queensland, providing assessment, care coordination, and clinical support for RACH residents presenting to four metropolitan EDs and associated inpatient units.
The exchange intervention consisted of a three-day observational placement in which RACH clinicians shadowed a CAREPACT clinical nurse within an ED environment. Participants attended the hospital closest to their workplace and were paired with the same CAREPACT nurse for continuity. Exchange days were scheduled as day shifts and could be completed consecutively or non-consecutively. Participants did not undertake clinical duties during the exchange; instead, they observed CAREPACT workflows, ED processes, and interprofessional communication. A structured observation checklist guided learning to ensure consistency across placements and included topics such as acute deterioration, delirium recognition, pain assessment, escalation pathways, communication, and referral to CAREPACT.
All participants completed required Queensland Health onboarding and confirmed insurance and indemnity coverage. To support feasibility and equity, a bursary of AUD $1,500 was provided to participating RACHs to assist with staff backfill. Eligible participants were clinicians employed in RACHs within the Brisbane South region serviced by CAREPACT. Recruitment occurred through an expression-of-interest process disseminated via email, leadership workshops, and professional networks. Applications were assessed by a selection panel against predefined criteria, including commitment to learning and dissemination of knowledge within their RACH. Participation in the exchange was independent of participation in the research evaluation, and informed consent was obtained for survey participation.
The primary outcome was change in confidence, measured using an adapted 21-item Confidence in Managing Challenging Situations (CMCS) scale. Secondary outcomes included sustained confidence at six months and participant experiences of the exchange. Data were collected using REDCap and analysed descriptively, with qualitative responses thematically summarised. The evaluation was underpinned by continuous quality improvement principles, including iterative feedback, structured learning tools, and stakeholder-informed refinement to support scalability and sustainability.
Discussion
This pilot evaluation demonstrates that a brief, bursary-supported observational exchange between RACH clinicians and CAREPACT clinical nurses working in EDs is both feasible and associated with sustained improvements in clinician confidence managing challenging situations. Several contextual factors were critical to the project’s success.
The exchange program was embedded within an established specialist gerontic service with strong relationships across both hospital and aged care sectors. Contributing greatly to the feasibility of this program is CAREPACT’s existing role at the aged care–hospital interface, providing an environment of trust and access.
Second, strong stakeholder engagement during program design ensured alignment with real-world clinical needs, low participant burden, and organisational support from both RACHs and ED leadership.
Third, the bursary model addressed a potential barrier to participation by enabling backfill, which is essential in the current workforce-constrained aged care setting. Several lessons emerged from the exchange; relationship-based, experiential learning appears to be a powerful mechanism for addressing communication gaps that cannot be resolved through policy or education alone. Standardisation through structured observation checklists improved consistency and replicability, while flexibility in scheduling supported participation. Limitations included the use of a convenience sample that lacked a comparator group, limiting causal inference.
Outcomes relied on self-reported confidence rather than objective measures of performance or service utilisation. Attrition at six months was substantial, raising the possibility of response bias, and post-exchange ceiling effects suggest future evaluations may require more sensitive or scenario-based measures. Despite these limitations, the program shows strong potential for scalability across Queensland Health. Similar exchange models could be successfully implemented within other Hospital and Health Services that support RACHs, as this model is particularly suited to services that rely on timely escalation, telehealth triage, and cross-sector communication.
This project shows potential to be replicated in reverse; to have ED clinicians shadow aged care clinicians in the RACH environment. This also could be facilitated by CAREPACT, with the overarching goal of building cross-sector communication and strong relationships. A shared-learning experience could aid in building mutual understanding of the different clinical environments that exist across the care continuum caring for older adults. Next steps should focus on program refinement and a more definitive evaluation. A phased approach would be advantageous, combining process evaluation (reach, fidelity, and resource requirements), behavioural measures (handover quality, escalation timing, telehealth versus in-person decision-making), and linkage to routinely collected system outcomes such as ED presentations and length of stay. This would allow testing of whether improved confidence and communication translates into measurable resident and system benefits.
References
1. Cain P, Alan J, Porock D. Emergency department transfers from residential aged care:
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2. Ahmetovic A, Drucker C, Huber L, Unroe K, Hickman S, Rittiwong T, et al. Hospital Transfers: Perspectives of Nursing Home Residents and Nurses. Innov Aging [Internet]. 2022 Dec 20 [cited 2025 Jan 8];6(Supplement_1):705–705. Available from: https://dx.doi.org/10.1093/geroni/igac059.2579
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4. Piper-Vallillo E, Zambrotta ME, Shields HM, Pelletier SR, Ramani S. Nurse–doctor co-teaching: A path towards interprofessional collaboration. Clin Teach [Internet]. 2023 Feb 1 [cited 2024 Oct 30];20(1):e13556. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/tct.13556
5. Burkett E, Scott I. CARE-PACT: a new paradigm of care for acutely unwell residents in aged care facilities. Aust Fam Physician. 2015 Apr;44(4):204–9.
Key contact
Emma-Kaitlin Murphy
Acting Clinical Nurse Consultant
Princess Alexandra Hospital CAREPACT ' Geriatric Emergency