Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
The Metro North Older Persons Emergency Network (OPEN) Long Stay Service (LSS) facilitates the discharge of extended stay patients from admitted hospital care into community respite under the care of the RACH’s local GP. This is a key point of difference to other hospital-RACH models for extended stay patients, which usually operate under admitted-patient models. The concept of partnering with a RACH to reserve respite beds for delayed discharge older patients was co-designed by senior leadership from Mtero North Health and local aged care partners.
Dates: Jul 2024 - Sep 2025
Implementation sites: Older Persons Emergency Network (OPEN), Metro North HHS
Partnerships: Morayfield-based residential aged care home
Aim
To reduce the non-acute extended stay hospital utilisation of older persons in the Caboolture, Kilcoy and Redcliffe hospital catchments.
Outcomes
- Discharged 86 extended stay patients to RACH respite.
- Diverted 3,546 occupied bed days to respite, valued at $5.3M in released acute capacity.
- Supported 62.8% of respite residents to find a permanent RACH placement and 14% of residents to return home.
Background
The delayed discharge of older patients from acute hospital beds presents a significant challenge for the health system in Queensland and nationally. This aged care crisis has gained significant media attention, with strong public pressure on governments to address the “bed block” that is putting immense strain on hospital capacity and the health budget.(1, 2) The pressure is expected to escalate, with hospital demand projected to rise 34% by 2033,(3) while the population of Queenslanders aged over 65 is forecast to increase 76.7% by 2046.(4) This pressure is compounded by shortages in residential aged care places,(3, 5, 6) community-based services,(3, 5-7) and inadequate integration across the acute – community – aged care interface.(5, 6) High demand for permanent RACH places, (3, 5, 6) workforce constraints,(5, 8) and decreased risk tolerance under the strengthened Aged Care Quality and Safety Standards(5) have hindered equitable access to residential aged care. As a result, older persons with complex needs, such as those living with dementia, mental illness or who smoke, are facing increasing difficulties finding a RACH willing to accept them.(5, 9)
Delayed discharge exposes older persons to an increased risk of hospital-associated complications, including delirium, functional decline, hospital-acquired incontinence, falls, and pressure injuries.(10) Additional risks arise on discharge, with fragmented communication between hospitals, General Practitioners (GPs) and RACHs increasing the likelihood of medication-related harms and hospital re-presentation.(11, 12) Internationally, various initiatives have demonstrated potential in reducing delayed discharges, however, many have been implemented with limited collaboration across hospital, primary and aged care sectors.(13) As a result, there is a risk that these efforts have merely shifted the problem from one part of the system to another, rather than achieving true resolution.(13) Addressing delayed discharge among older persons requires a coordinated, system-wide approach that tackles the underlying complexities.(3)
The MNH OPEN Long Stay Service (OLSS) pilot sought to alleviate the pressure on acute hospital beds in the Caboolture, Kilcoy and Redcliffe hospital catchments by collaborating with a local RACH and primary care providers to:
- support the coordinated transition of older non-acute patients from hospital to RACH-based respite, and then on to an appropriate and secure permanent residence.
- reduce the time spent in an acute facility, thereby preventing hospital-related deconditioning, functional or cognitive decline and improving quality of life.
- ensure timely and accurate transfer of health information, including pharmacist-led medication liaison at discharge (from hospital and respite), thereby reducing medication-related harm and unnecessary emergency department presentations and hospital readmissions.
- support the delivery of person-centred care in the right place, at the right time, and by the right people.
- contribute to improved system efficiency through reduced non-acute length of stays, greater integration and lower healthcare costs per patient.
Methods
The core value proposition of the OLSS is that extended stay patients are discharged from admitted hospital care into community respite under the care of the RACH’s local GP. The concept of partnering with a RACH to reserve respite beds for delayed discharge older patients was co-designed by senior leadership from MNH and local aged care partners. The model received non-recurrent funding from the Queensland Department of Health and MNH from 1 July 2024 to 30 June 2025, with subsequent extension to 30 June 2027. Following a robust procurement process and the establishment of the core clinical and project teams, the OLSS was rolled out in phases.
After an intensive phase of key stakeholder engagement and awareness-raising activities, the first referrals were accepted in October 2024. The full capacity of 10 residents at the Morayfield RACH was achieved in January 2025. Iterative process improvements occurred throughout 2025 to improve efficiencies and performance. The model of care initially operated as a shared-care model between the OLSS Nurse Practitioner (NP) and the local GP, with clinical escalation supported by the OLSS geriatrician.
The NP conducted weekly rounds and medication transcription to support residents transitioning to and from respite care. However, following contract extension negotiations in mid-2025, and the sale of the Morayfield RACH to another service provider, clinical care is now fully led by the RACH’s appointed GP. Residents are under the RACH’s clinical governance, and the OLSS NP no longer conducts weekly rounds. The contracted RACH provides OLSS respite residents with hotel and clinical services, including GP, nursing, pharmacy, medication management and allied health support. The RACH’s independently appointed GP manages all primary care needs as they arise, with the OLSS team available to support the RACH in accessing emergency department avoidance and hospital admission prevention services in the case of emergent care needs.
The OLSS Team includes:
- Clinical Nurses: Work under NP oversight to facilitate the inpatient referral process and undertake clinical suitability assessments before referrals are submitted to the RACH for their separate clinical approval.
- Pharmacy: Ensure continuity of medication management on discharge from MNH inpatient care to respite at Morayfield RACH, and from respite to permanent residence.
- Social Work: Support residents and their families to find a permanent placement, as part of outpatient outreach model.
- Administration: Coordinate referrals, admissions and discharges; communications with families/carers; and meetings between OLSS and Morayfield RACH.
To be eligible for a respite place, individuals need:
- current inpatient status with non-acute care needs and ready for discharge
- ACAT assessment with permanent residential and respite approval codes
- current and valid Enduring Power of Attorney (EPOA)
- current Acute Resuscitation Plan (ARP) / Advance Care Plan (ACP). The team used the Implementation Readiness Assessment Tool(14, 15) to inform improvements and changes to the OLSS model.
Discussion
This model’s success is in large part due to the overarching need to address the growing demand for suitable non-acute accommodation following hospitalisation of older persons. This system pressure enabled health leaders to build an organisational environment that is not only open to new ideas and cross-sector collaboration, but willing to fund and pilot innovative models.
In addition to the leadership and financial support, other key contextual factors include:
- The proximity of a partnering RACH to an acute care facility, and sufficient population density to ensure the ten reserved respite beds were filled on average at 97% capacity with local residents.
- The financial viability of the model for the partnering RACH, which can access both the QH daily bed reservation fee and Commonwealth respite funding.
- The placement of the service within the Older Persons Emergency Network, which enabled it to partner with other complementary acute outreach services to prevent avoidable hospital re-presentations and admissions following discharge to respite.
Key learnings include:
- The importance of engaging stakeholders early and the need for clear consistent communication to referring inpatient teams.
- The value of supporting governance structures to foster regular communication and set clear expectations between the health service and the RACH to ensure issues are identified early.
- The need to engage with primary care when building RACH-based models, to ensure expectations are realistic and financially viable for non-public sector health providers.
- The value of dedicated project time to plan, implement and evaluate the new service.
The contract development and negotiation phase in particular is time-consuming and expensive for both parties. The core limitation of this model relates to the patient eligibility restrictions, due in large part to respite-related requirements of our RACH partner under the Aged Care Act. Extended stay patients discharging into respite need to provide various financial / medical consents before transfer. Those individuals who are under the care of Office of the Public Guardian, have the Public Trustee appointed, or have an incomplete QCAT application pending have not been able to be placed under the project. The OLSS model is highly transferable and scalable across metropolitan and large regional areas that have RACHs located close to acute care facilities.
Within MNH alone there is potential to either increase the number of reserved respite places, or to partner with other RACHs to deliver the model in additional locations. It also has the potential to be adapted to other patient cohorts, for example funding reserved memory support unit beds to enable the discharge of more complex delayed discharge patient groups.
The next steps for the OLSS include:
- Conducting a 24-month evaluation of the service using implementation science methodologies (including RE-AIM).
- There are also plans to conduct a health economic evaluation to compare the service against standard care and other alternative models.
- Working with our health service executive to determine whether the service is funded at 10 places beyond 30 June 2027.
References
1. Dalzell S. 3,100 aged care patients stranded in hospitals as states again press Commonwealth for action. ABC News; February 13, 2026; Available from: https://www.abc.net.au/news/2026-02-13/aged-care-hospital-funding-bed-block/106336820.
2. Thousands stuck in public hospital beds amid nationwide aged care shortage. aged care insite; November 17, 2025 [25/02/2026]; Available from: https://www.agedcareinsite.com.au/2025/11/qld-bears-brunt-of-nationwide-aged-care-shortage/.
3. Reducing delayed discharge: A system level response for older patients. Queensland Health; 2025.
4. The health of Queenslanders: Report of the Chief Health Officer Queensland. Queensland Government; 2025 [cited 2026 20/2/26]; Available from: https://www.choreport.health.qld.gov.au/our-people/demography.
5. The Long Stay Crisis: Collaborative Solutions for Delayed Discharge from Hospital of Older People; Joint Discussion Paper of Dementia Australia, Council on the Ageing, Ageing Australia and the Older Persons Advocacy Network October 2025: Available from: https://s3.ap-southeast-2.amazonaws.com/cdn-production.opan.org.au/uploads/2025/12/Long-stay-crisis-delayed-discharge-older-people-1.pdf.
6. Inquiry into the provision of primary, allied and private health care, aged care and NDIS care services and its impact on the Queensland public health system. 57th Parliament Health and Environment Committee; April 2022; Available from: https://www.parliament.qld.gov.au/Work-of-the-Assembly/Tabled-Papers/docs/5722t506/5722t506-dea6.pdf.
7. Radford B, John JV. Clear the home care backlog. National Seniors Australia; August 29, 2025; Available from: https://nationalseniors.com.au/news/featured-news/clear-the-home-care-backlog#:~:text=The%20Royal%20Commission%20into%20Aged,lack%20of%20publicly%20available%20data.
8. Duty of Care: Aged Care Sector in Crisis. CEDA -Committee for Economic Development of Australia; 2022; Available from: https://www.ceda.com.au/research-and-policy/research/economy/duty-of-care-aged-care-in-crisis.
9. The National Aged Care Advocacy Program Presenting Issues - Report 5. Older Persons Advocacy Network; 2025; Available from: https://s3.ap-southeast-2.amazonaws.com/cdn-production.opan.org.au/uploads/2025/10/OPAN_Presenting_Issues_Report_100325.pdf.
10. Mudge AM, McRae P, Hubbard RE, Peel NM, Lim WK, Barnett AG, et al. Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care. J Am Geriatr Soc. 2019 Feb; 67 (2): 352-6.
11. Medication Safety in Transitions of Care: World Health Organization; 2019.
12. Medication Management at Transitions of Care Stewardship Framework. Sydney: Australian Commission on Safety and Quality in Health Care; 2025.
13. Cadel; L, Guilcher; SJT, Kokorelias; KM, Sutherland; J, Glasby; J, Kiran; T, et al. Initiatives for improving delayed discharge
from a hospital setting: a scoping review. BMJ Open. 2021; 11:e044291.
14. Implementation Readiness Assessment Tool. Implementation Evaluation Hub; 2024; Available from: https://www.implementationevaluationhub.com/assessment/.
15. Mutsekwa RN, Campbell KL, Canavan R, Angus RL, McBride LJ, Byrnes J. Performance Understanding and Learning System (PULSE-KEY)
Key contact
Alexandra Cation
Project Manager
Older Persons Emergency Network (OPEN)
Metro North Health