QEII Older Persons Coordinated Care Service Project

Overview

Initiative type

Model of Care

Status

Deliver

Published

12 September 2017

Summary

The QEII Older Persons Care Service is streamlining access to multidisciplinary Comprehensive Geriatric Assessment, management and care planning for people referred to QEII hospital, to facilitate and reduce delays in transfer care or placement in a residential aged care facility. Development of this service includes care provision for in ambulatory and domiciliary settings required to complete the proposed care system.

Key dates

Jan 2016 - Aug 2017

Implementation sites

Metro South Hospital and Health Service

Partnerships

Healthcare Improvement Unit, Brisbane South PHN

Aim


To provide coordinated, efficient care and improve integration of care throughout the continuum for this cohort of vulnerable disadvantaged people.

Benefits


  • Emergency Department ( ED), early case identification using a validated risk screening.
  • Rapid triage and selection of the appropriate care setting.
  • Comprehensive multidisciplinary assessment and management.
  • Focus on early decision making and behaviour care planning to support timely transfer to interim care or Residential Aged Care Facilities (RACF).
  • Improved linkages with community agencies especially interim care, nursing homes, CARE-PACT, General Practice and DBMAS (Dementia Behaviour Management and Assessment Service).

Background


Access to coordinated care has been shown to improve outcomes for complex, frail older people. Successful programs are characterised by high quality coordinated, multidisciplinary assessment and intervention including a Consultant Geriatrician, reliable implementation of care plans and review of progress. Optimal results are achieved when services are appropriately targeted.

The Integrated Care Innovation Fund provides financial support to innovative projects that deliver better integration of care, address fragmentation in services and provide high-value healthcare. Funded projects also demonstrate a willingness to embrace and encourage the uptake of new technology alongside the benefits of integrating care and improving communication between health care sectors.

Key contact

Dr Amanda Stiller

Director of Geriatrics and Rehabilitation

Metro South Hospital and Health Service

Email:  Amanda.Stiller@health.qld.gov.au

Last updated: April 2025

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