The Aged Care Emergency (ACE) program supports the staff of Residential Aged Care Facilities (RACF) to care for residents with acute, non-life threatening conditions within the facility, and potentially avoid unnecessary transfer to the hospital.
The ACE program aims to improve communication and clinical handover between care providers, such as RACF staff, general practitioners, paramedics and hospital staff, and where transfer to the Emergency Department is required, ensure the visit is pro-actively managed and health outcomes are optimised.
The ACE program currently operates across areas of the Hunter and New England, and is a partnership between the PHN, Hunter New England Local Health District, Hunter Primary Care and NSW Ambulance.
What is the ACE model of care?
The model of care utilises evidence-based guidelines to support Residential Aged Care Facility (RACF) staff to detect and manage an acute deterioration in the health of a resident. The manual is also a decision-support tool, assisting the RACF staff to determine when to call a general practitioner for advice or review of the resident, and when to call for an ambulance.
If the resident requires transfer to hospital, the RACF staff contact Emergency Department staff to provide a clinical handover, clarifying the reason for transfer and establishing the required care goals. This verbal communication is an important care management step, as it ensures hospital staff are able to plan for the arrival of the resident and pro-actively manage the resident’s care.
The ACE program utilises the ISBAR clinical handover tool for communication between care providers, which documents:
- Identify: contact names and details;
- Situation: summary of presenting symptom or problem, and duration;
- Background: relevant medical history, medication, advance care plan;
- Assessment: observations: Including pain and delirium assessment; and
- Recommendation: goals of care and outcome.
If the resident needs to be transferred to hospital, the ISBAR form is transported in a Yellow Envelope, along with copies of any relevant documentation, such as a medication chart, advance care directive, care plan, and pathology or imaging results. The Yellow Envelope is returned to the RACF when the resident is discharged from the hospital, to ensure continuity of care and the provision of updated documentation, such as a discharge summary and prescriptions.
The ACE model of care is supported by a train-the-trainer model of education for RACF staff, hospital staff, paramedics and general practitioners. Training for RACF staff includes recognition of the deteriorating patient, effective clinical handovers, communication techniques, and additional care strategies, such as Stop and Watch, and Top 5. The education is further supported with quarterly interagency meetings, a newsletter, RACF focus groups and the ACE HealthPathways website. The website provides stakeholders with an electronic version of the ACE manual, training videos and resources
How does the 24-hour telephone support service work?
The ACE service provides a 24 hour ACE telephone support phone number, and is available to eligible RACFs in the following locations: Armidale; Cessnock; Maitland; Greater Newcastle area; Tamworth; and Taree.
The ACE service provides telephone advice and support for RACF staff in making decisions about acute, non-life threatening conditions. Telephone support is provided by specifically trained registered nurses who understand the needs of aged care patients and use clinical guidelines developed specifically for the aged care environment. If the resident requires transfer to hospital, the RACF staff are also supported in the process to ensure that the hospital is prepared for the arrival of an aged care patient with specific and/or complex needs.
During business hours, the telephone support service is provided by Hunter New England Local Health District staff working within the Emergency Department, including ACE staff and the Agedcare Services Emergency Team. The after-hours service is funded by the PHN, and provided by Hunter Primary Care’s GP Access After Hours, 24 hour patient streaming service – for further information about this service, visit the Hunter Primary Care website.
For specific feedback about the ACE program, please send an email to firstname.lastname@example.org