Original Study| Volume 22, ISSUE 3, P670-675, March 2021

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Integration of Inpatient and Residential Care In-Reach Service Model and Hospital Resource Utilization: A Retrospective Audit

Published:September 11, 2020DOI:



      In parts of Australia, Residential In-Reach (RIR) services have been implemented to treat residential aged care (RAC) residents for acute conditions in their place of residence to avoid preventable hospital presentation. Our service was initiated in 2009 and restructured in 2014. We compared acute healthcare resource utilization (RIR activity and emergency hospital presentations) by RAC residents under 2 RIR models of care.


      Acute RAC RIR service model of care was changed from existing nurse/emergency physician-led service to nurse/geriatrician-led service and incorporate inpatient liaison nurse consultant into the team.


      RAC episodes and hospital presentations from a single tertiary referral hospital and its associated RAC RIR service.


      Retrospective audit comparing RIR activity, hospital presentations, and associated costs from 2 12-month periods, prior to and postimplementation. Data were expressed as a proportion of the total number of RAC beds in the hospital RIR catchment.


      After implementation of the new model of care, RIR episodes of care increased from 589 to 985 (15.3 vs 24.7 episodes/100 RAC beds, P < .001). Emergency department (ED) presentations fell from 1616 to 1478 (41.9 vs 37.2 presentations/100 RAC beds, P < .001). There were fewer unplanned ED presentations by RIR patients (2.4% vs 0.8%, = 0.03) and fewer 28-day ED re-presentations (16.8% vs 13.7%, P = .01) under the new model of care. ED cost [$AUD 30,830 vs $28,030/100 RAC beds ($USD 21,344 vs $19,407), P < .001] and inpatient admission costs [$145,607 vs $117,531/100 RAC beds ($USD 100,814 vs $81,380), P < .001] were each lower in the second period.

      Conclusions and Implications

      In the 12 months following implementation of the new model of care, an increase in RIR activity, and a decrease in ED presentations was observed. Further research is necessary to validate these retrospective findings and better evaluate clinical outcomes and consumer satisfaction of the service.


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        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: Evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M157
        • Graverholt B.
        • Riise T.
        • Jamtvedt G.
        • et al.
        Acute hospital admissions among nursing home residents: A population-based observational study.
        BMC Health Serv Res. 2011; 11: 126
        • Finucane P.
        • Wundke R.
        • Whitehead C.
        • et al.
        Use of in-patient hospital beds by people living in residential care.
        GER. 2000; 46: 133-138
        • Mudge A.M.
        • Denaro C.P.
        • O’Rourke P.
        Improving hospital outcomes in patients admitted from residential aged care: Results from a controlled trial.
        Age Ageing. 2012; 41: 670-673
        • Wang H.E.
        • Shah M.N.
        • Allman R.M.
        • Kilgore M.
        Emergency department visits by nursing home residents in the United States.
        J Am Geriatr Soc. 2011; 59: 1864-1872
        • Creditor M.C.
        Hazards of hospitalization of the elderly.
        Ann Intern Med. 1993; 118: 219-223
        • Fried T.R.
        • Gillick M.R.
        • Lipsitz L.A.
        Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer.
        J Am Geriatr Soc. 1997; 45: 302-306
        • Ackroyd-Stolarz S.
        • Mackinnon N.J.
        • Sketris I.
        • Sabo B.
        Potentially inappropriate prescribing of benzodiazepines for older adults and risk of falls during a hospital stay: A descriptive study.
        Can J Hosp Pharm. 2009; 62: 276-283
        • Fifield M.
        Australia, Department of Social Services. Report on the Operation of the Aged Care Act 1997.
        • Lafortune G.
        • Balestat G.
        Organisation for Economic Co-operation and Development. Trends in severe disability among elderly people: Assessing the evidence in 12 OECD countries and the future implications. Paris, France: OECD; 2007.
        Date accessed: February 4, 2020
        • Ingarfield S.L.
        • Finn J.C.
        • Jacobs I.G.
        • et al.
        Use of emergency departments by older people from residential care: A population based study.
        Age Ageing. 2009; 38: 314-318
        • Arendts G.
        • Reibel T.
        • Codde J.
        • Frankel J.
        Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews.
        Aust J Ageing. 2010; 29: 61-65
        • Finn J.C.
        • Flicker L.
        • Mackenzie E.
        • et al.
        Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia.
        Med J Aust. 2006; 184: 432-435
        • Lau L.
        • Chong C.P.
        • Lim W.K.
        Hospital treatment in residential care facilities is a viable alternative to hospital admission for selected patients: Hospital treatment in residential facilities.
        Geriatr Gerontol Int. 2013; 13: 378-383
        • Harvey P.
        • Storer M.
        • Berlowitz D.J.
        • et al.
        Feasibility and impact of a postdischarge geriatric evaluation and management service for patients from residential care: The Residential Care Intervention Program in the Elderly (RECIPE).
        BMC Geriatr. 2014; 14: 48
        • Martin R.S.
        • Hayes B.J.
        • Hutchinson A.
        • et al.
        Introducing goals of patient care in residential aged care facilities to decrease hospitalization: A cluster randomized controlled trial.
        J Am Med Dir Assoc. 2019; 20: 1318-1324.e2
        • Caplan G.A.
        • Ward J.A.
        • Brennan N.J.
        • et al.
        Hospital in the home: A randomised controlled trial.
        Med J Aust. 1999; 170: 156-160
        • Caplan G.A.
        • Meller A.
        • Squires B.
        • et al.
        Advance care planning and hospital in the nursing home.
        Age Ageing. 2006; 35: 581-585
        • Montalto M.
        • Chu M.Y.
        • Ratnam I.
        • et al.
        The treatment of nursing home-acquired pneumonia using a medically intensive hospital in the home service.
        Med J Aust. 2015; 203: 441-442
        • Bairstow P.
        • Ashe S.
        • Bairstow M.
        • Lithgo P.
        Hospital outreach service: Helping to prevent nursing home placement.
        Aust Health Rev. 1998; 21: 192-202
        • Crilly J.
        • Chaboyer W.
        • Wallis M.
        • et al.
        An outcomes evaluation of an Australian hospital in the nursing home admission avoidance programme.
        J Clin Nurs. 2011; 20: 1178-1187
        • Craswell A.
        • Wallis M.
        • Coates K.
        • et al.
        Enhanced primary care provided by a nurse practitioner candidate to aged care facility residents: A mixed methods study.
        Collegian. 2019; 27: 281-287
        • Caplan G.A.
        • Coconis J.
        • Woods J.
        Effect of hospital in the home treatment on physical and cognitive function: A randomized controlled trial.
        J Gerontol A Biol Sci Med Sci. 2005; 60: 1035-1038
        • Lloyd T.
        • Conti S.
        • Santos F.
        • Steventon A.
        Effect on secondary care of providing enhanced support to residential and nursing home residents: A subgroup analysis of a retrospective matched cohort study.
        BMJ Qual Saf. 2019; 28: 534-546
        • Hullick C.
        • Conway J.
        • Higgins I.
        • et al.
        Emergency department transfers and hospital admissions from residential aged care facilities: A controlled pre-post design study.
        BMC Geriatr. 2016; 16: 102
        • Huckfeldt P.J.
        • Kane R.L.
        • Yang Z.
        • et al.
        Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program associated with number of hospitalizations.
        J Am Geriatr Soc. 2018; 66: 1830-1837
        • Chan Carusone S.
        • Loeb M.
        • Lohfeld L.
        Pneumonia care and the nursing home: A qualitative descriptive study of resident and family member perspectives.
        BMC Geriatr. 2006; 6: 2
        • Menec V.H.
        • Nowicki S.
        • Blandford A.
        • Veselyuk D.
        hospitalizations at the end of life among long-term care residents.
        J Gerontol A Biol Sci Med Sci. 2009; 64A: 395-402
        • Travis S.S.
        • Loving G.
        • McClanahan L.
        • Bernard M.
        Hospitalization patterns and palliation in the last year of life among residents in long-term care.
        Gerontologist. 2001; 41: 153-160
        • Lamberg J.L.
        • Person C.J.
        • Kiely D.K.
        • Mitchell S.L.
        Decisions to hospitalize nursing home residents dying with advanced dementia.
        J Am Geriatr Soc. 2005; 53: 1396-1401
        • Arendts G.
        • Howard K.
        The interface between residential aged care and the emergency department: A systematic review.
        Age Ageing. 2010; 39: 306-312