Queensland-first trial aims to keep at-risk patients at home

Team Care Coordination is involved in a new trial at The Prince Charles Hospital that provides unprecedented access to in-home care and community support to patients over 65 at risk of a fall-related injury.

In a visit to the hospital on 10 October 2019, State Health Minister Steven Miles said Metro North HHS, Queensland Ambulance Service (QAS) and Brisbane North PHN had joined forces to better support elderly people in the community who experienced multiple and frequent falls at home.

“Each month, the Queensland Ambulance Services is seeing more than 1,200 callouts in Metro North area for falls and related incidents for people aged over 65,” Mr Miles said.

“This equates to around 40 falls a day across the whole of Metro North, many of which could potentially be avoided if the necessary community-based supports were in place.

QAS Director of Operations for Metro North region Michelle Holdsworth said many patients don’t require transport to hospital but may fall again within the month. Brisbane North PHN Deputy CEO Libby Dunstan said around half the patients who fall at home are not taking advantage of free PHN or Metro North community-based services offered.

“For more than twenty years, our Team Care Coordination program has been supporting older people to access care in the community,” Ms Dunstan said.

“Through this program, clinical nurses can assess an older person’s care needs in their home and coordinate access to services that support their health and wellbeing,” she said.

The Falls Community Referral pathway trial, which has begun in The Prince Charles Hospital local area, aims to investigate and address the increasing number of falls in the home, while reducing the access barriers to community-based support and care for the elderly.

Mr Miles said we have found that elderly people who fall at home often do not recognise or acknowledge the future risk of a further fall and therefore do not always accept the option to seek or receive further help.

“In addition, we are heavily dependent on the patient or their family initiating contact with their primary care provider or other care service,” he said.

“Some of the reasons for not accessing the available care include the person feeling that they had adequate family support or there were plans in place to visit and discuss with a GP in future.”

The Falls Community Referral Pathway trial is a collaborative response which aims to reduce the rate of falls and fall injuries, and improve functional capacity and quality of life, among older adults within the trial.

“The trial will focus on improving patient access and uptake of community-based services, focusing on those patients who were not transported to hospital, but referred to post-falls management and care coordination delivered in their home,” Mr Miles said.

The trial is targeting adults who would potentially be transported by the QAS to The Prince Charles Hospital for assessment and care, and who have experienced a fall at home and are aged over 65 years.

Mr Miles said the trial would continue over the next six months and will be rolled out further if successful.

Pictured above: Margaret Hilleard, recently hospitalised from a fall at The Prince Charles Hospital with Steven Miles MP, Metro North HHS Community and Oral Health Directorate Nursing Director Mary Wheeldon and Brisbane North PHN Deputy CEO Libby Dunstan.