How a simple phone call helps support older persons with delirium

The pathway involves a clinical assessment over the phone within 72 hours of discharge, including taking note of the patient’s sleep, feeding habits, mobility, pain and bowel movements, with the goal of ensuring patients have safely transitioned to their residential aged care homes (RACHs).

Geriatrician and Medical Lead for the project, Dr Anvi Butala says, “We’re able to do a medication review, pick up on early signs of infection or refer the patient on to the RMH’s Hospital in the Home team”.

This has led to big impacts for the patient’s transition of care to RACHs.

During the 12-month pilot period of the pathway, the team reduced the readmission rate of patients from 18% to 4% in the first 28 days.

Carrie O’Meara, Clinical Nurse Consultant and Nursing Lead for the project, says another positive outcome from the pathway is the support it provides for residential aged care staff.

“They have more confidence with managing the patient and are less likely to be calling an ambulance to send them back.”

Dr Anvi’s goal is for the project to continue “supporting safe discharges” for older patients as unnecessary readmissions are associated “with lots of complications for an older cohort of patients.”

Carrie sees the team expanding the pathway to support different conditions, including “behavioural and psychological symptoms of dementia and for people entering aged care for the first time”.

The model has since been shared with other local Residential in Reach services through the West Metro Health Service Partnership, creating new opportunities to support our older patients.