New community service supports healthy ageing, hospital avoidance and early discharges

An enhanced community healthcare service will improve the care provided to the elderly, reduce hospital presentations and ensure faster patient discharges from hospital.  

Community and Oral Health Acting Nursing Director Vicky Sinclair said the Post-Acute Care Service (PACS) had introduced a geriatrician-led model of care that would enhance the care available to the elderly and support healthy ageing. 

“Demand for care that is accessible and convenient for our elderly patients in their home or in the community is increasing,” Vicky said.  

“Community-based healthcare services are fast-becoming an extra option to support independent living and provide a safe alternative to hospital treatment.”  

As part of the innovative new service, PACS is supporting the early discharge of elderly patients from hospital or through referrals from GPs by delivering safe geriatric assessments and treatments led by a geriatrician and multidisciplinary team. 

“Patients have access to rapid assessments from the multi-disciplinary team within 24 hours of referral,” she said.  

“A geriatrician will undertake medical assessments and interventions and facilitate necessary medical liaison between the nominated GP and other specialists involved in the care of the client. 

“Nursing, social work, occupational therapy, pharmacists and physiotherapy will also provide expert assessment and care to support patients. 

“Importantly, the new service will also assess and address complex issues and conditions associated with ageing which can result in deterioration and admission to hospital.” 

The PACS service will provide up to two weeks of care to address the patient’s immediate care needs and coordinate longer-term services as required by the patient. 

“Services are flexibly provided within the home, via telehealth or at local community health clinics for patients who are stable, able to self-care or have a responsible carer,” Ms Sinclair said. 

“The new service will help people stay at home longer and avoid being re-admitted to hospital unnecessarily.”  

PACS will deliver care that better supports people with longer-term complex medical conditions to improve their overall function, wellbeing and independence in the community. 

“Key treatments delivered at home or in the community include medication administration and monitoring, catheter care, management of falls risk in the home, chronic disease support, and functional and home assessments,” she said.  

“We also provide nutrition support, swallowing assessments, personal care in the home, crisis intervention, carer support and short term acute wound management including stoma care.” 

Patients can be referred to the service through a Metro North Health hospital, or their GP or Queensland Ambulance Service. 

Referrals from GPs or Queensland Ambulance Service
1300 658 252
Referrals from Metro North Health hospitals  

Via the REFER application. Select PACS and indicate request for PACS Geriatrician Assessment in REFER SBAR field. 

Back to top