Patients are frequently discharged from hospital to residential aged care facilities without an advance care plan (ACP) in place, and when one is in place it is not uncommon that it has not been recently reviewed. Hospital teams usually complete a Goals of Patient Care form during admission, but such documents are normally only valid for the duration of the hospital admission. Valuable discussions regarding values and future wishes are often lost on discharge into residential aged care. 

 

In 2021, Bethesda Community Palliative Care (MPaCCS) secured additional funding through the National Project Agreement for Palliative Care in Aged Care (NPA) to create a new role within the service which aims to smooth the transition of patients moving between hospitals and residential aged care. 

 

The MPaCCS Liaison nurse works within four metropolitan hospitals in Perth and speaks to teams regarding goals of care discussions as well as having access to inpatient notes to review information captured about these discussions, during admission. This allows the Liaison Nurse to hand over to appropriate members of the MPaCCS team who follow-up the patient on discharge to residential aged care. MPaCCS can then support the residential aged care staff with completing advance care plans with residents/families which are consistent with these valuable in-hospital goals of care discussions. 

 

The success of the project has been reflected by the uptake of the service in hospitals where the service is available (over 600 admissions in the first 18 months) and also in the increase in updated or completed advance care plans once the patient/resident is back in residential aged care. The role also supports education and awareness within hospitals regarding the limitations that may be present in some residential aged care services, this facilitates smoother discharge and engagement of appropriate services on discharge.