A clinical trial to improve quality of life in aged care

A coordinated care planning intervention with three key components a. Comprehensive assessment which will incorporate an initial individual needs assessment focussing on current and likely future healthcare needs. The needs assessment will particularly focus on identifying patient preferences and goals (utilising informant perspectives where necessary) with respect to palliative care. It is anticipated the needs assessment will require at least two hour long sessions soon after enrolment. b. Individualised care planning utilising six strategies that are most likely to impact on hospital transfer and quality of life. 1. Patient +/- family education regarding diagnosis and prognosis. A research nurse will provide clear simple language verbal and written information regarding illness and expected clinical course. 2. An advanced care plan incorporating preferences of the patient and family for the setting of limits, if any, on hospitalisation, interventions, and resuscitation. 3. A palliative care plan for management of current and anticipated future symptoms. 4. Primary care and assessment plan for the management of minor injury and illness tailored to the patient and RACF requirements. This may involve use of the patient’s regular general practitioner or other existing primary care services that augment general practice. 5. Clinical practice guideline package for the management of major injury and illness. Tailored guidelines will be provided to deal with common acute complications requiring hospitalisation. 6. Root cause analysis of all hospitalisations. We will use QI methodology to assess any hospitalisations in the intervention group and determine whether they were possibly avoidable and if so, what changes would be required to prevent a similar hospitalisation. Whilst it is impossible to be proscriptive about how much contact will be required for each patient in the intervention arm, there will be minimum weekly contact with the patient and facility to manage the care planning. c. Coordination of these strategies, and their systematic application, based on individual patient needs identified through comprehensive assessment. Each patient in the intervention arm will be assigned to a research nurse who will be directly responsible for providing key aspects of the intervention (including some primary care surveillance and service provision) and coordinate other aspects that require specialist and/or multidisciplinary involvement. From enrolment, patients will be exposed to the intervention for a minimum period of eighteen months unless they die or return to live in the community on a permanent basis.