Aged Residential Care Healthcare Implementation Project (ARCHIP)

This is a facility level study in which a multidisciplinary, generic intervention is targeted on long-term care facilities for older people, with the aim of reducing avoidable acute hospitalisations for five conditions: stroke, ischaemic heart disease, COPD, pneumonia and congestive cardiac failure. The ARCHIP intervention is designed to provide intensive intervention and staff clinical coaching to improve assessment and care planning for those recently discharged from hospital with the ‘big 5’ diagnoses as described above. The Gerontology Nurse Specialist (GNS) will visit intervention facilities weekly for 3 months. Multidisciplinary team meetings will occur for approximately 20% to 25% of residents in each region. The facility will have direct telephone access to the geriatrician during normal business hours. Descriptions of each of the components of the intervention are described below: a. Post Hospitalisation Care Planning Clinical Coaching for facility RN by the GNS: Residents newly discharged from hospital will be targeted by the GNS as the subject of a clinical coaching to hone RN assessment and care planning skills. The following methods will be employed: Clinical Coaching, Case Study, Red Flag Recognition, Clinical Communication Skills, Advance Care Planning, GNS Care Coordination and Multi-disciplinary meetings. b. Multidisciplinary Team Meetings (MDT) Processes and Procedures: It is estimated that approximately 6 residents will be reviewed at a typical MDT meeting (up to 20%-25% of total residents in 1-4 MDT meetings). The criteria for selecting residents for discussion in the MDT meeting are as follows for residents with one of the ‘big 5’ diagnoses (as described above): * New acute hospital admissions within the last month * New admissions to the facility * Those residents on 9 or more medications * Any resident with important change(s) in physical or cognitive status since last review * Any resident who has been subject to an incident report since last review The GNS and facility clinical staff will create a list for the MDT using the above prioritised criteria. Residents will be reviewed in the order of highest priority. The GNS will finalise the list of residents to be discussed at the MDT in collaboration with the facility RN. The GNS with the RN will prepare a clinical review and assess each resident to be discussed, and work with senior nurse to contact family about MDT review. MDT meeting participants will include: * Resident’s General Practitioner (GP) * Facility Senior Nurse * DHB Geriatrician * GNS * Community pharmacist * Other available and relevant health professionals will be invited to participate as needed and available such as: dietitians, physiotherapists, occupational therapists and/or social workers.