Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration.

ARM 1. Health Intervention Projects for Seniors (HIPS) - Residential Aged Care Facility (RACF) and primary health sector mediated interventions including provision of a Nurse Practitioner Candidate (NPC) within the RACFs to support an enhanced model of Primary Health Care encompassing general practitioners (GP); development of advanced care plans for residents; better coordination of GP care in the RACF; a training program for RACF staff; and development of a sustainable model of care through endorsed NP medicare billing. ARM 2. Geriatric Emergency Department Intervention (GEDI) - Hospital ED mediated interventions (Clinical Nurse Consultant (CNC) and Clinical Nurses (CN) with further education/experience in gerontology and community health) providing a dedicated single point of contact within the ED for RACF and primary health professionals; rapid and comprehensive assessment of RACF residents on presentation; streamlined patient flow in ED; clear and timely intersectoral communication; focused discharge planning and health professional education and training a) How each intervention component is practically administered – Arm 1: The NPC supports the model of primary healthcare via: * Clinically reviewing RACF elders upon referral by the RACF nurse or as requested by the elder themselves. * liaising with GPs to order medications and tests * facilitates development of advanced care plans for elders in coordination with GP * provides one-on-one education to RACF staff in the review and care of specific elders at the bedside. The amount, type and length of training is determined by the NPC of the clinical service based on assessment of the situation and by the needs of the clinician. There is no formal education program in place Arm 2 - GEDI nurses will screen all people presenting to the ED who are 70 years of age and over or those who appear extremely frail. These nurses will provide frontload assessment, liaise with family, GP, other support services to collect all relevant information, discuss disposition planning with medical team and provide age appropriate interventions in the ED. Health professional education and training in ED is facilitated via GEDI nurses and Gerontology physician providing education sessions attended by ED staff on each shift changeover for up to 1 hour. One-on-one education with primary care staff in ED while reviewing patients presenting to ED will be provided. This will be a decision for the clinical service GEDI team and determined by the needs of the clinician by the GEDI CN or CNC b) The intervention will be evaluated for 12 months c) Strategies to monitor adherence – ongoing regular meetings both internal with research team, external with the CEDRiC team and expert advisory committee, time and motion studies of both the NPC and GEDI nurses.