Early Interventions for Healthy Ageing for Older People in Primary Care

Project Design: This research will include a pre-post study with mixed-methods approach underpinned by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation frameworks. Intervention and activities: The project involves implementation of a bundled intervention involving the following components: pre-assessment checklist completed by patients, nurse-coordination of health assessments, GP care planning, discussions and recommendations about advanced care directives (ACD) planning, and discussions and recommendations for social prescribing. The intervention will be delivered in 12 general practices across Adelaide metropolitan region. Implementation Phase: Implementation of bundled intervention involving nurse-coordination of health assessments, care planning, advanced care directives (ACD) planning, and social prescribing will be completed by general practice team members (practice nurses, GPs, practice managers) from the 12 participating general practices. To support implementation, external facilitation from Quality Improvement Performance (QIP) Consulting will occur from July 2026 - April 2027. During the initial 3 months of the project, practices will be required to identify and recruit patients that fit eligibility criteria, then provide the bundled intervention within exiting Medicare (MBS) billable consultations i.e chronic condition management planning/review appointments, practice nurse health assessments and/or 75+ health assessments (for those over 75 years). During this 9-month implementation phase Quality Improvement Performance (QIP) Consulting will support each practice in quality improvement processes and undertake communities of practice to facilitate implementation. Pre-assessment checklist: General practices will provide their patients with a pre-assessment checklist designed for this study, Healthy Home (home-check), Planning Ahead and Staying Social. The checklist is accessible via QR code to an online questionnaire. The pre-assessment will take up to 20 minutes. The pre-assessment will include information about their home environment, home safety hazards (steps, stairs, rugs, lighting etc), readiness for information about advanced care directive planning, level of social interactions per week and readiness for information about social activities. The pre-assessment checklist will be provided to patients at recruitment, Patients will be requested to complete the pre-assessment prior to their next clinic consultation. Health Assessments and GP care planning: GPs and practice nurses will encourage uptake of routinely used general practice health assessments and chronic condition management care planning with their recruited patients. The health assessments and chronic condition care planning are MBS funded items that GPs and practice nurses can implement with eligible patients for long-term management and proactive and preventative approaches to health and wellbeing. Health assessments and care planning appointments will be conducted with patients at the GP clinic by a GP and practice nurse Health assessments and chronic condition care planning items vary between practices, but commonly include height, weight, blood pressure, cardiovascular risk, vaccination status, smoking status, alcohol intake, risk of depression or anxiety, risk of social isolation or loneliness, risk of cognitive changes, risk of frailty, falls or mobility issues, risk or nutrition concerns, home and safety concerns. Health assessments and chronic condition care planning can also be tailored to address patient's specific concerns that arise and health goals, with referrals to allied health professionals and specialists, health education, follow up tests and scans based on individual patient's concerns or health issues. During these appointments, general practice clinicians will discuss and recommend options for advanced care planning and social prescribing. Health assessments and chronic condition care planning appointments generally take up to 1 hour with the nurse and GP. Practice teams will be encouraged to complete a the following components of health assessments and care planning: 1) initial health assessment and education - up to 1 hour, 2.) GP led chronic condition management plan within next 3 months (or as eligible depending of MBS criteria) - up to 1 hour, 3.) Health review by practice nurse 6-weeks later - up to 20 minutes, 4) Review of chronic condition management plan 3 months later - up to 1 hour. These assessments, care planning and reviews will be completed with GP and nurse with patients in the GP clinic. Advance care directive planning: During the health assessment and chronic condition care planning appointments outlined above, GPs and practice nurses will provide information and education about advanced care directives. Clinicians will provide patients with a range of routinely available education resources about advanced care directives, including a kit to complete advanced care directives. These resources are Advance Care Directive Kits available from Government of South Australia (2023), and information sheets and brochures about how to complete an advance care directive available from Advance Care Planning Australia (not dated). Throughout the program, practice teams will promote the uptake of advanced care planning and uploading completed directives to My Health Record. Social prescribing: During the health assessment and chronic condition planning appointments outline above, GPs and practice nurses will provide information and education about social activities and the importance of social connections on health. Clinicians will provide patients with information about community and council led services available in their local area including social groups, community centres and libraries, seniors activity programs, volunteer agencies, transport assistance, strength and balance programs, walking groups, falls prevention classes, carer services, My Aged Care referral for long-term home support. At subsequent clinic appointments throughout the program, practice nurses will ask patients about their level of engagement with recommended social activities provided. Quality improvement approach to facilitate implementation: QIP consulting will provide external facilitation and supervision to the general practices to support implementation through quality improvement processes. Quality improvement (QI) processes include QI planning through an audit practice teams will complete on their practice software to identify patients aged 65+ years eligible for health assessments and chronic condition care planning. QI Planning will inform gaps in care and inform QI plan to address gaps, set goals, and complete small tests of change using Plan, Do, Study, Act (PDSA) process. Practices will monitor adherence to the QI plans using a PDSA template designed specifically for this study. QIP consulting will meet with each practice on a monthly basis for 1 hour throughout the project implementation phase to focus on supporting recruited patients through the health assessment and care planning pathway, review progress against QI plans, provide support of general practice workflows, share learnings. QIP consulting will host 3x two hour face to face community of practice workshops. Communities of practice will involve: 1) practice sharing of what they have implemented, what has changed, what they are seeing; 2) consumer stories - sharing their patient's experience of ageing, care received, advance care planning and social supports; 3) connections with allied health and medical pathways for referral pathways, services, access criteria and connection points with external services. Practices will be provided with a "2026-2027 Early Interventions for Healthy Ageing in Primary Care Practice Toolkit" designed specifically for this study by QIP Consulting and Adelaide Primary Health Network. General practices will report adherence for each of the components of the bundled intervention (number and MBS items of health assessments, care planning appointments, outcomes of advance care planning and social prescribing discussions), in addition to clinical characteristics of patients in a spreadsheet database, specifically designed for this project.