OPTIMAL project aiming to reduce hospital readmissions for older persons

The OPTI­MAL (Opti­mis­ing old­er People’s Tran­si­tion from acute care Into res­i­den­tial aged care through Mul­ti­dis­ci­pli­nary Assess­ment and Liai­son) project is work­ing to enhance the tran­si­tion of old­er peo­ple from hos­pi­tal to res­i­den­tial aged care. Fund­ed by the Med­ical Research Future Fund (MRFF), this ini­tia­tive aims to reduce read­mis­sions and improve over­all care for indi­vid­u­als aged 65 and over.

Led by Flinders Uni­ver­si­ty in part­ner­ship with the CEIH, Reg­istry of Senior Aus­tralians (ROSA), and geri­atric ser­vices from the Roy­al Ade­laide Hos­pi­tal and the North­ern and South­ern Ade­laide Local Health Net­works (LHN), OPTI­MAL is bring­ing togeth­er key stake­hold­ers to address a crit­i­cal health­care chal­lenge. By map­ping patient path­ways and apply­ing a pre­dic­tive read­mis­sion risk mod­el devel­oped by ROSA, the project is lay­ing the ground­work for tar­get­ed inter­ven­tions. Col­lab­o­ra­tive work­shops have brought togeth­er clin­i­cians, aged care providers, and con­sumers to inform the pro­jec­t’s direc­tion dur­ing which Flinders Uni­ver­si­ty researchers show­cased the enhanced tran­si­tion­al care mod­els used over­seas, to sup­port work­shop atten­dees to iden­ti­fy evi­dence-informed tran­si­tion­al care inter­ven­tions to tri­al in a South Aus­tralian setting.

As OPTI­MAL will take place in mul­ti­ple wards, we have worked with the LHN rep­re­sen­ta­tives to map the old­er per­sons post dis­charge path­way. Lever­ag­ing exist­ing EMR data and the ROSA pre­dic­tive mod­el, we have cre­at­ed a dash­board to iden­ti­fy the lev­el of patients’ risk of read­mis­sion. The dash­board was show­cased in Feb­ru­ary 2024 to a pos­i­tive recep­tion from OPTI­MAL researchers, who will use the work for read­mis­sion mod­el­ling. This will enable researchers to eval­u­ate if risk strat­i­fied inter­ven­tions, reduce emer­gency depart­ment (ED) vis­its and readmissions. 

With over­sight by Dr Ishi­ta Bat­ta and Dr Chloe Furst, the Roy­al Ade­laide Hos­pi­tal has been ran­dom­ly select­ed to be the first site for the study and will imple­ment a nurse led tran­si­tion­al care inter­ven­tion in 3 wards. South­ern and North­ern Ade­laide LHNs will roll-out into the study as inter­ven­tion sites at sub­se­quent inter­vals to test a strat­i­fied nurse-led tran­si­tion­al care approach in sev­er­al geri­atric wards.

A key com­po­nent of OPTI­MAL is col­lab­o­ra­tion to strength­en exist­ing approach­es. We have brought togeth­er clin­i­cians, aged care providers, and con­sumers to co-design care solu­tions. By shar­ing knowl­edge and exper­tise, we are work­ing towards a sys­tem that bet­ter sup­ports old­er Australians.

As Aus­trali­a’s pop­u­la­tion ages, the need for inno­v­a­tive care solu­tions that reduce old­er per­sons read­mis­sions becomes increas­ing­ly urgent. OPTI­MAL is a sig­nif­i­cant step for­ward in address­ing this chal­lenge and build­ing a stronger, more resilient health­care system.

To know more about OPTI­MAL, con­tact ceih@​sa.​gov.​au.