OPTIMAL care: Enhancing transitions for older persons in hospitals

We are thrilled to be part of the OPTI­MAL Research Project, with the inter­ven­tion phase of the project com­menced in three wards in Cen­tral Ade­laide Local Health Net­work (LHN) in Novem­ber 2024. The project is being imple­ment­ed in a step­wise man­ner over 14 months and will com­mence in South­ern Ade­laide LHN in March 2025 and North­ern Ade­laide LHN in May 2025. 

OPTI­MAL (Opti­mis­ing old­er Peoples’ Tran­si­tion from acute care Into res­i­den­tial aged care through Multidis­ci­pli­nary Assess­ment and Liai­son) is an enhanced care inter­ven­tion for old­er per­sons mak­ing a first-time tran­si­tion into per­ma­nent res­i­den­tial aged care from hos­pi­tal. As a part­ner in this Med­ical Research Future Fund project, CEIH has worked close­ly with Flinders Uni­ver­si­ty (the lead), Reg­istry of Senior Aus­tralians (ROSA) and clin­i­cians pro­vid­ing care to this group. 

We know oth­er coun­tries have been able to reduce hos­pi­tal read­mis­sions by enhanc­ing tran­si­tion­al care for old­er per­sons being dis­charged from hos­pi­tal. OPTI­MAL is using evi­denced based risk strat­i­fied approach­es, to assess the effec­tive­ness of post dis­charge inter­ven­tions in an Aus­tralian setting.

CEIH enabled the imple­men­ta­tion of this work, build­ing a unique dash­board which applies the pre­dic­tive mod­el devel­oped by ROSA, to sup­port this research inter­ven­tion. This inno­va­tion enables clin­i­cians to mon­i­tor con­sent­ing old­er person’s tran­si­tions from acute wards through Care Await­ing Place­ment, and dis­charge from SA Health, until arrival at per­ma­nent res­i­den­tial aged care. 

Facil­i­tat­ed train­ing is an impor­tant suc­cess fac­tor for project imple­men­ta­tion. The CEIH demon­strat­ed the dash­board at stake­hold­er work­shops ear­li­er this year and pro­vid­ed cus­tomised train­ing to the OPTI­MAL research nurs­es from Cen­tral and South­ern Ade­laide LHNs.

We are excit­ed to see the out­comes for old­er per­sons enter­ing into res­i­den­tial aged care for the first time in met­ro­pol­i­tan South Australia.

If you would like to know more about this research, please email Carmel.​McNamara@​flinders.​edu.​au If you would like to know more about the part­ner­ship work of CEIH, please email ceih@​sa.​gov.​au