Continuity of care key to better outcomes

Aged care residents have 8 per cent fewer emergency department presentations when they continue seeing their regular general practitioner after entering a facility, according to a national study led by the Registry of Senior Australians Research Centre at the South Australian Health and Medical Research Institute.

The study noted that continuity of care during a transition to an aged care home was the second most important element affecting emergency department presentations, unplanned hospitalisations, potentially preventable hospitalisations, falls- and dementia-related hospitalisations, weight loss and malnutrition.

Of the 330,000-plus residents whose health outcomes were analysed for the study, those who saw the same doctor had 6 per cent fewer unplanned hospitalisations, 11 per cent fewer fall-related hospitalisations and 21 per cent fewer dementia-related hospitalisations.

But just 17 per cent of residents in the study were able to continue seeing their usual GP after entering care.

ROSA principal investigator Professor Gillian Caughey said the results highlighted the crucial nature of continuity of care.

“For too long, older Australians in residential care have struggled with fragmented services and a revolving door of providers. Our study shows that when residents maintain a consistent relationship with their GP, their risk of hospitalisation and even death goes down,” Professor Caughey said.

But it is about more than just seeing a regular GP, Professor Caughey said. Podiatrists, optometrists, pharmacists and nurse practitioners also play an important role in keeping residents healthier and reducing unnecessary pressure on hospitals.

Published in Age and Ageing, the study also highlighted that accessing more services was not necessarily better. It found that preventative services coupled with less reactive care resulted in better outcomes.

Preventative health checks, management plans and allied health services were found to deliver the best outcomes, and compared to reactive, crisis-driven care, had 9 per cent lower mortality.

“We need to set up our system so that residents don’t lose access to trusted GPs when they move into a facility, and other healthcare professionals are part of the team caring for those people from the start,” she said.

The study represents the first national evaluation of its kind and analysed the health outcomes of over 330,000 residents across 3,000 aged care homes. ROSA is now calling for national investment in making continuity of care a priority, and to make proactive, team-based models the norm in aged care.