Brisbane North PHN’s Team Care Coordination program is involved in a new trial at The Prince Charles Hospital providing unprecedented access to in-home care and community support to patients over 65 at risk of fall-related injuries.

Team Care Coordination supports patients who have chronic complex medical conditions to improve or maintain their health and wellbeing at home.

Patients can access the program via referral from their GP or on discharge from a public hospital in the North Brisbane and Moreton Bay region.

Patients who do not require urgent complex clinical services but who may benefit from support at home may be eligible for support under Team Care Coordination.

Visiting the hospital on October 10th, State Health Minister Steven Miles said the new program would help address the hundreds of elderly people in the community having multiple and frequent falls at home.

“Each month, the Queensland Ambulance Service is seeing more than 1,200 callouts in the North Brisbane and Moreton Bay area for falls and related incidents for people aged over 65,” Mr Miles said.

“This equates to around 40 falls a day across the whole of Metro North, many of which could potentially be avoided if the necessary community-based supports were in place.

“This is really important because we know elderly people are more likely to deteriorate once admitted to hospital. So keeping older Queenslanders out of hospital and in the comfort of their own homes is the best scenario.”

Metro North Hospital and Health Service, the Queensland Ambulance Service (QAS) and Brisbane North PHN have joined forces to deliver the inter-agency program.

QAS Director of Operations for Metro North region Michelle Holdsworth said many patients don’t require transport to hospital but may fall again within the month.

“Along with things like chest pain and respiratory distress cases, falls are some of our most common incidents, so we saw a need to find a solution to prevent repeat patients,” she said.

“We developed a patient pathway in conjunction with Metro North HHS and Brisbane North PHN with the aim of providing better patient education and care and reducing ambulance call outs.”

Brisbane North PHN Deputy CEO Libby Dunstan said around half the patients who fall at home are not taking advantage of free PHN or Metro North community-based services offered.

“For more than twenty years, our Team Care Coordination program has been supporting older people to access care in the community,” Ms Dunstan said.

“Through this program, clinical nurses can assess an older person’s care needs in their home and coordinate access to services that support their health and wellbeing,” she said.

The Falls Community Referral pathway trial, which has begun in The Prince Charles Hospital local area, aims to investigate and address the increasing number of falls in the home, while reducing the access barriers to community-based support and care for the elderly.

Mr Miles said elderly people who fall at home often do not recognise or acknowledge the future risk of a further fall and therefore do not always accept the option to seek or receive further help.

“In addition, we are heavily dependent on the patient or their family initiating contact with their primary care provider or other care service,” he said.

“Some of the reasons for not accessing the available care include the person feeling that they had adequate family support or there were plans in place to visit and discuss with a GP in future.”

The Falls Community Referral Pathway trial is a collaborative response which aims to reduce the rate of falls and fall injuries, and improve functional capacity and quality of life, among older adults within the trial.

“The trial will focus on improving patient access and uptake of community-based services, focusing on those patients who were not transported to hospital, but referred to post-falls management and care coordination delivered in their home,” Mr Miles said.

The trial is targeting adults who would potentially be transported by the QAS to The Prince Charles Hospital for assessment and care, and who have experienced a fall at home and are aged over 65 years.

Mr Miles said the trial would continue over the next six months and will be rolled out further if successful.

Featured image caption: Pictured (L-R) are Margaret Hilleard, recently hospitalised from a fall at The Prince Charles Hospital, with the Minister for Health, Hon Steven Miles MP, Metro North HHS Nursing Director (Community and Oral Health Directorate) Mary Wheeldon and Brisbane North PHN Deputy CEO Libby Dunstan.