Background:
Residents of residential aged care facilities (RACFs) have high rates of unplanned hospitalisation, yet evidence guiding effective post-discharge follow-up remains limited.
Aims:
To evaluate the impact of a new post-discharge screening process implemented by Northern Health’s Residential In-Reach (RIR) team on referral patterns and hospital re-presentations among RACF residents.
Methods:
A retrospective cohort study compared RACF residents discharged from Northern Hospital in two periods: February to May 2024 (pre-intervention) and February to May 2025 (post-intervention). Outcomes included referral patterns,hospital and Victorian Virtual Emergency Department (VVED) re-presentations within 28 days, readmission length of stay, and 28-day mortality.
Results:
A total of 737 patients were included (331 in 2024,406 in 2025),with median age 85 years in both cohorts. Hospital-initiated RIR referrals increased post-intervention (32.6% versus 46.6%, P = <0.001), while RACF-initiated referrals within 7 days reduced (5.4% versus 1.2%, P = <0.001). Hospital re-presentations within 28 days decreased significantly (22.1% versus 14.5%, P = 0.009),including reductions in ED-only presentations (8.2% versus 4.9%, P = 0.028) and ward admissions (13.9% versus 9.6%, P = 0.028). Median readmission length of stay remained similar (3.0 versus 3.2 days, P = 0.741). VVED re-presentations increased modestly (13.3% versus 17.7%, P = 0.105). Mortality was low and comparable (2.1% versus 3.0%, P = 0.641). Missed referrals were detected in 28.1% of cases,with 13.3% retrospectively assessed as appropriate for RIR involvement.
Conclusions:
Routine post-discharge screening reduced hospital re-presentations without increasing length of stay or mortality, supporting a structured follow-up to improve continuity of care in RACF residents.