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Geriatric Rapid Acute Care Evaluation (GRACE) Model of Care

Northern Sydney Local Health District
Project Added:
16 September 2013
Last updated:
9 January 2015

Geriatric Rapid Acute Care Evaluation (GRACE) Model of Care

Hornsby Ku-ring-gai Hospital Service (HKHS) has developed the Geriatric Rapid Acute Care Evaluation (GRACE) model of care to improve the health care journey of aged care residents.

Under the GRACE model hospital staff work in collaboration with general practitioners and aged care facilities to avoid hospital admissions and reduce access block and length of stay for older patients at Hornsby Ku-ring-gai hospital.

Data indicates that GRACE is having positive effects and enhancing the journey of aged care facility residents. It is also helping to improve communication and trust between the hospital, general practitioners and aged care facilities.

Download the GRACE Model of Care (PDF File pdf - 994k)

GRACE Patient Journey

Step 1: Lilly, resident in a Nursing Home, has a leg ulcerStep 2: The GP or nurse in charge contacts the GRACE CNC who triages over the phoneStep 3: GRACE CNC refers Lilly to the hospital's Wound CNC who visits Lilly and establishes that a three week vacuum dressing is neededStep 4: The GRACE CNC liaises with the dressing supplier to provide in-service training for the nursing home staff on the use of the dressing and after care supportStep 5: The Wound CNC reviews the wound weekly, and after three weeks, Lilly has healed enough to allow the application of a moist dressingStep 6: Lilly is happy that she did not have to leave her home


 

Implementing GRACE

Establishing GRACE

Patient Journey

Communication

What is GRACE?

Residents of aged care facilities get access to rapid treatment and appropriate care either in the hospital or their home environment under the GRACE model of care

There is strong evidence that treating nursing home and hostel residents in the home improves their outcomes. While the benefits of caring for residents in their home rather than a hospital are increasingly recognised, facilities are often challenged in managing acute and sub-acute illness.

Under GRACE, hospital staff work in collaboration with general practitioners (GPs) and aged care facility staff to provide enhanced care “at home” for aged care facility residents. There is provision of hospital resources not traditionally available to aged care facilities. When hospital admission is necessary, GRACE patients are given access to rapid treatment to ensure their hospital stay is as short as possible. Key to the model is the GRACE Clinical Nurse Consultant (CNC) who takes responsibility for the telephone triage service and case manages all patients.

GRACE aims to:

  • supporting GPs and aged care facilities with enhanced hospital resources to provide care “at home” and reduce unnecessary hospital admissions.
  • reduce the average length of stay of aged care facility residents in the emergency department and hospital.
  • collaborate with the GPs and aged care facilities to develop a model of care that:
    • provides a decision support system
    • provides hospital resources to assist with assessment and care provision
    • provides coordinated management plans.
    • increase the profile and uptake of Advance Care Directives in aged care facilities.

Contacts


Geriatrician
Hornsby Ku-ring-gai Hospital
Northern Sydney Local Health District
Phone: 02 9477 9245


GRACE CNC
Hornsby Ku-ring-gai Hospital
Northern Sydney Local Health District
Phone: 02 9477 9910

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