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Aged Care Emergency (ACE)

Aged Care Emergency (ACE) support for Residential Aged Care

The Aged Care Emergency (ACE) program supports Residential Aged Care Facilities (RACF) staff to care for residents with acute, non-life-threatening conditions and potentially lessens the likelihood of unnecessary transfers to hospital.

The ACE program aims to improve communication and clinical handover between care providers, RACF staff, general practitioners, paramedics and hospital staff, and where transfer to the Emergency Department is required, aims to ensure that the visit is pro-actively managed and health outcomes are optimised.

The ACE program is a partnership between the PHN, Hunter New England Local Health District, Hunter Primary Care and NSW Ambulance, and currently operates across areas of the Hunter and New England regions.

What is the ACE model of care?

The ACE model of care utilises evidence-based guidelines to support RACF staff to detect and manage acute deterioration in the health of a resident.

The manual is also a decision-support tool, assisting RACF staff to determine when to call a general practitioner for advice or review of the resident, and when to call for an ambulance.

If the resident requires transfer to hospital, RACF staff contact Emergency Department staff to provide a clinical handover, clarifying the reason for transfer and establishing the required care goals.

This verbal communication is an important care management step, as it ensures that hospital staff can plan for the arrival and pro-actively manage the resident’s care.

The ACE program utilises the ISBAR clinical handover tool for communication between care providers, which documents:

  • Identify: contact names and details
  • Situation: summary of presenting symptom or problem, and duration
  • Background: relevant medical history, medication, advance care plan
  • Assessment: observations including pain and delirium assessment
  • Recommendation: goals of care and outcome

If the resident needs to be transferred to hospital, the ISBAR form is transported in a Yellow Envelope, along with copies of any relevant documentation, such as a medication chart, advance care directive, care plan, and pathology or imaging results. The Yellow Envelope is returned to the RACF when the resident is discharged, to ensure continuity of care and the provision of updated documentation, such as a discharge summary and prescriptions.

The ACE model of care is supported by a train-the-trainer model of education for RACF staff, hospital staff, paramedics and general practitioners. Training for RACF staff includes recognition of the resident’s deterioration, effective clinical handovers, communication techniques, and additional care strategies, such as Stop and Watch, and Top 5. Education is further supported with quarterly interagency meetings, a newsletter, RACF focus groups and the ACE HealthPathways website which includes an electronic version of the ACE manual, training videos and resources.

How does the 24-hour telephone support service work?

The ACE service provides a 24 hour ACE telephone support phone number for the Hunter New England region (1300 223 555) and is available to eligible RACFs in the following locations: Armidale; Cessnock; Maitland; Greater Newcastle area; Tamworth; and Taree.

RACFs in the Central Coast region should contact the Aged Care Response Team via Gosford Hospital on (02) 4320 2111.

The ACE service provides telephone advice and support for RACF staff in making decisions about acute, non-life-threatening conditions. Telephone support is provided by specifically trained registered nurses who understand the needs of aged care patients and use clinical guidelines developed specifically for the aged care environment. If the resident requires transfer to hospital, the RACF staff are also supported in the process to ensure that the hospital is prepared for the arrival of an aged care patient with specific and/or complex needs.

During business hours, the telephone support service is provided by Hunter New England Local Health District staff working within the Emergency Department, including ACE staff and the Aged Care Services Emergency Team.

The after-hours service is funded by the PHN, and provided by Hunter Primary Care’s GP Access After Hours, 24 hour patient streaming service. For further information about this service, visit the Hunter Primary Care website.

Want to know more about the ACE Program?

For specific feedback about the ACE program contact

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