The White Paper describes a new model of in-hospital acute Geriatric care as opposed to the unsustainable acute traditional Geriatric models of hospital care. It includes:

• a new multidisciplinary Orthogeriatric Service with an Evidence Based Medicine fractured neck of femur protocol
• multidisciplinary early inpatient mobility and rehabilitation programmes
• sharing the load of Geriatric patients with other Physicians
• expanding the role of Emergency Department ASET to multidisciplinary team assessments in the ED and the community
• comprehensive multidisciplinary community domiciliary consultations to manage people in the community to prevent unnecessary ED presentations
• a comprehensive electronic medical record available to all medical and health staff instantly as required
• comprehensive dementia care, and
• strategic links within the area supporting the GP’s and the community health workers.

Set a new vision and direction for both acute and community geriatric medical care and to produce a better model of medical care for these complex older patients.

Over the next 20 years the major diseases will be dementia, delirium, carer collapse, adverse drug reactions, recurrent falls, osteoporotic fractures, malnutrition with complications including recurrent infections, prolonged, expensive and complicated hospital stay.  The lack of multidisciplinary holistic care in the community has overwhelmed both the GP’s and the hospital ED with avoidable geriatric presentations.

The lack of an electronic medical record, inability of the hospital to provide rapid access to old medical records and the fragmentation of medical information results in a delay in medical treatment and worsens the health outcome.

In this older group any acute illness may cause preventable major geriatric syndromes including delirium, falls, loss of mobility leading to prolonged, complex and costly acute hospital admission requiring prolonged rehabilitation and complex post acute care. These acute hospital admissions could potentially be avoided by better and early appropriate geriatric community care. 50% of geriatric patients greater than 75 years of age presenting to the Gosford Emergency Department are admitted as a direct result of major preventable adverse drug reactions.

For each $ spent of high quality nutritional care $5 is saved for the health care system budget. Better nutritional care results in better health outcomes for the elderly.

The lack of domiciliary consultation for geriatric patients to support the General Practitioners in the community results in premature functional decline in these patients and potentially preventable public hospital Emergency Department presentations and acute hospital admissions.

The White Paper provides a sustainable model of acute geriatric hospital care of Geriatricians working in a multidisciplinary care setting, sharing the load with General Physicians.

Multidisciplinary Orthogeriatric Service to provide a better health outcome for orthogeriatric patients, early inpatient mobility and rehabilitation programmes for geriatric patients to produce the best health outcome and efficient use of hospital resources. 

The expansion of community geriatric care to keep people well and functional at home and electronic medical record to provide an immediate clinical record for doctors and other health professionals.

1. A combined Geriatric / General Medical Roster where the work is shared between General Physicians and Geriatricians; Providing acute multidisciplinary holistic diagnosis and management of geriatric patients with the view to early mobility is the most cost effective care model to produce best health outcomes for elderly patients in acute public hospital settings.
2. Early morning multidisciplinary board round to plan complex discharges and prioritise inpatient management to expedite a safe and effective discharge plan within 12 hours of admission.
3. The empowerment of all other Physicians to be able to approve hostel and nursing home placement to avoid the unnecessary delay to be seen by a limited number of Geriatricians and for the Physicians to work closely with Allied Health teams.
4. Early nutritional screening with the blue placemat programme, identification of patients at risk of malnutrition and needing feeding assistance, nutritional supplementation.
5. Providing a comprehensive Orthogeriatric multidisciplinary medical service, the new concept of a "medical management arm" of a surgical unit.
6. Early inpatient mobility and rehabilitation programmes for geriatric patients to avoid the unnecessary delay in transferring patients to the General Rehabilitation ward.
7. Expanding ED ASET teams to provide multidisciplinary assessment.
8. Providing community geriatric care domiciliary consultation service supporting the GP and health workers in the community.
9. Developing a complete electronic medical record with clear, comprehensive medical direction for these complex patients accessible by all relevant health care workers, GP's and shared between the acute hospital and the community.
10. The development of a weekly electronic discharge summary review meeting where the Junior and Senior Medical Staff review all patients under their care to assess the quality of the medical care, the health outcomes and maintaining the standard of the electronic discharge summary produced by the Junior Medical Staff.

Dramatically reduced the prevalence of adverse drug reactions.

Multidisciplinary and better nutritional care of geriatric patients results in a reduced length of stay, reduced health care costs, reduction in nutritionally related complications and better health outcome.

Cost savings estimated to be at least $32.5 million per year for Central Coast Health with the new model of care.

This includes:

• $5 million for 50% reduction of adverse drug reactions.
• $4.73 million per year for DRG Casemix funding for the diagnosis of malnutrition in the elderly.
• $10.6 million by reducing length of stay through improved nutritional support for the elderly (2,500 admissions per year).
• $4 million per year for reduced length of stay in a multidisciplinary Geriatric Ward environment.
• $2.5 million for delirium screening and management per 1000 cases.
• $1.4 million through domiciliary consultations and community care of the elderly - 140 hospital admissions prevented per year.
• $1.8 million by 50% falls reduction through improved monitoring of standing blood pressure (30 fractured neck of femur per month admitted to Gosford Hospital).
• $2.5 million saved per year through Electronic Medical Record reducing length of stay (2,500 admissions).

Improving awareness of safe prescribing habits.

The measurement of postural blood pressures and weights to estimate the GFR for renal clearance to reduce adverse drug reactions by hospital nursing staff, doctors and GP's.

Major improvements in Orthogeriatric care through the Orthogeriatric Service as demonstrated by our audit.

Improved awareness of malnutrition by hospital staff and GP’s.

Physicians taking on the responsibility of assessing geriatric patients for high and low care working closely with multidisciplinary Allied Health.

Improving awareness of delirium and its management within the hospital.

The electronic domiciliary report provides a teaching template for GP’s in better management of the elderly and better drug prescribing.

The White Paper is a powerful document because it relates to not only Central Coast hospitals but all Australian public hospitals in providing a 50% split between acute hospital and community care of geriatric patients.

It recognises workforce shortages in Geriatric Medicine and enhances the role of General Physicians in managing complex geriatric patients in a multidisciplinary team setting, developing the concept of a multidisciplinary geriatric approach in all medical and surgical wards.

Better recognition of major geriatric syndromes including falls, malnutrition, adverse drug reactions and postural hypotension.