Residential In-Reach Program

What is the Residential In-Reach Program

Residential In-Reach (RIR) is a non-admitted service with the aim of decreasing avoidable presentations to Emergency Departments (ED) from Residential Aged Care Facilities (RACF).  RIR provides care, consultation, referral, education and support for clients and care providers in Residential Aged Care Facilities. The client/patient remains under the clinical governance of their General Practitioner at all times. Residential In-Reach staff must be invited into the aged care facility by the client/patient or their family, RACF staff, a General Practitioner or Ambulance Victoria.

Residential In-Reach helps to:

• Ensure that care is delivered in the right place at the right time
• Prevent avoidable hospital presentations where appropriate by bringing expert hospital care to the facility
• Support transition of clients from hospital to their place of residence
• Assist the facilities’ staff in the ongoing development of clinical skills and knowledge
• Support emergency services such as Ambulance Victoria and our Emergency Departments by providing a clinical resource in the community
• Assist with the transition to substituted in-patient care in the community for clients requiring medical therapies under the Hospital in the Home program

Services / possible reasons to refer

• Falls management
• New device or treatment plan requiring speciality care such as colostomy, drain tube, syringe driver or nasogastric tube
• Trial of Void
• Complex Wound management
• Family Concerns
• Uncontrolled pain issues
• Unstable diabetes on insulin
• Challenging behaviours
• Chronic Diseases such as CHF, COPD
• Palliative / end-of-life support
• Inappropriate or frequent presentations to Emergency Departments
• Dehydration issues
• Aspiration Pneumonia
• Advance Care Planning

Please note:

• Follow-up of blood tests is the responsibility of the General Practitioner
• Suprapubic Catheter Management is part of the residential aged care facility’s core business
• PEG management- In-Reach can provide a temporary replacement PEG with Foleys catheter whilst waiting for PEG Outreach to provide the required service
• When possible, Residential In-Reach (RIR) will seek the treating General Practitioner’s (GP) consent before consulting on a patient. Afterwards, the RIR team or facility staff will inform the GP of their review so any issues or actions can be followed up. If necessary, the RIR team will contact the GP for discussion and verbal handover.

Eligibility Criteria

People living in residential aged care facilities.

Cost

No cost to the client

Referrals

Please call 1300 4467 3224 (1300 4 InReach)

Telephone support from a nurse is available 24 hours a day.

Residential InReach medical and nursing teams visiting hours are 0830 – 2000 seven days a week.