RECIPE

Residential Care Intervention Program in the Elderly

A model that addresses the challenge of working between Acute
Hospitals and Residential Care Facilities
It is well acknowledged that Australia and many other western countries have an aging
population. It is also acknowledged that for the frail elderly, hospitalisation can be a
stressful experience.

What is RECIPE?
RECIPE is an aged care support service to local doctors and aged care facilities in the outer
northern metropolitan region of Melbourne. RECIPE is an acronym for REsidential Care
Intervention Program in the Elderly. RECIPE is funded under the Department of Human
Services Hospital Admission Risk Program. It is part of Northern Alliance HARP
Chronic Disease Management Program with funding commencing in 2002.

Background:
The number of frail older people being admitted to hospital is projected to continue to
increase in the coming decades. Hospital admissions from residential care facilities (RCF)
are likely to increase as well. The hospitalisation process can be detrimental to the frail
elderly, especially for those who live in a RCF. It can lead to increased risk of delirium,
bowel and bladder problems, pressure sores, reduced independence and mobility.
RECIPE initially commenced as randomised controlled trial (RCT). The aim of the trial
was to evaluate the effectiveness of a post-discharge multidisciplinary intervention for
residents from a RCF in preventing hospital readmissions and improving quality of life.
The RCT ran from 2002 until 2005. The RCT focused on medical inpatients who were 65
years or older, who had been admitted into TNH from a RCF with at least once common
medical condition (i.e. dehydration, chest infection, cellulitis).
Participants in the intervention and control groups received a visit in their RCF within 96
hours of hospital discharge, at one month and at six months. The control group received
usual care. The intervention group received usual care plus comprehensive geriatric
assessment, chronic disease management, advance care planning and management of intercurrent illness in the RCF over the six-month follow-up period.
This post-discharge intervention for older people admitted to hospital from a RCF was a
feasible and cost effective service. There was no difference in hospital readmissions or
survival between the intervention or control groups. Satisfaction was significantly higher in
the intervention group.

The Model:
In 2005 the RECIPE service was launched. Similar to the RCT patients are referred after
admission into TNH. This referral occurs primarily from the Aged Care Medical Unit
doctors, the care coordination team or the Emergency Department doctors.
Referral criteria:
The referral criteria are now opened to a wider patient population and includes patients:
RECIPE Supporting Documentation

Who are from a RCF within the RECIPE catchment area (approx 20 minute drive
from TNH &
Who are 65 years or older &
Have end-stage chronic or complex illnesses that could cause representation to
hospital or
Require terminal transition back to a RCF
The RCT primarily focused on patients who had a medical diagnosis. The service now
accepts patients who have been admitted with a surgical diagnosis (i.e. small bowel
obstruction or post Fractured Neck of Femur (NOF)) who may be at high risk of
representation due to chronic or complex diseases (i.e. end-stage dementia with risk of
presentation due to dehydration or aspiration pneumonia).
This expansion occurred due to a survey conducted in 2004 prior to the transition from
RCT to an ongoing service. This survey aimed at gaining an understanding from RCFs of
what RECIPE could do to improve. A common comment was the request that more
patients should receive the RECIPE intervention.
Northern Health
The catchment area for the RECIPE program is similar to the TNH catchment area. This
area is made up of five different local government areas including Darebin, Moreland,
Hume, Whittlesea, Banyule and Nillumbik city councils. During the RCT patients were
recruited from across these five councils. There has been a substantial increase in the
number of RCFs and the number of RCF beds in the catchment since RECIPE first
commenced, which has lead to a need to expand the programs resources.
Triaging of patients:
A Geriatrician and nurse will review patients soon after discharge from TNH. Unlike the
RCT , a more sophisticated triaging process has been developed, to best meet the needs of
each individual. The new criteria for time of review is -:
Urgent and to be reviewed within 24 hours (high risk of representation or death
within 48 hour period after discharge),
Semi-urgent and to be reviewed within 2-3 weeks (low risk of representation or
death within 1 month of discharge) or
Non-urgent and to be reviewed within 6 weeks (very low risk of representation or
stable patient known to RECIPE with a clear management plan).
Provision of Service:
To allow increased numbers of patients to be provided with the service, the duration of
active monitoring and intervention was reduced from 6 months (as in the RCT) to 3 months
in the program. Due to the experience gained by the team during the RCT, and with
improved working relationships across the acute-community interface, Advance Care
Planning has become much more efficient and achievable in this shorter time frame.
Similar to the RCT the support provided on discharge is individualised depending on need
and can include:
Medication review
Family meetings
Staff education
Streamlining outpatients appointments
Referral to other appropriate support programs
RECIPE Supporting Documentation

Treatment of recurrent medical conditions in the RCF for those that choose
including:
o Blood transfusions
o Intravenous antibiotics
o Subcutaneous fluid
Medical and nursing support is provided when RECIPE patients (both active or non
active) are admitted into hospital
o Patients are admitted under Aged Care Unit unless admission is required due
to surgical concern
All patients are encouraged to consider advance care planning

Unlike the RCT, in the RECIPE service support is now provided to terminal patients to
assist in the transition back to RCF from the acute hospital. This support includes:
Interim drug charts to allow administration of medications on return until own
GP can visit to chart on RCF drug chart
Appropriate palliative care medications dispensed upon discharge from hospital
Basic palliative care guide
Telephone support post discharge +/- nursing visit
A patient is only discharged from the service when a management plan is complete and the
patient is stable or on death. However, the general practitioner and facility staff can refer
patients known to RECIPE back to the program at any time for further support or
reassessment.
A Coordinated Approach:
To help improve relationships with RCFs RECIPE has worked with the Care Coordination
team. The Care Coordination team has been integral in improving the relationships
between acute hospital and RCF. This has occurred by development of meetings that are
aimed at sharing information, improving the service between Northern health and RCF and
developing education programs of interest to staff at RCFs.
RECIPE has also successfully worked with other providers to residential care from
Northern Health and community. The aim is sharing of information and maximise the
appropriate support. This includes working with the community providers of palliative
care (Banksia Palliative Care and Melbourne City Mission) and importantly the local
medical doctor.
A close working relationship has been forged between Hospital in the Home (HITH) and
RECIPE. Management plans can now include the option of direct referral into HITH when
a recurrent illness (i.e. infection, dehydration or anaemia) occurs, bypassing the emergency
department.
Staffing:
January 2005 until February 2008 staff has consisted of -:
2 Geriatricians covering 3 sessions per week
1 full-time nurse (40 hours per week)
2 part-time nurses job-sharing (16 hours per week)
Allied Health brokered as required (i.e. speech pathology)
February 2008 staffing has increased to -:
2 Geriatricians covering 3 sessions per week
RECIPE Supporting Documentation

1 Aged Care Trainee Registrar (community rotation shared with HITH and clinics)
1 Full-time nurse (40 hours per week)
3 part-time nurses job-sharing (32 hours per week)
Allied Health brokered as required

Results to date:
From January 2005 until February 2008 354 patients admitted into the RECIPE service.
Demographic Information:
Variables
Age (Mean, SD)
Male n (%)
Low-level RCF n (%)
Australian born n (%)
English speaking

Trial data
Intervention
(n=57)
83.8, 7
19 (33)
27 (47)
34 (60)
44 (77)

Control
(n=59)
86.7, 7
24 (41)
26 (44)
38 (64)
45 (76)

Significance
p = 0.02
P = 0.45
P = 0.85
P = 0.43
P = 0.66

RECIPE data
Program (n =
354)
82.8, 7.79
131(37)
106 (30)
174 (50)
200 (56)

Even if a low-care facility or hostel had Aging in Place the supports were still limited
when compared to a high-level facility or nursing home.
It is important to note that from the RCT to the service there is a decrease in number of
patients referred to RECIPE from low-level RCF. This may relate to the increased
numbers of high levels beds that have opened within the northern catchment region, and
also may be partly explained by a substantial increase in terminal care patients, the majority
of whom reside in high level care.
There were more Australian born patients in the RCT than in the program. This reflects the
difficulty in recruiting patients into an RCT where English is not the main language
spoken. The diversity of patients recruited into the service is a typical reflection of the
population that is serviced by Northern Health.
Assessment Information:
Variables
Baseline AMTS
Mean (SD)
Baseline pQoL
Mean (SD)
Baseline fQoL
Mean (SD)
Baseline Barthel
Mean (SD)
ATP complete
%

Trial data
n
Intervention
30
3.5 (3.4)

n
37

Control
3.9 (4.1)

Significance
P = 0.74

21

32.8 (8.0)

24

31.7 (7.3)

P = 0.24

RECIPE data
n
Program
18 3.6 (3.7)
6
82 28.2 (7.4)

27

29.2 (7.7)

28

27.3 (6.2)

P = 0.43

64

24.5 (7.0)

33

50.6 (32.6)

36

45.5 (34.1)

P = 0.50

39.7 (30.9)

54

67%

59

0%

15
0
15
7

43.9%

As part of the standard assessment of all patients admitted into RECIPE is the completion
of Abbreviated Mental Test Score (AMTS), patient and family Quality of life (QoL),
Barthel and completion of Advance Treatment Plan (ATP). The lower scores (Barthel and
ATP) in the program are likely to reflect the increased number of terminal/palliative
patients . Whilst verbal care planning takes place, it is usually not appropriate to encourage
formal Advance Care Plan documentation in the last days of life, when family have an
RECIPE Supporting Documentation

overwhelming emotional burden to deal with. The lower scores in the program may also
reflect an increasingly frail residential care population within the TNH catchment.
Admission back to hospital :

Variables
Number of Hospital
admissions prevented
ED presentation rate

Trial data
Intervention
(n=57)

0.33(in
6mths)
29

Hospital admission rate

(number of pts
readmitted at least once)
Average LOS for hosp
9 days (7.9)
admission mean (SD)
Mortality rate n (%)
22 (39)
Number of deaths from
22 (39%)
admission to 6 months n
(%)
Average time from ref to
death (SD)

Control (n=59) Significance

between

RECIPE data
Program (n =
357) 2005-08
240

0.47(in 6mths)

P=0.40

36

P= 0.47

0.13 (in
3.05mths)
80

10days(8.8)

P=0.54

7.5days (5.6)

22 (37)
22 (37%)

P=0.52
P=0.52

172 (48.2%)
139 (38.9%)

108.6days
(166.4days)

The average length of stay for a patient on the Aged Care Unit from 1st July 2007 to 29th
February 2008 was 10.47 days. The Aged Care Unit refers most patients to RECIPE.
RECIPE involvement with patients who have been admitted could decrease the length of
stay by approx 2-3 days.

Palliative transition patients:

Total number patients
Number hospital admissions
avoided
Number of hospital admissions
Number of ED presentations

Palliative Care patients

n=73
23

Non Pall care patients

n=284
210

0
0

80
47

Discussion:

Treatment in the RCF can successfully be provided for recurrent medical conditions
(i.e. chest infection or dehydration) if the patient, family, GP and staff at the RCF
are in support and where there is a clear management plan in place. This is a
successful alternative for the frail elderly where hospitalisation can cause confusion,
pressure injuries, falls and deconditioneing.

Advance Care Planning should be an important part of the management of patients

who have chronic or complex disease and are from a RCF.

The option to die in the familiar and/ or culturally specific environment of a RCF
should be considered as an alternative to hospital transfer. On realisation that death
may be imminent, the preferred location should be discussed with either the patient

RECIPE Supporting Documentation

or appropriate person responsible and adequate support should be provided if a

choice is made to return to the RCF.

An acute based RCF support program (such as RECIPE) can decrease the length of
stay of patients who are admitted to hospital. This occurs by the provision of a
team that often already knows the patient well and can advocate for early discharge
(for appropriate patients) and a post discharge medical and nursing review.

Conclusion:

The development of a treatment and communication model of support from acute to

RCF is a feasible option.

The RECIPE program provides the option to allow medical services to be provided
in the RCF.

The potential outcome can be decreasing readmissions into hospital by provision of

some direct medical services to the RCF (i.e. blood transfusions or IV antibiotics)
by use of clear plans.

During hospital admission, the LOS could be decreased (on average) by 2-3 days by
a team that can review and facilitate early discharge.

Future:

Direct referrals from RCF and local medical doctors to RECIPE for review of
patients at risk of presentation to develop clear management plans in consultation
with family and patient for option of HITH treatment instead of hospitalisation.

All patients who present to hospital with an acute episode 2nd to chronic and
complex end-stage diseases are referred to the RECIPE program for development of
clear management plans for future treatment of recurrent illnesses.

Improved information technology is under development to improve the sharing of

care plans (including advance care plans) between acute hospital, local doctor and
RCF.

I was pleased hospital X was on by-pass and my mum came to The Northern Hospital. I
was pleased she was referred to RECIPE. I never thought I would have wanted my Mum to
die in a nursing home. The option of hospital did not seem right. Thank-you for your
support
Anonymous family
For further information:
Meg Storer (Team Leader/Clinical Nurse Consultant) or
Dr. Penny Harvey (Geriatrician)
RECIPE Service
The Northern Hospital
185 Cooper St
Epping VIC 3071
Telephone: 03 8405 8712
Fax: 03 8405 886
RECIPE Supporting Documentation