An interventional study of Residential In-Reach Program in Aged and Acute Disease, sponsored by Monash University. Recruiting at 8 sites in Australia. Open to participants aged 65 Years and older. Per ClinicalTrials.gov, last updated 2025-05-30.
Sponsored by Monash University · Not applicable, Interventional, and Health services research
Residential In-Reach (RIR) programs are designed to provide responsive care for residents in residential aged care homes (RACH) with the aim of avoiding unnecessary hospital transfers. The evidence for their clinical and cost-effectiveness and implementation has been established in urban settings, but there is a small amount of low-quality evidence for rural and regional settings. The Grampians Region Health Service Partnership Resi-In-Reach Redesign Committee will be implementing a new RIR program to be offered to all RACHs in the Grampians region, this project aims to evaluate the clinical and cost-effectiveness of this program, and its implementation in the rural and regional setting. A stepped-wedge trial will be conducted so that as the RIR program is gradually rolled-out across the region, outcomes can be compared in the same facilities across time and between different facilities. The primary outcome measure will be presentation to emergency departments and urgent care centres, and data will also be collected on other clinical outcomes and barriers and enablers of implementing the program. It is anticipated that there will be a reduction in hospital presentations, and a range of barriers and enablers unique to the rural and regional setting will emerge.
285 studies on the registry are indexed under Acute Disease; 39 are open to participants now.
This study's planned enrollment of 100 is above the median of 81 across 194 interventional studies indexed under Acute Disease.
Browse Acute Disease studies →Monash University is the lead sponsor of 81 studies on the registry; 22 are open to participants now.
Counted across the registry records on this site, refreshed daily.
Exclusion Criteria:
All enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance).
Other: Residential In-Reach Program
All enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance).
Rate of presentations from residential aged care homes to emergency departments and emergency care centres
Primary clinical effectiveness outcome Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Time frame: From enrolment to the end of the trial for 14 months
Days spent in hospital by aged care home resident
Secondary clinical effectiveness outcome Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Time frame: From enrolment to the end of the trial for 14 months
Location of mortality in hospital
Secondary clinical effectiveness outcome Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Time frame: From enrolment to the end of the trial for 14 months
Number of barriers to residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Number of enablers to residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported feasibility of the residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported acceptability of the residential in-reach program
Secondary implementation outcome - collected via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff, general practitioners, aged care home residents) after occasions of service on a monthly basis.
Time frame: From enrolment to the end of the trial for 14 months
Stakeholder reported appropriateness of the residential in-reach program
Secondary implementation outcome - collected via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff, general practitioners, aged care home residents) after occasions of service on a monthly basis.
Time frame: From enrolment to the end of the trial for 14 months
Number of aged care staff who attend education sessions for the use of the residential in-reach program
Secondary implementation outcome - recorded attendance of education sessions for residential aged care home staff for the use of the residential in-reach program.
Time frame: From enrolment to the end of the trial for 14 months
Number of adaptations made to the residential in-reach program
Secondary implementation outcome - documented adaptations made to the program during the trial period.
Time frame: From enrolment to the end of the trial fo
Number of times the residential in-reach program is utilised
Cost-effectiveness outcome: number of times the RACHs enrolled in this trial utilises the residential in-reach program, both in-person and via telehealth. Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home each month Collection approach: Extraction from hospital records
Time frame: From enrolment to the end of the trial for 14 months
Number of times the Victorian Virtual Emergency Department is utilised
Cost-effectiveness outcome: number of times the RACHs enrolled in this trial uses the Victorian Virtual Emergency Department. Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home each month Collection approach: Extraction from residential aged care home records
Time frame: From enrolment to the end of the trial for 14 months
Number of times that the general practitioner is utilised
Cost-effectiveness outcome: number of times that the RACHs enrolled in this trial consults the general practitioner, both in-person and via telehealth, including in and out of hours consultations. Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home each month Collection approach: Extraction from residential aged care home records
Time frame: From enrolment to the end of the trial for 14 months
Number of calls to Ambulance Victoria
Cost-effectiveness outcome: number of times the RACHs enrolled in this trial calls an ambulance for their residents. Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home each month Collection approach: Extraction from residential aged care home records and Ambulance Victoria records
Time frame: From enrolment to the end of the trial for 14 months
Number of transfers to hospital via Ambulance Victoria
Cost-effectiveness outcome: number of times that Ambulance Victoria transfers a resident from one of the RACHs enrolled in this trial to hospital. Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home each month Collection approach: Extraction from residential aged care home records and Ambulance Victoria records
Time frame: From enrolment to the end of the trial for 14 months
Plan to share: No — Individual participant data will not be analysed and reported on. Planned data management involves analysis and reporting of aggregated data from all participants from all sites.
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