Residential In Reach

What we do

RIR is an acute referral service that aims to provide assistance for residents at RACFs.

Contact us if you:

• Are unable to access the resident’s GP (or if the GP is requesting additional RIR support)
• Are considering sending a resident to the emergency department
• Need assistance to perform a procedure
• Need timely clinical advice

Who we are

RIR aims to reduce potentially avoidable presentations to the emergency department by providing acute support, early intervention and patient-centred health care in RACFs. It is not intended to replace the primary care provided by general practitioners.

Our team of highly trained nurses have advanced clinical skills and experience and liaise closely with consulting geriatricians from the Royal Melbourne Hospital (RMH), as well as other appropriate community services.

What we offer

• Assessment and management of acutely unwell or deteriorating residents
• Initial treatment with intravenous therapies (diuretics, antibiotics) - with referrals for ongoing support as needed
• Acute palliative care support
• Review of falls and injuries
• Emergency and routine care of PEG, SPC and IDC
• Trial of void (TOV)
• Specialist geriatrician consultation to support GP with complex medical issues/care
• Iron infusions (requires GP referral)
• Assessment and management of delirium
• Support and Advice for Residents with Behavioural and Psychological Symptoms (BPSD) of Dementia
• Acute wound management advice
• Post-hospital support for eligible patients through our Post Hospital Support service (more information below)

Assessment and follow-up care

The assessment comprises an initial comprehensive consultation and management plan. We liaise with next of kin, facility staff and the Geriatrician from the RMH.

Following initial assessment and treatment, if ongoing or continuing care is required, referral to an appropriate service (including RMH@Home Acute or community/outreach palliative care support) will be made or recommended.

We may also recommend follow up with other community care providers such as:

• Dementia Support Australia
• Wound nurse consultant
• Community Palliative Care Service
• Private geriatricians

A copy of In Reach’s detailed assessment and management plan will be provided to the RACF and faxed to the resident's GP.

Post Hospital Support service

Our Residential In Reach Post Hospital Support service provides assistance to help patients safely transition from a hospital admission to a Residential Aged Care Home (RACH).

The service focuses on supporting older adults with dementia or recent delirium, helping to reduce the chance of readmission and ensuring they receive the right care in the right place. As part of this service, we provide:

• Collaborative discharge planning with patients, families, carers and the aged care home
• A personalised support plan tailored to the patient’s medical, cognitive and functional needs
• Two to four weeks of follow-up after discharge, with regular contact through:  up after discharge, with regular contact through in-person visits, phone check-ins and Telehealth appointments
• Access to geriatrician review if clinically required
• A final safety net appointment and a summary sent to the resident’s GP and aged care home net appointment and a summary sent to the resident’s GP and aged care home

Our team works closely with aged care staff and families to help residents settle safely back into familiar surroundings with the right support in place.

Who can use our Post Hospital Support service

Our Post Hospital Support service is designed for older adults, aged 65 and over (or 50 and over for First Nations people) who:

• are moving from a hospital stay into a new Residential Aged Care Home
• have dementia or delirium and are at risk or readmission
• are likely to experience a challenging transition