Residential In-Reach Service

In This Section

The Western Health Residential In-Reach (RIR) service offers specialty health care assessment and a rapid response service for people with complex medical conditions who live in Residential Aged Care Facilities.

What we do

The service offers, but is not limited to: 

telephone and telehealth consultancy
assessment of the unwell resident
percutaneous endoscopic gastrostomy (PEG) management
in dwelling catheter (IDC) / supra pubic Catheter (SPC) management, urinary retention or trial of void (TOV)
wound assessment and management
palliative care
facility staff education
post hospital discharge follow up (including newly transitioning to residential care).

The Residential In-Reach services provides specialist consultation for the management of conditions such as:

delirium
sepsis
urinary tract infections (UTI)/urosepsis
upper and lower respiratory tract infection (URTI/LRTI)
cellulitis
falls and potential traumatic injury
dementia including behavioural and psychological symptoms of dementia (BPSD)
functional decline
dehydration
post-operative infection
heart failure (CCF)
pain and other distressing symptoms
infectious disease outbreaks (e.g. gastroenteritis, influenza, COVID).

Inclusion criteria

Residents in a Residential Aged Care Facility within the Western Health catchment.
Residents requiring a short-term specialist consultation on complex conditions (not otherwise able to be provided by the General Practitioner (GP).
Residents at high risk of readmission to hospital who would benefit from short-term specialist consultation post discharge.
Requires advance practice procedures such as PEG tube and IDC/SPC management.
The resident (or appropriate medical treatment decision maker) consents to be seen by the Residential In-Reach service. 
Referrals must be made by a health service provider (Nurses at RACFs, GP, intra and inter-hospital).

The Residential In-Reach service provides care to residents to reduce avoidable escalations of care to Ambulance Victoria or transfer to an Emergency Department.

Residential Aged Care Facilities are encouraged to contact the Residential In-Reach service if there is concern about clinical deterioration of a resident.

Exclusion criteria

Residents in a Residential Aged Care Facility outside of the Western Health catchment.
The resident’s medical or mental health needs require management within an inpatient hospital ward environment.
People residing in a private home, disability accommodation, a retirement village or supported residential service (SRS). 
Referrals from patients or family members. 
Cover for routine GP care whilst GPs are on leave or to replace routine GP care (e.g., checking routine blood test results).
Routine Advanced Care Planning is the responsibility of the RACF and GP. 
Routine medical care for chronic conditions, routine female IDC replacement, nasogastric tubes, suturing, tracheostomy management, chronic wound care, blood, or iron transfusions. 
Acute mental health concerns (e.g., suicidal ideation) should be referred to the most appropriate mental health service (Accessing Mental Health Services - Victorian Government Health Information).