Funded by: Tasmanian Government
Overview: The "To Call or Not to Call" initiative celebrates a collaboration aimed at reducing unnecessary hospital transfers from residential aged care (RAC) by equipping nursing staff with the knowledge, tools and confidence to deliver care in place.
Why it matters: Australia’s population is ageing. Tasmania has the oldest and fastest ageing population as well as the highest proportion of the population aged over 65 years. Hospital admissions are increasing for older adults and often result in costly, stressful and preventable hospital stays. The initiative addressed these challenges by empowering the RAC nursing workforce to foster person-centred care, improve clinical decision-making and strengthen sector-wide collaboration.
Key activities:
- Multi-modal training: Staff participated in online modules, face-to-face workshops, and ongoing peer support sessions.These covered clinical reasoning, emergency decision-making and use of evidence-based resources.
- Collaborative co-design: The program was shaped by input from frontline staff, sector leaders and external partners, ensuring relevance and practical value.
- Case study learning: Real-case scenarios helped participants apply new skills, reflect on outcomes, share best practices and engage with local resources and referral services.
Lessons learned:
- Barriers identified: Challenges included resource gaps, policy limitations, staff skill variability and communication hurdles, especially during night shifts and in rural areas.
- Leverage points: Peer learning, practical tools and site-specific inter-agency partnerships proved critical for driving change and sustaining improvements.
- Scalable solutions: The approach is adaptable for other states and regions, with recommendations to localise data, expand resource libraries and strengthen external collaborations.
Impact & outcomes:
- Empowered staff: Clinical practice changes included enhanced documentation, improved communication including structured handovers, greater confidence in clinical decision-making and access to resources and referral services.
- Organisational wins: clarification of and increased engagement with site-specific and organisational clinical governance policies and processes.
- Inter-agency integration: Stronger links between aged care, ambulance, hospital and community services enabled more seamless care pathways. Feedback from workshops initiated the development of the THS virtual heath service and facilitated the update to the Afterhours tool kit by PHT.
- Continuous improvement: Ongoing mentoring, regular follow-ups, and shared case discussions fostered a culture of continuous improvement and peer support, providing enduring connections to support ongoing learning and adaptation.
Recommendations for scale:
- Foster and maintain peer support networks and a community of practice; this will also provide a localised data context.
- Expand and share practical resources and training modules.
- Deepen partnerships with external services and specialist teams.
- Monitor outcomes and adapt interventions based on data and frontline feedback.
Collaborative partners: Aged Care Reform Unit of the Tasmanian Health Service (ACRU/THS), Aged Care Quality and Safety Commission (ACQSC), Aged Care Research and Industry Innovation Australia (ARIIA) with Ambulance Tasmania.
Supported by: Primary Health Network (PHN) Tasmania and Primary Health Tasmania
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