Evaluation of a Residential In-Reach Program in Regional and Rural Australia

May 25, 2025 updated by: Monash University

Evaluation of a Region-wide Residential In-Reach (RIR) Program in Regional and Rural Health Services: A Stepped-wedge Trial

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.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Study Type

Interventional

Enrollment (Estimated)

100

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Australia
    • Victoria
      • Ararat, Victoria, Australia, 3377
        • Recruiting
        • East Grampians Health Service
        • Contact:
        • Principal Investigator:
          • Michele Conlin
        • Sub-Investigator:
          • Jake Romein
      • Ballarat, Victoria, Australia, 3350
        • Recruiting
        • Grampians Health
        • Contact:
        • Principal Investigator:
          • Narelle Ryan
      • Beaufort, Victoria, Australia, 3373
        • Recruiting
        • Beaufort and Skipton Health Service
        • Contact:
      • Daylesford, Victoria, Australia, 3460
        • Recruiting
        • Central Highlands Rural Health
        • Contact:
      • Maryborough, Victoria, Australia, 3465
        • Recruiting
        • Maryborough District Health Service
        • Contact:
      • Nhill, Victoria, Australia, 3418
      • St Arnaud, Victoria, Australia, 3478
      • Warracknabeal, Victoria, Australia, 3393
        • Recruiting
        • Rural Northwest Health
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Health services that have emergency departments and/or emergency care centres that admit residents from residential aged care homes (RACH)
  • RACHs that do not currently have access to RIR programs
  • health service staff who have been involved with the set-up and delivery of the RIR program,
  • RACH staff who have experience of or accessing the RIR service for residents at least once,
  • residents living at a RACH who has experienced receiving medical care from the RIR program and can provide informed consent, or a family member of the resident,
  • general practitioners whose case load includes residents from RACHs.

Exclusion Criteria:

• RACHs that already have access to a RIR program will be excluded

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: N/A
  • Interventional Model: Single Group Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Residential-in-reach
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).

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Rate of presentations from residential aged care homes to emergency departments and emergency care centres
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Days spent in hospital by aged care home resident
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Location of mortality in hospital
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Number of barriers to residential-in-reach program implementation
Time Frame: From enrolment to 1 month after the end of the trial, for 15 months
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
From enrolment to 1 month after the end of the trial, for 15 months
Number of enablers to residential-in-reach program implementation
Time Frame: From enrolment to 1 month after the end of the trial, for 15 months
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported feasibility of the residential-in-reach program implementation
Time Frame: From enrolment to 1 month after the end of the trial, for 15 months
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported acceptability of the residential in-reach program
Time Frame: From enrolment to the end of the trial for 14 months
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.
From enrolment to the end of the trial for 14 months
Stakeholder reported appropriateness of the residential in-reach program
Time Frame: From enrolment to the end of the trial for 14 months
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.
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
Time Frame: From enrolment to the end of the trial for 14 months
Secondary implementation outcome - recorded attendance of education sessions for residential aged care home staff for the use of the residential in-reach program.
From enrolment to the end of the trial for 14 months
Number of adaptations made to the residential in-reach program
Time Frame: From enrolment to the end of the trial fo
Secondary implementation outcome - documented adaptations made to the program during the trial period.
From enrolment to the end of the trial fo

Other Outcome Measures

Outcome Measure
Measure Description
Time Frame
Number of times the residential in-reach program is utilised
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Number of times the Victorian Virtual Emergency Department is utilised
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Number of times that the general practitioner is utilised
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Number of calls to Ambulance Victoria
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months
Number of transfers to hospital via Ambulance Victoria
Time Frame: From enrolment to the end of the trial for 14 months

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
From enrolment to the end of the trial for 14 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Monash University

Collaborators

Deakin University

Investigators

  • Principal Investigator: Terry Haines, Monash University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

May 1, 2025

Primary Completion (Estimated)

May 31, 2026

Study Completion (Estimated)

June 30, 2026

Study Registration Dates

First Submitted

March 4, 2025

First Submitted That Met QC Criteria

March 23, 2025

First Posted (Actual)

March 28, 2025

Study Record Updates

Last Update Posted (Actual)

May 30, 2025

Last Update Submitted That Met QC Criteria

May 25, 2025

Last Verified

March 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • HREC/112397/GHSJOG-2025-462490

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

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.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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