A service model of short-term case management for elderly people at risk of hospital admission

Abstract

This article presents the model of a short-term case management program focused on reducing emergency department presentations and unplanned hospital admissions for a targeted group of older people with complex care needs. As a semi-integrated health care program, Treatment Response and Assessment for Aged Care (TRAAC) is implemented by short-term case managers located in a variety of community agencies as well as acute and sub-acute hospital settings. The article discusses the features of the model including case finding, early intervention and risk screening, combined with the rapid mobilisation of specialised geriatric assessment services. The model has the potential to contribute to positive results in managing the complex health needs of this group. Evaluation outcomes including reductions in hospital use for the target group, and positive client and staff perceptions of the service model are discussed in relation to the unique features of the intervention program.