Hospitalisations and emergency department presentations by older individuals accessing long-term aged care in Australia

Introduction

In Australia, older individuals (aged ≥65 years) account for 16% of the population yet they accounted for 43% of the 11.6 million hospitalisations and 21% of the 8.8 million emergency department (ED) presentations in 2021–2022.¹ Of the older people who have an ED presentation, more than one in two are subsequently admitted to hospital, compared to just over one in four younger people.¹ Unplanned hospitalisations can be burdensome for older people, disrupt their continuity of care, cause further deconditioning and contribute to growing demands for health services.^2–4

Currently, one in six Australians are aged ≥65 years, and this is expected to increase to almost one in four by 2066, placing increased demands on aged care services.^5–7 In Australia and internationally, government-subsidised long-term aged care services are critical to support older people requiring help with personal and health care. In 2022–2023, approximately 1.5 million individuals received long-term aged care services. Of these, over 314,000 people accessed home care packages and approximately 250,000 accessed permanent residential aged care (also known as nursing homes or care homes).⁸

Older adults consistently report an overwhelming preference to ‘age in place,’ which means to remain living at home for as long as possible,⁹ and the Australian Government’s home care packages program aims to support older adults with complex care needs to continue to live in their own homes. Older people frequently enter permanent residential aged care following a hospitalisation, e.g. in 2017 one in four people living with dementia moved to residential aged care after a hospitalisation.¹⁰

Once in permanent residential care, almost one in three people are admitted to a public hospital annually, while 43% of those with home care packages have been reported to experience these events.^11,12 It is likely that the high hospitalisation rates in the older population accessing long-term aged care may be a contributing factor associated with the national challenges of ‘ambulance ramping’.^11–14

This study used an integrated aged care and healthcare data platform of older people accessing long-term aged care in Australia in 2019. The aim was to examine the cumulative incidence of ED presentations, unplanned hospitalisations, potentially preventable hospitalisations and days spent in hospitals by individuals living in residential aged care facilities and by people living at home with care package support.

Methods

Results

Emergency department presentations

Of people accessing home care packages, 43.1% [95% confidence interval (CI) 42.8–43.3] had an ED presentation, whereas 37.8% [95% CI 37.6–38.0] of people accessing permanent residential aged care had an ED presentation (Fig. 1). There were 929 [95% CI 928–930] ED presentations per 1000 people accessing home care packages, compared to 701 [95% CI 699–703] ED presentations per 1000 people accessing permanent residential aged care (Fig. 2). Of the total 118,805 ED presentations in people accessing home care packages, and 146,964 in people accessing residential aged care, 69.1% (n = 82,128) and 71.0% (n = 104,293) resulted in a hospital admission, respectively. By state, the proportion of individuals in permanent residential aged care having an ED presentation ranged from 34.2% [95% CI 33.8–34.5] in VIC to 40.4% [95% CI 39.9–40.8] in QLD. For home care package recipients, the smallest proportion of people having an ED presentation was in VIC (39.6% [95% CI 39.1–40.1]), whereas the highest proportion was in NSW (46.0% [95% CI 45.5–46.4], Table 2).

Fig. 1.

Proportions of cohort with ED presentations, potentially preventable and unplanned hospitalisations.

Fig. 2.

Rates of emergency department presentations, potentially preventable and unplanned hospitalisations per 1000 persons.

Table 2.Emergency department presentations by type of long-term care received, 2019.

Type of long-term care received	State	Number persons	Number of people with ED presentations	Cumulative incidence of ED presentations (% [95% CI])	Number of ED presentations	Rate of ED presentations/1000 individuals [95% CI]
Permanent residential care		209,639	79,322	37.8 [37.6–38.0]	146,964	701 [699–703]
	NSW	79,449	31,386	39.5 [39.2–39.8]	59,112	744 [741–747]
	QLD	45,399	18,321	40.4 [39.9–40.8]	36,216	797 [794–801]
	SA	21,107	7858	37.2 [36.6–37.9]	14,347	680 [673–686]
	VIC	63,684	21,757	34.2 [33.8–34.5]	37,289	586 [582–589]
Home care packages		127,893	55,084	43.1 [42.8–43.3]	118,805	929 [928–930]
	NSW	49,888	22,928	46.0 [45.5–46.4]	48,977	982 [981–983]
	QLD	30,221	12,805	42.4 [41.8–42.9]	29,678	982 [981–984]
	SA	10,482	4595	43.8 [42.9, 44.8]	10,064	960 [956–964]
	VIC	37,302	14,756	39.6 [39.1–40.1]	30,086	807 [803–811]

CI, confidence interval; ED, emergency department; NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria.

Discussion

This large cohort study of older people in Australia accessing long-term care in 2019 shows important differences in ED presentations, unplanned hospitalisations and potentially preventable hospitalisations by the type of long-term care received. ED presentations, unplanned hospitalisations and potentially preventable hospitalisations were high in all people receiving long-term care, but these events were consistently higher for people accessing home care packages than those living in permanent residential aged care. Additionally, the number of days in hospital per 1000 individuals due to unplanned hospitalisations was also higher for those receiving home care packages. Important differences in the proportions of recipients with ED presentations, unplanned hospitalisations and potentially preventable hospitalisations by type of long-term care received were observed in the four states examined (QLD, NSW, VIC and SA).

While many hospitalisations are unavoidable and often prevent further deterioration and premature death, some hospitalisations may be potentially preventable with appropriate primary care provision.¹⁸ These potentially preventable hospitalisations are high in older people in Australia. Between 2017 and 2018, 46% of 748,000 potentially preventable hospitalisations were for people aged 65 years and over.¹⁹ Estimates for 2020–2021 suggested there were over 379,000 potentially preventable hospitalisations for older people living in the community, equating to a cost of A$3.7 billion.²⁰ The results of this study highlight the high proportion of older people accessing home care packages who had an ED presentation (43.1%), unplanned hospitalisation (39.8%) and potentially preventable hospitalisation (11.8%), and almost 1 million hospital days were associated with their unplanned hospitalisations.

In 2019–2020, there were 767,151 ED presentations in the general population aged 65 years and over in the four states examined in the current study.²¹ Direct comparisons between the current study cohort and the general population cannot be made. However, as 146,964 and 118,805 ED presentations were observed in the current study in 2019 by people living in residential aged care and people with home care packages respectively, it can be estimated that approximately one-third of ED presentations in people aged 65 years and over may be by people receiving long-term care.

The results of this study are in line with a previous analysis which showed that although only 6% of older people in Australia live in residential aged care, over 27,500 potentially preventable hospital admissions and over 47,500 ED presentations from people living in residential aged care were estimated for 2020–2021, and this equated to costs of $A312 and $A112 million respectively.²⁰ The results of the current study further show that over 112,000 unplanned hospitalisations were experienced by people living in residential aged care resulting in over 639,000 hospital days. While the underlying reasons for people with home care packages having more ED presentations, unplanned hospitalisations and potentially preventable hospitalisations need further exploration, it is likely that in-house medical services within residential aged care facilities prevent hospitalisations and that facilities may have a higher threshold for hospital transfer.

Unplanned hospitalisations are stressful events for older people that can lead to further adverse events, including hospital-acquired infection, delirium, pressure sores and the need for a higher level of care upon discharge including residential aged care if they were previously living in the community.^10,22,23 Therefore, interventions to reduce unplanned hospitalisations and ED presentations in older people accessing aged care services could offer substantial cost savings and reduce the subsequent detrimental impact of hospitalisations for these individuals.

Previous studies have examined potential predictors of unplanned hospitalisations and ED presentations in older people receiving long-term aged care. Advancing age, being male and increasingly complex health issues and care needs have been identified as potential predictors of unplanned hospitalisations in older people both receiving home care package support and living in residential aged care.^14,24 In people receiving home care package support, cognitive impairment may also be a predictor of unplanned hospitalisations, whereas medicine use, including polypharmacy and high sedative medication load, may also be predictors of unplanned hospitalisations and ED presentations in people living in residential aged care.^25,26

Studies that have examined the implementation of interventions to reduce hospitalisations in residential aged care settings have been mixed.^27,28 Multi-faceted interventions that incorporate support from primary care and aged care, improve advance care planning, increase staff expertise, increase use of telemedicine and become integrated as part of everyday person-centred care may have potential to reduce avoidable hospitalisations in residential aged care.^28–31 However, further focus should be given to the challenges, barriers and enablers to implementing change, e.g. issues with resources, novel workforce models, competing demands and leadership.³²

Interventions focusing on specific causes of unplanned hospitalisations may also have an impact, e.g. falls are the leading cause of injury hospitalisations in Australia.³³ A national study suggested almost 10% of people experience a fall-related hospitalisation within the first year of moving to permanent residential aged care.³⁴ International evidence of interventions to reduce falls in residential aged care suggests that achieving sustained improvements is difficult, but interventions that are multifactorial, tailored to individual residents and include co-design approaches may improve success rates.^35,36

For older people living in the community, studies examining hospital admission and ED avoidance programs including hospital-at-home services and urgent care centres for older people have shown many safe options that can reduce the need for hospitalisation and the length of time receiving care.^37,38 These approaches may be acceptable to older adults, but these studies have not specifically focused on older adults receiving home care services who may be at higher risk of admission.^37,38

Significant changes in access to home care packages have occurred since 2017 including increasing choice and transparency of pricing of home care packages to recipients (February 2017 and July 2019, respectively) and increasing number of home care packages, which have brought the number of home care package recipients in 2022–2023 to >314,000 (up from >133,000 in 2018–2019).^39,40 The current study could inform future plans for home care support changes.⁴¹

Conclusion

With the aging population, understanding older people’s use of health care is essential for future planning and provision of services. In Australia, high numbers of older people receiving long-term care have ED presentations, unplanned hospitalisations and potentially preventable hospitalisations. In this study, these events were higher in people receiving home care packages than in those accessing permanent residential aged care. As we move to having more individuals nationally accessing long-term care through home support than residential care, and further decreases in residential care entry projected,⁴³ it is critical that an in-depth understanding and planning for the high burden of hospitalisations affecting individuals in home care are planned for. Hospitalisations can be unnecessarily stressful and potentially harmful to the individuals and may lead to older people in the community moving to residential aged care sooner, which also represents a substantial economic cost to the Australian Government. Interventions in the aged care and primary care sector are required to support the increasing number of older Australians living in the community with home care packages to remain living at home as long as possible.