Residential In-Reach Service

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

The service offers a range of support, including but not limited to: 

• advice and support over the phone or via telehealth
• assessing residents who are unwell
• management of feeding tubes (PEG tubes)
• help with catheters, including indwelling (IDC) and suprapubic (SPC), and support for urinary issues
• wound assessment and treatment
• palliative care
• training and education for aged care staff
• follow-up care after hospital discharge, including support for new residents.

Our team helps manage a wide range of health issues, including:

• sudden confusion or delirium
• serious infections like sepsis
• urinary tract infections (UTIs) and related infections
• upper and lower respiratory tract infections (URTIs/LRTIs)
• skin infections such as cellulitis
• falls and potential traumatic injuries
• dementia, including behaviour and mood changes (also known as BPSD)
• loss of strength or ability to carry out daily tasks (functional decline)
• dehydration
• infections after surgery
• heart failure (CCF)
• pain and other distressing symptoms
• outbreaks of infectious disease outbreaks (like gastro, influenza or COVID-19).

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 re-admission 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 (e.g. nurses working in Residential Aged Care Facilities, GPs, intra and inter-hospital staff). 

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 are concerns about the 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 while 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 Residential Aged Care Facility 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). 

The Residential In-Reach Service is for eligible residents within the Western Health catchment area (local government municipalities of Brimbank, Hobson's Bay, Maribyrnong and Melton).

Phone referrals are accepted 24 hours, 7 days a week via the Western Health at Home Connect number (1300 229 656).

If you have any enquiry about the Residential In-Reach Service, feel free to contact our friendly team by phone or email.

Phone: 1300 229 656, 24 hours, 7 days a week
Email: RIR@wh.org.au 

Geriatricians are available Monday to Friday during business hours.

Clinical nurse consultants are available 7 days a week.

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