Community Outreach Visits: Characteristics & Outcomes of Older People reviewed by a RANP

Abstract Background Registered Advanced Nurse Practitioner (RANP) community outreach visits are offered as part of an older persons day hospital service. Older people unable to attend the day hospital due to increasing frailty are offered a RANP led community outreach visit. This study aims to review characteristics and outcomes of older people who were seen and assessed on a RANP community outreach visit. Methods A prospective cohort study was completed on older people who had received a RANP community outreach visit. Visits completed over a 15 month period were included. Data on demographics, reason for visit, functional status, frailty, initial outcomes, outcomes at 6 and 12 months including ED attendance and admission to nursing home care was collected. Results 92 RANP community outreach visits were completed over a 15 month period. Reason for visits included dementia review, long term care (LTC) application, general decline and increasing frailty. Mean age was 85.85 years (69-101 years; SD +7). 78.6% (n=72) were female. 28.3% (n=26) lived at home alone. 82.6% (n=76) were in receipt of home supports. Mean Barthel Index was 11.63, (0-20). 77.17% (n=71) were Clinical Frailty Score of 6 or 7. Initial outcomes included medication changes 25% (n=23), supporting LTC application 25% (n=23), social work referral 9.78% (n=9), ceiling of care discussion 6.52% (n=6) and PHN follow up 63.4% (n=58). Presentations to the emergency department at 6 months were 35.8% (n=33) and 12 months 6.52 % (n=6). 17.39% (n=16) had transitioned to LTC at 6 months and 12 months 6.52% (n=6). 12 months following the visit 18.5% (n=17) of the cohort had died. Conclusion The cohort of older people reviewed at home by the RANP is a frail group who require significant support to continue living at home. This is reflected in the community supports provided and in the number applying for and transitioning to LTC.