Barwon Health’s Residential In-Reach (RIR) service provides specialist consulative care for residents in residential aged care facilities, where appropriate and safe with the aim of preventing avoidable hospital transfers.

Residential In-Reach is an acute non-admitted service that provides an alternative to the Emergency Department.

The specialty service of geriatricians, general practitioners, registrars, nurse practitioners and registered nurses provides rapid assessment, early intervention and treatment for geriatric residents with complex needs in their own environment where the general practitioner (GP) is unavailable.

Residential In-Reach is not intended to replace the care provided by your general practitioner or aged care facility.

Contact

Phone: 0481 479 022
Email: [email protected]

For urgent referrals, please contact the triage phone 0481 479 022

Service hours

Monday – Friday: 9am to 5pm

Saturday – 8am to 12pm (selected facilities only)

Not available on public holidays

Cost

Nil

Services provided (inclusion criteria)

Residential in-Reach provides comprehensive assessment and management of residents with complex needs who are acutely unwell, deteriorating or at risk of hospital presentation.

Eligibility criteria

The service is available to residents living within residential aged care facilities within the Geelong, Lara, Bannockburn, Bellarine Peninsula, Surf Coast, Colac, Apollo Bay, Winchelsea and Lorne areas.

See attached list of facilities.

Facilities in Lorne, Apollo Bay, Winchelsea and Colac are by telehealth only.

Referrals

Referrals accepted from

  • Residential aged care facilities
  • General practitioners
  • Ambulance Victoria
  • Barwon Acute Referral Service (BARS)
  • Victorian Virtual Emergency Department (VVED)
  • Emergency Departments
  • Acute and sub-acute hospitals

Assessment and management of unwell or deteriorating residents where:

  • Resident is at risk of Emergency Department presentation
  • Resident or the decision-maker consents to RIR referral
  • GP is unavailable or requesting additional support
  • Care can be safely provided at an aged care facility
Service Inclusion criteria Exclusion criteria
Falls management Examination and review post-fall where there are injuries, clinical concerns or deterioration.

Geriatric comprehensive falls assessment (frequent falls >3 in one month)

 Post-fall assessment with no injuries or clinical concerns.
Device management New device or treatment plan requiring specialty care such as colostomy, drain tube or syringe driver. Exclusion criteria

  • Naso-gastric tubes
  • PEG tubes
Bowel management Acute bowel complications.

Investigation and management of constipation and diarrhea

 Prescribing of nurse-initiated medications for constipation
Urinary Catheters Emergency/unplanned catheter changes including male and female indwelling catheter and supra-pubic catheters.

Management and advice (troubleshooting) with catheter associated problems (bypassing, pain, CAUTI, difficult insertion)

 Routine/planned catheter change.
Wound management Acute wound management advice

Wound complications

Localised or spreading infection

Cellulitis

 Management or advice of/for chronic wounds.
Pain Pain assessment and management

Uncontrolled pain
Behavioural and Psychological Symptoms (BPSD) of Dementia Acute onset of agitation, aggression, hallucinations/delusions, intrusive behaviours, disinhibition, wandering that pose risk to person and others. Gradual changes in cognition or behaviour – Consider General Practitioner, Dementia Support Australia and referral to Geriatrician 
Acute exacerbation of chronic diseases Acute onset of worsening symptoms associated with underlying chronic disease including but not limited to;

  • Chronic Obstructive Pulmonary Disease (COPD)
  • Heart Failure
  • Chronic Kidney Disease

Initial treatment provided to manage acute complications with referrals for ongoing support as needed.
Palliative Care Acute palliative care support

Prognostication of end-of-life/terminal phase

Palliative Care advice and referral (including direct referral and secondary consult)
Wound closure Closure of minor lacerations and injuries (includes glue and sutures)
Delirium Assessment and management of new/rapid onset confusion, changes in mental state, disorientation, agitation, restlessness, lethargy, drowsiness, disrupted speech or eating and hallucinations.
Dehydration Assessment and management of dehydration

Rehydration strategies implemented as appropriate
Infection Assessment and management of infection.

Parental antibiotic treatment where clinically indicated.

 

Specialist geriatrician consultation to support general practitioner with:

  • Medical evaluation (geriatric opinion and management)
  • Assessment of cognition, function and mental state
  • Behavioural and Psychological Symptoms of Dementia (BPSD)
  • Medication review (polypharmacy)
  • Falls assessment (Comprehensive Geriatric Assessment)
  • Short‑term intervention

For Rapid Response, contact intake on 0481 479 022.

SERVICE-SPECIFIC CRITERIA

Inclusion criteria:

  • Residents of aged care facilities
  • Aged more than 65 years, or just under 65 years with geriatric issues
  • Frailty or multiple comorbidities
  • General decline in health and function
  • Complex general medical problems
  • Cognitive assessment, behavioural management, medication review, delirium, falls, continence issues or change in function

Exclusion criteria:

  • Patients residing in independent living units/supported residential services
  • Capacity assessments
  • Medico‑legal assessments, reports or opinions

Complete the Residential In‑Reach referral template using your practice software and send via email or

Referral requirements

Requires GP Referral

Information from the patient’s medical history, including:

  • Allergies
  • Current medications
  • Current medical history
  • Past medical history
  • Family history (if relevant)
  • Smoking and alcohol consumption
  • Results from recent/relevant investigations

The following investigations:

  1. Screening bloods:
    • Full Blood Examination (FBE)
    • Biochemistry-electrolytes, renal and liver function
    • Thyroid function test
    • Vitamin B12 and Folate
    • Syphilis serology and HIV if indicated
  1. Mid-Stream Urine (MSU)

It can also be helpful to provide us with a copy of either of the following to better inform our care plan:

    • Past medical diagnosis history from a Comprehensive medical assessment (CMA) by current or past GP, or
    • Aged Care Assessment Service (ACAS) assessment report if CMA is not available.

Residential In-Reach can support the timely discharge of aged care residents through the provision of time-limited post-hospitalisation support.  This service is available for older people with complex needs entering or returning from residential aged care from hospital.

This service is not intended to replace or substitute for care provided by the aged care home and/or the resident’s general practitioner. The aim is to support timely discharge and reduce discharge delays whilst ensuring a seamless transition to residential aged care to avoid unplanned re-admissions.

Referral requirements

  • Discharge to residential aged care facility from acute or sub-acute hospital setting *Available to all hospitals, not just Barwon Health
  • Complete referral form and email to [email protected]
  • Phone intake 0481 479 022 for verbal handover and confirmation of referral being received/accepted.

Referrals should be initiated several days prior to discharge to enable planning and a seamless discharge back, with discharge summary provided to aged care facility, general practitioner and Residential In-Reach.

The discharging department is responsible for communication of discharge with family and facility.

 

Triage

Referrals are prioritised according to acuity.

All incoming acute referrals are triaged by a registered nurse.

To facilitate the triage, have the following information available at referral using the ISBAR handover tool.

Resident details

  • Name
  • DOB
  • Residential aged care facility
  • General practitioner details
  • Goals of care/advanced care directive

Situation

  • Reason for referral

Background

  • Medical history
  • Medications
  • Allergies
  • Baseline function

Consent

We require consent from the

  • Resident/medical treatment decision maker
  • Facility
  • General practitioner*

*Where possible, RIR will seek consent from the resident’s treating GP before consulting  a patient. Where necessary, the RIR team will contact the GP for discussion and verbal handover.

Assessment and follow up care

A comprehensive initial assessment will be undertaken in conjunction with the resident, next of kin, general practitioner and facility.

Following initial assessment and treatment, if ongoing or continuing care is required (according to the need of the resident) a referral to an appropriate service will be facilitated (or secondary consult)

  • Geriatrician
  • Connected Care (HARP)
  • Continence Service
  • Wound Specialist Clinic
  • Aged Psychiatry Service
  • Palliative Care
  • Hospital in the Home

We may also recommend follow-up with other community care providers such as:

  • Dementia Support Australia
  • Wound Clinical Nurse Consultant
  • Palliative care (private)
  • Geriatrician (private)

A detailed copy of the Residential In-Reach assessment plan and management (including assessment outcomes, interventions and changes) will be provided to the aged care facility and the general practitioner.

Page last updated: July 7, 2026