EmbrACE the ACE

Category: Consumer Directed Care and re-ablement

Bupa Cardiff, NSW

In the After Hours Needs Assessments which were undertaken in 2011 and 2012 by Medicare Local, the issue of providing after hours primary care into aged care facilities was raised by the facilities, Ambulance and Emergency Department staff and by GPs. This group represents the highest volume of calls requiring after hours intervention by GPs and yet there are limited GPs available who are prepared to visit.

The Aged Care Emergency (ACE) program is a strategic and coordinated approach to reduce inappropriate hospital transfers of residents who become acutely unwell, providing better support at the home. 

The program seeks to empower staff through education, telephone support, improved relationships and understanding.

ACE brings together a multi-organisational approach to enable staff to detect the deteriorating patient and determine the right care requirements in the right place for residents.

Initial education was scheduled for Aged Care Facility managers, to ensure the longevity of the program despite staff turnover. Two-day train the trainer workshops and ongoing education is offered on and off site in an effort to embed the program in RACFs.

The training includes the use of Identification Situation Background Assessment Recommendation (ISBAR tool) for improved clinical handover. ACE training and use of the ISBAR tool are a part of each new RN’s induction. All RNs at the home have been trained in the implementation of the ACE program. There are approximately five training sessions per year for new RNs as well as refreshing the knowledge of existing RNs.

Bupa Cardiff nominated an RN to be their ‘ACE’ nurse, to monitor training requirements, support new RNs in the use of the ISBAR tool and ACE program and record outcomes of ACE referrals.

Staff expressed a desire to have additional support after hours as they can feel very isolated, so after consultation with RACFs, the ACE support line commenced after hours operation in December 2013.


During a 14 week monitoring period (1 July 14 - 8 Sept 14), five calls were recorded from Bupa Cardiff to the ACE team. Four out of five residents were able to be confidently managed onsite avoiding transfer; one resident was transferred, received targeted treatment and was ready to return to the facility within 50 minutes.

Interagency meetings monitor the program seeking continuous improvement.

Feedback has shown that staff calling the ACE team have reported feeling comfortable and supported during the experience, relatives are reassured and GPs have reported an improvement in clinical handover. With the RNs being trained in the use of the ISBAR tool, GPs have clarity of information on which to base decision making and more timely reviews.

For more information on the program, contact Anita Agafonoff, email: Anita.Agafonoff@bupacare.com.au or phone: (02) 4954 9003.