G.R.A.C.E. stands for Geriatric Rapid Acute Care Evaluation. The HKH GRACE
service developed in response to feedback received at an HKR Division of GPs aged care forum in
August 2004. The forum was attended by GPs and Residential Aged Facility Managers and Directors of Nursing.
Feedback identified the need for a program to minimise hospital admissions for
residents of Residential Aged Care Facilities (RACFs), since admission to hospital may be
disruptive and unsettling for residents. The GRACE program was developed under the direction of
Associate Professor Kurrle and Dr Gardiner (HKH Director Medical Services), to meet that need. We also faciltitate rapid &
appropriate care for residents of RACFs when admission is necessary.
 Who are we?
The GRACE team consists of an aged care Clinical Nurse Consultant and specially trained registered nurses, who are part of the GRACE
and Agedcare Services in Emergency (ASET) teams, are rostered on after-hours.
What do we do?
 GRACE provides an outreach service and a system of prioritised hospital treatment to improve the 'patient journey' for residents of RACFs in the Hornsby and
Ku-ring-gai local government areas. We work collaboratively with residential aged care facilities and GPs to achieve our outcomes.
We work closely with the HKH ASET team, who take responsibility for providing a similar
service for hostel patients.
The GRACE Project is managed in such a way that it can be flexible and responsive to the needs of
residents/families, facilities and general practitioners. We aim to provide better and more
appropriate and timely care for residents of aged care facilities, in the Hornsby and
Ku-ring-gai LGAs, who require hospital admission. We also seek to support nursing home residents to remain in their
facilities, by providing appropriate services and support to RACFs. This is done through collaboration with
a supportive network of hospital, ambulatory care, primary care and residential aged care
services. This is achieved by:
- Providing a single entry point telephone triage system to the GRACE team, so that aged
care facilities and general practitioners can discuss treatment options.
- Building acute care capacity within aged care facilities through education and support of
new treatment options under a brokerage system.
- Providing aged care facilities with access to the community acute/post acute care services
where appropriate.
- Providing aged care facilities and general practitioners with access to services, where
appropriate, that are generally only available to inpatients. This may include access to
diagnostics, specialist review and access to allied health and CNC review.
- Offering a prioritised care system in the Emergency Department
and Emergency Medical Unit (EMU) combined with ongoing GRACE feedback
to the patient’s aged care facility and general practitioner.
- Holding regular meetings with the aged care facilities to discuss patient care and other
issues. This helps us to stay in touch with the needs of our consumers.
How you can access our service
All aged care facilities in the Hornsby and Ku-ring-gai areas are eligible to contact the service.
RACFs should contact the GRACE nurse (phone 0434 183 549, or 9477-9910) to assist with the decision of whether to
transfer a patient to hospital. GRACE nurses advise
on the most appropriate course of action. Where admission is required the GRACE nurse will faciliate a 'fast track' process
to ensure timely and optimal patient care.
Hostels should ring the GRACE service on 9477-9123 and ask for page number 52676, to access the GRACE hostel service.
Where you can find us
We are based at Hornsby Ku-ring-gai Hospital. However our friendly team will also come to your facility on request, to discuss the GRACE service,
perform appropriate procedures (such as supporting urinary catheter change) and deliver training for staff on those procedures. Contact the GRACE CNC to discuss your needs.
What are our hours?
GRACE staff are usually available 8am to 10pm Monday to Saturday, 11.30am to 8pm Sunday.
How you can contact us
Within office hours (8am - 4.30pm Monday to Friday) ring Nadia Yazdani on the GRACE mobile on 0434 183 549 or the landline number, which is 9477 9910. Outside office hours please
ring 9477-9123 and ask for page number 52676. The service works best for your resident if GRACE has already been given the necessary information
about them.
To access the GRACE service for hostels please ring 9477-9123 and ask for page number 52676.
When your resident arrives at HKH
By the time your resident arrives at HKH we hope that you have already alerted the GRACE CNC that
the resident is coming to hospital. This faciltates quick assessment of the patient by ensuring that:
- The GRACE triage sheet is completed.
- If the patient is being transferred to hospital the pre-admission information
is written in the notes and the patient notes are flagged with a green GRACE sticker.
- The patient details are put in Emergency Department Information System “patient expects” so that the triage nurse will
notify GRACE nurse when the patient arrives.
- The GRACE nurse will work with ED nurses and medical staff to initiate & prioritise
care and document a preferred plan from an aged care perspective.
- We also have rapid access to geriatric support.
The GRACE team will continue to work to facilitate an optimal 'journey' for the patient. Where ongoing support will be needed to maintain the resident in their RACF,
GRACE will discuss ongoing support services with the facility.
If admission is not required and the GRACE patient can remain in the community,
GRACE may assist the RACF to maintain the resident in the facility. This may be done by
providing access to hospital staff (eg clinical nurse consultant, geriatrician), provision of
consumables to prevent an ED presentation (eg subcutaneous fluids) or referral to Northern
Sydney Home Nursing Service or Acute Post Acute Care for additional care.
More information
We have a variety of tools available to assist you. Contact us for more information.
You might also like to read more about GRACE on the ARCHI website.
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