Nurse Navigator Aged Care Model

Initiative Type
Model of Care
18 August 2017
Last updated
28 August 2020


A new Nurse Navigator Aged Care Model has been developed to support the Nurse Practitioners Aged Care Nurse Navigators (NPACNNs).  The Hospital In The Nursing Home (HITNH) model of care focuses on 3 main components;

  • Telephone triage service providing advice and triaging of RACF residents before a hospital admission is required (in concert with the GP). Also the response team can be dispatched out to a nursing home should the patient require assessment to prevent transportation to Toowoomba Hospital.
  • Advocacy, education, training and support for RACF staff.
  • Communication and Partnership with General Practices.
Key dates
Jul 2015
Aug 2017
Implementation sites
Darling Downs Hospital and Health Service


  • Manage avoidable hospital admissions
  • Increased capability,, competency and confidence of Rural Aged Care Facility (RACF) staff to provide earlier proactive recognition, assessment and intervention of a deteriorating patient within the RACF.
  • Enhance partnerships and integrated working relationships between Hospital and Health Service, GPs and RACF.
  • Enhance health outcomes for aged care residents.


  • Acute response and evaluation service for residents of nursing homes in partnership with primary care providers such as GPs.
  • “Virtual” admission of nursing home residents allowing acute care to be provided under the medical governance of a Geriatrician within their nursing home.
  • Early Geriatrician assessment and management of nursing home residents presenting to the Emergency Department (ED)
  • Admission of medically unwell nursing home residents under the care of a specialist Geriatrician.


In 2015, the government introduced 400 new Nurse Navigator positions throughout Queensland. The Darling Downs Hospital and Health Service (DDHHS) has been successful in obtaining 19 of these positions – 5 of whom will be NPACNNs.

Lessons Learnt

The initial pilot has been successful with positive case study findings.

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Key contact

Karen Gordon
Nursing Director
Baillie Henderson Hospital
(07) 4616 6179