QEII Older Persons Coordinated Care Service Project

Initiative Type
Model of Care
12 September 2017
Last updated
13 May 2020


The QEII Older Persons Care Service is streamlining access to multidisciplinary Comprehensive Geriatric Assessment, management and care planning for people referred to QEII hospital, to facilitate and reduce delays in transfer care or placement in a residential aged care facility. Development of this service includes care provision for in ambulatory and domiciliary settings required to complete the proposed care system.

Key dates
Jan 2016
Aug 2017
Implementation sites
Metro South Hospital and Health Service
Healthcare Improvement Unit, Brisbane South PHN


To provide coordinated, efficient care and improve integration of care throughout the continuum for this cohort of vulnerable disadvantaged people.


  • Emergency Department ( ED), early case identification using a validated risk screening.
  • Rapid triage and selection of the appropriate care setting.
  • Comprehensive multidisciplinary assessment and management.
  • Focus on early decision making and behaviour care planning to support timely transfer to interim care or Residential Aged Care Facilities (RACF).
  • Improved linkages with community agencies especially interim care, nursing homes, CARE-PACT, General Practice and DBMAS (Dementia Behaviour Management and Assessment Service).


Access to coordinated care has been shown to improve outcomes for complex, frail older people. Successful programs are characterised by high quality coordinated, multidisciplinary assessment and intervention including a Consultant Geriatrician, reliable implementation of care plans and review of progress. Optimal results are achieved when services are appropriately targeted.

The Integrated Care Innovation Fund provides financial support to innovative projects that deliver better integration of care, address fragmentation in services and provide high-value healthcare. Funded projects also demonstrate a willingness to embrace and encourage the uptake of new technology alongside the benefits of integrating care and improving communication between health care sectors.

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Key contact

Dr Amanda Stiller
Director of Geriatrics and Rehabilitation
Metro South Hospital and Health Service
(07) 3182 6111