Enhancing care for vulnerable patients with complex needs

Initiative Type
Service Improvement
09 February 2020
Last updated
27 February 2020


Development and implementation of a student resourced service to provide Engagement Intervention to vulnerable patients at risk of hospital acquired complications. Furthermore, this project allows for the co-design individualised care strategies focussing on risk minimisation through Personalised Support Plans supporting staff to meet unmet needs of this population incorporating non-pharmacological approaches.

Key dates
Feb 2018
Oct 2019
Implementation sites
Robina Hospital General Medicine and Acute Care of Elderly wards
MEST has a strong focus on partnering with clinical care teams and health consumers. Collaboration with patients/families and carers


To empower vulnerable frail aged patients to actively engage in their health journey with the aim of preventing hospital acquired complications. This approach focuses on strong collaboration between patients, staff, family and carers to identify and respond to unmet complex care needs improving patient centred care, outcomes and efficiency.


  • The PSP is utilised as a handover tool upon discharge to support sustainable transitions and prevent readmissions to hospital.
  • Staff are more confident with non-pharmacological intervention strategies as first point of call. Evidence of promoting person centred care by Mobile Engagement Support Team (MEST) modelling individualised care to meet unmet needs of patients, resulting in opportunities for point of care education.
  • Lower care costs are associated with successful prevention of hospital acquired complications and a reduction of nurse special hours and occupational violence due to risk minimisation strategies.
  • Improved patient functional outcomes as evidenced by MBI scores.
  • Unique student placement opportunity and learning experience utilising an Occupational Therapy (OT) practice model that assists in developing a future collaborative practice ready workforce.
  • Improved clinical effectiveness and patient safety due to positive patient experience as per PREM.
  • Background: Literature supports that a large population of older and/or cognitively impaired patients are at risk of hospital acquired complications and deterioration in the acute hospital setting. It was identified that patients with acute delirium or other confusion were not seen by Allied Health.


Development and implementation of a student resourced Occupational Therapy service to provide engagement intervention to vulnerable patients at risk of hospital acquired complications; and to co-design individualised care strategies focussing on risk minimisation through Personalised Support Plans supporting staff to meet unmet needs of this population incorporating non-pharmacological approaches.

Solutions Implemented

  • Establishment of an innovative Occupational Therapy student resourced service under clinical supervision of a Senior Occupational Therapist, named the Mobile Engagement Support Team (MEST)
  • MEST provides Engagement Intervention which is responsive, flexible and individualised to patient needs. Engagement Intervention focuses on domains of personalised and meaningful conversation, ADL participation, sensory and cognitive stimulation, leisure/hobbies and physical prehab.
  • Development of an Interprofessional Screening Tool adapted from the Vona du Toit Model of Creative Ability (VdTMoCA) to an acute hospital environment (Casteleijn, 2014; de Witt, 2014; du Toit, 1972). This unique adaptation of the Occupational Therapy practice model incorporates additional cognitive and sensory models to facilitate advanced clinical interpretation of patient presentation guiding clinical reasoning for skilled intervention.
  • Clinical interpretation is translated into a comprehensive Personalised Support Plans (PSP) to provide care teams with individualised non pharmacological care strategies to optimise patient participation in therapy, self-care needs and to minimise/prevent risks (e.g. delirium, occupational violence/deprivation, behaviour escalation, falls, pressure injury etc.).
  • Consultation with patient discharge destinations (e.g. Residential aged care facilities) resulted in PSPs being updated as a handover tool to support transference of knowledge and transitioning to prevent readmissions.
  • A Patient Reported Experience Measure (PREM) was developed to capture cognitively impaired patient experiences more effectively through verbal and non-verbal methods, as patient experience is positively linked with clinical effectiveness and patient safety (Anhang et.al., 2014, p.534).

Evaluation and Results

Outcomes were measured using the Modified Barthel Index, a well-recognised standardised functional outcome measure (de Morton, Keating & Davidson, 2008). Consumer feedback was captured through the developed PREM and informal discussion with family/carers. Staff surveys provided Qualitative data on benefit of the MEST service and PSPs.

MBI: The results (n=39) showed that 41% of patients who received the MEST intervention had an improvement in function and the remaining 59% of patients maintained the same level of function with no evidence of deterioration.

Patient reported (PREM): “ I enjoyed the consistent contact, conversation and genuine care for my needs and wellbeing - listening when I spoke and providing me with a beautiful crochet blanket that reminds me of home”. Patients (n=9) described the service as “excellent, caring, and heart-warming”.

Family reported: “your company and care, all the assistance you have provided with exercises making life easier for my mother”; “I have no constructive feedback as I feel you have done so well caring for my mother, I feel like I can’t thank you enough, you have developed a genuine relationship with not only my mother but myself and I want to thank you for that.”

Staff surveys: ˜PSP have been an excellent tool to assist provide care to patient with complex needs”; “helped facilitate discharge for patients that required an in-depth PSP”; ”valuable to get feedback in regard to new ideas to engage patients, also nice to debrief in regard to difficult patients”.

Additionally, the Mobile Engagement Support Team were successful in supporting another team with preventing, weaning and cessation of nurse specials for patients requiring continuous supervision. Interestingly, MEST received direct referrals from Geriatricians as they perceived the service as high benefit care for this patient population. The MEST was awarded a $100 000 grant shared by the GC Hospital Foundation and the Health Minister through the GCH Improvers Award Programme to develop a ‘Zen Zone’ cognitive and sensory stimulation therapeutic area that would be accessible to this cohort of patients.

Lessons Learnt

Collating the feedback from the staff surveys and PREMS has demonstrated the overwhelming support, benefit and need for the service and how much value it was able to provide to the families, staff and the patients with complex care needs. This strengthened advocacy for such a service upon completing the pilot project within a challenging environment of budget constraints. The pilot period was too short for a sustainable culture change and should be considered with future implementation. The clinical supervision ratio of 1:4 (Supervisor: Students) was challenging to maintain due placement timeframes, student changeover and variation in student learning needs. Ideal clinical placements to support this model should be 7-10 weeks.


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Key contact

Jenny Nel
Assistant Director of Occupational Therapy - Acute Services
Robina Hospital - Gold Coast Health