Background Our health service serves the largest proportion of older people in Western Australia, and numbers of adults aged over 65 years is projected to increase by over 40% by 2030. Older people now live longer with more complex health needs; and, especially once hospitalised, can receive care that is not aligned to their values and wishes. Advance care planning (ACP) can help ensure that older hospitalised people receive the type of care they would like to receive that aligns with their preferences, wishes and values.

Method A pilot senior clinical nurse service, the Transition Support Navigator, aims to improve advance care planning discussions, documentation and communication (between patients, carers, health and aged care providers) being discharged from hospital to a residential aged care facility (RACF). This includes screening for palliative care needs (Symptom Assessment Scale, Problem Severity Score, Performance Status, Clinical Frailty Scale), facilitating ACP discussions and documentation (including statutory documents), uploading ACP documents to electronic medical records, and facilitating communication between acute, subacute, primary care and aged care services.

Results The pilot commenced in October 2022 and will see patients aged over 65 years in our acute tertiary hospital and subacute secondary hospital diagnosed with frailty and multimorbidity, including moderate to severe dementia. In addition to demographic data, we will collect quantitative and qualitative data regarding number of ACP discussions, number and type of ACP documents completed and uploaded to digital medical records, referrals to specialist palliative care services, hospital readmissions, and place of death.

Conclusion A new nursing led service, based in the Department of Geriatric Acute and Rehabilitation Medicine, aims to improve ACP discussions, documentation and communication for frail, older hospitalised patients who required residential aged care, to reflect the values and preferences of these patients.