Abstract
Objective
To describe the types of hospital and out‐of‐hospital services provided by public geriatric medicine departments in Australia and New Zealand, and to explore head of department (HOD) views on issues in current and future service provision.
Methods
An electronic survey was sent to HODs of public geriatric medicine departments.
Results
Seventy‐six (89%) of 85 identified HODs completed the survey. Seventy‐one (93%) departments admit inpatients and 51 (67%) admit acute inpatients, with variable admission criteria. Sixty‐four (84%) have hospitals with an inpatient general medicine service, and 58 (91%) of these admit older patients with acute geriatric issues. Sixty (79%) departments provide inpatient rehabilitation. Forty (53%) have beds for behavioural symptoms of dementia and/or delirium. Seventy (92%) provide a proactive orthogeriatric service. In terms of out‐of‐hospital services, 74 (97%) departments have outpatient clinics, 59 (78%) have telehealth and 68 (89%) perform home visits. Forty‐five (59%) provide an inreach/outreach service to nursing homes. The most frequent gaps in service provision identified by HODs were acute geriatrics, surgical liaison, a designated dementia/delirium behavioural management unit, geriatricians in Emergency, outreach/inreach to residential care and shared care with some medical specialities. Increasing staff numbers and government policy change were the most frequently identified ways to address these gaps.
Conclusions
Geriatric medicine service provision is variable across Australia and New Zealand, with key gaps identified. These findings will inform future directions in implementation of geriatric medicine models of care and discussions with various levels of government about the ongoing development of geriatric medicine services.
Keywords: aged, geriatricians, geriatrics, health services research, policy
Policy Impact.
This study has found that geriatric medicine service provision is variable across Australia and New Zealand, with key gaps identified. Our findings will inform future directions in implementation of geriatric medicine models of care and discussions with various levels of government about the ongoing development of geriatric medicine services.
Key definitions.
Geriatric Evaluation and Management (GEM)
Geriatric Evaluation and Management (GEM) services provide ‘care in which the primary clinical purpose or treatment goal is improving the functioning of a person with multidimensional needs. These needs are associated with medical conditions related to ageing. They include falls, incontinence, reduced mobility, delirium and depression’.*
Transitional Care Unit (TCU)
Transitional Care Units offer ‘an extended patient stay of up to 12 weeks, providing short‐term support for older people who are medically stable but need time to complete their recovery’. They aim ‘to help patients maximise their mobility and independence and give patients time to finalise their living arrangements’.†
1. INTRODUCTION
In Australia, patients aged greater than 65 years accounted for 42% of public hospital admissions in 2016. 1 A large proportion of non‐admitted services provided by public hospitals in Australia are also for older patients. Of the 38 million non‐admitted patient service events 2 provided by public hospitals in 2019–20, 34% were for people aged 65 years and over. 3 In New Zealand, one in three hospitalisations were for people aged 65 years and over, and hospitalisation rates were highest in the 85+ years age group. 4 Furthermore, an increasing number of older patients in both countries require health care. 5 , 6
The speciality of geriatric medicine has grown in Australia and New Zealand over the last two decades. The number of geriatricians is estimated to have increased from 300 in 2002 to 619 in 2016 7 and 874 in 2019. 8 This increase is one of the reasons why geriatric medicine services appear to have expanded over the last 20 years. These services have developed to meet local demand, influenced by local institutional strategy and resource provision and policy at various levels of government.
Little is known, however, about the type of hospital and out‐of‐hospital services provided by geriatric medicine departments in Australia and New Zealand currently. The last relevant study in 2001 examined the level of provision of hospital bed‐based geriatric medical services in Australia in a survey of senior hospital administrators. 9 The most striking finding was how much geriatric medicine services available at hospitals varied between states and location. The study did not examine out‐of‐hospital services such as outpatient clinics, home visits, telehealth and services to residential care and did not include New Zealand. As this survey was conducted over 20 years ago, it is expected that significant change has occurred since. In addition, the participants of this study were senior hospital administrators rather than heads of departments of Geriatric Medicine. A gap therefore existed in our knowledge of the current state of both hospital and out‐of‐hospital services provided by public geriatric medicine departments in Australia and New Zealand.
The aims of the study were to examine the type of hospital and out‐of‐hospital services provided by geriatric medicine departments in Australia and New Zealand in the public health system and to explore head of department (HOD) views on issues in current and future service provision.
2. METHODS
2.1. Survey design
A descriptive cross‐sectional survey was conducted using an electronic self‐completion questionnaire built in Research Electronic Data Capture (REDCap). Item generation and questionnaire selection were based on literature review and expert input, ensuring content validity. The expert input was from co‐investigators who were eight senior geriatricians in different regions of Australia and New Zealand and two academics with expertise in aged care policy. Questionnaire piloting and sensibility testing were undertaken with co‐investigators to ensure face and content validity and to assess ease of use. 10
The questionnaire used a combination of directed response and free‐text questions (see Appendix S1).
2.2. Sampling and recruitment
A list of hospitals with geriatric medicine departments in Australia and New Zealand used in a previous study was obtained and updated by co‐investigators. 11 A total of 85 heads (or acting heads) of geriatric medicine departments (HODs) across Australia and New Zealand were identified and invited to participate in the study. They were sent an email with information about the study. Participants who agreed to take part in the study were sent an email with a link to the questionnaire.
2.3. Survey mail‐out and completion dates
Round one email invitations with a link to the questionnaire for all but two geriatricians were sent on 4 September 2022, with all completed by 14 December 2022. Round 2 invitations for two further geriatricians (with a request to complete the survey based on information from late 2022) were sent on 19 March 2023 and completed by 22 March 2023.
2.4. Data analysis
Data responses were analysed using descriptive statistics in Microsoft Excel. Descriptive statistics were presented as frequency and percentages for the categorical variables. Descriptive data were categorised by the following characteristics: country (Australia or New Zealand) and if in Australia by state/territory and rurality (metropolitan or regional/rural). Rurality was defined by the Rural, Remote and Metropolitan Area Regional (RRMA) classification. 12 Free‐text responses to questions about possible gaps in services and barriers to addressing these gaps were categorised in Microsoft Excel and the most frequent categories were then identified.
The study was approved by the Sydney Local Health District Human Research Ethics Committee at Concord Hospital (HREC Approval Number: 2022/ETH00685).
3. RESULTS
The response rate was 89%, with 76 out of 85 identified HODs completing the survey. Fifty‐eight participants (76% of the total) were in Australia, of which 42 (72% of Australian participants) were in a metropolitan site, 14 (24%) in a regional site and 2 (3% of the total) in a rural site.
Within Australia, the breakdown by state was as follows: 21 (36%) New South Wales, 12 (21%) Victoria, 11 (19%) Queensland, 6 (10%) Western Australia, 3 (5%) South Australia, 2 (3%) Australian Capital Territory, 2 (3%) Tasmania and 1 (2%) Northern Territory.
3.1. Department demographic information
The majority of services (63%) across Australia and New Zealand catered to population sizes ranging from 100,000 to 500,000, and around a quarter catered to >500,000 (see Table 1). A higher proportion of participants in regional/rural Australia compared to metropolitan areas reported serving a population where the proportion of the population aged >65 was 15–20% or 20–30%. A quarter of participants were unsure of the population age distribution in their region.
TABLE 1.
Demographic information of Geriatric Medicine Departments categorised by country and type of location.
| Total (%), n = 76 | Australia (%), n = 58 | New Zealand (%), n = 18 | Metropolitan Australia (%), n = 42 | Rural/Regional Australia (%), n = 16 | |
|---|---|---|---|---|---|
| Population size catered to | |||||
| 0–10,000 | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| 10,000–50,000 | 3 (4) | 0 (0) | 3 (17) | 0 (0) | 0 (0) |
| 50,000–100,000 | 7 (9) | 6 (10) | 1 (6) | 3 (7) | 3 (19) |
| 100,000–500,000 | 48 (63) | 39 (67) | 9 (50) | 27 (64) | 12 (75) |
| >500,000 | 18 (24) | 13 (22) | 5 (28) | 12 (29) | 1 (6) |
| Proportion of population aged >65 | |||||
| 10%–14% | 7 (9) | 6 (10) | 1 (6) | 5 (12) | 1 (6) |
| 15%–20% | 27 (36) | 19 (33) | 8 (44) | 14 (33) | 5 (31) |
| 20%–30% | 18 (24) | 16 (28) | 2 (11) | 9 (21) | 7 (44) |
| Unsure | 19 (25) | 13 (22) | 6 (33) | 12 (29) | 1 (6) |
| Other | 4 (5) | 4 (7) | 1 (6) | 2 (5) | 2 (13) |
| Types of hospitals serviced | |||||
| General hospital | 32 (42) | 23 (40) | 9 (50) | 21 (50) | 2 (13) |
| Tertiary referral centre or similar | 30 (39) | 24 (41) | 6 (33) | 18 (43) | 6 (38) |
| District hospital or similar | 19 (25) | 13 (22) | 6 (33) | 7 (17) | 6 (38) |
| Rural base hospital or similar | 13 (17) | 8 (14) | 5 (28) | 0 (0) | 8 (50) |
| Small local hospital | 18 (24) | 17 (29) | 1 (6) | 8 (19) | 9 (56) |
| Rehabilitation hospital | 13 (17) | 10 (17) | 3 (17) | 7 (17) | 3 (19) |
| Subacute hospital | 24 (32) | 21 (36) | 3 (17) | 15 (36) | 6 (38) |
| Transition care centre | 13 (17) | 11 (19) | 2 (11) | 8 (19) | 3 (19) |
| Extended care centre | 2 (3) | 1 (2) | 1 (6) | 1 (2) | 0 (0) |
| Other | 2 (3) | 2 (3) | 0 (0) | 2 (5) | 0 (0) |
Table 2 shows the services provided by geriatric medicine departments in Australia and New Zealand. Table 3 shows these services categorised by state/territories, and Table 4 shows the services provided categorised by metropolitan versus regional/rural site.
TABLE 2.
Services provided by Geriatric Medicine Departments in Australia and New Zealand.
| All data (%), n = 76 | Australia (%), n = 58 | NZ (%), n = 18 | |
|---|---|---|---|
| Inpatient service—general | |||
| Inpatients (any) | 71 (93) | 55 (95) | 16 (89) |
| Top admission source to inpatient geriatric beds a | |||
| Emergency | 29 (38) | 27 (47) | 2 (11) |
| Transfer from other teams | 42 (55) | 28 (48) | 14 (78) |
| Other | 1 (1) | 1 (2) | 0 (0) |
| Geriatric beds allocated within general medical wards | 22 (29) | 20 (34) | 2 (11) |
| Shared care with general medicine | 14 (18) | 12 (21) | 2 (11) |
| Acute care | |||
| Acute inpatients admitted from ED | 51 (67) | 43 (74) | 8 (44) |
| Admission policy b | |||
| No formal admission policy | 3 (6) | 3 (7) | 0 (0) |
| Needs‐based | 14 (27) | 14 (33) | 0 (0) |
| Aged‐based—inclusionary (e.g., all patients >65) | 1 (2) | 0 (0) | 0 (0) |
| Aged‐based—exclusionary (e.g., no patients <65) | 7 (14) | 6 (14) | 1 (13) |
| Both inclusionary and exclusionary | 19 (37) | 14 (33) | 5 (63) |
| Other | 7 (14) | 5 (12) | 2 (25) |
| Associated inpatient general medicine service b | 64 (84) | 48 (83) | 16 (89) |
| Admitting older patients with acute geriatric problems | 58 (91) | 42 (88) | 16 (100) |
| Hospital subacute care and rehabilitation | |||
| Rehabilitation | 59 (78) | 41 (71) | 18 (100) |
| GEM | 49 (64) | 41 (71) | 8 (44) |
| Transitional care unit | 30 (39) | 25 (43) | 5 (28) |
| Other | 18 (24) | 15 (26) | 3 (17) |
| Inpatient bed‐based geriatric medicine rehabilitation services b | 60 (79) | 42 (72) | 18 (100) |
| In designated aged care rehabilitation unit | 30 (50) | 22 (52) | 8 (44) |
| In general purpose ward | 2 (3) | 2 (5) | 0 (0) |
| In general rehabilitation unit | 25 (42) | 16 (38) | 9 (50) |
| Other | 3 (5) | 2 (5) | 1 (6) |
| Dementia/Delirium behavioural management beds | |||
| Inpatient beds b | 40 (53) | 35 (60) | 5 (28) |
| Primarily managed by geriatrician | 33 (83) | 32 (91) | 1 (20) |
| Primarily managed by psychiatrist | 3 (8) | 1 (3) | 2 (40) |
| Primarily managed by other | 4 (10) | 2 (6) | 2 (40) |
| Located in a specialised inpatient unit | 23 (58) | 22 (63) | 1 (20) |
| Located in a general aged care unit | 12 (30) | 8 (23) | 4 (80) |
| Located in a psychiatric ward | 5 (13) | 2 (6) | 3 (60) |
| Located in another place | 3 (8) | 3 (9) | 0 (0) |
| Associated psychogeriatrics service | 51 (67) | 36 (62) | 15 (83) |
| Stroke services | |||
| Stroke services (any) b | 42 (55) | 28 (48) | 14 (78) |
| Admitted primarily under the care of a geriatrician | 13 (31) | 8 (29) | 5 (36) |
| Stroke rehabilitation | 21 (50) | 12 (43) | 9 (64) |
| Both acute stroke care and rehabilitation | 15 (36) | 10 (36) | 5 (36) |
| Neither | 4 (10) | 4 (14) | 0 (0) |
| Perioperative/Orthogeriatric care | |||
| Proactive orthogeriatric care | 70 (92) | 52 (90) | 18 (100) |
| Other proactive perioperative care | 27 (36) | 20 (34) | 7 (39) |
| Hospital‐based outpatient services | |||
| Outpatient clinics (any) | 74 (97) | 56 (97) | 18 (100) |
| General geriatric clinic | 70 (92) | 53 (91) | 17 (94) |
| Osteoporosis clinic | 17 (22) | 10 (17) | 7 (39) |
| Memory and cognition clinic | 51 (67) | 44 (76) | 7 (39) |
| Fall clinic | 40 (53) | 36 (62) | 4 (22) |
| Continence clinic | 20 (26) | 18 (31) | 2 (11) |
| Other | 28 (37) | 21 (36) | 7 (39) |
| Remote or telehealth services (any) b | 59 (78) | 48 (83) | 11 (61) |
| Phone | 41 (69) | 30 (63) | 11 (100) |
| Videoconferencing | 52 (88) | 44 (92) | 8 (73) |
| Other | 6 (10) | 6 (13) | 0 (0) |
| Dementia‐specific services | |||
| Dementia support services | 46 (61) | 37 (64) | 9 (50) |
| Dementia‐specific rehabilitation | 10 (13) | 7 (12) | 3 (17) |
| Dementia education | 43 (57) | 38 (66) | 5 (28) |
| Community | |||
| Home visits (any) b | 68 (89) | 51 (88) | 17 (94) |
| Geriatrician | 60 (88) | 45 (88) | 15 (88) |
| Aged care specialist nurse | 47 (69) | 32 (63) | 15 (88) |
| Allied health | 43 (63) | 32 (63) | 11 (65) |
| Other | 17 (25) | 14 (27) | 3 (18) |
| Rehabilitation at home | 47 (62) | 35 (60) | 12 (67) |
| Residential aged care facilities (RACF) | |||
| Outreach/Inreach to RACFs (any) b | 45 (59) | 37 (64) | 8 (44) |
| Geriatrician | 40 (89) | 34 (92) | 6 (75) |
| Nurse | 42 (93) | 34 (92) | 8 (100) |
| Allied health | 7 (16) | 4 (11) | 3 (38) |
| Other | 11 (24) | 10 (27) | 1 (13) |
| Able to perform acute medical review within <24 h | 33 (73) | 31 (84) | 2 (25) |
Not all participants responded to this question.
Denominator for percentages shown below is the number providing this category of service, not the total number of departments in the study.
TABLE 3.
Services provided by Geriatric Medicine Departments in Australia by states/territories.
| Australia (%), n = 58 | NSW (%), n = 21 | VIC (%), n = 12 | QLD (%), n = 11 | WA (%), n = 6 | SA (%), n = 3 | ACT (%), n = 2 | TAS (%), n = 2 | NT (%), n = 1 | |
|---|---|---|---|---|---|---|---|---|---|
| Inpatient service—general | |||||||||
| Inpatients (any) | 55 (95) | 20 (95) | 12 (100) | 11 (100) | 6 (100) | 3 (100) | 1 (50) | 1 (50) | 1 (100) |
| Top admission source to inpatient geriatric beds a | |||||||||
| Emergency | 27 (47) | 17 (81) | 0 (0) | 4 (36) | 4 (67) | 1 (33) | 1 (50) | 0 (0) | 0 (0) |
| Transfer from other teams | 28 (48) | 3 (14) | 12 (100) | 7 (64) | 2 (33) | 2 (67) | 0 (0) | 1 (50) | 1 (100) |
| Other | 1 (2) | 0 (0) | 0 (0) | 1 (9) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Geriatric beds allocated within general medical wards | 20 (34) | 4 (19) | 5 (42) | 4 (36) | 3 (50) | 3 (100) | 0 (0) | 1 (50) | 0 (0) |
| Shared care with general medicine | 12 (21) | 2 (10) | 1 (8) | 4 (36) | 2 (33) | 0 (0) | 1 (50) | 2 (100) | 0 (0) |
| Acute care | |||||||||
| Acute inpatients admitted from ED | 43 (74) | 17 (81) | 9 (75) | 7 (64) | 4 (67) | 3 (100) | 1 (50) | 2 (100) | 0 (0) |
| Associated inpatient general medicine service b | 48 (83) | 15 (71) | 10 (83) | 11 (100) | 6 (100) | 1 (33) | 2 (100) | 2 (100) | 1 (100) |
| Admitting older patients with acute geriatric problems | 42 (88) | 11 (73) | 10 (100) | 10 (91) | 5 (83) | 1 (100) | 2 (100) | 2 (100) | 1 (100) |
| Hospital subacute care and rehabilitation | |||||||||
| Rehabilitation | 41 (71) | 15 (71) | 7 (58) | 9 (82) | 5 (83) | 2 (67) | 1 (50) | 2 (100) | 0 (0) |
| GEM | 41 (71) | 9 (43) | 12 (100) | 10 (91) | 5 (83) | 3 (100) | 0 (0) | 1 (50) | 1 (100) |
| Transitional care unit | 25 (43) | 6 (29) | 11 (92) | 3 (27) | 1 (17) | 2 (67) | 1 (50) | 1 (50) | 0 (0) |
| Other | 15 (26) | 7 (33) | 3 (25) | 2 (18) | 0 (0) | 2 (67) | 1 (50) | 0 (0) | 0 (0) |
| Inpatient bed‐based geriatric medicine rehabilitation services b | 42 (72) | 14 (67) | 9 (75) | 9 (82) | 5 (83) | 2 (67) | 1 (50) | 1 (50) | 1 (100) |
| In designated aged care rehabilitation unit | 22 (52) | 6 (43) | 4 (44) | 4 (44) | 4 (80) | 1 (50) | 1 (100) | 1 (100) | 1 (100) |
| In general purpose ward | 2 (5) | 1 (7) | 0 (0) | 1 (11) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| In general rehabilitation unit | 16 (38) | 7 (50) | 4 (44) | 3 (33) | 1 (20) | 1 (50) | 0 (0) | 0 (0) | 0 (0) |
| Other | 2 (5) | 0 (0) | 1 (11) | 1 (11) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Dementia/Delirium behavioural management beds | |||||||||
| Inpatient beds b | 35 (60) | 11 (52) | 8 (67) | 8 (73) | 2 (33) | 2 (67) | 1 (50) | 2 (100) | 1 (100) |
| Primarily managed by geriatrician | 32 (91) | 9 (82) | 8 (100) | 8 (100) | 2 (100) | 2 (100) | 1 (100) | 1 (50) | 1 (100) |
| Primarily managed by psychiatrist | 1 (3) | 1 (9) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Primarily managed by other | 2 (6) | 1 (9) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (50) | 0 (0) |
| Located in a specialised inpatient unit | 22 (63) | 8 (73) | 4 (50) | 7 (88) | 1 (50) | 2 (100) | 0 (0) | 0 (0) | 0 (0) |
| Located in a general aged care unit | 8 (23) | 2 (18) | 2 (25) | 1 (13) | 1 (50) | 0 (0) | 1 (100) | 0 (0) | 1 (100) |
| Located in a psychiatric ward | 2 (6) | 1 (9) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (50) | 0 (0) |
| Located in another place | 3 (9) | 0 (0) | 2 (25) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (50) | 0 (0) |
| Associated psychogeriatrics service | 36 (62) | 15 (71) | 8 (67) | 5 (45) | 4 (67) | 2 (67) | 1 (50) | 1 (50) | 0 (0) |
| Stroke services | |||||||||
| Stroke services (any) b | 28 (48) | 8 (38) | 6 (50) | 6 (55) | 5 (83) | 1 (33) | 1 (50) | 1 (50) | 0 (0) |
| Admitted primarily under the care of a geriatrician | 8 (29) | 3 (38) | 0 (0) | 1 (17) | 3 (60) | 1 (100) | 0 (0) | 0 (0) | 0 (0) |
| Acute stroke care (admitted under geriatric medicine) | 2 (7) | 0 (0) | 0 (0) | 1 (17) | 0 (0) | 1 (100) | 0 (0) | 0 (0) | 0 (0) |
| Stroke rehabilitation | 12 (43) | 3 (38) | 5 (83) | 2 (33) | 2 (40) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Both acute stroke care and rehabilitation | 10 (36) | 4 (50) | 0 (0) | 3 (50) | 2 (40) | 0 (0) | 0 (0) | 1 (100) | 0 (0) |
| Neither | 3 (12) | 0 (0) | 1 (20) | 0 (0) | 1 (20) | 0 (0) | 1 (100) | 0 (0) | 0 (0) |
| Perioperative/Orthogeriatric care | |||||||||
| Proactive orthogeriatric care | 50 (89) | 19 (95) | 9 (82) | 11 (100) | 5 (83) | 3 (100) | 1 (50) | 1 (50) | 1 (100) |
| Other proactive perioperative care | 20 (36) | 10 (50) | 4 (36) | 4 (36) | 1 (17) | 1 (33) | 0 (0) | 0 (0) | 0 (0) |
| Hospital‐based outpatient services | |||||||||
| Outpatient clinics (any) | 54 (96) | 19 (95) | 11 (100) | 10 (91) | 6 (100) | 3 (100) | 2 (100) | 2 (100) | 1 (100) |
| General geriatric clinic | 51 (91) | 18 (90) | 9 (82) | 10 (91) | 6 (100) | 3 (100) | 2 (100) | 2 (100) | 1 (100) |
| Osteoporosis clinic | 10 (18) | 6 (30) | 1 (9) | 0 (0) | 3 (50) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Memory and cognition clinic | 43 (77) | 12 (60) | 11 (100) | 9 (82) | 5 (83) | 3 (100) | 1 (50) | 1 (50) | 1 (100) |
| Fall clinic | 35 (63) | 8 (40) | 11 (100) | 5 (45) | 5 (83) | 3 (100) | 1 (50) | 1 (50) | 1 (100) |
| Continence clinic | 18 (32) | 3 (15) | 10 (91) | 1 (9) | 4 (67) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Other | 21 (38) | 5 (25) | 6 (55) | 1 (9) | 6 (100) | 0 (0) | 1 (50) | 1 (50) | 1 (100) |
| Remote or telehealth services (any) b | 46 (82) | 17 (85) | 9 (82) | 8 (73) | 5 (83) | 3 (100) | 1 (50) | 2 (100) | 1 (100) |
| Phone | 29 (63) | 11 (65) | 5 (56) | 4 (50) | 4 (80) | 1 (33) | 1 (100) | 2 (100) | 1 (100) |
| Videoconferencing | 43 (93) | 16 (94) | 9 (100) | 8 (100) | 5 (100) | 2 (67) | 1 (100) | 1 (50) | 1 (100) |
| Other | 5 (11) | 1 (6) | 0 (0) | 2 (25) | 0 (0) | 1 (33) | 0 (0) | 1 (50) | 0 (0) |
| Dementia‐specific services | |||||||||
| Dementia support services | 36 (64) | 13 (65) | 5 (45) | 10 (91) | 4 (67) | 2 (67) | 1 (50) | 0 (0) | 1 (100) |
| Dementia‐specific rehabilitation | 7 (13) | 2 (10) | 0 (0) | 1 (9) | 1 (17) | 2 (67) | 0 (0) | 1 (50) | 0 (0) |
| Dementia education | 37 (66) | 12 (60) | 8 (73) | 8 (73) | 5 (83) | 2 (67) | 0 (0) | 1 (50) | 1 (100) |
| Community | |||||||||
| Home visits (any) b | 49 (88) | 16 (80) | 10 (91) | 10 (91) | 6 (100) | 3 (100) | 2 (100) | 1 (50) | 1 (100) |
| Geriatrician | 44 (90) | 16 (100) | 10 (100) | 9 (90) | 3 (50) | 3 (100) | 2 (100) | 0 (0) | 1 (100) |
| Aged care specialist nurse | 32 (65) | 6 (38) | 8 (80) | 7 (70) | 4 (67) | 3 (100) | 2 (100) | 1 (100) | 1 (100) |
| Allied health | 31 (63) | 9 (56) | 7 (70) | 7 (70) | 3 (50) | 3 (100) | 2 (100) | 0 (0) | 1 (100) |
| Other | 14 (29) | 7 (44) | 3 (30) | 2 (20) | 1 (17) | 1 (33) | 0 (0) | 0 (0) | 0 (0) |
| Rehabilitation at home | 33 (59) | 8 (40) | 10 (91) | 7 (64) | 3 (50) | 3 (100) | 1 (50) | 1 (50) | 0 (0) |
| Residential aged care facilities (RACF) | |||||||||
| Outreach/Inreach to RACFs (any) b | 37 (66) | 13 (65) | 10 (91) | 9 (82) | 1 (17) | 2 (67) | 1 (50) | 0 (0) | 1 (100) |
| Geriatrician | 34 (92) | 13 (100) | 7 (70) | 9 (100) | 1 (100) | 2 (100) | 1 (100) | 0 (0) | 1 (100) |
| Nurse | 34 (92) | 12 (92) | 9 (90) | 9 (100) | 0 (0) | 2 (100) | 1 (100) | 0 (0) | 1 (100) |
| Allied health | 4 (11) | 2 (15) | 0 (0) | 1 (11) | 0 (0) | 1 (50) | 0 (0) | 0 (0) | 0 (0) |
| Other | 10 (27) | 3 (23) | 3 (30) | 4 (44) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Able to perform acute medical review within <24 h | 31 (84) | 10 (77) | 9 (90) | 9 (100) | 0 (0) | 2 (100) | 1 (100) | 0 (0) | 0 (0) |
Not all participants responded to this question.
Denominator for percentages shown below is the number providing this category of service, not the total number of departments in the study.
TABLE 4.
Services provided by Geriatric Medicine Departments in Australia by Metropolitan and Regional/Rural location.
| Metropolitan Australia (%), n = 42 | Rural/Regional Australia (%), n = 16 | |
|---|---|---|
| Inpatient Service—general | ||
| Inpatients (any) | 40 (95) | 15 (94) |
| Top admission source to inpatient geriatric beds a | ||
| Emergency | 21 (50) | 6 (38) |
| Transfer from other teams | 19 (45) | 9 (56) |
| Other | 0 (0) | 1 (6) |
| Geriatric beds allocated within general medical wards | 17 (40) | 3 (19) |
| Shared care with general medicine | 8 (19) | 4 (25) |
| Acute care | ||
| Acute inpatients admitted from ED | 34 (81) | 9 (56) |
| Associated inpatient general medicine service b | 33 (79) | 15 (94) |
| Admitting older patients with acute geriatric problems | 29 (88) | 13 (87) |
| Hospital subacute care and rehabilitation | ||
| Rehabilitation | 30 (71) | 11 (69) |
| GEM | 28 (67) | 13 (81) |
| Transitional care unit | 16 (38) | 9 (56) |
| Other | 12 (29) | 3 (19) |
| Inpatient bed‐based geriatric medicine rehabilitation services b | 33 (79) | 9 (56) |
| In designated aged care rehabilitation unit | 18 (55) | 4 (44) |
| In general purpose ward | 2 (6) | 0 (0) |
| In general rehabilitation unit | 11 (33) | 5 (56) |
| Other | 2 (6) | 0 (0) |
| Dementia/Delirium behavioural management beds | ||
| Inpatient beds b | 23 (55) | 12 (75) |
| Primarily managed by geriatrician | 22 (96) | 10 (83) |
| Primarily managed by psychiatrist | 0 (0) | 1 (8) |
| Primarily managed by other | 1 (4) | 1 (8) |
| Located in a specialised inpatient unit | 17 (74) | 5 (42) |
| Located in a general aged care unit | 3 (13) | 5 (42) |
| Located in a psychiatric ward | 2 (9) | 0 (0) |
| Located in another place | 1 (4) | 2 (17) |
| Associated psychogeriatrics service | 27 (64) | 9 (56) |
| Stroke services | ||
| Stroke services (any) b | 19 (45) | 9 (56) |
| Admitted primarily under the care of a geriatrician | 7 (37) | 1 (11) |
| Acute stroke care (admitted under geriatric medicine) | 1 (5) | 1 (11) |
| Stroke rehabilitation | 9 (47) | 3 (33) |
| Both acute stroke care and rehabilitation | 7 (37) | 3 (33) |
| Neither | 2 (11) | 2 (22) |
| Perioperative/Orthogeriatric care | ||
| Proactive orthogeriatric care | 38 (90) | 14 (88) |
| Other proactive perioperative care | 17 (40) | 3 (19) |
| Hospital‐based outpatient services | ||
| Outpatient clinics (any) | 41 (98) | 15 (94) |
| General geriatric clinic | 38 (90) | 15 (94) |
| Osteoporosis clinic | 8 (19) | 2 (13) |
| Memory and cognition clinic | 32 (76) | 12 (75) |
| Fall clinic | 28 (67) | 8 (50) |
| Continence clinic | 15 (36) | 3 (19) |
| Other | 17 (40) | 4 (25) |
| Remote or telehealth services (any) b | 32 (76) | 16 (100) |
| Phone | 22 (69) | 8 (50) |
| Videoconferencing | 30 (94) | 14 (88) |
| Other | 4 (13) | 2 (13) |
| Dementia‐specific services | ||
| Dementia support services | 27 (64) | 10 (63) |
| Dementia‐specific rehabilitation | 5 (12) | 2 (13) |
| Dementia education | 29 (69) | 9 (56) |
| Community | ||
| Home visits (any) b | 37 (88) | 14 (88) |
| Geriatrician | 33 (89) | 12 (86) |
| Aged care specialist nurse | 24 (65) | 8 (57) |
| Allied health | 24 (65) | 7 (50) |
| Other | 11 (30) | 3 (21) |
| Rehabilitation at home | 27 (64) | 8 (50) |
| Residential aged care facilities (RACF) | ||
| Outreach/Inreach to RACFs (any) b | 28 (67) | 9 (56) |
| Geriatrician | 27 (96) | 7 (78) |
| Nurse | 26 (93) | 8 (89) |
| Allied health | 3 (11) | 1 (11) |
| Other | 8 (29) | 2 (22) |
| Able to perform acute medical review within <24 h | 25 (89) | 6 (67) |
Not all participants responded to this question.
Denominator for percentages shown below is the number providing this category of service, not the total number of departments in the study.
3.2. Inpatient services
The majority of departments had inpatient services. Transfer from other teams was the leading admission source to inpatient geriatric beds, followed by the emergency department (ED). A larger proportion of departments in Australia (47%) compared to New Zealand (11%) reported the ED as the leading source of admission (Table 2). Within Australia, In NSW, the leading source of admission was the ED, while in Victoria, the leading source was transfers from other teams (Table 3). Overall, a relatively low proportion of services had geriatric medicine beds allocated within general medical wards and even fewer had shared care with general medicine.
3.3. Acute care
Around two‐thirds of services overall had acute inpatients admitted directly from ED, with more in Australia (74%) compared to New Zealand (44%) and more in metropolitan Australia (81%) compared to rural/regional Australia (56%) (Tables 2 and 4). There were a variety of admission policies.
The majority of departments (over four‐fifths) had an inpatient general medicine service present at their site, with a lower proportion in NSW (71%) compared to most other states in Australia (83%–100%; Table 3) and a higher proportion in rural/regional Australia (94%) compared to metropolitan Australia (79%) (Table 4). Most of these general medicine services admitted older patients with acute geriatric problems, with a higher proportion in New Zealand compared to Australia (Table 2).
3.4. Hospital subacute care and rehabilitation
The majority of services (around four‐fifths) provided inpatient bed‐based rehabilitation with fewer proportionally in Australia (72%) compared to New Zealand (100%). Fewer departments in Victoria compared to the other states had inpatient rehabilitation; however, all in Victoria had Geriatric Evaluation and Management (GEM) units. Around two‐thirds of services overall had GEM beds with fewer in New Zealand (44%) than Australia (71%) and fewer in NSW (43%) compared to most other states (Tables 2 and 3). Around 4 out of 10 services had a transitional care unit (TCU), which was more common in Victoria (92%) compared to most other states, as well as in rural/regional Australia (56%) compared to metropolitan Australia (38%) (Table 4).
3.5. Dementia/delirium behavioural management inpatient beds
Around half of services (53%) had inpatient beds allocated to the management of patients with behavioural symptoms related to dementia and/or delirium, with more in Australia (60%) compared to New Zealand (28%) (Table 2). Within Australia, Queensland had the highest proportion (73%) (Table 3) and rural/regional services had a higher proportion of these beds (75%) compared to metropolitan services (55%) (Table 4). These beds were primarily managed by geriatricians in most services other than in New Zealand.
The location of these beds varied. While they were mostly in a specialised inpatient unit (58% of departments which had those beds), a higher proportion (80%) of New Zealand departments had these beds located in a general geriatric medicine ward. However, the numbers in New Zealand were small. Queensland had the highest proportion of any Australian state of departments with beds located in a specialised inpatient unit (88% of relevant departments). Rural/regional Australia proportionally had a lower proportion of departments with beds located in a specialised inpatient unit compared to metropolitan Australia.
Around two‐thirds of departments had an associated psychogeriatrics service, with a higher proportion in New Zealand (83%) compared to Australia (62%). Within Australia, NSW had the highest proportion (71%) of such a service (Tables 2, 3, 4).
3.6. Stroke services
Overall, around half of all departments had any stroke service (55%), with more in New Zealand providing this compared to Australia (Table 2). Western Australia had the highest proportion of such services (83%) out of all Australian states (Table 3). A higher proportion (64%) of New Zealand departments provided stroke rehabilitation compared to Australia (43%).
3.7. Perioperative/orthogeriatric care
Proactive orthogeriatric care was offered by most (92%) departments (Table 2). Proactive perioperative care to non‐orthopaedic surgical services was offered in approximately a third of departments, with more in NSW (50%) than in other Australian states (Table 3), and more in metropolitan Australia (40%) than in rural/regional Australia (19%) (Table 4).
3.8. Hospital‐based outpatient services
Almost all departments (97%) offered outpatient clinics, and most (92%) offered a general geriatric clinic. A higher proportion of Australian compared to New Zealand departments provided the following speciality clinics: memory and cognition (76% vs. 39%), fall clinics (62% vs. 22%) and continence clinics (31% vs. 11%) but more New Zealand departments had osteoporosis clinics (39% vs. 17%) (Table 2). Within Australia, NSW had a higher proportion of departments with osteoporosis clinic (30%) than other states. Victoria had the highest proportion of departments with memory and cognition clinics (100%), fall clinics (100%) and continence clinics (91%) (Table 3).
Remote and telehealth services existed in most departments (78%), though fewer in New Zealand (61%) compared to Australia (83%) (Table 2) and more in rural/regional Australia (100%) compared to metropolitan Australia (76%) (Table 4). Of the departments that offered telehealth, around two‐thirds did so by phone (69%) and most did so by videoconferencing (88%).
3.9. Dementia‐specific services
Around two‐thirds of departments offered dementia support services, with around a quarter offering dementia‐specific rehabilitation. While over half of the departments provided dementia education, more provided this in Australia (66%) compared to New Zealand (28%) (Table 2).
3.10. Out‐of‐hospital services
3.10.1. Community
Almost all departments provided home visits. Of the departments providing home visits, most had a geriatrician providing home visits and around two‐thirds had an aged care specialist nurse providing them. More New Zealand departments had an aged care specialist nurse as part of this service (88%) compared to Australian departments (63%) (Table 2). A lower number of NSW departments had an aged care specialist nurse providing this service (38%) compared to other Australian states (Table 3). Around two‐thirds of departments provided rehabilitation at home, with a high proportion in Victoria (92%) compared to other Australian states.
3.10.2. Residential Aged Care Facilities (RACF)
Around 6 out of 10 services provided outreach/inreach to RACFs, with a lower proportion in New Zealand (44%) compared to Australia (64%) (Table 2), a high proportion in Victoria and Queensland (91% and 82% respectively) and a low proportion in Western Australia (17%) and in Tasmania (0%) (Table 3). Geriatricians and nurses were part of this service in most places. Of the departments offering inreach/outreach, 73% were able to respond to acute medical problems requiring review within 24 hours, with fewer proportionally in New Zealand (25%) compared to Australia (84%) and a high rate in Victoria and Queensland (90% and 100% respectively) compared to other Australian states.
3.10.3. Gaps in service provision
The most frequent gaps identified by HODs were acute geriatrics, surgical liaison services, a designated dementia/delirium behavioural management unit, geriatricians in emergency departments, outreach/inreach to residential care and shared care with some medical specialities. Increasing staff numbers and government policy change were the most frequently identified ways to address these gaps.
4. DISCUSSION
There are several key findings from our study. Almost all departments provide inpatient care and two‐thirds had patients admitted directly from the ED. There was no consistent admission policy for acute inpatients. At many sites, there is also a general medicine department that provides care for older adults, particularly in New Zealand and rural/regional Australia. Fewer New Zealand departments have acute inpatients beds compared to Australia, but a larger proportion have specific inpatient rehabilitation beds. In Australia, however, some inpatient rehabilitation is being conducted in GEM and TCU beds. New Zealand has a lower proportion of departments with inpatient beds specifically for dementia/delirium. Only around 30% of departments had a dedicated behavioural management unit. Most departments have proactive orthogeriatric care, confirming findings from previous research 13 ; however, only around a third of departments provide proactive perioperative care to non‐orthopaedics surgical units. Most departments have outpatient clinics and home visits and 6 out of 10 services provide outreach/inreach to RACFs.
While research on geriatric medicine services in Australia and New Zealand has been limited, studies to date suggest geriatric medicine services have substantially developed in the past 30 years. A government survey in 1993 of 942 Australian hospitals showed that geriatric medicine services mostly consisted of visiting care (consultative services), with only 6% of hospitals having an inpatient geriatric service, 14 while a survey in 2001 found that 22% of 778 Australian hospitals had an inpatient service. 8 It is difficult to compare our study directly to this 2001 survey as its participants were senior hospital administrators, and it targeted all hospitals. Our study however suggests that geriatric medicine services have expanded in terms of the types of services offered, given the breadth of services offered by departments surveyed in our study.
Within Australia, some regional variation exists. NSW has the highest proportion of departments with acute inpatient beds and patients admitted directly from ED. Victoria has the highest proportion of departments with GEM beds and transitional care unit beds. The differences likely reflect the historical differences in how geriatric medicine departments developed between the states. The pioneers of geriatric medicine in Sydney developed their services with a focus on acute medicine, while in Melbourne the focus was on subacute care. Victoria has the highest proportion of memory and cognition clinics, fall clinics and continence clinic. This is explained by the fact that Victoria Health has specifically funded speciality clinic services such as the Cognitive, Dementia and Memory Service Clinics (CDAMS). 15 Our findings confirm findings from a previous study from 2009 which suggested a variation in the distribution of geriatric services between states. 16 , 17
4.1. Strengths and limitations
Our study is the first to examine both hospital and out‐of‐hospital services in geriatric medicine departments across Australia and New Zealand. The response rate was high. The study included participants from all states across Australia and included hospitals with small to large geriatric medicine departments. The inclusion of co‐investigators from all states in Australia and from different parts of New Zealand assisted in this good response rate.
There is likely to be a degree of non‐response bias, although this is mitigated by the study's relatively high response rate. We did not verify the accuracy of respondents' answers. We did not quantify the size and reach of the services provided as we felt this more in‐depth understanding of services would be best explored in follow‐up interviews with HODs. Furthermore, our study does not capture geriatric medicine services provided in the private system. A different methodology would be required to capture this information.
We were not able to quantify the changes in geriatric medicine services over time as our survey used a different methodology to previous surveys.
4.2. Future steps/directions
Our study is descriptive rather than normative. It did not aim to define the best service provision possible but rather to describe the current state of services. It shows what services are possible and poses important questions for discussion: What are the best models of care that should be provided by public geriatric medicine departments in Australia and New Zealand? How can different places achieve the service provision they would like to achieve? Should there be more consistency in service provision across Australia and New Zealand? These core questions touch on the identity of geriatric medicine, advocacy for geriatric medicine services and equity of service provision.
The findings of our study can inform future service development and research about models of care of geriatric medicine in Australia and New Zealand. Our study should foster an exchange of ideas between departments about different models of care and inform the strategic direction of ANZSGM. The 2022–2024 ANZSGM strategic plan describes using the information from our study to stimulate discussions about models of care, advocate for the further development of geriatric medicine services and use the data during discussions with the various levels of government in Australia and New Zealand. 18 In the longer term, the data from this study can inform future service development and research about models of care of geriatric medicine in Australia and New Zealand.
5. CONCLUSIONS
Although many public geriatric medicine departments across Australia and New Zealand offer a wide breadth of services which have expanded in recent decades, geriatric medicine service provision is variable across both countries, with differences noted between the two countries, between states in Australia and between metropolitan and regional/rural Australia. Key gaps have been identified. This knowledge can inform discussions with different levels of government and the ongoing development of geriatric medicine models of care.
CONFLICT OF INTEREST STATEMENT
Prof Vasi Naganathan and Dr Janani Thillainadesan are associate editors and A/Prof Chris Moran is a member of the Management Committee of the Australasian Journal on Ageing. The other authors declare no conflict of interest.
ETHICS APPROVAL
Study protocol approved by the Sydney Local Health District Human Research Ethics Committee at Concord Hospital (HREC Approval Number: 2022/ETH00685).
Supporting information
Data S1.
ACKNOWLEDGEMENT
Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australian University Librarians.
Azarias E, Thillainadesan J, Hanger C, et al. Hospital and out‐of‐hospital services provided by public geriatric medicine departments in Australia and New Zealand. Australas J Ageing. 2024;43:748‐761. doi: 10.1111/ajag.13331
Footnotes
Department of Health. Victoria A. Geriatric Evaluation and Management. www.health.vic.gov.au. https://www.health.vic.gov.au/patient‐care/geriatric‐evaluation‐and‐management.
SLHD ‐ Balmain Hospital ‐Transition Care. www.slhd.nsw.gov.au. https://www.slhd.nsw.gov.au/balmain/OurServices_TransitionCare.html.
DATA AVAILABILITY STATEMENT
The data that supports the findings of this study are available in the supplementary material of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1.
Data Availability Statement
The data that supports the findings of this study are available in the supplementary material of this article.