AgedNCT06901167
Evaluation of a Residential In-Reach Program in Regional and Rural Australia
A study testing Residential In-Reach Program in people with Aged and Acute Disease, run by Monash University at 8 sites in Australia.
Trial summary
Residential In-Reach (RIR) programs are designed to provide responsive care for residents in residential aged care homes (RACH) with the aim of avoiding unnecessary hospital transfers. Read more about this study
- Who is it for?
- Ages 65 years and older
- Conditions the study is for
- Aged, Acute Disease
- What is being tested?
- Residential In-Reach Program
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 100 participants
- Where
- 8 sitesAustralia
- Study dates
- 1 May 2025to 30 Jun 2026
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 65 years and older
- All sexes
- No healthy volunteers
- Older adult
Who may be able to join
- Health services that have emergency departments and/or emergency care centres that admit residents from residential aged care homes (RACH)
- RACHs that do not currently have access to RIR programs
- health service staff who have been involved with the set-up and delivery of the RIR program,
- RACH staff who have experience of or accessing the RIR service for residents at least once,
- residents living at a RACH who has experienced receiving medical care from the RIR program and can provide informed consent, or a family member of the resident,
- general practitioners whose case load includes residents from RACHs.
Who cannot join
- RACHs that already have access to a RIR program will be excluded
Trial locations and contacts
8 sites in 1 country. Contact the study team or a site near you to ask about taking part.
Catherine Huggins contact
8 sites in 1 country
Australia8 sites, 8 recruiting
- Recruiting
East Grampians Health Service
Ararat, Victoria, 3377
Michele Colin, 61 03 5352 9300, michele.conlin@eghs.net.au
Michele Conlin
- Recruiting
Grampians Health
Ballarat, Victoria, 3350
Narelle Ryan, 61 0417 590 832, narelle.Ryan@gh.org.au
Narelle Ryan
- Recruiting
Beaufort and Skipton Health Service
Beaufort, Victoria, 3373
Andrea Flenley, 61 03 5349 1600, andreaf@bshs.org.au
- Recruiting
Central Highlands Rural Health
Daylesford, Victoria, 3460
Susan Jennings, 61 03 5321 6500, susan.jennings@chrh.org.au
- Recruiting
Maryborough District Health Service
Maryborough, Victoria, 3465
Debbie Rogers, 61 03 5461 0333, drogers@mdhs.vic.gov.au
- Recruiting
West Wimmera Health Service
Nhill, Victoria, 3418
Cheree Schneider, 61 03 5391 4222, Cheree.Schneider@wwhs.net.au
- Recruiting
East Wimmera Health Service
Saint Arnaud, Victoria, 3478
Genette Heslop, 61 03 5477 2100, genette.heslop@ewhs.org.au
- Recruiting
Rural Northwest Health
Warracknabeal, Victoria, 3393
Joseph Bermudo, 61 03 5396 1200, josph.bermudo@rnh.net.au
About this study
Official title: Evaluation of a Region-wide Residential In-Reach (RIR) Program in Regional and Rural Health Services: A Stepped-wedge Trial
Residential In-Reach (RIR) programs are designed to provide responsive care for residents in residential aged care homes (RACH) with the aim of avoiding unnecessary hospital transfers. The evidence for their clinical and cost-effectiveness and implementation has been established in urban settings, but there is a small amount of low-quality evidence for rural and regional settings. The Grampians Region Health Service Partnership Resi-In-Reach Redesign Committee will be implementing a new RIR program to be offered to all RACHs in the Grampians region, this project aims to evaluate the clinical and cost-effectiveness of this program, and its implementation in the rural and regional setting. A stepped-wedge trial will be conducted so that as the RIR program is gradually rolled-out across the region, outcomes can be compared in the same facilities across time and between different facilities. The primary outcome measure will be presentation to emergency departments and urgent care centres, and data will also be collected on other clinical outcomes and barriers and enablers of implementing the program. It is anticipated that there will be a reduction in hospital presentations, and a range of barriers and enablers unique to the rural and regional setting will emerge.
- Conditions
- Aged, Acute Disease
- Being tested
- Residential In-Reach Program
- Keywords
- stepped-wedge trial, residential aged care home, residential in reach, hospital avoidance
- Medical subject headings
- Acute Disease
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Residential In-Reach ProgramOther
All enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance).
| Study group | Role | What they receive |
|---|---|---|
| Residential-in-reach | Experimental | All enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance). Receives: Other: Residential In-Reach Program |
What is being measured
The primary outcome is the main question the study is designed to answer.
Rate of presentations from residential aged care homes to emergency departments and emergency care centres
Primary clinical effectiveness outcome
Collection schedule:
- Once at the end of the evaluation
- At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Measured: From enrolment to the end of the trial for 14 months
Secondary outcomes (9)
Days spent in hospital by aged care home resident
Secondary clinical effectiveness outcome
Collection schedule:
- Once at the end of the evaluation
- At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Measured: From enrolment to the end of the trial for 14 months
Location of mortality in hospital
Secondary clinical effectiveness outcome
Collection schedule:
- Once at the end of the evaluation
- At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
Measured: From enrolment to the end of the trial for 14 months
Number of barriers to residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Measured: From enrolment to 1 month after the end of the trial, for 15 months
Number of enablers to residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Measured: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported feasibility of the residential-in-reach program implementation
Secondary implementation outcome - collected once via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff).
Measured: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported acceptability of the residential in-reach program
Secondary implementation outcome - collected via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff, general practitioners, aged care home residents) after occasions of service on a monthly basis.
Measured: From enrolment to the end of the trial for 14 months
Stakeholder reported appropriateness of the residential in-reach program
Secondary implementation outcome - collected via semi-structured interviews with key stakeholders (health service staff, residential aged care home staff, general practitioners, aged care home residents) after occasions of service on a monthly basis.
Measured: From enrolment to the end of the trial for 14 months
Number of aged care staff who attend education sessions for the use of the residential in-reach program
Secondary implementation outcome - recorded attendance of education sessions for residential aged care home staff for the use of the residential in-reach program.
Measured: From enrolment to the end of the trial for 14 months
Number of adaptations made to the residential in-reach program
Secondary implementation outcome - documented adaptations made to the program during the trial period.
Measured: From enrolment to the end of the trial fo
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted28 Mar 2025
- Study start1 May 2025
- Primary completion31 May 2026 (estimated)
- Study completion30 Jun 2026 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (6)Papers the sponsor has linked to this study.
- Other trials for AgedStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Model description
- This will be a stepped-wedge trial, in which all enrolled facilities and participants will receive the same intervention, but the intervention roll-out will be conducted in a sequential manner based on a randomised order. During the 14 months of the trial, all facilities and participants will receive the same intervention, but for different lengths of time depending on the randomisation.
- Masking
- None (open label)
- Enrolment
- 100 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Monash University
- Sponsor type
- University, hospital or other
- Collaborators
- Deakin University
- Responsible party
- Sponsor
- Investigators
- Terry Haines, Principal investigator, Monash University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06901167
- Sponsor's protocol ID
- HREC/112397/GHSJOG-2025-462490
- Status last verified
- Mar 2025
- First submitted
- 4 Mar 2025
- Last updated
- 30 May 2025
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No: Individual participant data will not be analysed and reported on. Planned data management involves analysis and reporting of aggregated data from all participants from all sites.
Publications
Sunner C, Giles MT, Parker V, Dilworth S, Bantawa K, Kable A, Oldmeadow C, Foureur M. PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities. BMC Health Serv Res. 2020 Jul 20;20(1):672. doi: 10.1186/s12913-020-05539-1.
PubMed 32690008Sunner C, Giles MT, Kable A, Foureur M. Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study. J Clin Nurs. 2023 Aug;32(15-16):4694-4709. doi: 10.1111/jocn.16529. Epub 2022 Sep 8.
PubMed 36081333Lukin B, Fan LJ, Zhao JZ, Sun JD, Dingle K, Purtill R, Tapp S, Hou XY. Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia. World J Emerg Med. 2016;7(3):183-90. doi: 10.5847/wjem.j.1920-8642.2016.03.004.
PubMed 27547277Hullick C, Conway J, Hall A, Murdoch W, Cole J, Hewitt J, Oldmeadow C, Attia J. Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study. BMC Geriatr. 2022 Jan 10;22(1):40. doi: 10.1186/s12877-021-02703-y.
PubMed 35012480Haines TP, Palmer AJ, Tierney P, Si L, Robinson AL. A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial. Med J Aust. 2020 May;212(9):409-415. doi: 10.5694/mja2.50565. Epub 2020 Apr 1.
PubMed 32237279Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. Health Soc Care Deliv Res. 2023 Oct;11(18):1-130. doi: 10.3310/KLPW6338.
PubMed 37916580
Study at a glance
From the registry record, last updated by the sponsor on 30 May 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Evaluation of a Region-wide Residential In-Reach (RIR) Program in Regional and Rural Health Services: A Stepped-wedge Trial
- ClinicalTrials.gov ID
- NCT06901167
- Acronym / sponsor ID
- HREC/112397/GHSJOG-2025-462490
- Conditions
- Aged, Acute Disease
- Keywords
- stepped-wedge trial, residential aged care home, residential in reach, hospital avoidance
- Study type
- Interventional
- Recruitment status
- Recruiting
- Enrolment
- 100 participants (estimated)
- Lead sponsor
- Monash UniversityUniversity, hospital or other
- Collaborators
- Deakin University
- Study start
- 1 May 2025 (actual)
- Primary completion
- 31 May 2026 (estimated)
- Study completion
- 30 Jun 2026 (estimated)
- First posted
- 28 Mar 2025 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Residential In-Reach (RIR) programs are designed to provide responsive care for residents in residential aged care homes (RACH) with the aim of avoiding unnecessary hospital transfers. The evidence for their clinical and cost-effectiveness and implementation has been established in urban settings, but there is a small amount of low-quality evidence for rural and regional settings. The Grampians Region Health Service Partnership Resi-In-Reach Redesign Committee will be implementing a new RIR program to be offered to all RACHs in the Grampians region, this project aims to evaluate the clinical and cost-effectiveness of this program, and its implementation in the rural and regional setting. A stepped-wedge trial will be conducted so that as the RIR program is gradually rolled-out across the region, outcomes can be compared in the same facilities across time and between different facilities. The primary outcome measure will be presentation to emergency departments and urgent care centres, and data will also be collected on other clinical outcomes and barriers and enablers of implementing the program. It is anticipated that there will be a reduction in hospital presentations, and a range of barriers and enablers unique to the rural and regional setting will emerge.
Study design
- Primary purpose
- Health services research
- Allocation
- Not applicable
- Intervention model
- Single group
- Masking
- None (open label)
- Number of arms
- 1
- Model description
- This will be a stepped-wedge trial, in which all enrolled facilities and participants will receive the same intervention, but the intervention roll-out will be conducted in a sequential manner based on a randomised order. During the 14 months of the trial, all facilities and participants will receive the same intervention, but for different lengths of time depending on the randomisation.
| Arm | Type | Receives |
|---|---|---|
| Residential-in-reach | Experimental | Other: Residential In-Reach ProgramAll enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance). |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (6 listed)
- Health services that have emergency departments and/or emergency care centres that admit residents from residential aged care homes (RACH)
- RACHs that do not currently have access to RIR programs
- health service staff who have been involved with the set-up and delivery of the RIR program,
- RACH staff who have experience of or accessing the RIR service for residents at least once,
- residents living at a RACH who has experienced receiving medical care from the RIR program and can provide informed consent, or a family member of the resident,
Key exclusion criteria (1 listed)
- RACHs that already have access to a RIR program will be excluded
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Residential In-Reach ProgramAll enrolled residential aged care homes will be able to access the residential-in-reach (RIR) program intervention. The RIR program provides a consultation service from a central hospital to an aged care facility in the Grampians region in the state of Victoria, Australia. Aged care staff will make a telehealth referral to central hub, where a nurse practitioner will triage the patient and make recommendations (for example, monitor resident condition, more examples: comprehensive assessment for unwell residents, liaison with the General Practitioners for diagnosis and treatment plan, provide education and support to staff) or further referrals (for example, refer to geriatrician or call an ambulance). | Other | Residential-in-reach |
Primary outcome
Rate of presentations from residential aged care homes to emergency departments and emergency care centres
Time frame: From enrolment to the end of the trial for 14 months
Primary clinical effectiveness outcome Collection schedule: * Once at the end of the evaluation * At the level of each residential aged care home presentation to hospital each month Collection approach: Extraction from hospital records and extraction from residential aged care home systems
9 secondary outcomes
Days spent in hospital by aged care home resident
Time frame: From enrolment to the end of the trial for 14 months
Location of mortality in hospital
Time frame: From enrolment to the end of the trial for 14 months
Number of barriers to residential-in-reach program implementation
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Number of enablers to residential-in-reach program implementation
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported feasibility of the residential-in-reach program implementation
Time frame: From enrolment to 1 month after the end of the trial, for 15 months
Stakeholder reported acceptability of the residential in-reach program
Time frame: From enrolment to the end of the trial for 14 months
Stakeholder reported appropriateness of the residential in-reach program
Time frame: From enrolment to the end of the trial for 14 months
Number of aged care staff who attend education sessions for the use of the residential in-reach program
Time frame: From enrolment to the end of the trial for 14 months
Number of adaptations made to the residential in-reach program
Time frame: From enrolment to the end of the trial fo
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 30 May 2025.
- Background: PubMed 32690008Sunner C, Giles MT, Parker V, Dilworth S, Bantawa K, Kable A, Oldmeadow C, Foureur M. PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities. BMC Health Serv Res. 2020 Jul 20;20(1):672. doi: 10.1186/s12913-020-05539-1.
- Background: PubMed 36081333Sunner C, Giles MT, Kable A, Foureur M. Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study. J Clin Nurs. 2023 Aug;32(15-16):4694-4709. doi: 10.1111/jocn.16529. Epub 2022 Sep 8.
- Background: PubMed 27547277Lukin B, Fan LJ, Zhao JZ, Sun JD, Dingle K, Purtill R, Tapp S, Hou XY. Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia. World J Emerg Med. 2016;7(3):183-90. doi: 10.5847/wjem.j.1920-8642.2016.03.004.
- Background: PubMed 35012480Hullick C, Conway J, Hall A, Murdoch W, Cole J, Hewitt J, Oldmeadow C, Attia J. Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study. BMC Geriatr. 2022 Jan 10;22(1):40. doi: 10.1186/s12877-021-02703-y.
- Background: PubMed 32237279Haines TP, Palmer AJ, Tierney P, Si L, Robinson AL. A new model of care and in-house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial. Med J Aust. 2020 May;212(9):409-415. doi: 10.5694/mja2.50565. Epub 2020 Apr 1.
- Background: PubMed 37916580Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. Health Soc Care Deliv Res. 2023 Oct;11(18):1-130. doi: 10.3310/KLPW6338.
- Individual participant dataSharing planned: No. Individual participant data will not be analysed and reported on. Planned data management involves analysis and reporting of aggregated data from all participants from all sites.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Catherine Huggins contact
Terry Haines principal investigator
Monash University
8 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Residential In-Reach Program in people with Aged and Acute Disease, run by Monash University at 8 sites in Australia.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 6 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: looking for participants now, as of the sponsor's last update on 30 May 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 8 sites in Australia. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Dai Pu (61 03 9904 4004, debbie.pu@monash.edu), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Rate of presentations from residential aged care homes to emergency departments and emergency care centres (time frame: From enrolment to the end of the trial for 14 months). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT06901167, which also lists 6 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 30 May 2025; AzTrials last refreshed its copy on 7 Nov 2026.