Residential aged care residents in regional Australia face persistent barriers to timely medical care. Specialist shortages, limited after-hours GP coverage and high staff turnover within facilities contribute to delayed clinical intervention, avoidable emergency department presentations and unplanned hospital admissions. These challenges are compounded by rising resident acuity and growing demand for complex, end-of-life and palliative care. Addressing these access gaps requires models of care that bring the right clinician to the resident at the right time, regardless of geography.

A national aged care service provider serving approximately 5,000 residents across 115 facilities has developed a hybrid model of care combining in-person GPs and dedicated practice nurses in each home with geriatricians, palliative care specialists and other specialists via telehealth, supported by a locum team for after-hours access. The model is designed around early intervention: approximately 85% of consults are demand-driven, responding to urgent and escalating care needs among unstable and end-of-life residents, with the remaining 15% focused on preventative and palliative care planning. A digital ticketing platform captures care needs from each facility’s nursing team, triages them against clinical guidelines and generates a draft round schedule for refinement by the clinical team.

The provider designed and implemented a Clinical Quality Register with data from 34 homes and 1,927 residents collected so far. Analysis of the first 6 months of this data shows that the care model delivered 22% fewer ED presentations, 67% fewer hospitalisations and 17% lower medication usage compared to published national benchmarks (AIHW). This amounts to over $8,000 per resident in healthcare system cost savings (primarily through reduced demand for hospital beds). These results suggest that a structured, team-based shared care with embedded specialist access can materially reduce acute care utilisation for aged care residents.

The model is now operating at scale, with approximately 85% of residents served residing within regional Primary Health Network catchments. By distributing clinical responsibility across a multidisciplinary team and ensuring consistent after-hours coverage, the model also supports GP retention in aged care – addressing one of the sector’s most pressing workforce challenges. As demand for residential aged care continues to grow, hybrid models that combine in-person and telehealth care offer better clinical outcomes for residents at scale, reduced healthcare system cost and an equitable approach to closing the gap between regional and metropolitan standards of clinical care.