Silverchain’s approach to innovation, enabling technologies and new research is strengthening the intersection between general practice and health and aged care sectors, within home care. A strong and connected primary and community care system is key to improving consumers’ health outcomes and experience as well as delivering on avoidable emergency department presentations and hospital admissions.
Silverchain recently presented at the Royal Australian College of General Practice’s annual conference recently in Perth, Western Australia.
Most care can and should be provided in the community - provided it is safe to do so and funded appropriately. We believe that better coordinated care within the community will help reduce the health system challenges that are being experienced nationally.
We believe the role of GP as a consultant-partner is crucial for the future of Australian health and aged care services - especially for older Australians - and for anyone with chronic and complex care needs.
Silverchain’s approach to care
At Silverchain, we often work at the intersection of health and aged care services, but we care for people of all ages. Our clients’ journeys have a number of different starting points. Older people may come in through the front door of My Aged Care to our aged care services. We also accept referrals from hospitals or emergency departments to our Home Hospital, subacute and post discharge services. People of all ages are also be referred to us by their GP for acute hospital in the home care, palliative care or care for their chronic conditions.
We also deliver allied health care, chronic disease education and support, medication management services, continence management, home oxygen and respiratory services, and paediatrics services.
We are accredited to the Aged Care Quality Standards, and the National Safety and Quality Health Service Standards, and our clinical teams can deliver acute, subacute, palliative and chronic and complex care. At Silverchain, we think about in home care as far and beyond domestic or personal aged care services, and we maintain close oversight and governance over the clinical quality of our care. We are experienced providers of aged care services, and our teams aim to work closely with providers outside of Silverchain, such as GPs, and their practice nurses and teams.
Wound management is the largest core service delivered by our nursing teams. We have a strong focus on research into wound care and our program is internationally recognised. It is also Australia’s largest program by volume.
Silverchain’s registered and enrolled nurses manage more than 56,000 wounds in partnership with 24,000 clients. Of these wounds, 78% (more than 38,000) of all wounds, from all our services, were discharged either healed or nearly healed, to a point where patients could manage by themselves.
Silverchain’s acute care, subacute and post discharge services are designed to help our patients recover faster, avoid hospital-acquired complications, and receive care in their preferred place - their home.
Our experienced doctors and nurses oversee and manage the care of Home Hospital patients and most of our Home Hospital doctors are GPs who combine working with us, while still working in general practices.
We provide a wide range of services:
- iron infusions
- management of blood thinners for surgical bridging; commencement or switching from subcutaneous to oral etc
- intravenous, intramuscular and subcutaneous antibiotics particularly for the management of conditions such pneumonia, urinary tract infections, chest, and bone infections, bacterial endocarditis, syphilis, mastitis, cellulitis etc
- rehydration therapy and care of hyperemesis gravidarum
- wound and drain care, catheter and Percutaneous Endoscopic Gastrostomy tube management.
In South Australia, RDNS Silverchain also delivers a unique service in the home, delivering blood and blood product transfusions (from 100-140 per month). Patient satisfaction with the blood and blood product transfusion service is very high. RDNS Silverchain has been delivering this service for almost 10 years.
Silverchain's client journeys
At Silverchain, our care operates at the intersection of health and aged services, often involving transitions between hospital stays and in home care. We thoroughly review all referrals for complex in home care to ensure we can deliver safe care, acknowledging that the referrals are growing increasingly complex due to pressures on the health care system.
As specialist generalists, GPs play a pivotal role in coordinating the intricate health care needs of older patients, especially those in aged care. According to the 2024 Productivity Commission report, approximately 1.5 million Australians receive government-funded aged care services annually, with many facing multi-morbidity and cognitive impairments.
Research from the Registry of Senior Australians (ROSA) highlights that once older individuals enter long-term residential care, there is often inadequate use of primary and specialty health care services, despite their complex needs.
ROSA data also indicates that patients with strong continuity of care from their usual GP experience fewer hospitalisations, emergency department visits, and lower mortality rates. Those accessing preventative care with their GP see a 17% reduction in mortality and significant decreases in hospitalisations.
GPs also feel constrained by the MBS and funding systems, which do not adequately support the delivery of complex aged care in the home especially outside of business hours. Currently only 10% of GPs now spend time in residential aged care facilities.
At Silverchain, we believe that providing significant levels of acute and complex care at home is the future of health care. This approach is essential for alleviating pressure on the health system and should be increasingly led by GP consultants within metropolitan centres (noting this already occurs in many rural regions).
Innovation and Technology at Silverchain
Silverchain has invested in research and innovation to enhance in home care delivery. With funding from a Medical Research Future Fund grant, we are piloting a new screening model for mental health issues among older adults living at home, marking a first for this demographic.
We are also integrating ConsultMed, an Australian digital health referral platform, to streamline referrals for GPs and other referrers, improving access to community-based care and enhancing information integrity while reducing cybersecurity risks.
Following a successful pilot, we are also implementing smart glasses technology in our services. This allows for real-time clinical support and competency assessments while minimising travel, exposure risks, and enhancing the quality of care delivered in the home. Additionally, we have adopted virtual double checks for blood transfusions and high risk medications which significantly improves efficiency.
The power of partnership
Silverchain aims to partner with General Practice to enhance primary and community care systems for our communities. GPs face increasing complexity in patient care, particularly with multi-morbidity and mental health issues, as highlighted by the RACGP Health of the Nation 2024 report, which indicates that 70% of GPs feel their workload is related to mental health and access challenges.
Recognising that General Practices may not always be able to meet all community needs, Silverchain offers an integrated care model that complements GP services, providing support to patients in their homes when safe and appropriate. Our co-design approach ensures that our services add value to GP care without duplicating efforts.
Silverchain can assist with specialised care, such as palliative support, offering access to teams who can operate effectively in patients' homes under the guidance of GPs but with specialist palliative support available if needed.
The Federal Government's new Support at Home program presents an opportunity for enhanced partnerships in home health care, particularly for end-of-life care.
We envision in home care as a vital support system for older Australians, creating a virtual ‘hospital’ that integrates general practice with other health care providers. By collaborating, we can transform our collective strengths into valuable support for patients, enhancing continuity of care and improving outcomes.
Silverchain can act as a support team for GPs, monitoring patients at home and identifying issues early. Our commitment is to enhance, not diminish, the role of GPs, as we work together to build a better in home care system for all Australians.
