Staying with regular GP in aged care reduces risk of ED visits and death

A recent study has found that older Australians entering residential aged care have better health outcomes when they continue seeing their regular GP, including fewer hospital visits and lower premature mortality.

The national study, led by the South Australian Health and Medical Research Institute's (SAHMRI) Registry of Senior Australians (ROSA) Research Group, analysed the health outcomes of more than 330,000 residents across 3,000 aged care facilities.

Published in Age and Ageing, it is the first national evaluation to quantify how continuity of primary care affects people transitioning into long‑term care.

ROSA Principal Investigator Professor Gill Caughey said older Australians in residential care have struggled with fragmented services for too long.

“Our study shows that when residents maintain a consistent relationship with their GP, their risk of hospitalisation and even death goes down,” she said.

“For too long, older Australians in residential care have struggled with fragmented services and a revolving door of providers.”

The study revealed that only 17 per cent of aged care residents were able to continue visiting their regular GP after entering care – a figure researchers say reflects structural barriers such as workforce shortages, limited on‑site services and the difficulty of coordinating care across multiple providers.

Compared to aged care residents who began seeing a new GP, those who stayed with the same doctor experienced:

• Eight per cent fewer emergency department presentations
• Six per cent fewer unplanned hospitalisations
• 11 per cent fewer fall‑related hospitalisations
• 21 per cent fewer dementia‑related hospitalisations.

“This is about more than just GPs. Podiatrists, optometrists, pharmacists and nurse practitioners all play a critical role. Together, they help residents stay healthier for longer and reduce unnecessary pressure on hospitals,” Professor Caughey said.

The research also found that residents receiving preventive health checks, management plans and allied health services had around nine per cent lower mortality than those receiving reactive, crisis‑driven care.

Access to optometric services, podiatry and comprehensive medication reviews were all associated with a lower risk of premature death.

Nurse practitioner attendances had the widest impact on health outcomes, including a lower risk of ED presentations, potentially preventable hospitalisations, unplanned hospitalisations, and falls and fractures.

Researchers say this highlights the value of advanced clinical decision‑making within facilities, particularly as the aged care workforce continues to face shortages.

The findings also reinforce long‑standing concerns raised in the Royal Commission into Aged Care Quality and Safety, which identified poor clinical integration as a major contributor to avoidable harm.

The ROSA team argues that continuity of care should be treated as a core safety measure, not an optional extra.

Wider economic benefit

Beyond individual health outcomes, the study also shows that prioritising continuity of primary care for older people entering residential aged care may have system‑wide benefits.

“Given the substantial costs associated with outcomes such as ED presentations and unplanned hospitalisations, our findings also have potential economic implications for aged‑care and health‑system planning,” the study said.

The authors said that better integration between aged care and primary care could reduce avoidable hospital demand, improve quality of life and support a more sustainable system.

“Future long‑term care facility standards should include shared clinical governance with primary health care, driven by care plans codeveloped between sectors.

“Investments to support better clinical care integration between long‑term care facilities and primary care can significantly affect the experiences of residents.”

ROSA is urging governments to invest in the continuity of care for older Australians entering LTC, and to make “proactive, team-based models the norm in aged care.”