GSTF Journal of Nursing and Health Care (JNHC)

, 3:7

First online:

Open Access This content is freely available online to anyone, anywhere at any time.

Exploring the Ambulatory Transitional Care Experience from Residential Aged Care Facilities (RACF) to Ambulatory Care Services

  • Anthony Paul O’BrienAffiliated withUniversity of Newcastle
  • , Michelle GilesAffiliated withNursing and Midwifery Research Centre
  • , Lisa CorbettAffiliated withRoyal Newcastle Centre
  • , Sushilla WagenerAffiliated withRoyal Newcastle Centre
  • , Linda RossAffiliated withRoyal Newcastle Centre
  • , Kamana BantawaAffiliated withNursing and Midwifery Research Centre
  • , Kerry CooperAffiliated withJohn Hunter Hospital
  • , Darran PaulAffiliated withQuakers Hill Nursing Home
  • , Deborah BarnesAffiliated withRoyal Newcastle Centre
    • , Karen McNeilAffiliated withNursing and Midwifery Research Centre



To explore the transitional care journey through Ambulatory care Services (ACS) for older residents from Residential Aged Care Facilities (RACF). To develop a clearer understanding of older residents needs and any gaps in current services provided; and to inform the development of a model of care to improve the resident’s transitional care journey.

Study Design:

A qualitative project design using extensive stakeholder engagement


The Ambulatory Care (AC) experience was explored through semi-structured interviews with residents and their carers to determine gaps in transitional care continuity. Focus groups with RACF and ACS staff were also utilized. Journey mapping was used to support anecdotal evidence.


Three residents and 2 carers were interviewed and a total of 40 RACF and ACS staff attended 5 focus groups. Principal Findings: Qualitative data analysis identified four main themes across the transition journey:

  • Inconsistent and adhoc communication;

  • Just waiting around;

  • Is it doing more harm than good?; and

  • Unmet expectations.


The results of this study have highlighted shortcomings in the provision of quality care in this transitional care group of older clients. A collaborative approach across organizational boundaries is necessary to ensure the development of an integrated person centered model to ensure the best transition to ambulatory care for RACF residents exists.


Qualitative research ambulatory care outpatient clinics Residential Aged Care transitional care