Aged Care


Program Officer

Jason Phillips - 

1300 986 991

The Aged Care Team's role is to support and co-ordinate services for older people living in the community and those living in Residential Aged Care Facilities (RACF), CESPHN works closely with and supports general practitioners (GPs), allied health professionals (AHPs), Sydney Local Health District (SLHD), South Eastern Sydney Local Health District (SESLHD) and other health networks to improve the availability of health services for our ageing population.


Royal Commission into Aged Care Quality and Safety

Central and Eastern Sydney PHN has provided a submission to reflect the thoughts and opinions of the primary care sector across the Central and Eastern Sydney PHN region, including people working in residential aged care facilities. Central and Eastern Sydney PHN would like to thank those who provided feedback. The feedback is important and greatly helped to shape the submission which will contribute to making services better for older people now and in the future. To view the submission, click here

The Royal Commission into Aged Care Quality and Safety released its three-volume Interim Report ‘Neglect’ on Thursday 31 October 2019.

  pdf Click here (197 KB) to read CESPHN’s summary of this report. 

The Royal Commission heard compelling evidence that the “aged care system designed to care for older Australians is woefully inadequate. Many people receiving aged care services have their basic human rights denied. Their dignity is not respected and their identity is ignored. It most certainly is not a full life. It is a shocking tale of neglect. The neglect that we have found in this Royal Commission to date is far from the best that can be done. Rather, it is a sad and shocking system that diminishes Australia as a nation."

The Commission’s  interim report calls for urgent action to address significant issues in three key areas:

  • Access to home care support packages
  • The use of chemical and physical restraint 
  • Younger people with disability going into residential aged care.

In 2020, CESPHN will engage in strategic conversations with all service providers in our region to promote greater access to high quality care for older people.


Advance Care Planning

What is advance care planning?

Advance Care Planning (ACP) involves a patient thinking about and communicating to tohers how they would like to be treated in the future if they have a condition where they can no longer speak for themselves. This may happen, for example, as a result of stroke, progressive dementia, or becoming unconscious from some form of accident or illness.

An Advance Care Directive (ACD) is a component of an Advance Care Plan and contains information relevant to specific areas of healthcare and the values and wishes of an individual which would be expected to impact on treatment options. Numerous directives have been developed by a variety of organisations to meet the needs of our diverse population. Indeed, any written and recorded statement of wishes is legally vinding. Endorsement by a medical practitioner is recommended but not essential.

Why advanced care planning is important

Understaking ACP means that the future decisions about a person's care are more likely to reflect their wishes. ACP identifies sensitive issues and clarifies the actions an individual would prefer in certain medical situations should they occur in the future. For many reasons these topics of discussion between family, carers and GPs are often avoided. Having an ACP means other people will not have to make decisions on a person's behalf without an appreciation of that person's feelings or wishes. It also reduces the likelihood of confusion and conflict regarding decisions of care between all parties involved. With an ACP in place a person can feel comfortable and reassured that there will be a common and calm approach to their care toward end-of-life.

Dr Peter Saul John Hunter Hospital explains the 5 steps for Advance Care Planning

Dr Dimity Pons speaks about how ACP can assist health professionals

What does ACP involve for GPs?

The role of GPs in advance care planning may include:

  • discussing the idea of advance care planning with patients/residents
  • assessing capacity of patient/resident to appoint a representative and complete an advance care plan
  • providing patients/residents with information regarding their current health status, prognosis and future treatment options
  • witnessing or completing instructional directives where appropriate
  • applying patients'/resident's wishes to medical management

NSW Health


  • palliAGED is an online resource providing evidence-based information, practice guidance and resources on end of life and palliative care for aged care. Includes the palliAGED Apps for clinicians to provide support at the point of care for advanced care planning, case management and symptoms and medicines related to end of life and palliative care issues.

Other Resources


Carer Gateway is a national online and phone service that provides practical information and resources to support carers while the interative service finder helps carers connect to local support services. The contact centre does not collect personal information nor does it assess callers for a service.

Free call 1800 422 737 for support and advice Monday to Friday 8am to 6pm.

For information in other languages, click here.

NSW Ambulance Authorised Care Plans/protocol update

NSW Ambulance paramedic protocols have recently been updated and changes initiated. These changes will benefit and streamline patient care through greater collaboration with local health care providers, primarily the patients' General Practitioner (GP).


Dementia is the term used to describe the symptoms of a large group of illnesses which cause a progressive decline in a person's functioning. It is a broad term used to describe a loss of memory, intellect, rationality, social skills and physical functioning. There are many types of Dementia including Alzheimer's disease, bascular dementia, frontotemporal dementia and dementia with Lewy Bodies. Dementia can happen to anybody, but it's more common after the age of 65.

Key facts and statistics 2017

  • Dementia is the second leading cause of death in Australia and there is no cure
  • Dementia is the single greatest cause of disability in older Australians (aged 65 years or older) and the third leading cause of disability burden overall.
  • By 2025, the total cost of dementia is predicted to increase to $18.7 billion in today's dollars, and by 2056, to over $36.8 billion, which represents a 2.6 fold increase in costs from 2016.
  • The lifestyle risk and protective factors for dementia offer very real opportunities for prevention programs that reduce the number of  Australians developing  dementia each year.


NSW Elder Abuse Helpline and Resource Unit

The abuse of older people is a globally recognised issue that is becoming more prevalent. Research suggests that as many as 50,000 older people in NSW may have experienced some form of abuse and it is estimated that only one in five cases of elder abuse is reported. The majority of alledged abusers are trusted family members, neighbours or paid carers.

My Aged Care

My Aged Care is a key feature of the Commonwealth Government's reform of the aged care system which came about following release of the Productivity Commission Inquiry report 'Caring for older Australians' (2011). One of the Commission recommendations is that consumers be viewed as active partners throughout the care journey and be part of decision making processes and be providedthe resources and information to do so.

My Aged Care was implemented as a national, clear entry point of access for Aged Care services and information. It consists of the My Aged Care website and contact centre (1800 200 422). Both provide information and referrals for clients and their carers to be assessed for Aged Care services such as domestic assistance, personal care, nursing, home maintenance and modifications; and residential and respite care.

As part of ongoing refinements to the My Aged Care portal, a referral web form was introduced. Health practitioners should complete online referrals which are sent directly ro wither the Regional Assessment Service (RAS) for entry level support services or the Aged Care Assessment Term (ACAT) for those with higher care needs. The link to online referrals is here, with a video explaining how to make an online referral.

  • An updated fact sheet for General Practioners explaining the June 2016 changes including information about urgent referrals. Changes were implemented in July 2017 to better support clients with diverse needs and improve access to information for health professionals. There is now a clearer approach about who can speak on a client's behalf and a client now has more flexibility to appoint a regular representative to assist with decision making.
  • Appointment of a representative form
  • Health professionals now have improved access to information affecting their patients which enables them to follow-up on referrals and add information if needed. It is also possible to access information from My Aged Care assessors regarding implementation of services.

New Aboriginal and Torres Strait Islander resources on My Aged Care

  • Here you will find resources specifically for Aboriginal and Torres Strait Islander people, including translated materials. They can be viewed or downloaded from the My Aged Care website.
  • There is also a video for Aboriginal and Torres Strait Islander audiences on the My Aged Care website, which provides an overview of My Aged Care, including the services available and how to access them.
  • My Aged Care resources for CALD people.
Residential Aged Care Facility Support

CESPHN supports the various Geriatric Flying Squads and Outreach Services that are operated by Local Health Districts. These  services are intended to reduce the need for transfer to hospital by managing residents at their facility.

Geriatric Flying Squads (GFS) and other outreach services contact details

  1. Sutherland Shire Catchment area - Southcare GFS - 9540 7956
  2. St George GFS - 9113 3999 - Referrals pdf Form (647 KB) and GFS  pdf flyer (210 KB)
  3. War Memorial Hospital GFS - 9369 0400: WMF-GFS RACF pdf Flyer (266 KB)  April 2016
  4. pdf GFS Services (373 KB)
  5. SLHD Nurse Practitioner Outreach Program - 1300 722 276 :  pdf Access Care Team Flyer (486 KB) , pdf RACF Outreach (803 KB)
  6. NSW Ambulance Fact Sheet

Regional Medication Advisory Committee (RMAC)

The Regional Medication and Advisory Committee (RMAC) is a committee inclusive of a broad membership of Aged Care Specialists, GPs, Executive Staff of RACFs and Allied Health Professionals and is currently conducted in the Sutherland Shire and St George regions. The RMAC allows for a multidiscriplinary approach where members can participate in problem solving and local development of Aged Care policy and procedures to do with medication management in RACFs. RMAC meetings are held quarterly. The St George meeting at CESPHN Kogarah and the Sutherland meeting in Sylvania. Contact Lucy Armstrong on 9330 9980 for more information.

Transfer to Hospital Clinical Information Handover Tool - Yellow Envelope

CESPHN has developed a clinical information handover envelope in collaboration with Local Health Districts and through consultation with Residential Aged Care Management to be utilised between RACFs and hospitals. The purpose of the envelope is to improve the safety of residents during their transfer, assessment, treatment and discharge from hospital. Audits have shown that critical resident information is often lost or not communicated in writing during resident transfers. Poor communications can contribute to poor health outcomes.

CESPHN provides these envelopes to RACFs at no cost to the facility. If you require more envelopes, please contact the Aged Care Team

Palliative Care

According to the World Health Organisation, Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccible assessment and treatment of pain and other problems, physical, psychosocial and spiritual.


  • palliAGED is an online resource providing evidence-based information, practice guidance and resources on end of life and palliative care for aged care. Includes the palliAGED Apps for clinicians to provide support at the point of care for advanced care planning, case management and symptoms and medicines related to end of life and palliative care issues.
  • CareSearch provides evidence-based end of life and palliative care information and resources for health professionals and patients carers and families to enable informed decision making and quality care across the life span and health care system.
Restorative/Wellness approaches to Care

Wellness, reablement amd restorative approaches are emerging as powerful ways to help older people improve their function, independence and quality of life. The following fit the short-term approaches to improving functioning and wellbeing.

The Active and Healthy website links community members and health professionals to resources and programs on staying active and living a healthy lifestyle. There is a focus on falls prevention activities with the Staying Active on your feet downloadable booklet providing consumers with information and ideas on ways to reduce their risk of falling.

Falls Prevention

The Stepping On through LHDs program offers older people a way to reduce the incidence of falls and to build confidence to manage situations where they are at risk of falling. The program is delivered over seven consecutive weeks followed by a booster session after two months.

SESLHD Stepping On