Aged Care
Program Officer
Jason Phillips - ph1300 986 991 | j.phillips@cesphn.com.au
Objective: Central and Eastern Sydney PHN works to improve access to high quality primary healthcare for older people, including residents of residential aged care facilities and older people living in the community.
Approximately 224,000 people, or 14 per cent of people in our region are aged 65 years and over. This number is predicted to increase a further 43% to 320,000 by 2031. To support the health needs of our older people, Central and Eastern Sydney PHN are providing a number of programs and initiatives focused on improving access to high quality primary healthcare.
For aged care clinical and referral pathways and resources, please view Sydney Healthpathways and South East Sydney Healthpathways
Royal Commission into Aged Care Quality and Safety
In August 2019, 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 will help shape better services for older people now and in the future.
Submissions
Below are links to the latest submissions:
The Royal Commission into Aged Care Quality and Safety released its three-volume Interim Report ‘Neglect’ on Thursday 31 October 2019. To read CESPHN’s summary of this report pdf Click here (197 KB) .
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.
NSW Ageing and Disability Abuse Helpline
The abuse of older people is a globally recognised issue that is increasingly becoming more prevalent. Research suggests that as many as 50,000 older people in NSW may have experienced some form of abuse and only one in five cases is reported. In the majority of cases the alledged abusers of older people turn out to be trusted family members, neighbours and paid carers. A range of tools exist to help better understand how to prevent abuse, neglect and exploitation.
- Suspected abuse can be reported through the Ageing and Disability Helpline 1800 628 221 (Mon - Fri 9-5)
Elder Abuse resources
- NSW Ageing and Disability Commission
- NSW Elder abuse toolkit
- Elder abuse suspicion index for health professionals
- Elder abuse - video for health professionals
- Aged Care Quality and Safety Commission
Advanced Care Planning
Central and Eastern Sydney PHN is working with GPs, nurses, practice managers and RACFs to embed Advance care planning in General practice. Starting discussions early when patients are still relatively well, avoids people missing out on the opportunity to plan for their future care.
The Advance Project
The Advance Project is a free evidence-based toolkit and training package funded by the Australian Governement Department of Health, designed to support GPs, nurses, and practice managers to initiate advance care planning conversations. Training consists of three different online training activities. All resources can be found at:
Other resources
- Advanced Care Plans and the law
- NSW Ministry of Health Advance Care Directive Form and Booklet
- NSW Government tools to assist planning
- NSW Government Attorney General's guide to assessing capacity
- Advance care planning for end of life for people with mental illness
- RACGP Advanced care planning
- Advanced Care Planning Australia
- Aboriginal and Torres Strait Islander discussion starter
- Aboriginal stories about Approaching the End of Life
- End of Life Directions for Aged Care (ELDAC)
- Dementia Australia - Start2Talk
- Working out what's right for you - discussion starter
- Sydney Local Health District (Advance Care Planning - My Wishes)
NSW Ambulance Authorised care plans
NSW Ambulance authorised care plans allow GPs and Specialist service providers to provide authorisation and direction to patient treatment that can be delivered by NSW Ambulance paramedics.
- Authorised Care Plans
- NSW Amulance Authorised Adult General Care Plan - Form
- NSW Ambulance Authorised Adult Palliative Care Plan - Form
- NSW Ambulance patient referrals to GPs
pdf
(278 KB) - NSW Ambulance bookings to ED
- pdf Point of care testing in NSW Ambulance (389 KB)
Accessing Home and Residential Care services
The following services are available through the Australian Governments My Aged Care website.
- Commonwealth Home Support Program (CHSP) (entry level services)
- Home Care Packages (higher level services)
- Retorative Care
- Transitional Care
- Respite
- Residential Accomodation
My Aged Care resources
Residential aged care facility support
Central and Eastern Sydney PHN provides funding and support to various Geriatric Flying Squads and Outreach Services operated by partner Local Health Districts and Hospital Networks. These services are intended to reduce the need for transfer to hospital by managing residents at their facility.
RACF Outreach services
Geriatric Flying Squads (GFS) and RACF Outreach service contact details
- Sutherland Shire Catchment area - Southcare GFS - 9540 7956
- St George GFS - 9113 3999 - Referrals pdf Form (647 KB) and GFS pdf flyer (210 KB)
- pdf (210 KB) War Memorial Hospital GFS - 9369 0400: WMF-GFS RACF pdf Flyer (373 KB)
- SLHD Outreach Program - 1300 722 276 : pdf Access Care Team Flyer (486 KB) , pdf RACF Outreach (803 KB)
RACF Clinical handover tool - Yellow envelope
Central and Eastern Sydney PHN has developed a Clinical handover tool (Yellow envelope) in collaboration with Local Health Districts partners and in consultation with RACF managers, for utilisation in transfer of residents from RACFs and hospitals. The purpose of the envelope is to improve the quality of clinical handover by ensuring critical resident information is communicated in writing during resident transfers.
CESPHN provides these envelopes to RACFs at no cost. If you require more envelopes, please contact the Jason Phillips at j.phillips@cesphn.com.au
Palliative Care
CESPHN is working with public and private providers including GPs and RACFs to improve access to safe quality palliative care. Program activities include supporting patient preferences for end of life care in their preferred location, integrating care between different existing services and service providers and enhancing confidence of GPs and RACFs staff to support patients with their palliative end of life care needs in their preferred location.
Resources
- Palliative Care Australia
- Palliative Care NSW
- NSW Palliative Care After Hours Helpline - 1800 548 225
- palliAGED online resource providing evidence-based information, practice guidance and resources on end of life and palliative care for aged care.
- 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.
- Palliative Care Clinical Guidelines developed by Calvary Health Care Kogarah and local GPs
Smartphone apps
- palliAGED Apps for clinicians
Dementia
An estimated 460,000 Australians living with Dementia. This number is expected to increase to 590,000 by 2028, with costs expected to exceed 18.7 billion dollares per annum, by 2025. Despite no cure, lifestyle risk and protective factors for dementia offer opportunity and promise for prevention programs aimed at reducing the number of Australians developing dementia each year.
Dementia Education for RACFs and Carers
It is estimated 1.6 million people in Australia are involved in the care of someone with dementia, and more than half of all residents living in RACFs have a diagnosis of dementia. Central and Eastern Sydney PHN are working with local RACFs and carers of people with dementia to increase knoweledge, understanding and skills to address the management needs and provide high quality care for people with dementia.
Over the next two years the Dementia Education program will;
- Deliver 70 workshops to RACF staff and 35 workshops to carers within our region.
Resources
- Dementia Australia statistics
- CDPC Clinical Practice Guidelines and Principles for Care of People with Dementia
- CDPC Diagnosis, Treatment of Care for People with Dementia: Consumer Companion Guide
- Detecting Dementia in General Practice
- Clinical tools and resources
- Dementia Australia NSW
- Free Dementia Kit
- Aboriginal and Torres Strait Islander Dementia resources
- Antipsychotics and Dementia: Managing Medications
- pdf Eastern Sydney Dementia Directory of Services (904 KB)
- Eastern Sydney Dementia Assessment Services Pathway
- Dementia Behaviour Management Advisory Services (DBMAS)
- Dementia Enabling Environments Project (DEEP)
- pdf Creating Dementia Friendly Communities (287 KB)
-
pdf
What is a Dementia Friend
(339 KB)
- Driving and Dementia
Useful Links for carers
My Aged Care
My Aged Care is the national 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 including residential and respite care.
Information, assessment and system navigation
Central and Eastern Sydney PHN is working with providers to ensure consumers are viewed as active partners throughout their care journey. This includes being provided the right information and resources to be part of decision making processes.
Resources
- Link to online referrals
- How to make an online referral
- Appointment of a representative to assist decision making form
- My Aged Care assessment portal for health professionals
- My Aged Care Aboriginal and Torres Strait Islander resources
- My Aged Care resources for CALD people.
Supporting Independent Living and reducing Falls in CALD communities
Central and Eastern Sydney PHN are committed to preventing community falls. As part of this committment we are commissioning a capacity building falls prevention program targeting CALD populations within the CESPHN region experiencing service reach and access issues to traditional falls programs. Stay Standing is proving a powerful way to empower older people in CALD communities stay active, and improve their function and quality of life.
Over the next twelve months the program will;
- Deliver 26 Falls prevention programs to older people in CALD communities within our region
- Train 6 Stay Standing trainers from within local CALD communities to buid sustainable falls risk prevention.
Resources
.
Dementia Education
It is estimated 1.6 million people in Australia are involved in the care of someone with dementia, and more than half of all residents living in RACFs have a diagnsis of dementia. Central and Eastern Sydney PHN are working with local RACFs and carers of people with dementia to increase knoweledge, understanding and skills in the address the management needs and provide high quality care for people with dementia.
Over the next two years the Dementia Education program will;
- Deliver 70 workshops to RACF staff and 35 workshops to carers within our region.
Reducing Falls in CALD communities
Central and Eastern Sydney PHN are committed to preventing community falls. As part of this committment is commissioning a capacity building falls prevention program targeting CALD populations within the CESPHN identified as experiencing service reach and access issues to traditional falls programs. Stay Standing is proving a powerful way to empower older people in CALD communities stay active, and improve their function and quality of life.- Deliver 26 Falls prevention programs to older people in CALD communities within our region
- Train 6 Stay Standing trainers from within local CALD communities to buid sustainable falls risk prevention.
Telehealth Chronic disease management program for older people
Central and Eastern Sydney PHN are supporting the use of new and emerging telehealth technologies to benefit chronic disease management, coordination of care, and patient time and convenience. The 12 week Staying Healthy Living Well program is assisting older people with chronic conditions to better understand and self-manage their health conditions.