Aged Care

Program Officer

Jason Phillips - ph1300 986 991  |  

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

Royal Commission into Aged Care Quality and Safety

Concurrent with the 2021-2022 Federal budget, the Federal government outlined its response to the final report from the Royal Commission into Aged Care Quality and Safety. The response is packaged into ‘five response pillars’ aimed at guiding reform and delivering a new aged care system that rebuilds trust, provides dignity and respect, and is supported by continued investment.

Government response to the final report recommendations
Royal Commission Reports
CESPHN Submissions

CESPHN provided two submissions to the Aged Care Royal Commisison: 

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

Advanced Care Planning

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

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.

Accessing Home and Residential Care services

The following services are available through the Australian Governments My Aged Care website.

The My Aged Care website is set up to help older Australians, their families and carers to get the support they need. To make a referral click here or call 1800 200 422  

My Aged Care resources

Residential aged care facility support


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

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

Palliative Care

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. 


Smartphone apps

Dementia care


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 and training for RACFs care workers and Family and Carers of people with Dementia

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 family and carers of people with dementia to improve the knoweledge and skills needed and provide high quality care for people with dementia.

Over a two year period between Jul 2019 and June 2021 the Dementia Education program has a target of delivering;

  • 70 Dementia education and training workshops to RACF staff and
  • 35 Dementia education and training workshops to family and carers of people with dementia.


Useful Links for carers

My Aged Care

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.


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.


Quality Improvement Activities 

75+ Health Assessments

The 75+ Health Assessment provides an opportunity to improve the health of your older patients while also generating extra income for your practice. Conducting the 75+ Health Assessments is a great  way to engage with your older practice population. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to intervention. 

How does the 75+ Health Assessment help my business? 

Completing 75+ Health Assessments helps to

  • Build relationships and trust with your older patients, which may help their loyalty to you or your practice and make them more likely to come back for their future care.
  • It is also likely that you will pick up on new health issues that need addressing, or existing conditions that are not being managed as well as they could be. This may lead to the patient being recalled to the practice for a GP Management Plan or a Mental Health Treatment Plan, which can improve the care of these patients and improve practice income.
  • Provide protected time for planning supports that may be required to; maintain a patients’ current level of independence and mobility, assist patients stay socially active within their community and
  • Provide protected time for Advanced care planning decisions.

Set up you Practice processes

Consider developing a practice policy and streamlining systems and processes within your practice.

           Helpful tips

  • Identify a team member who can identify eligible patients and recall them either using your clinical software or PEN / POLAR clinical audit Tool
  • Check with Provider Digital Access (PRODA) to see if patients have already had a 75+ Health Assessment billed in the last 12 months before recalling
  • Make sure your staff know the booking rules for health assessments - Time spent with the nurse and time spent with the GP
  • Make sure your GPs are aware of the correct item number to be billed and the billing rules
  • Review your practice current 75+ health assessment template and how it might be improved
  • Ensure your GPs and nurses know where to record advance care plans or directives in the practice software
  • Have a process to ensure patients are then put back on recall in 12 months for another assessment
  • Regularly complete data cleansing activities to establish up to date lists (registers) of eligible patients due for the 75+ years health assessment
  • Measure the baseline improvement in the percentage of 75+ Health Assessments in your practice

Plan your 75+ Health Assessments

Health assessments work best if done in a planned way.  

Helpful tips

  • Consider using a Practice nurse. A practice nurse can conduct the majority of the 75+ Health Assessment and may have more flexibility than a GP to visit a patient at home. The patient must still see the GP to follow up on findings and recommendations and for the item to be billed. By seeing the patient in their own environment, you may be able to detect problems that may not be obvious in the consulting room.
  • Note: The patient can see the GP on a separate day, but processes need to be in place to alert the GP to complete and bill the assessment.
  • It is also important to note that the 75+ Health Assessment item cannot be billed in conjunction with another consultation on the same day, except where it is clinically required (for example the patient has an acute problem that needs to be managed separately from the assessment).

Medicare health assessment items

The below Medicare health assessment items can be claimed annually and include GP and Practice nurse time.


assessment lasting 30 minutes



assessment lasting 30-45 minutes



assessment lasting 45-60 minutes



assessment lasting 60 minutes


.For further information on 75+ Health assessments visit the Australian Government Department of Health 75+ Health Assessment webpage

Commissioned Services

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 a two year period between Jul 2019 - Jun 2021 the Dementia Education program aims to deliver;

  • 70 Dementia education and training workshops to RACF care staff and
  • 35 Dementia education and training workshops to family and carers of people with dementia.
Health and Wellbeing Programs
Exercise Classes and Health information for older adults
Find an exercise program

To find an exercise programs available in your local area that suit your needs visit the Active and Healthy website. The website is designed to provide a high-quality on-line directory of physical activity programs and evidence-based information for older people on the benefits of physical activity and ways in which you can increase your levels of physical activity and improve your strength and balance.

To search for a program in your area visit the Active and Healthy website  .

Healthy and Active for Life Online
What is Healthy and Active for Life Online?

Healthy and Active for Life Online is a FREE 10-week healthy lifestyle program for adults aged 60 years* and over. Each 10-week program begins at the start of the school term. It is designed for those looking to make lifestyle changes and get active.

How does it work?

The program is delivered online, in the comfort of your own home, by logging in to your online account where you complete the weekly healthy lifestyle modules and exercises videos.

To register and find out more about the Healthy and Active for Life Online program visit:


Stepping On
What is Stepping On?

The Stepping On program is a falls prevention program for over 65's that aims to reduce the incidence of falls in older people by teaching simple strength and balance exercises.The educational program promotes independence and builds confidence, with presentations by experts in their field, on topics relating to falls risk. The program is delivered over seven consecutive weeks followed by a booster session after two months. To learn more and register for the program contact your local stepping on coordinator via the below links. GPs and allied health professionals can access a referral form at these web links also.