Canterbury Cluster Manager
Kim - 8752 4954 | 

Sutherland Cluster Manager
Jason - 9330 9974 | 

Frailty increases dependence, hospital admissions, and accelerates the need to enter an aged care facility, with frail patients having 2-3 times the healthcare utilisation and associated costs of their non-frail counterparts. Information gained from a well-administered comprehensive geriatric assessment allows clinicians to implement a person-centred care plan, which can reduce functional decline, support independence and improve quality of life.

Optimised 75+ Health Assessment

For older people, wellness, enablement and restorative care approaches are emerging as powerful ways to help improve function and maintain independence and quality of life. General practice plays an important role in promoting and supporting healthy ageing within our community and is well placed to identify older people who could benefit from these approaches. Furthermore, contemporary models of care focus increasingly on understanding what really matters to the older person in combination with managing disease risks.

CESPHN’s new Optimised 75+ Health Assessment template incorporates a person-centred approach and objective assessments that support early detection and management of functional and cognitive decline. The template offers a user-friendly and comprehensive format that aims to achieve better outcomes for older people. Importantly the optimised Health Assessment has the potential to avert a health crisis that can result in emergency department presentation and hospitalisation.

Optimised 75+ Health Assessment templates 
PDFWordBest PracticeMedical Director 
document pdf text Microsoft Word document download Best Practice template download Medical Director template download

Benefits of using the new Optimised 75+ Health Assessment:

  • Simple and easy to use
  • Designed by a GP with expertise in frailty and reviewed by local GPs and practice nurses
  • Added frailty dimensions for early detection of physical and cognitive decline
  • Improved checklists to support the management of older people and avoid potentially preventable hospitalisation
  • Assists development of care plans that incorporate what really matters to older people (focus on wellness optimisation)
  • Supports older people to live as safely and independently as possible
  • Integration with local referral pathways
  • Improves overall documentation of care needs/alerts for older people.
Assistance to identify ‘At-Risk’ older patients in your practice

Central and Eastern Sydney PHN can assist you to:

  1. Extract information from your clinical software to identify ‘at risk’ community-dwelling patients aged 75 years and older that were seen in last 6 months, take 8+ medications, and diagnosed with one or more of the following diagnoses (dementia, heart failure, COPD, stroke, CKD or depression).
  2. Generate a de-identified report that describes key characteristics of patients aged 75 years and older such as:
  • Percentage who had a 75+ health assessment in the past 12 months;
  • Percentage who take 8+ medications;
  • Percentage who had a Home Medicine Review in the past 12 months;
  • Percentage who had their Body Mass Index checked in the past 6 months.

For further information please contact Kim Sherman or Jason Phillips on 1300 986 991.

Frailty resources

The Staying Well at Home project has commissioned a suite of quality improvement (QI) activities to address this emerging field of medicine. The first of these activities were two continuing professional development (CPD) events hosted in the Sutherland and Canterbury areas in November to raise awareness of the role of the over 75 health assessment in identifying early signs of decline and informing a tailored care plan. Local geriatricians co-presented at both events, which attracted a range of health professionals, representing the team care approach that is necessary to manage frailty issues. To access the recording of the Frailty CPD please follow this link: