Aged Care

Program Officers

Collette McClelland Phone: 9330 9960

Lucy Armstrong Phone: 8752 4961


The Aged Care Team's role is to support and coordinate 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.

Advance Care Planning

Click here to visit CESPHN's dedicated Advance Care Planning page


The Carer Gateway is a national online and phone service that provides practical information and resources to support carers while the interactive service finder helps carers connect to local support services. The contact centre does not collect personal information nor assesses callers for a service. More information is available on the Carer Gateway website or by calling 1800 422 737 between Monday - Friday, 8 am – 6 pm.

Translated information about the Gateway is available in 14 languages on the Carer Gateway website


Dementia statistics in Australia - a snapshot

  • Dementia is the second leading cause of death in Australia and there is no cure
  • Three in ten people over the age of 85 and almost one in ten people over 65 have dementia
  • Without a medical breakthrough, the number of people with dementia is expected to be almost 900,000 by 2050
  • There are approximately 25,100 people in Australia with Younger Onset Dementia (a diagnosis of dementia under the age of 65; including people as young as 30)
  • An estimated 1.2 million people are involved in the care of a person with dementia
  • On average symptoms of dementia are noticed by families three years before a firm diagnosis is made

It has been recognised that there are potential benefits for early diagnosis and improved services for people with dementia and their carers and families, as well as the potential to reduce the prevalence of dementia by considering modifiable risk factors such as physical inactivity, smoking, body weight, and diet and alcohol consumption (SCoH 2012).

Information for clinicians

Clinical practice guidelines 

The guidelines will provide health professionals and carers in primary care, aged care and hospital settings with access to recommendations reflecting current evidence on dementia care. See more at the Alzheimer's Australia website.

Antipsychotics and dementia: managing medications

This video presentation (19:07m) provides some insight into the debate surrounding the use of antipsychotic medications in the management of dementia.


Eastern Sydney Dementia Resources

A Dementia Assessment Services Pathway and a directory for community health and dementia services for older people have been developed for the Eastern Sydney region to assist clinicians to navigate service provision for their patients with dementia and other mental health conditions.

Information for clinicians, consumers and carers

New South Wales’ peak organisation: Alzheimer’s Australia NSW

The Alzheimer's Australia NSW website provides information on numerous aspects of living with dementia, fact sheets and cultural diverse information.

Driving and dementia

The decision on when to stop driving after a diagnosis of dementia is often difficult on numerous levels. The University of Wollongong has developed a Dementia and Driving Decision Aid to assist with this process. The guide can be accessed here.

Alzheimer's Australia NSW also the licensing requirements around driving after a diagnosis. This information can be accessed here.

Dementia Behaviour Management Advisory Services (DBMAS)

DBMAS is a nationwide network of services funded by the Australian Government to provide individualised support for the carers of people living with dementia whose behavioural and psychological needs are rapidly changing and impacting on the person's care and quality of life. For more information visit the DBMAS website.

Information in other languages

Dementia does not only affect our English speaking population. Alzheimer’s Australia is committed to helping people from culturally and linguistically diverse population and Aboriginal and Torres Strait Islander Communities and has translated resources to meet the linguistic needs of the community.

Dementia Enabling Environments

The Dementia Enabling Environments Project (DEEP) is a collaboration between Alzheimer’s Australia WA and the NSW Dementia Training Study Centre based at the University of Wollongong. The project hosts a virtual information centre which provides practical tips, guides and resources to make the places we live more dementia friendly.

To view the interactive virtual information centre go to the Dementia Enabling Environments website and select the environment that you wish to adapt.

At home with dementia - A manual for people with dementia and their carers

This resource was developed by NSW Government Department Family and Community Services, Ageing, Disability and Home Care.

Dementia Advisory Service - St George and Sutherland Shire

A support service with contacts in the St George and Sutherland areas.


CPD Program

Aged Care Update – Southern Sector

Speakers: TBC

Venue: Torwood Lounge, 247 Rocky Point Rd, Sans Souci NSW 2219

Date: Thursday 6 October 6.30pm for Registration and Dinner, 7-9pm for Presentation

Target Audience: GPs, Practice Nurses, Allied Health Professionals and RACF Senior Clinical Staff

Registrations opening soon

RACF specific education

Dementia Behaviour Management for RACF Staff

Facilitated by staff from Dementia Centre, HammondCare. Topics for the session will include:

  • Understanding the perspective of the person living with dementia
  • Communicating effectively
  • Understanding behaviours
  • Responding effectively to the needs of the person

Venue: Education Centre, War Memorial Hospital, 125 Birrell St, Waverley NSW 2024

Date: Thursday 29th September. Participants can attend the morning (9am-12pm) OR afternoon (1pm-4pm) session.

Target Audience: Care staff who work closely with residents who have dementia

Registrations opening soon

My Aged Care

My Aged Care (MAC) is a national website and contact centre for older people who need services and for their carers and other family/friends who need information about the types of supports/services available. It is also a single point of access to information about residential care and services such as domestic assistance, personal care, nursing, home maintenance and modifications, and respite care. The steps to typically access a service are as follows:

  1. Contact MAC on 1800 200 422 between 8am – 8pm, Mon-Fri and between 10am – 2pm on Sat,
  2. Contact Centre assesses the caller for a service and makes a referral to either the Aged Care Assessment Team (ACAT) for complex care that may require packages or residential access; or Regional Assessment Service (RAS) for respite, transport or domestic help
  3. ACAT or RAS conduct a comprehensive assessment of the older person’s needs for support and services and makes a referral to Home Support Program (CHSP) or Home Care Packages (HCP) or residential care (RACF).

Published on March 26, 2015, the videos below outline how the My Aged Care system supports the My Aged Care contact centre agent, home support assessor and service provider to work with a fictional client named Alexi, to help him access services.


My Aged Care Update (June 2016)

As part of ongoing refinements to the My Aged Care portal, in June 2016, a new referral web form was introduced for use by Health Care Professionals. The video below highlights how to complete the new referral form.

fact sheet for General Practitioners has also been released to explain the June 2016 changes.

The referral form is available here

New Aboriginal and Torres Strait Islander resources on My Aged Care

Resources specifically for Aboriginal and Torres Strait Islander people, including translated materials, can be viewed or downloaded from the My Aged Care website:

  • brochures
  • fact sheets
  • print advertisements
  • radio advertisements
  • a poster (in English only) 

A new video for Aboriginal and Torres Strait Islander audiences is also on the My Aged Care website. It provides an overview of My Aged Care, including the services available and how to access them. 

View the animation and resources.

Residential Aged Care Facility support

10 Questions to Ask leaflets

A new resource has recently been released to assist consumers when navigating a path into residential care.

As aged care continues to move into the model of consumer directed care, it is imperative that information is available to support decision making. ‘Asking the Right Questions’ can make all the difference when selecting a new home for yourself or family member.

A partnership of aged care professionals, consumers, carers and nurses has developed a series of brochures covering a range of topics such as facility staffing levels, cultural needs in residential care, availability of GP services, applicable contracts and fees and more.

These leaflets have been developed and endorsed by a variety of relevant organisations including, NSW Nurses and Midwives Association, Central and Sydney GP Network, Palliative Aged Care Network NSW, COTA NSW, Combined Pensioners & Superannuants Association, Carers Australia NSW, PICAC NSW-ACT and Country Women’s Association NSW.

external link Download the 10 Questions to Ask leaflets

Geriatric Flying Squads (GFS) and other outreach services

  • Southcare GFS 9540 7956
  • St George GFS 9113 3999
  • War Memorial Hospital GFS 9369 0400
  • SLHD Nurse Practitioner Outreach Program 1300 722 276

Quality improvement

The National Aged Care Quality Indicator Programme (QI Programme) is a federal government initiative and a voluntary programme for aged care services.
Quality Indicators (QIs) measure aspects of service provision which contribute to the quality of care and services given by the provider, and to the consumers’ quality of life and experiences. The main objectives of the QI Programme are:

  • To give consumers transparent, comparable information about quality in aged care to assist decision making.
  • For providers to have robust, valid data to measure and monitor their performance and support continuous quality improvement.

For more information, click here.

Regional Medication and Advisory Committee

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 multidisciplinary 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 Collette McClelland on 9330 9960 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. This was done as a result of audits showing 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.

Restorative/wellness approaches to care

Wellness, reablement and 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 & 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.

Uniting Aged Care has established Seniors Gyms for the over 65s with personalised exercise and movement programs. Contact 1800 486 484 or email

iREAP (Integrated and Rehabilitation and Enablement Program) is a multidisciplinary semi-intensive rehabilitation service for clients who are frail aged or have a neurological condition. For more information, contact 9369 0457

Falls prevention

Stepping On through LHDs

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

Stepping On is delivered in English and a few community languages particularly for communities who have a much older population and are at risk of falls. The program is delivered in the CESPHN region by both Sydney Local Health District and South East Sydney Local Health District. For more information contact:

Rachelle Love - Sydney Local Health District (SLHD)
Phone: 1300 722 276

Patricia Lynch - South Eastern Sydney Local Health District (SESLHD)
Phone: 1800 823 002

Retirement villages

Alzheimer's Australia has developed a guide for retirement village operators and managers to support the needs of the increasing number of their residents that may be living with dementia.

Other resources


Palliative Care guidelines

Palliative Care guidelines have been developed by a Local GP- Dr Alison Vickers and Calvary Health Care. To view the guidelines click here.

Wellbeing in later life - Your Guide to Programs and Activities

NSW Health has developed a guide for older persons for accessing information on state wide programs, activities and services. This is a comprehensive and highly recommended resource. To view the resource click here.

Ambulance Service of New South Wales

Authorised Palliative Care Plans - Respecting patient wishes. General Practitioner Information Kit. To view the resource click here.