Aged Care

Project Officer: Lara Leibbrandt
Phone: 8752 4911

News Item

A national Framework for Advance Care Directives
The National Advance Care Directives Working Group has released and distributed a national framework in October 2011. Advanced Care Directives (ACDs) are used in all states and territories in Australia, however there is much variability about the way they take form. This can cause legal issues with an ACD from across states and concern about correct interpretation. Also, the lack of case law in Australia to provide direction on the legality of an ACD and how an ACD should be followed in practice. This has been recognized by the Australian Government and has released the framework to address these issues.

The Framework document answers many questions about Advance Care Planning: general information about ACDs, challenges, best practice, a code of ethics, Australian Legislation, how to complete an ACD and even problem solving for disputes. This should be a fantastic resource for all GPs. Copies can be downloaded from:

A national framework for Advanced Care Directives

Aged Care Overview

The Aged Care Team’s aim is to provide support to general practice/General Practitioners (GPs) and Allied Health Professionals (AHPs) with a goal of enhancing access to services to improve the quality of care for residents of Residential Aged Care Facilities (RACFs).

CSGPN works closely with RACFs, GPs, AHPs and Sydney Local Health District (SLHD) to facilitate access to aged care services.

Information for GPs

CSGPN Aged Care Program - the Aged Care Access Initiative (ACAI)
The aim of the Aged Care Access Initiative (ACAI) is to improve access to primary care -including GP and allied health services - for residents of aged care facilities.

The GP component of the ACAI recognises some of the difficulties faced by GPs in providing care in these settings and aims to encourage GPs to continue to provide increased and continuing services in RACFs. GPs who care for residents will be paid an Incentive Payment directly through Medicare Australia. This payment will be based on a the number of Medicare services provided by a GP in RACFs over a financial year

Over 75 Health Assessment
A medical practitioner may select MBS item 701 (brief), 703 (standard), 705 (long) or 707 (prolonged) to undertake a health assessment for a person aged 75 years and older, depending on the length of the consultation which will be determined by the complexity of the patient’s presentation.

A health assessment of an older person is an in-depth assessment of a patient aged 75 years and over. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life.

Components of a health assessment for a person aged 75 years and older
The health assessment must include:

  * information collection, including taking a patient history and undertaking or arranging examinations and investigations as required;
  * making an overall assessment of the patient;
  * recommending appropriate interventions;
  * providing advice and information to the patient;
  * keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and
  * offering the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer.

Specific components of the health assessment for older people include:

  * measurement of the patient’s blood pressure, pulse rate and rhythm;
  * an assessment of the patient’s medication;
  * an assessment of the patient’s continence;
  * an assessment of the patient’s immunisation status for influenza, tetanus and pneumococcus;
  * an assessment of the patient’s physical function, including the patient’s activities of daily living, and whether or not the patient has had a fall in the last 3 months;
  * an assessment of the patient’s psychological function, including the patient’s cognition and mood; and
  * an assessment of the patient’s social function, including the availability and adequacy of paid and unpaid help, and whether the patient is responsible for caring for another person.

For further information on these MBS items please follow the below link to the DoHA website and Fact Sheet released by DoHA.
Health Assessment for People over 75 years
0lder_persons_health_assment_FACT_SHEET.pdf


Comprehensive Medical Assessments (CMA)
A comprehensive medical assessment is a review of the resident, including assessment of the resident’s health and physical and psychological functioning.
Components of a comprehensive medical assessment
A comprehensive medical assessment must include a personal attendance by a medical practitioner. The components of the assessment include:

  * information collection, including taking a patient history and undertaking or arranging examinations and investigations as required;
  * making an overall assessment of the patient;
  * recommending appropriate interventions;
  * providing advice and information to the patient;
  * keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and
  * providing a written summary of the outcomes of the assessment for the resident’s records and to inform the provision of care for the resident by the residential aged care facility and assist in the provision of medication management review services for the resident.

Medical practitioners may review and incorporate into the comprehensive medical assessment relevant assessments or information about the resident that is available from the residential aged care facility.
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In undertaking the assessment the medical practitioner should consider the following, as appropriate to the resident:

  * cardiovascular and respiratory systems, and other systems as indicated;
  * physical causes of acute and chronic pain;
  * an assessment of the resident’s:
      - physical function, including activities of daily living;
      - psychological function, including cognition and mood;
      - oral health, nutrition status and dietary needs; and
      - skin integrity.

The comprehensive medical assessment may also cover matters of particular relevance to the resident.
For example, an assessment of the following factors may be undertaken as relevant to the resident:

  * hearing and vision;
  * smoking and alcohol use;
  * foot care;
  * sleep; and
  * incidents of falls.

For further information on these MBS items please follow the below link to the Department of Health and Ageing.
Comprehensive Medical Assessment for residents of residential aged care facilities
A Comprehensive Medical Assessment (CMA, item 712) is not a requirement of ACFI - however, the contents of a CMA will assist RACF staff in completing an ACFI assessment. It is also recognized as best practice.

Previously CSGPN advised RACFs that concern had been expressed by many local GPs that some RACFs have either contracted with private medical companies or are in negotiation with private medical companies to complete CMAs on their residents. This trend has been met with alarm from CSGPN members. While CSGPN understands that most RACFs have not been taking this approach the following clarification was made:

  1. Doing CMAs on all residents is not required by the ACFI.
  2. Doing CMAs on all residents would be regarded by the MBS as overservicing.
  3. Outsourcing CMAs compromises the care of residents as their usual GP is disengaged from the care and treatment decisions by having a private company contracted to do CMAs. This is not best practice. We have had feedback from many GPs that they would withdraw their services from RACFs who compromised the care of their patients in this way.

Enhanced Primary Care (EPC) Services
Residents of Residential Aged Care Facilities (RACFs) are eligible for comprehensive assessment and multidisciplinary care through Enhanced Primary Care (EPC) Services.

For further information: EPC/Chronic Disease
Or contact Lisa Maude on 8752 4902

Commonwealth Respite and Carelink Centres (CRCC)
The Inner West office of CRCC presents general practitioners and health professionals with time saving services. A single phone call by freecall 1800 052 222 will link you to your local centre, and up to date information about community services for patients, including costs and eligibility and assessment requirements.

Offering both

  • Quick access to information about community services
  • 24 hours support for carers who require urgent or planned respite.

Call 1800 052 222 to find out more or go to www.wesleymission.org.au/crcc to read more about our services, such as Mental Health Respite and Young Carer Program, and find links to useful information for your patients to take home.

Information for Residential Aged Care Facilities and Allied Health Professionals

Aged Care Access Initiative (ACAI) information for Residential Aged Care Facilities (RACFs) and Allied Health Professionals (AHPs)

CSGPN is managing the ACAI program. ACAI facilitates the provision of quality and related programs from AHPs in RACFs. Funding has been allocated following the initial round of submissions and will continue as per agreements.

In the 2009/10 financial year, ACAI applies to residents of low care Commonwealth funded RACFs, Services provided on an individual and group basis are eligible. AHPs cannot claim from Medicare for the same function performed under this initiative. These facilities (low care RACFs) will be informed by letter and allocated funding in the above allied health areas.

Individual services may include one-on-one services such as podiatry or physiotherapy. Group services might include group psychology sessions or exercise and falls prevention programs and staff education.

The CSGPN allied health priority program areas were based on a needs analysis conducted in 2008 and are:

  • Speech Pathology
  • Dietitian/Nutritionist
  • Physiotherapist/Occupational Therapist/
  • Exercise Physiologist/Diversional Therapist
  • Podiatrist
  • Specialist Nurse in Mental Health /Counsellor/Psychologist

Other Allied Health Service areas will be considered on a case by case basis.

Submissions were sought from RACFs for ACAI funding and contractual arrangements entered into with interested AHPs.

If you are a RACF or an AHP working in Central Sydney and are interested in the ACAI program please contact Lara Leibbrandt on 8752 4911. To apply for funding please download the submission form by clicking on the link below.

RACFSubmissionProforma.doc

Funding of Residential Aged Care Facilities (RACFs)

Aged Care Funding Instrument (ACFI) and Comprehensive Medical Assessments (CMA)
In March 2008, the ACFI replaced the Resident Classification Scale (RCS) as the method of determining residential care subsidies. The ACFI is a funding tool; it measures only those care elements that best distinguish the costs of care.

    The ACFI was designed to:
  • better match funding to the complex care needs of residents;
  • reduce the documentation created by aged care providers to justify funding; and
  • achieve higher levels of agreement between aged care staff and departmental review officers in review audits (known as validation).

Sydney Local Health District (SLHD) information about services

SLHD Contacts and Services

The following services have been established to assist GPs and RACFs in the clinical care of residents.

Aged & Chronic Care Triage Service (ACCT)
Contact ACCT on 1800 556 211 available 7 days, from 0800 hrs - 2200 hrs
The ACCT aims to provide the best care for residents of RACFs in the most appropriate setting. Offering clinical advice and arranging of services for residents to support their care within the RACF and to minimize the unnecessary transfer of residents to hospital. The ACCT is a single point of telephone contact service that provides clinical advice and support to residential aged care facility staff, GP and Carers and includes clients enrolled “Connecting Care” Program. It offers a partnership between RACFs, GPs and hospitals within the SLHD by linking medical specialists and Clinical Nurse Consultants (CNCs), of our hospitals with GPs, Community teams, RACF staff and the Referral Information Center (RIC). ACCT has the capacity to facilitate and coordinate transfers to the most appropriate health services, such as appropriate emergency department if required.

The ACCT can arrange outreach or outpatient services for clinical issues such as:

  • Wound management
  • Continence management
  • Behavioural issues
  • IV antibiotic therapy
  • Diabetes management

The ACCT staff have access to other specialist nurses and on-call geriatrician should they need advice on how to best meet the needs of the resident.

Community Nursing (CHAIN) and Community & Post Acute Care Service (CAPAC)
SLHD has also introduced the Community & Post Acute Care Service (CAPACS) program. One of the aims of this initiative is to support GPs in caring for patients at home or in Residential Aged Care Facilities, who either have been discharged from hospital with ongoing support or to initiate care which enables patients to be cared for at home or in the aged care facility.

Community Nursing and CAPAC Guidelines
CHAIN GP Referral form

Mental Health Services for older people: Specialist Mental Health Services for Older Persons (SMHSOP)
SMHSOP has now separated and no longer comes under the Aged Care Assessment Team (ACAT) Structure. This service works across the Health Districts, including Central Sydney (inner west), South West Sydney (Bankstown, Liverpool and Campbeltown). The service provides:
• Case management,
• Outpatient clinics,
• Home visits, and
• RACF visits
It includes the in the team a Psycho geriatrician.

The SMHSOP look after people who have developed or are at risk of developing a mental health disorder such as Depression or Psychosis or may have severe behavioural problems. The SMHSOP comprises:

• Community Teams located across the area (Concord, Camperdown, Catnerbury and through South West) and provide specialist clinical assessment and case management in conjunction with GPs and other service providers.

• Inpatient Facilities are provided at Concord, Braeside and Bankstown Hospitals providing specialist clinical assessment, treatment and case management.

• BASISI/DBMAS Teams (Behaviour Assessment and Intervention Service and Dementia Behaviour Management Advisory Service) provide clinical assessments and support for challenging behaviours associated with dementia or mental illness

To refer to any of these SMHSOP services, fax or phone the Referral and Information Centre (RIC) of Sydney Local Health District (SLHD). Office hours are 10am to 4pm Monday to Friday.

Contact SMHSOP via RIC
Phone: 1800 556 533
Fax:  9767 6929 (preferred)
Email: RICNorth@sswahs.nsw.gov.au (scanned and attached)

Please also find the most recent referral form to download at the following location on our website:
http://csgpn.org.au/services/info/aged_care/  then scroll down to DOWNLOADS.

Advance Care Planning

Advance Care Planning involves a patient thinking about and communicating to others how they would like to be treated in the future if they have a condition where they can no longer speak for themself. This may happen, for example, because of a stroke, progressive dementia, or becoming unconscious from some form of accident or illness. For information on Advance Care Planning please follow the below link.
Advance Care Planning information

NPS Drug Use Evaluation (DUE) for RACFs

Drug use evaluation (DUE) is a quality improvement activity which uses an ongoing cyclical process to improve the Quality Use of Medicines and health outcomes. It involves monitoring and reviewing drug use, evaluating and comparing it with best practice guidelines, and using multifaceted interventions to improve drug use and overall patient care - this cycle is repeated as often as necessary to achieve set goals. DUE activities put focus on specific disease states or therapeutic areas for residents of aged care facilities as well as hospitals. These priority areas are chosen based on evidence of a therapeutic problem, variation in prescribing or adverse outcomes, and existence of best practice guidelines.

    Why do a DUE?
  • To assist your aged care facility to meet components of the Residential Care Standards issued by the Aged Care Standards and Accreditation Agency
  • To comply with the Australian Pharmaceutical Advisory Council Guidelines for medication management in aged care homes
  • To assist you to provide facility - focused activities to promote the quality use of medicines (QUM) in line with Pharmaceutical Society of Australia Guidelines and Standards
  • To contribute to your professional development and education; this activity is recognised by a number of professional bodies for continuing professional development points.

DUE kit for care homes

Useful contact numbers and websites

For information on accessing services

Translation and Interpreting Services (TIS)
TIS Doctors Priority Line: 1300 131 450
To Register: 1300 655 820

The Doctors Priority Line is a free telephone interpreting service which helps medical practitioners to communicate with their non-English Speaking patients.

Medical Practitioners can use the Doctors Priority Line when providing services that are: Claimable under Medicare, and in private practices, as well as providing to non-English speakers who are Australian citizens and permanent residents.

Commonwealth Carer Resource Centre
Commonwealth Carer Resource Centres can give you up-to-date, relevant information about all the government programs designed to support carers.

  • Carers Australia For carer information, counselling and support freecall (except mobiles) 1800 242 636
  • Carers NSW For carer information, counselling and support freecall (except mobiles) 1800 242 636
  • Council of the Ageing
  • Guardianship Board
  • Guardianship Tribunal
  • Local Government Information
  • The Aged Care Rights Service (TARS)
    The Aged-care Rights Service (TARS) is a community legal centre that provides advocacy for the residents of Commonwealth funded hostels and nursing homes, self-care retirement villages and recipients of in-home aged care in NSW. We also give information on the costs associated with entering an aged care facility and give advice on retirement village contracts. All calls to TARS are confidential.
  • NSW Transcultural Aged Care Service (TACS) The NSW Transcultural Aged Care Service (TACS) is for aged care service providers, community organisations, carers and other members of the community, providing information about cross-cultural resources such as training, translated materials, recipes, demographic data, contacts and links.

For clinical or program information

DOWNLOADS

Do you have patients in Residential Aged Care Facilities? – Infectious Disease Information for RACF patients

Dementia Awareness and Resources

There are currently around 245,000 people with dementia in Australia. By mid-century, we will have over 1.13 million Australians with dementia. Dementia is the leading single cause of disability in older Australians (aged 65 years or older) and is responsible for one year in every six years of disability burden for this group.

It is one of the fastest growing sources of major disease burden. Dementia will become the third greatest source of health and residential aged care spending within about two decades. By the 2060’s, spending on dementia is set to outstrip that any other health condition. It is projected to be $83 billion (in 2006-2007 dollars), and will represent around 11.0% of the entire health and residential aged care sector spending. (Access Economics 2009)

By 2011 it is estimated that 22.5% of the total older Australian population will come from culturally and linguistically diverse backgrounds. The strategic plan of Ashfield Council in the heart of CSGPN’s region indicates that dementia is set to increase six fold by 2050 in Middle Eastern communities.

Purpose of the Project:

  • Engage with the Arabic GP’s in the Canterbury LGA in relation to the gaps which currently exists in the understanding of dementia on the part of the Arabic community and health service providers in Canterbury LGA
  • Facilitate GP’s participation in an education and information program which uses existing partnerships and resources to improve their understanding of the needs of the Arabic patients, their families and carers in Canterbury LGA
  • Involve in this program where appropriate relevant community organizations and conduct community education
  • Assess the outcomes
  • Thereby derive recommendations for future sustainable action to achieve:
    1. Improved GP care and referral pathways for Arabic patients suffering from dementia in Canterbury LGA, their families and carers.
    2. Positive attitudes around dementia in the Arabic community within the Canterbury LGA.
    3. Reduce isolation of patients, families and carers living with dementia in the target group.

Dementia Support Services

GP_Dementia_services_and_resources_CSGPN.pdf

  • The Cognitive Disorders Service Concord Repatriation General Hospital (diagnosis, education, and management services) 1800 556 533 or 9767 5200
  • Inner West Dementia Advisory Service 9378 1258
  • Carers’ NSW (counseling, support, groups & information) 1800 242 636
  • Carer Respite & Carelink Centre 1800 052 222
  • Aged Care Assessment Teams 1800 556 553
  • Dementia Support Service (Home respite) 9767 7888
  • National Dementia Helpline 1800 100 500
  • NSW Dementia Behaviour Management Advisory Services 1800 699 799
  • “On Track” Café  Rhodes Park. Support group for people with Dementia, families, friends. Concord. 9378 1258
  • DeSteel Cafe’ - multicultural support group. For people with dementia, families, friends - Marrickville - 9378 1258
  • Canterbury Dementia Carer support group. Canterbury hospital 9378 1258
  • Inner west community transport 9745 5800
  • Canterbury & Marrickville multicultural home respite & Dementia support service (language specific) 9550 4637
  • Guardianship tribunal 9556 7600

Resources

Websites

Tuesday, February 7th 2012

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