Elderly Australians are healthier than they have ever been. However, with 90% of the population aged 65 and over having at least one chronic condition and 57% with three or more, the complexity and resources of treating patients with multiple morbidities is expected to continue to increase. Older people will also visit the hospital frequently and require more support to remain independently living in our community. Improvements in primary and community care are required in order to meet these service needs, including better integration of care and an increase in home support service (SNPHN Needs Assessment 2016).
The proportion of people aged 75 and over in Northern Sydney is forecast to increase from 7.5% in 2016 to 9.1% in 2026. Within the SNPHN region, North Sydney and Mosman LGAs are projecting the strongest growth in the number of people aged over 75 – 57% and 55% respectively. Hornsby alone will make up 22% of the population growth in the SNPHN region.
Ageing Strategy Network
We have developed the Ageing Strategy Network with the objective to improve quality of and access to primary health care. The Ageing Strategy Network will link GPs with Aged Care services, in particular residential care facilities, home care service providers and allied health professionals, to ensure better outcomes for their patients and families.
Aged Care Program Information
Northern Sydney Dementia Collaborative
In partnership with Northern Sydney LHD, Community Care Northern Beaches Ltd and Alzheimer’s Australia, Sydney North Primary Health Network’s objective is to improve people’s journey with dementia by helping them to navigate the healthcare system and access dementia services. The project focuses on:
- People with dementia and their carers; and
- Health care providers (Primary Care, Community, Hospital) in Northern Sydney.
The project has resulted in enabling access to information about appropriate dementia management and available services that are close to home. The priority is to ensure that management of the patient’s health is appropriate and comprehensive, and that when support is required, this can be accessed in a timely fashion, avoiding hospital admissions and premature admission to a Residential Aged Care Facility (RACF).
The project outcomes include a GP Social Work service, Hospital Dementia Discharge services, Memory Problems booklet and development of quality indicators to support best practice in General Practice.
Improvement Foundation – Supporting Quality Dementia Care in General Practice
Sydney North Primary Health Network, the Improvement Foundation and a local expert reference panel has been convened to develop quality indicators that will support improvement in dementia care in general practice nationally, including detection, timely diagnosis and management. The final quality indicators will be published when completed.
- Better Health for People Living with Dementia: A guide for Allied Health Professionals
- Memory Problems brochure
- New Dementia Guidelines (March 2016)
- A new Carer Guide for GPs
- Dementia diagnosis and treatment recommendations
- 14 Essentials for Good Dementia Care in General Practice
- Hospital Avoidance Services
- CDPC Clinical Practice Guidelines and Principles of Care for People with Dementia
- CDPC Diagnosis, Treatment of Care for people with Dementia: Consumer Companion Guide
- Advance Care Planning resources for people with dementia
- Future Planning and Advance Care Planning Report: Why it needs to be different for people with dementia
- Future Planning and Advance Care Planning Companion Document
- Dementia Behaviour Management Advisory Service (DBMAS) 24-hour helpline – 1800 699 799
For more resources, CLICK HERE.
Access Services and Residential Care
- Commonwealth Home Support Services (entry level support)
- Home Care Packages (complex home support)
- Respite and Residential Accommodation
All Aged Care services can now be accessed through the My Aged Care website or by calling 1800 200 422.
Please note: My Aged Care will prioritise emergency or urgent services for meals, personal care and transport. My Aged Care will allocate patients to providers based on vacancies and will organise a follow-up, holistic care assessment for the patient. For emergency nursing services please refer to Referral Flow Chart for GPs: How to Refer Persons for Aged Care Services.
Aged Care Resources
- Defining Characteristics of Consumer Directed Care (CDC) – differences between traditional home care service delivery, person-centred care and CDC
- NSW Elder Abuse Helpline: 1800 628 221
- Expressions of Interest from RACFs – My Health Record registration and Secure Messaging
Services for Carers
Advance Care Planning
Advance Care Planning is a series of steps to help patients plan for their future healthcare. Studies conducted in a range of healthcare settings suggest that advance care planning can improve individual and family satisfaction with care, reduce the number of people transferred from nursing homes to hospitals, as well as reduce stress, anxiety and depression in surviving relatives.
Advance Care Planning Resources
- Advance Care Directives and Enduring Guardianship
- Advance Care Planning brochure for GPs – helping your patients to make their wishes known
- Advance Care Planning Community Workbook
- Advance – training for practice nurses and GPs
- Advance Care Planning Australia
- CALD Advance Care Planning
- Decision Assist
- NSW Ministry of Health
- How to start the discussion
- Aboriginal and Torres Strait Islander discussion starter
- NSW Ministry of Health ACD Form and Booklet
- Advance care plans and the law
Palliative Care helps people live their lives as fully and as comfortably as possible when living with a life-limiting or terminal illness.
Palliative Care identifies and treats symptoms which may be physical, emotional, spiritual or social. It is a family-centred model of care, meaning that families and carers can receive practical and emotional support.
Palliative Care Resources
Deteriorating Patient Online Module
New Training Module for RACF staff now Available
Sydney North Primary Health Network has developed a new online training module for staff of residential aged care facilities, in collaboration with the Northern Sydney Local Health District Hospital Avoidance Teams (AART, APAC, BRACE & GRACE) on the Deteriorating Aged Care Resident.
The online training was developed to assist and supplement use of the ‘Sick Patient Flipchart’ resource, which supports:
- Earlier identification of elderly residents who are “deteriorating”
- Triage and decision making on appropriate referral options (when to monitor, when to call the GP, when to call an ambulance)
The online module will support and empower residential aged care staff in assessing the deteriorating resident and aims to prevent unnecessary trips to hospital.
The module topics include:
- Triage principles and standards based on existing modules
- Scenarios on symptoms and what to do based on the charts already used
- Recognising and prioritising levels of urgency
- Case studies
- 2-3 based on key topics such as chest pain, falls, decreased oral fluid intake, breathing difficulties etc.
To access this online training, please complete the form below.