Aged Care

Ageing Well

For more information please contact

For Health Professionals

What is Care Fnders?

Care Finders is a national program delivered by all PHNs and funded by the Australia Government.

What do Care Finders provide?

Outreach and intensive one-to-one support to help vulnerable older people access My Aged Care, and connect to aged care and other relevant services. Care finders exists to support people who would not be able to access services without assistance. Care Finders provide trauma-informed, inclusive care, and speak multiple languages.

How much does it cost?

This is a free, fully funded service for people who need extra, intensive support to access the care they need and other supports in the community.

Is this the right service for my patient?

To be eligible a patient must:

  • have no carer or support person who can help them, or
  • not have a carer or support person they feel comfortable or trust to support them, and
  • be eligible for government-funded aged care.

In addition, they should have one or more of these reasons for needing intensive support:

  • have difficulty communicating because of language or literacy problems.
  • find it difficult to understand information and make decisions.
  • be reluctant to engage with aged care or government.
  • be in an unsafe situation if they do not receive services.

The eligibility criteria are flexible, and help is not means-tested. The program is mainly to help care recipients but, with permission, care finders can also work with carers or representatives.

Specific examples of who might be eligible to receive support from a care finder are:

  • People who are uncomfortable with government due to past discrimination or trauma
  • LGBTQIA+ community
  • Forgotten Australians
  • Care Leavers
  • Refugees or migrants from conflict zones
  • People with language barriers and no support
  • People with cognitive impairments and no support
  • People at risk of homelessness
  • People at risk of elder abuse
  • Veterans
  • People struggling with dependence on alcohol and other drugs
  • People living with mental illness

Find out more

What is care finders? – Your Side

The new DETECT Training module and materials are available at www.detect.snhn.net.

Sydney North Health Network  & the Northern Sydney Local Health District  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.

Sydney North Health Network, the Improvement Foundation and a local expert reference panel collaborated to develop quality indicators to support improvement in dementia care in general practice nationally, including detection, timely diagnosis and management.

The Dementia Quality Improvement Program (DQIP) commenced in Feb 2018, the program provides support to participating practices to analyse current dementia care management utilising the specified indicators. Practices are participating in education and peer support programs to develop individualised improvement plans to support implementation of evidence-based best practice care.

What is frailty?

Frailty is a common syndrome that occurs from a combination of de-conditioning and acute illness on a background of existing functional decline that is often under recognised. Many of the causes of frailty can be managed and, in some cases reversed to create better health outcomes and quality of life. It is  therefore important to identify older people who are living with frailty.


How to identify frailty

Current health guidelines suggest that people over the age of 70 should be screened routinely.

In Northern Sydney we recommend the use of the The Frail Scale to identify a level of frailty.

A score of 1 to 2 indicates pre-frailty and a score of 3 or more indicates frailty.

Frailty is more common in females and the risk of frailty increases with age.


How to manage frailty

Correctly managing frailty can significantly improve a person’s function and quality of life. It can also provide a better chance of recovery from acute illness as it reduces susceptibility to negative health outcomes.

Once you have assessed a person’s level of frailty (pre-frail or frail,) it is important to develop a management plan that addresses the corresponding sections of the frail scale.

This targeted approach can include:

  • Referral to appropriate allied health professional such as a physiotherapist or dietitian
  • Exercise classes
  • Reviewing medications
  • Managing weight loss

The decision support tool below provides more detail and some guidance for best course of action.

Frailty Management and Decision Support

Things to consider when implementing the Frail scale


Clinical Resources

The Best Practice and Medical Director templates

The Best Practice and Medical Director templates (.rtf files) can be imported to your software. These templates should not be opened and viewed before importing them. You will need to right click, copy and save or drag the .rtf file onto your desktop. Refer to the instructions below.

Frail Scale Templates for Medical Director

Frail Scale Templates for Best Practice

Other Resources

Evidence to Support Frail Scale: 


HealthPathways – For detailed clinical referral , assessment and management information related to the Northern Sydney region visit Sydney North HealthPathways site.

(Log in details are required and if you do not already have these please email healthpathways@snhn.org.au and they will be sent directly to you.)

Geriatrician – To refer to a Geriatrician for a comprehensive geriatric assessment please use the following:

  • Search for a Geriatrician via postcode on Healthshare Open Search
  • NSLHD Geriatrician referral
    • Hornsby Ku-Ring-Gai Hospital – Ph: (02) 9477 9514  / Fax:  (02) 9477 5684
    • Royal North Shore Hospital Campus – Ph: (02) 9462 9333 / Fax: (02) 9906 4301
    • Brookvale Community Centre – Ph: (02) 9998 6120 / Fax: (02) 9979 7876
    • Mona Vale Community Centre – Ph (02) 9998 6120 / Fax: (02) 9979 7876

Geriatrician Outreach to Primary Care  – aims to increase Geriatrician input into GP-led patient planning and care in the community while building relationships and facilitating two-way learning opportunities.​ It works with GPs to manage complex patients and prevent conditions that may be at potential risk of deterioration.

Search for Allied Health Professionals in Sydney North

Please use this search tool for Allied Health providers in Northern Sydney listed with an interest in frailty as registered in the Primary Health Network, this includes pharmacists that can assist with polypharmacy review.



Active and Healthy Frailty prevention exercise program options in NSW

ViviFrail – for professionals responsible for the prescription of a program of physical exercise

Progressive resistance training for frailty

For patients requiring individual exercise prescription, a physiotherapist or exercise physiologist:

Australian Physiotherapy Association: Find a physiotherapist

Exercise & Sports Science Australia: Find an exercise physiologist

NSLHD outpatient Physiotherapy referral information


Dietary advice

Dietitians Australia

NSLHD outpatient Dietitian referrals (accepts GP referral)


Home safety assessment and occupation therapy

Occupational Health Australia

  • NSLHD outpatients
    • Hornsby Ku-ring-gai Hospital Outpatients – Ph: (02) 9477 9493
    • Northern Beaches Health Service –  Ph: (02) 9998 6100
    • Royal North Shore Hospital – Ph: (02) 9462 9666
    • Ryde Hospital – Ph: (02) 9858 7888

Sydney Home Nursing Safe and Steady Program

Regal Home Health Ph: (02) 9264 4555 – Care coordination links to assist in conducting 75+ health assessments with patients

My Aged Care portal

Falls can be prevented – help your older patients prevent falls and stay independent

Falls are common in older people but they can be prevented.

Do your older patients relate to either of the following risk factors?

  • Having had a fall or worried about falling
  • Unsteadiness when walking
  • Conditions that impact mobility such as diabetes, stroke, arthritis
  • Taking psychotropic medications
  • Polypharmacy
  • Poor vision
  • Dizziness
  • Urge incontinence
  • Clutter in the home

Developing routine for fall prevention in general practice.

For more videos on the role of health professionals in preventing falls in older people please click here.

GP Resources

Prof Lindy Clemson and a team of multidisciplinary researchers including GPs have developed a clinical decision tool and resources based on the latest research evidence and practice guidelines.1-4 We anticipate that these will help GPs and practice nurses identify people at risk of falling and provide tailored management options. GPs are also offered a directory of trained fall prevention service providers in their local area to facilitate patient referral.

The clinical decision tool, resources, and referral directory are now available online through the iSOLVE tool button below. Please contact Alex Jaksetic by email ajaksetic@snhn.org.au if you would like educational visiting to be organised.


Find a Falls Prevention Provider

Practice Education EOI

Download resources
Software partnership
    • Decision tool, information and resources within SNPHN HealthPathways
    • HotDoc reminder to prompt patients to discuss with their GPs or practice nurses about preventing falls

Allied Health Resources

SNHN offered various workshops to health service providers to facilitate referral pathways and implementation of evidence-based fall prevention interventions. SNHN will continue to promote future fall prevention workshops through the Education Events page. You may wish to view some of the recorded workshops here: www.falls.armchairmedical.tv.

If you are a community-based service provider and have undertaken fall prevention training with SNHN or another organisation, you may wish to be listed as a provider for patient referral from GP practices for interventions relevant to your practice. To express interest please contact Alex Jaksetic by email ajaksetic@snhn.org.au.

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.


For Community Members

Northern Beaches Dementia-Friendly Community Project

The Advisory group is open to people living with dementia and their carers and has been set up to create a dementia-friendly community in the Northern Beaches.

Northern Beaches Dementia Alliance 

NBDA consists of aged care, dementia, and healthcare professionals as well as community members, people living with dementia, and their carers. NBDA aims to increase awareness and understanding of dementia on the Northern Beaches, and to encourage dementia-friendly communities.

Northern Sydney Dementia Collaborative

The Northern Sydney Dementia Collaborative was established in 2014, with assistance from the NSW Agency for Clinical Innovation’s “Building Partnerships” program, which aimed to form alliances that work together to integrate care for older people with complex health needs. Nowhere is this more needed than in people with dementia. There are a range of services available in Northern Sydney for people with dementia and their carers. However, information about these services and how to access them is not well understood by the people who need them the most or by health professionals. It is estimated that over 12,000 people in Northern Sydney are living with dementia and this figure will continue to grow as the population ages.

Better Journeys for People with Dementia in Northern Sydney

Focus Area – Supporting providers to deliver care, and engaging older people and their carers through improving transparency and accessibility of available services.

In Australia, three in ten people over the age of 85 and almost one in ten people over 65 have dementia. In Northern Sydney, there is projected growth of 23% in the population of people aged 75 years and older between 2011 and 2021, indicating a substantial increase in the number of people with dementia in the region over the next 6 years. In addition, there are approximately 24,700 people in Australia with Younger Onset Dementia (a diagnosis of dementia under the age of 65; including people as young as 30).

On average symptoms of dementia are noticed by families three years before a firm diagnosis is made. The journeys of many people with dementia and their carers include points of contact with the health system with an absence of helpful advice or information about services, and a series of points of stress, pain or crisis. People with dementia are relatively high users of acute hospitals. In Australia the mean LOS for all hospital separations is 8.6 days, compared with a mean of 19.6 days for any diagnosis of dementia and 30.1 days for separations with a principle diagnosis of dementia (Draper 20071).

This work will also include health promotion including brain health, building capacity in General Practice and working together to promote advanced care planning for the benefit of people with dementia and their carers in Northern Sydney.

It is expected that with access to this information people with dementia will have better plans in place to manage their care, more timely access to support, and there will be reduced unplanned admissions to hospital for people with dementia.

A partnership between Northern Sydney Local Health District, Sydney North Health Network, Community Care Northern Beaches, and Dementia Australia NSW will be developing a dementia pathway which will provide guidance around appropriate services, with information regarding how to access these in the region.

The Collaborative includes representatives from SNHN, Northern Sydney Local Health District, Dementia Australia  Community Care Northern Beaches, Northern Sydney Regional Dementia Advisor, local GPs and a carer with lived experience caring for a family member with dementia. This group aims to develop strategies to improve the healthcare journey for people with dementia and their carers. This includes:

  • Creation and extensive distribution of the “Memory Problems” brochure which provides both consumers and health professionals with essential local service information.
  • Development of a cognitive impairment pathway – one of Northern Sydney’s first HealthPathways.
  • Co-design of a discharge follow-up service to support transition from hospital to home for people at high risk of readmission.
  • Education events for health professionals, carers and consumers.
  • Working in partnership to develop dementia friendly communities.
  • Supporting the efforts of local councils to develop dementia friendly communities, as well as supporting health care services to be more dementia friendly.

It is expected that with access to this information, people with dementia will have better plans in place to manage their care, more timely access to support, and there will be reduced unplanned admissions to hospital for people with dementia.

1 Draper et al (2007) Hospital Dementia Services Project: Dementia Services Provided in Public Hospitals, NSW, Australia, downloaded via AIHW website, contact Brian Draper; b.draper@unsw.edu.au.

  • Carer Gateway
    Call on: 1800 422 737
    Carer Gateway is a national online and phone service that provides practical information and resources to support carers. The interactive service finder helps carers connect to local support services.

Complete your own online positive ageing screening.

Eating well booklet 

Healthy eating to stay strong and independent

Living Well brochure

Staying active booklet

Staying active website

Health coaching website

Stepping On brochure (falls prevention program)

My Aged Care brochure

Meals on wheels contact numbers:

  • Crows Nest –  Ph: (02) 9437 7517
  • Hornsby Ku-Ring Gai – Ph: (02) 9144 2044
  • Hunters Hill Ryde – Ph: (02) 9817 0101
  • Lane Cove –  Ph: (02) 9427 6425
  • Mosman –  Ph: (02) 9978 4130
  • Willoughby  – Ph: (02) 9777 7830
  • Manly –  Ph: (02) 9976 1469
  • Northern Beaches –  Ph: (02) 9970 8399

NSLHD Health Contact Centre  – Ph: 1300 732 503 (Mon-Fri: 7.30 am to 6.30pm)

NSLHD Carer support information website

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