Aged Care Program Information
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 (SNHN 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 SNHN 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 SNHN region.
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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; email@example.com.
Dementia Friendly Communities
“A dementia-friendly community is a place where people living with dementia are supported to live a high quality of life with meaning, purpose and value.”
Find out more at the YourSide Website.
Supporting Quality Dementia Care in General Practice
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.
- CDPC Clinical Practice Guidelines and Principles of Care for People with Dementia
- CDPC Diagnosis, Treatment of Care for people with Dementia: Consumer Companion Guide
- 14 Essentials for Good Dementia Care in General Practice
- Dementia Behaviour Management Advisory Service (DBMAS) 24-hour helpline – 1800 699 799
- The Physical Comorbidities of Dementia
For more resources, CLICK HERE.
Access Home and Residential Care Services
- Commonwealth Home Support Services (entry level support)
- Home Care Packages (complex home support)
- Respite and Residential Accommodation
- Restorative Care Package
- Transitional Care
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.
My Aged Care Resources
Services for Carers
- Northern Sydney Local Health District – Carer Support Service
Call on: 02 9462 9488
- 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.
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
- NSW Ministry of Health ACD Form and Booklet
- Advance care plans and the law
- Advance Care Planning brochure for GPs – helping your patients to make their wishes known
- Advance Care Planning Australia
- CALD Advance Care Planning
- Aboriginal and Torres Strait Islander discussion starter
- End of Life Directions for Aged Care (ELDAC)
The Advance Project
The Advance Project TM is a free, evidence-based toolkit and training package specifically designed to support GPs, nurses and practice managers to initiate advance care planning conversations and assess patients’ and carers’ palliative and supportive care needs.
The purpose of the project is to build capacity of general practices and primary care clinicians to provide better care through team-based initiation of advance care planning and palliative care. General practices are in an ideal position to start advance care planning discussions with their patients
because of the trusted relationships that develop. The general practice environment enables advance care planning discussions to start early, when a patient is still relatively well, so they don’t miss out on the opportunity to plan for their future care.
The Advance ProjectTM resources consists of a number of resources to help primary care clinicians work as a team to initiate conversations about advance care planning, and to assess patients’ and their carers’ palliative and supportive care needs. Three different online training activities, specifically tailored to the unique learning needs of Australian GPs, nurses and general practice managers, explain how to use these resources in everyday clinical practice. All resources can be found here www.theadvanceproject.com.au including access to the online learning modules.
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
- Palliative Care Australia
- Everything you need to know about dying!
- Palliative Care Network – NSLHD
- NSW Palliative Care After Hours Helpline – 1800 548 225
- Palliative Care Referral Form – HammondCare April 2018
- HammondCare Palliative Care – End of life resource booklet
- HammondCare Palliative Care – End of life flip chart
- HammondCare Quality of End of Life Care Newsletter Edition One
- HammondCare Quality of End of Life Care Newsletter Edition Two
- HammondCare Quality of End of Life Care Newsletter Edition Three
- HammondCare Quality of End of Life Care Newsletter Edition Four
Hammondcare – Palliative Care at Home Partnership – Bupa and Medibank
HammondCare and Bupa have worked together to design a program that further enhances the palliative care services already available through HammondCare’s community palliative care team to all people residing in the Northern Sydney Local Health District (NSLHD). A similar initiative is also available to patients with Medibank Private Health Insurance. If you require further information please contact the HammondCare Program Manager or Clinical Navigator on 1300 014 424 or for further information https://www.bupa.com.au/health-programs/palliative-care-choices-program
Hospital Avoidance Services
These services support GPs, carers and Residential Aged Care Facility (RACF) staff to provide home based management of elderly people at risk of hospitalisation. They can also facilitate fast track through the hospital system when required.
Deteriorating Patient Online Module for Residential Care
New Training Module for RACF staff will be available soon
Sydney North Health Network is developing 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 ‘Deteriorating Resident Clinical Decision Tool’ 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
- How to do A-G physical assessement recognize change in the resident’s conditions
- Scenarios on symptoms and what to do based on the charts already used
- Recognising and prioritising levels of urgency
- Case studies
If you are interested in trialling the module at your facility, please contact us at firstname.lastname@example.org