Aged Care
Improving aged care services
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Year in review
Our PHN is committed to improving the care of older people across our region to enable optimal wellbeing and living well up to and including the end of life.
Planning for older people’s care
To ensure the region is best placed to support older people live well, our PHN developed the Plan for Older People’s Care 2019 - 2021 to inform future commissioning activities.
The Plan identified five (5) key areas to be addressed in order to improve care for older people:
- Inadequate systems: Deficits with My Aged Care, availability of Home Care Packages and inadequate funding.
- Knowledge and understanding: Help with navigation for consumers through the complex aged care system is critically important.
- Navigation: More training about care for older people is required across the region
- Whole of system approach: Access to services and adequate transport in outer regional and remote areas is challenging.
- Access to services: Inadequate understanding of the system by community and health care professionals.
The Plan was developed following extensive consultation with a range of stakeholders, including residential aged care providers, community aged care providers, acute service providers and GPs.
Key themes regarding strengths, weaknesses and opportunities for older people’s care emerged through the consultation and these have been adapted into nine (9) action items to be completed by 2021.
The Plan was endorsed by the Project Governance Committee which includes representatives from the PHN, peak bodies for older people, Darling Downs Health and West Moreton Health, and academia.
Supporting older Australians to live well
The PHN continued to fund a number of programs and services in 2019-20 to support older Australians living in the Darling Downs and West Moreton region.
West Moreton Aged Care Collaborative Forum
Over 30 health professionals from the West Moreton region attended the first Aged Care Collaboration Forum on Monday, 10 February 2020. A partnership project between the PHN and West Moreton Health’s Residential Aged Care Acute Support Services (RaSS), the forum focused on geriatric and aged care addressing areas of concern and providing improvements for older people’s care in West Moreton.
The forum was structured around the topic of ‘Detecting acute deterioration in older people’. Discussions were held about intricate residential aged care facility pathways, key health indicators, chronic disease, delirium vs dementia, triaging appropriately, emergency department pathways, standardised referral forms and under-diagnosing.
The Forum also touched on when to refer to a GP, how important teamwork and communication is, delirium being a medical emergency, the critical relationship between primary and secondary care, and the services that are available within the West Moreton catchment to provide care for RACF patients in their location of choice. Further forums had been planned however were moved to shorter virtual forums due to COVID-19 restrictions.
Improved mental health support for RACF residents
In 2019-20, the NewAccess Program developed by Beyond Blue was made available via in-reach support to people living in residential aged care facilities (RACFs).
The service supports older people with, or at risk of, developing a mild mental health condition and links the older person with a qualified, specially trained coach.
This service was delivered across the Darling Downs and West Moreton PHN region by Lives Lived Well and Richmond Fellowship Queensland.
Palliative Care in RACFs
AGES Model of Care Project
We continued to support in-hours and after-hours palliative care services for residents of residential aged care facilities (RACFs) in the Ipswich and Lockyer Valley local government areas.
The service, provided by CiMAS Home Nursing Services, provides residents access to coordinated and high-quality palliative care that is timely, patient-centred, based on clinical need and the patient’s GP palliative care plan.
Our PHN continued to support Darling Downs Health’s Acute Geriatric Evaluation Service (AGES) Model of Care Project in the after-hours period in 2019-20. The project provides a ‘Hospital in the Nursing Home’ model of care, focused on providing:
- a telephone triage service (in consultation with the GP);
- telehealth consultations providing virtual assessments;
- rapid assessments in the RACF by the AGES team;
- advocacy, education and training support for RACF staff; and
- integration with GPs promoting cross sector exchange of information, as well as education about the AGES–Nurse Navigator model of care.
Care at the End of Life Collaborative
Our PHN continues to play a significant role in the Care at the End of Life Collaborative.
In 2019-2020, the focus was on developing training and information to Queensland Ambulance Services (QAS) and developing pathways to ensure QAS officers had access to appropriate information to determine care and if a transition to hospital was required.
Our PHN has also participated in the development of a services website for people and their carers during the end of life.
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Acknowledgement of Country
The Darling Downs and West Moreton PHN wishes to acknowledge Australia’s Aboriginal people as the Custodians of this land. We pay our respect and recognise their unique cultures and customs and honour their Elders past, present and emerging.
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