Aged Care Resources for GPs

 Aged Care Access Initiatives
 Comprehensive Medical Assessment (CMA)
 Important Notice - Allied Health Professionals (AHP) on EPC Items
 Medication Management 
 Resident Consent Form for individual EPC Items
 Transfer of Medical Care
 Directories - community 
 Directories - Southcare Services
 Transfer Medical Care
 Advance Care Directives
 Information System - Register/Follow-up System for RACF patients
 Dementia
 Palliative Care
 Falls
 General Clinical Guidelines
 Office of Public Guardian
 Surviving the Maze - Information Sheets for Carers
 Links to RACF Aged Care Funding Instrument

ENHANCED PRIMARY CARE IN RACFs - GP RESOURCES


Comprehensive Medical Assessment 

Checklist - Comprehensive Medical Assessment (CMA) for residents of aged care facilities (PDF 90 KB)
Proforma - Comprehensive Medical Asssessment (CMA) for residents of aged care facilities   (PDF 267 KB)
Proforma - Best Practice and MD Template CMA for residents of aged care facilities (RTF 4094 KB)

MBS Benefits Schedule Online - CMA for residents of aged care facilities

Click here

Other useful Resources:

 

Residential Medication Management Reviews (ITEM 903)

Overview of Residential Medication Management Review Item 903    

PDF (KB)
RMMR GP Referral Form          PDF (36.4KB)      MD TEMPLATE RTF (28KB ) 

RMMR Management Template       

 PDF (30.4KB) MD TEMPLATE RTF (19KB)

Contribution to Care Plan (ITEM 731)

It is NOT appropriate for allied health professionals to provide part-completed referral forms to GPs for signature, or pre-empt the GP's decision about the services required by the patient. 

Overview of Contribution to Care Plan Item 731    

PDF (26KB)

  
Care Plan Management Template - for GPs only        GP LOGIN SECTION
        

IMPORTANT NOTICE - ALLIED HEALTH PROFESSIONALS - EPC MBS ITEMS:
(Source: Department of Health and Ageing website http://www.health.gov.au )

It is NOT appropriate for allied health professionals to provide part-completed referral forms to GPs for signature, or pre-empt the GP's decision about the services required by the patient. 

It is expected that the GP’s contribution to the resident's multidisciplinary care plan would be through direct collaboration with the aged care facility at the request of the facility.  The contribution must be based on the GP’s knowledge of the resident and the health and care needs and may include a personal attendance by the GP with the patient.

It is up to the GP to determine that the resident has a clinical need to for allied health services and to determine the type and number of services required by the resident.

It would NOT be appropriate for a third party (i.e. allied health professionals) to either request the GP’s contribution on behalf of the aged care facility or to direct the GP on what the contribution should be. Consequently, it is not appropriate for allied health providers to provide part-completed referral forms to GPs for signature, particularly in a way that pre-empts the GP’s decision about the services required by the patient.

Referral to Allied Health Services

Overview of Allied Health    

PDF (31KB)

Allied Health Form under Medicare - Manual Template      

PDF (89KB)  

Allied Health Form under Medicare - Best Practice & MD Templates  RTF (310KB)   
GP Letter - Refusal Letter to Allied Health Professionals - Best Practice & MD Templates  RTF (15KB)
GP Letter - "Reverse Referral" Allied Health Professionals providing part-completed  
referral forms to GPs for signature, or pre-empting the GP's decision - Best Practice & MD Templates  		RTF (4KB)

 

Case Conference Items (ITEMS 734-738 and 775-779)

Overview of Case Conference

PDF (KB)

  
Case Conference Management Template      
 PDF (32KB)     MD TEMPLATE RTF (27KB) 

Other EPC Resources

Information leaflet for residents on EPC items in RACF       

PDF (71KB)

Resident Consent Form for individual EPC Items

PDF (40KB)

 

Aged Care Program 2009-2010

In the 2008-09 Federal Budget, the Government announced the redirection of funds from the Aged Care GP Panels Initiative to support primary care service provision in residential aged care facilities through the Aged Care Access Initiative. The aim of the Aged Care Access Initiative is to improve access to primary care (GP and allied health services) for residents of aged care facilities. The two components to this initiative are:
1. Aged Care Access Initiative GP incentive component; and
2. Aged Care Access Initiative allied health services component.

GP incentive component

  • All GPs in practices participating in the Practice Incentive Program (PIP) will be eligible for an incentive payment once they have provided a predetermined number of Medicare claimable services.
  • Funding will be available on a two tiered model and payments will be made automatically by Medicare Australia once predetermined Qualifying Service Levels have been reached,
  • Payment will be made to the GP who provided the service rather than the practice.
  • The program applies to services provided to residents in Commonwealth-funded Residential Aged Care Facilities.

What are the Qualifying Service Levels?
Tier one provides a payment of $1000 when the first qualifying service level of 60 services is claimed in 2009-2010.
Tier two provides a payment of $1500 when the second qualifying level of 140 services is claimed in 2009-2010. 

The maximum payment any one GP can receive in one financial year is $2500.

A service is those provided to aged care residents in Commonwealth funded aged care facilities and Multipurpose services. MBS items that count towards qualifying service levels include attendances in RACFs, Comprehensive Medical Assessments, contributions to care plans, case conferences and residential medication management reviews. 

Further enquiries about the GP incentive can be made to the PIP enquiry line on 1800 222 032.


Allied Health Services component

The Allied Health Initiative aims to deliver clinical services by allied health professionals within residential aged care facilities, where this is not funded by Medicare or other government funding sources. The initiative only applies to allied health professionals providing clinical services in Commonwealth funded residential aged care facilities (RACFs) and Multipurpose Services (MPS).

A comprehensive local needs assessment undertaken identified two gaps in service provision to RACFs:

  • Individual psychology services, and
  • Group gentle exercise/falls prevention classes

In response to the identified needs, there were a select number of facilities who expressed an interest in participating in this initiative. These facilities and the residents GPs will identify residents who will benefit from these services, and then GP referrals and medical clearances will be obtained.

Both the psychology and gentle exercise services have been contracted out to suitably qualified and registered allied health professionals. Services will be delivered on location at the aged care facility to low care residents.

If you would like more information on this initiative please contact the program officer, Laura Denegris.

Allied Health Directory for Aged Care Facilities 2009

The directory can be used as a guide in referring to allied health professionals under the Enhanced Primary Care (EPC) initiative. Every effort was made to contact all allied health disciplines eligible under EPC, however, some did not express interest in being included in the directory. This means that not all allied health disciplines are represented in this directory. Allied Health Directory for Aged Care Facilities (2009 edition) Click here to download (PDF 573KB) 

Residential Aged Care Facilities 2010/2011 developed by the Sutherland Shire Council

Information on Low Care (Hostels) and High Care (Nursing Homes) Facilities in the Sutherland Shire and St George Areas.Residential Aged Care Directory developed by the Sutherland Shire Council Click here to download (PDF 102 KB) 

Seniors Services Directory developed by the Sutherland Shire Council

Groups, services and facilities for older people in the Sutherland Shire,including a detailed index and list of Frequently Asked Questions.Click here to download (PDF 1.2MB)

Retirement Villages Directory developed by the Sutherland Shire Council

Information on Retirement Villages in the Sutherland Shire and St George Areas. Click here to download ( PDF 61KB)

Sutherland Hospital Services - Southcare Directory and Access/Referral Intake Form

Overview of Southcare       PDF (KB)  
Southcare Services (Aged Care Services) - description of each service, referral criteria and how to refer    CLICK HERE
Common Referral Form for Sutherland Access and Referral Intake Form   CLICK HERE
 
 

MEDICATION MANAGEMENT

Guidelines for Medication Management in Residential Aged Care Facilities APAC 2002      PDF (30KB)
Regional Medication Advisory Committee Terms of Reference    PDF (21KB)
RMAC Nurse Initiated Medication Policy    PDF (21KB) 
RMAC Nurse Initiated Medication List     PDF (16KB)
RMAC Strategies for Improving Prescription Management in RACFs  PDF (27KB)
NSW Health Key Principles for the Production &
Use of Computer-generated Medications Charts in RACFs   		 PDF (58KB)
Residential Medication Management Reviews (Item 903)    PDF (550KB)

TRANSFER OF MEDICAL CARE - GP TO GP FOR PATIENTS ENTERING RACFs

Transfer of Medical Care Flowchart    PDF (28KB)
Transfer of Medical Care form    PDF (38KB)
Transfer of Medical Care MD (Medical Director) Template        MD TEMPLATE RTF (37KB)

HOSPITAL INTERFACE 

RACF Transfer to Hospital Form (Nursing) - this form was developed and piloted by local RACFs, Sutherland Hospital and the Division. Through collaboration with the SESIAHS the form has been further enhanced for use by RACFs and all hospitals in the SESIAHS. It is suggested that RACFs use this form when transferring a patient to hospital. This form is used by all the hospitals in the SESIAHS when discharging a patient to an RACF.

RACF Transfer to Hospital Form - Nursing   PDF (332KB) 
RACF & SESIAHS Aged Care Discharge Summary Form  

 PDF (29KB)

 

INFORMATION SYSTEM - REGISTER AND REMINDER SYSTEM FOR RACF PATIENTS  

Guideline of how to set up a Residential Aged Care Facility register and reminder system  PDF (71KB)

 

ADVANCE CARE PLANNING 

DEMENTIA

PALLIATIVE CARE

FALLS

GENERAL CLINICAL GUIDELINES/BEST PRACTICE INFORMATION 

OFFICE OF THE PUBLIC GUARDIAN 

The Office of the Public Guardian exists to promote the rights and interests of people with disabilities through the practice of guardianship, advocacy and education. The Guardianship Tribunal appoints the NSW Public Guardian as guardian of last resort and the Public Guardian then acts as a substitute decision-maker for people under his guardianship. http://www.lawlink.nsw.gov.au/lawlink/opg/ll_opg.nsf/pages/OPG_index

SURVIVING THE MAZE

A series of 60 information sheets written specifically for people who are caring for an older family member or friend. Click here to download these information or go this link http://www.survivingthemaze.org.au 

AGED CARE FUNDING INSTRUMENT (ACFI)  

The Aged Care Funding Instrument (ACFI) is a new funding tool for aged care facilities. It is important to note that there should be no change to the practice of GPs working within residential aged care facilities, however it is important to know how this new tool will impact on the care needs of your residents. GPs visiting RACFs are advised to liaise with their RACFs to discuss mechanisms that can facilitate the sharing of information collected from ACFI.  For further information please refer to the following website http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-acfi-aboutacfi.htm . Links to useful resources below:

 

Other useful resources on Aged Care

Ageing with vitality: Your everyday guide to healthy active living - Queensland Government http://www.health.qld.gov.au/stayonyourfeet/ageing_vitality.asp
This is an excellent resource on healthy active living with tips, real-life stories and sample exercises to make being healthy and active fun.  The guide suggests everyday activities and exercises for strength, balance, flexibility and endurance that you can do at home.  It includes tips, simple step-by-step instructions and photographs.   The guide has been made available in smaller downloadable sections.