The Ageing Well Initiative Update 11 October

The Ageing Well Initiative Update 11 October

The Ageing Well Initiative in The Prince Charles Hospital Area


Older people face a range of issues in accessing the right care, in the right place, at the right time within the current health and aged care system. The Ageing Well Initiative is a once in a generation opportunity to improve healthcare for older people. 

The Health Alliance Core Group has been meeting since mid-2017 and has developed a number of interventions to improve care for older people. The Ageing Well Initiative has further developed these ideas, with a specific focus on older people in TPCH area.

This update includes highlights from recent discussions held with clinicians from The Prince Charles Hospital (TPCH), GPs, Metro North Hospital and Health Service’s Community and Oral Health department, and older people themselves.

The health journey

In an attempt to be able to describe the breadth of this initiative we have been using a model which represents an older person’s health journey, from living well to dying well. It is acknowledged that this is not a linear journey, and most older people will move back and forth through these different stages.





Our conversations to date have garnered strong support for this model, particularly as it has helped different stakeholders think of an older person’s needs at different stages, and from the older person’s perspective as well.

There has been strong advocacy by all groups that greater attention be paid to the ‘living well’ component of the health journey. During the consultations we were fortunate enough to hear numerous personal stories related to ‘dying well’, and many touched on the difficulties experienced accessing the appropriate service response during this stage.

A different story about the lives older people

A strong theme from older people has been the need for a different public story or narrative about their lives. Media representation of older people tends to seriously undervalue the diversity of their lives. An older person told us, the only way we are portrayed is “going on a river cruise in Europe or going into a retirement village.” Valuing the rich experience and diversity of older people is seen as an essential element of a new model of care. Transport challenges, particularly to The Prince Charles Hospital, have also featured strongly in feedback. One senior remarked:

“The geography of the region and the transport routes throughout it make public transport across and around the region difficult and often non-existent. Public transport to TPCH is very poor, and parking is expensive.”

The parking problem impacted on visiting loved ones in hospital. The transport difficulties are multiplied when older people lose their licence and are more reliant on public transport.

Care that follows the patient 

The discussion with clinical groups has centred on the opportunities and challenges of providing continuity of care, particularly for older people who are frail.

Older people themselves have highlighted their experience of a disconnected and confusing array of services. The hospital developed a RADAR service to better connect care between the hospital and RACFs. This idea could be developed further; with a single point of contact for community services, and for older people themselves.

Hospital specialists and GPs have described the difficulties at the point of transfer between the hospital and the community, particularly for older people with complex needs. One senior hospital specialist commented, “It’s a nightmare to discharge an older person with complex health needs.”

They highlighted a number of negative system impacts, including issues around polypharmacy.

GPs have described the funding environment which is not supportive of providing care at patients’ homes, despite that being preferred by many patients.

A number of ways of addressing this have been discussed, including: 
•    maintaining specialist support post discharge for people with complex conditions
•    a video conference one week post discharge with an older person’s GP and specialist
•    better connections to care coordinators for older people with complex conditions
•    increased remuneration for GP home visits.

A team response is required

Feedback from across the sector has shown enthusiasm to improve the care of older people, tempered with frustration that a lot of care is provided in a fragmented and piecemeal way. Care of older people with complex health conditions is a team activity, no one individual or part of the sector can operate effectively in isolation. The team starts with the older person, carers and family, and includes community services, general practice, and the hospital services.

There is an active discussion of what a properly constituted team caring for older people would look like, and what roles different services would play. One idea is that professional support is maintained irrespective of the setting in which care is occurring. For older people with complex needs specialist care could be maintained to support general practice looking after the patient in community settings.

To execute this vision though, we need to improve the coordination of activities, while addressing the gaps and overlaps that currently occur.

In an upcoming news item we will share the insights from other stakeholder groups including non-government aged care providers and residential aged care facilities (RACFs).