The Ageing Well Initiative Update 23 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 last edition focused on highlights from 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. This update includes highlights from recent discussions held with residential aged care and community service providers.
Discussions with residential aged care and community services providers
What we heard from community service providers
Three clear themes were identified during our conversations with community service providers, these being:
• service navigation
• care coordination
Improved communication between care providers
Community service providers identified communication at transition points in care as a key issue. They are often unaware a client is in hospital and do not receive a care plan or list of services put in place upon discharge from hospital. Likewise, they identified that hospital staff experience difficulties in identifying who the community service provider is and the services already in place.
A number of ways to address these issues were discussed, including:
• an identifier included on medical records and care plans showing which community service provider/s are already involved in a person’s care
• Improved communication between hospital and community service providers upon admission and discharge, for example, a discharge summary sent to the community service provider as well as the GP
• a shared communication platform across sectors where information can be viewed and uploaded on a live basis
More help to navigate the system and better coordination of care
Community service providers recognised that older people struggle to navigate the aged care system and access the services they need. Many older people have multiple chronic illnesses, frailty and disabilities and have a number of health professionals involved in their care. These health professionals often work in silos with limited communication, coordination and integration across sectors. Community service providers recognised the need for improved care coordination across all sectors to assist older people to remain living at home for as long as possible.
Ideas to improve care coordination and navigation across all sectors included:
• service navigators based in community that can assist older people to navigate the aged care system and other services where required (housing, mental health services etc.)
• care planning to be coordinated between all care providers
• improved information for both older people and health professionals on available local aged care services.
What we heard from residential aged care providers
Improved access to primary and specialist care
Residential aged care facilities (RACFs) find it difficult to access primary healthcare services, especially after hours. Long wait times for after-hours medical services and limited access to quality geriatric and palliative after hours care contribute to unnecessary hospital presentations by RACF residents.
RACFs in the Prince Charles Hospital (TPCH) catchment have found access to specialist advice and support through Metro North Hospital and Health Service’s (MNHHS) Residential Aged Care District Assessment and Referral (RADAR TPCH) service (previously known as the Geriatric Outreach Assessment Service - GOAS) to be of significant benefit.
A number of ways of improving access to primary and specialist care were discussed, including:
• a dedicated after hours medical service for RACFs
• increased numbers of Nurse Practitioners working in RACFs
• increased access to allied health within RACFs, in particular, social workers
• increase the current RADAR TPCH operating hours to include the after-hours period
• improved specialist support available to GPs and RNs via a telephone support line or telehealth
• improved links with specialist palliative care, such as a direct support line for GPs
Increased emphasis on rehabilitation and reablement
RACFs recognise the potential for residential aged care to have a greater role in rehabilitation and reablement. RACFS would like to see better pathways for residential aged care to be used for rehabilitation with the ability for a resident to transition back home once their health and capacity has been restored.
Staff knowledge and skill development
RACFs recognise the importance of staff training and development, but a lack of funding for training can be a barrier. RACFs would like to see improved competency based training for staff and better peer support such as telephone-based nurse to nurse clinical support after hours.