Feb

26

2019

Aged Care Assessment and Consultation Service in Tweed Heads

Do you see older patients who have complex health care needs and are at risk of hospitalisation or dependence?

Registered Nurse Practitioner Lisa Garland provides an Aged Care Assessment and Consultation Service to general practices and their patients in Tweed Heads. Lisa is employed by the Northern NSW Local Health District, but the service is jointly funded with NCPHN.

Who is eligible?

  • People over 65 years.
  • At risk of hospitalisation or multiple hospitalisations.
  • Multiple complex comorbidities associated with disability.
  • Frailty, falls, unsteady gait or reduced physical mobility.
  • Common geriatric syndromes, incontinence or confusion.
  • Weight loss with no obvious cause.
  • Dementia, depression, anxiety, cognitive decline or delirium risk.
  • Concerns about level of care patient receives at home or threatened dependence.

The service aims to maintain wellness and supports patients by providing:

  • Comprehensive Aged Care Assessment by an experienced Aged Care Nurse Practitioner.
  • Assessment includes patient, family and carers.
  • Recommendations and referrals for ongoing care and support or further assessment.
  • Consultation with GP and health care team.
  • Patient and carer education about early recognition of deterioration and planning for this.
  • Follow-up, monitoring and case management according to priority.

There is no cost to the practice or the patient.

A referral form is available to load in practice software. The form can be faxed to (07) 5599 3757.

Further enquiries and information can be sought from Lisa Garland, Nurse Practitioner, Aged Care NNSWLHD. Phone 0408 647 987.

Click here to download a flyer for this service.

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Healthy North Coast acknowledges the Traditional Custodians of the lands across our region, and pay our respect to Elders past, present and on their journey. We recognise these lands were never ceded and acknowledge the continuation of culture and connection to the land, sky and sea. We acknowledge Aboriginal and Torres Strait Islander peoples as the Land’s First Peoples and honour the rich diversity of the oldest living cultures.

The PHN program is an Australian Government Initiative.
ACNC registered charity healthy north coast

flags We acknowledge the traditional custodians of the land we live and work, the Bundjalung, Arakwal, Yaegl, Gumbaynggirr, Githabul, Dunghutti and Birpai Nations, and their continuing connection to land, sea and community. We pay our respects to elders past, present and future.

Our regional partners

  • Local Health District partners in our footprint: Mid North Coast Local Health District (MNCLHD) & Northern New South Wales Local Health District (NNSWLHD)
  • Aboriginal Medical Services (AMS)
  • The Royal Australian College of General Practitioners (RACGP)
  • Australian College of Rural and Remote Medicine (ACRRM)
  • Rural Doctors Network (RDN)
  • Rural Clinical Schools & Regional Training Hubs
  • General Practitioners
  • Registrars and International Medical Graduates
  • North Coast Allied Health Association (NCAHA)
  • Local Councils
    Pharmaceutical Society of Australia (PSA)
  • Universities including: Charles Sturt University (CSU), University of New South Wales (UNSW), Southern Cross University (SCU)

Aged Care Disaster Management Planning

Strategic Priority Area: One team

North Coast is identified as the region most likely to be impacted by climate change in Australia and also forecasted greatest growth in those 65+.

Healthy North Coast takes a lead role in ensuring the older population and the sector that supports them are prepared for, can respond to and recover from disasters and other emergencies.

We have led eight regional disaster management capacity building workshops, bringing together SES, community organisations and the aged care sector.

We have also developed disaster preparedness tip sheets for both residential and community aged care providers.

Read the media release: Aged Care Homes Prepare for Disasters

Voluntary Assisted Dying

Strategic Priority Area: One team

In May 2022, the NSW Parliament passed the Voluntary Assisted Dying Act 2022. Effective from Tuesday, 28 November 2023, eligible people have the choice to access voluntary assisted dying. 

Healthy North Coast has developed a webpage for both health professionals and consumers, with links to available information and resources.

Visit the Voluntary Assisted Dying webpage

Living with Dementia resources

Strategic Priority Area: No one is left behind

Healthy North Coast has worked with people living with dementia, their families and local service providers to develop an information booklet that will help them connect with local and national supports along their journey.

Highly regarded by a range of professional supporting those on or starting the dementia journey, the booklet includes commonly asked questions for people to ask their GP and/or specialist.

“It’s a fantastic resource and I give it to everyone on their first diagnosis. Its easy to read, so well planned and thought through and has lots of really useful information, tailored to the region.
I also find it very helpful when educating clinical staff.”

−Geropsychiatric Nurse Practitioner, Mid North Coast.

The resource is available in digital and printed copies, with more than 5,000 distributed across the region. An e-version is available to clinicians via the Dementia and Cognitive Impairment HealthPathway.

View the Living with Dementia booklet (PDF)

Deteriorating Resident Triage Tool Pilot

Strategic Priority Area: One team

The Deteriorating Resident Response Tool (DRRT) has been developed to guide RN’s in Residential Aged Care homes (RACHs) to better understand, anticipate and make clinical decisions responding to the deteriorating health of residents.

The objective of the DRRT is to give RACH staff clear information to triage and provide appropriate care for a range of residents’ health conditions, and, in turn, prevent unnecessary presentations to ED.

The tool has been designed together with a specialist geriatrician, consulting with stakeholders such as Residential Aged Care Managers, NSW Ambulance, GPs, and experts from Mid and North Coast LHDs.

The pilot commences in March with four participating RACHs. Evaluation measures will include effectiveness in building RN confidence and reported reduction in unnecessary hospitalisations. Findings will inform a future planned, region-wide implementation.

View the deteriorating resident response tool

North Coast Care Finders Program

Strategic Priority Area: No one is left behind

The Care Finders program is a free region-wide service to support vulnerable older people who have no-one else to help them, to learn about, apply for and set up support services.

Care finders can help people understand what aged care services are available, set up an assessment, and find and choose services. They also help people with access to other supports in the community, both accessing services for the first time and changing or finding new services and supports.

On the North Coast, Healthy North Coast has commissioned four organisations to provide this important service: EACH, Carexcell, Lifetime Connect and Footprints.

Download the 'Older people with a focus on priority target populations and access to services' Needs Assessment
Visit the commissioned services listings to find out more, including service contact information.
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Psychological services in residential aged care homes

Strategic Priority Area: Improving Lives Now

Healthy North Coast commissions two service providers to deliver psychological therapies and supports for older people with, or at risk of developing, a mental illness and who are living in residential aged care homes (RACHs).

The aim of the program is to both provide direct support to residents and their families and carers, as well as upskill the RACH workforce to respond to the needs of residents presenting with mental health concerns.

Visit the commissioned services listings to find out more, including service contact information.​

Social prescribing (Healthy Me Healthy Community)

Strategic Priority Area: Securing a Healthier Future

Delivered by Feros Care, the Healthy Me, Healthy Community program aims to build individual and community connections to reduce loneliness and improve wellbeing in Port Macquarie.

The program helps people to connect with community, activities, supports and services that address their broader social determinants of health, as an alternative or supplement to a clinical approach.

Visit the Healthy Me Healthy Community service page
Read the consumer story: Jim’s confidence boost brings a new lease on life
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Telehealth in Residential Aged Care

Strategic Priority Area: Improving Lives Now

The Royal Commission into Aged Care Quality and Safety identified several critical areas affecting aged care residents and our health system. Key challenges include:

  • Limited access to general practitioners (GPs) and allied health professionals in aged care facilities.
  • Difficulties accessing out-of-hours services

Telehealth offers valuable opportunities to enhance support for residents living in aged care homes. Funded by the Commonwealth Department of Health and Aged Care, this initiative provides telehealth equipment and staff training as part of the response to the Royal Commission’s findings.

By improving access to primary care clinicians, specialist services, and other service providers through telehealth, we can significantly enhance health outcomes for residents, reducing unnecessary hospital transfers and emergency department visits.

The selection of telehealth equipment was guided by our Healthy Ageing Strategy (HAS), a comprehensive digital discovery questionnaire, and consultation workshops with various stakeholders. These efforts included interviews with residents to understand their attitudes toward telehealth, ensuring the initiative meets their needs and preferences.

For more information, visit the Telehealth in Residential Aged Care​ webpage
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Greater Choice at Home Palliative Care Program

Strategic Priority Area: Improving Lives Now

Aims to provide people who have life limiting conditions the opportunity to exercise choice and receive high quality care at home, harnessing improved and better coordinated supports and services that meet their individual needs.

Program objectives:

  • Improve access to palliative care at home and support end-of-life care systems and services (in primary health care and community care)
  • To enable the right care at the right time and in the right place (to reduce unnecessary hospitalisation)
  • Generate and use data to support continuous improvement of services across sectors
  • Use available technologies to support flexible and responsive palliative care at home, including in the after-hours.

These objectives will contribute to achieving the following intended overarching outcomes of:

  • Improved capacity and responsiveness of services to meet local needs and priorities
  • Improved patient access to quality palliative care services in the home
  • Improved coordination of care for patients across health care providers and integration of palliative care services in their region.
Read more about the Greater Choice at Home Palliative Care Program
Download the 2023 Palliative and End-of-life Care Needs Assessment (PDF)

Education & training funding elibility

Funding is open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.

References

  1. Healthy North Coast Health Needs Assessment, 2022-2025
  2. Northern Rivers Community Foundation (2023). Northern Rivers Vital Signs, 2023
  3. Northern Rivers Community Foundation Flood Impact Report, May 2023
  4. Ang, C., Abdo, M., Rose, V., Lim, R., and Taylor, J. (2023). Participatory Grantmaking: Building the Evidence. Centre for Evidence and Innovation. 
  5. Lee, G., Vine, K., Atkinson, A-R., Tong, M., Longman, J., Barratt, A., Bailie, R., Vardoulakis, S., Matthews, V., & Mizanur Rahman, K. (2023). Impacts of Climate Change on Health and Health Services in Northern New South Wales, Australia: A Rapid Review. International Journal of Environmental Research and Public Health, 20, 6285. 
  6. Sewell, T., Stephens, R., Dominey-Howes, D., Bruce, E., & Perkins-Kirkpatrick, S. (2016), Disaster declarations associated with bushfires, floods and storms in New South Wales, Australia between 2004 and 2014. Scientific Reports (6). 
  7. Dominey-Howes, D., Bruce, E., Stephens, R., Perkins-Kirkpatrick, S., & Sewell, T. (2016). Natural disasters are affecting some of Australia’s most disadvantaged communities. The Conversation. 

Workforce Locum support and R&R funding criteria

  • Available to primary care services in disaster impacted communities within the Healthy North Coast footprint.
  • Available to support short-term workforce coverage, allowing clinicians to rest and recover.
  • Workforce-support funding in total is capped for each site, over a 12-month period:
    • $10k for GPs and/or
    • $5K for nursing and/or
    • $5k administration support and/or
    • $5K allied/pharmacy and other.
  • Funding is not to be used to fill gaps in staffing that have not been able to recruit to and not to replace existing staff.
  • Healthy North Coast will assess requirements and approve available funding directly with the service requesting support.
  • Priority will be given to sites that have immediate, short-term workforce support needs.
  • Requests will be reviewed and supported on a case-by-case basis.
  • Program funding administered via RCTI Agreement (Recipient Created Tax Invoice) to be paid monthly, or on completion of the placement (whichever comes first).
  • Practices will be required to complete a request for payment form monthly, or on completion of the placement (whichever occurs first).

Wellbeing Flexible Funding Criteria & Eligibility

  • Open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
  • Activity must be purposeful, with the aim of increasing the wellbeing of your team.
  • Requests will be assessed on a case-by-case basis, with funding allocated based on team size.*
  • Following approval by Healthy North Coast, funding will be administered via RCTI Agreement (Recipient Created Tax Invoice) upon providing proof of expenses.
  • Funding cannot be used for the purchase of alcohol, or any other goods or services where the vendor cannot quote their Australian Business Number.
  • Planned activities must occur prior to 30th June 2024.
  • Funding will not be available for retrospective activities.
*Team Size
(Total staff and contractors)		Funding Available
Small (1-5)$500-$1500
Medium (6-20)$1500-$4000
Large (>20)$4000-$5000