This is a Less Involved QI – includes PIP QI measures
Advance care planning allows health professionals to understand and respect a person’s future healthcare preferences, for a time when they become seriously ill and unable to communicate for themselves.
Registered and non-registered health practitioners have a role in advance care planning and require capability to facilitate these conversations effectively. The National Quality Standards for aged care, general practice and health services all promote advance care planning. (National framework for advance care planning documents, 2021)
Advance care planning conversations should be routine and occur as part of a person’s ongoing healthcare plan. Better outcomes are experienced when advance care planning is introduced early as part of ongoing care rather than in reaction to a decline in condition or a crisis situation.
Improve practitioner confidence in advance care planning discussions
Increase number of patients with recorded advance care directives
HealthPathways
Read the Advance Care Planning Pathway for clinician information on the background, assessment and management of Advance Care Planning in Primary Care
Healthy North Coast Education – Advance Care Planning, a Webcast Conversation with Dr Dan Curley
Watch our recorded webinar with Dr Dan Curley, Palliative Care Physician, on Advance Care Planning (Recorded March 2024). Topics covered include:
https://vimeo.com/926083280/e2f383a696
Advance Care Planning Australia – Fact Sheet for Health Professionals
This fact sheet outlines the basics of Advance Care Planning for health professionals.
Advance Care Planning Improvement (ACPI) Toolkit
The ACPI Toolkit provides health and aged care services with resources to support organisational advance care planning uptake, performance monitoring, and quality improvement. The toolkit complies with the National Safety and Quality Health Service (NSQHS) Standards and Aged Care Quality Standards.
Advance Care Planning Australia – Health professionals: roles and responsibilities
Information for how to support your patient’s future health care preferences.
Palliative Care Australia – Discussion Starters
Palliative Care Australia’s (PCA) Discussion Starter series and Card packs have been developed to reach into communities to normalise early conversations about the end-of-life, rather than waiting until more time-critical or medical-focused discussions need to occur. The resources have been developed to help Australians work out what’s right for them if they were to become very sick or at the end of their lives.
ELDAC – Advance Care Planning Toolkit
End of Life Directions for Aged Care (ELDAC) has compilied a toolkit for advance care planning in primary care. The Toolkit contains links to forms and legislation, patient and clinician information and education resources.
https://www.eldac.com.au/Toolkits/Primary-Care/Clinical-Action/Advance-Care-Planning
The Advance Project
The Advance Project provides practical, evidence-based resources and training that empower aged and primary care professionals to initiate advance care planning and palliative care. It is specifically designed to support residential and community aged care professionals, and GPs, nurses and support staff in general practice and primary care, to implement a team-based approach to initiating advance care planning (ACP) and palliative care into everyday practice and care provision.
Advance Care Planning Australia – Navigating the topic of Voluntary Assisted Dying in Advance Care Planning Conversions: Guiding Principles for Health Care Professionals
Voluntary assisted dying (VAD) as an end-of-life treatment option is now lawful in all Australian states and appears likely to become lawful in the territories. The passing of these laws means that the topic of VAD may arise during Advance Care Planning (ACP) conversations. Health professionals have a responsibility to be open and ready to support the person to be heard, regardless of their personal views.
End of Life Law for Clinicians
A training program for medical practitioners and students, nurses and allied health professionals that focuses on Australian laws on end of life decision-making.
https://palliativecareeducation.com.au/course/index.php?categoryid=5
NSW Health – Advance Care Planning
NSW Health resources for clinicians regarding advance care planning.
https://www.health.nsw.gov.au/patients/acp/Pages/default.aspx
NSW Health – Advance care planning for the Aboriginal Community
Specific resources for advance care planning with the aboriginal community.
https://www.health.nsw.gov.au/patients/acp/Pages/advance-care-planning-aboriginal-community.aspx
LGBTIQ+ Health Australia – LGBTIQ+ Inclusive Palliative Care eLearning
This FREE eLearning aims to increase healthcare providers’ confidence in providing LGBTIQ+ inclusive palliative care including:
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.
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.
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.
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.
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.
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.
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.
Strategic Priority Area: Securing a Healthier Future
Connection and a sense of belonging are protective factors for both individual and community health and wellbeing. Evidence highlights that the social determinants of health play a critical role in addressing many of our regions health challenges.
That’s why Healthy North Coast has long been committed to supporting communities to strengthen and to build social health. Our initiatives, including contemporary ‘Social Prescribing’, help people to connect to activities, supports and each other, and assist communities to integrate services and bridge gaps.
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:
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.
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:
These objectives will contribute to achieving the following intended overarching outcomes of:
Funding is open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
Workforce Locum support and R&R funding criteria
Wellbeing Flexible Funding Criteria & Eligibility
| *Team Size (Total staff and contractors) | Funding Available |
| Small (1-5) | $500-$1500 |
| Medium (6-20) | $1500-$4000 |
| Large (>20) | $4000-$5000 |
