General approach to medical care of residents
General practitioners are the primary medical care providers for older people in the community, including those living in residential aged care facilities (RACFs) . Residential aged care is an expanding and rewarding area of general practice. It offers GPs the opportunity to be at the forefront of new treatments and management practices and to make a difference to the quality of life of a patient group with complex medical needs. Providing high quality medical care for older persons living in RACFs requires a special set of knowledge, clinical skills, attitudes and practice arrangements.
This fourth edition of the Medical care of older persons in residential aged care facilities ('silver book') is primarily for use by GPs who are commencing, or already providing, care for patients in residential aged care. It recognises the multidisciplinary nature of care and may also be useful as a clinical or educational resource for:
nurses and staff in RACFs in their work with GPs
other health professionals who provide services to residents
divisions of general practice that work collaboratively with GPs and residential aged care staff, and
other regional, state and national support groups.
Section one presents principles and essential components of residents' care including comprehensive medical assessment, advance care planning, palliative and end of life care, and medication management. Section two discusses common clinical conditions. Section three offers additional resources including organisational and clinical tools.
Given that the focus is on medical care of people living in aged care facilities, the terms 'resident' and 'patient' have been used interchangeably. The resident centred approach acknowledges the important role that relatives, carers and legally appointed representatives play in the provision of medical care to residents, particularly as most older residents have some degree of cognitive impairment. Younger residents are also likely to benefit from the assessment and care processes presented in this edition of the 'silver book'.
Since the 1999 third edition of the 'silver book', several trends have presented challenges to GPs providing care to patients in residential aged care. The ageing of the population has increased the demand on the health care system overall. Historically, a reduction in the number of hospital beds and length of stay, and a move toward community based care has been the trend. In recent times, however, the number of hospital beds has increased slightly and the average length of stay has decreased. People now enter residential care with higher levels of dependency and with more complex medical needs in relation to chronic illness, physical disability and dementia.1
The number of GP attendances to RACFs has been decreasing over recent times due to factors such as workforce shortages, high GP workloads, and part time work preferences.2
However, during the same period, some developments have increased support for medical care provision to residents. These include:
an increased focus on evidence based preventive care and integrated systems of care for improving residents' health outcomes
continuing development of clinical guidelines, practice standards and accreditation systems in general practice, government subsidised RACFs, and pharmaceutical services
information technology such as electronic health records, clinical aids and health information management systems
models of specialist outreach services to RACFs, including hospital in the home, aged care, postacute care, rehabilitation and palliative care.
Recent Australian Government initiatives have increased funding for: GP and multidisciplinary medical care to residents; divisions of general practice to support GP participation in quality improvement activities in residential aged care; and for dementia care as a national health priority.
There is considerable diversity in residential aged care across Australia. Therefore, it is advisable to adapt the information contained in the 'silver book' to the local context, in ways that take account of particular needs of the local resident population, as well as local organisational structures, staffing levels and access to specialist services for residents' health care.
It is hoped that the Medical care of older persons in residential aged care facilities will continue to enhance the work of GPs, staff of RACFs, and others caring for residents of RACFs.