Medical care of older persons in residential aged care facilities


The Silver Book
Service systems and templates
☰ Table of contents


The provision of medical care to residents of RACFs requires a systematic approach and arrangements between general practice, residential aged care and other organisations. An understanding of differences in their work structures, funding, accreditation standards and cultures is essential for developing effective systems.

Steps for organising the general practice and RACF to deliver medical care to residents are:

  1. Identify the health care needs of the residents in your care
  2. Identify service providers, stakeholders and support organisations with whom you need to develop partnerships
  3. Select resources and tools from Table 15
  4. Use quality improvement processes to implement resources and tools in your practice, RACF or other organisation.

Organisational systems and tools can be applied to support service delivery for residents at the patient and facility level. Table 15 contains examples of resources and tools that GPs and RACF staff can use. It also includes strategies that divisions of general practice can use to support GPs and RACF staff to improve quality of care for residents.

Types of resources and tools include:

  • service systems and templates, eg. work arrangements, registers, recall/reminder systems, checklists, health information management and technology
  • Medicare item numbers that remunerate GPs for multidisciplinary care of residents, including new Medicare item numbers for chronic disease management
  • funded aged care GP panels through divisions of general practice
  • information resources for residents and their relatives/carers, eg. rights and responsibilities, GP and RACF services, advance care planning, clinical conditions, state based support services
  • clinical resources for individual care, eg. assessment tools, guidelines, protocols, local service directories
  • facility wide programs and systems using multiple interventions to maintain a safe and healthy environment for residents and staff, eg. falls prevention programs, infection control procedures, medication management systems
  • professional education and training, geriatric assessment, advance care planning, dementia, medication management
  • quality improvement strategies, eg. advisory committees, 'plan, do, study, act' (PDSA) cycle, working groups, audits.

Table 15. Examples of resources and tools for the delivery of medical care to residents

 

Organisational aspect of care

GP tools

RACF tools

DGP tools

Develop partnerships between service providers

  • Designate a practice staff member as RACF coordinator
  • Establish work arrangements with RACFs
  • Provide practice information on GP services for residents (including respite)
  • Medical Deputising Service after hours arrangements
  • Identify local allied health and dental practitioners for referral
  • List of local specialist services
  • Knowledge of staff skills and services of RACF (high/low level, respite, dementia)
  • Accreditation and compliance with privacy legislation
  • Designated GP/health care coordinator
  • Register of attending GPs
  • Checklist of GP work arrangements
  • Medical and/or medication advisory committees
  • Accreditation and compliance with privacy legislation
  • Establish and maintain aged care GP panel in consultation with RACFs and other stakeholders
  • Develop agreed goals for working together
  • Information on liaison and support for special needs patients, eg. Aboriginal And Torres Strait Islander peoples, culturally and linguistically diverse people, those with disabilities

Arrange care for the new resident/patient

  • GP request transfer of medical record for new patient
  • Comprehensive medical assessment (CMA)
  • Advance care plan
  • MBS: CMA, RACF visits, GP contribute to care plan, case conference
  • Provide practice information on GP services
  • Discussions with resident and family/carer
  • State based entry application
  • Discussions with resident and family/carer
  • Identify authorised representative
  • Consent form for resident or authorised representative for exchange of health information
  • Identify resident's GP
  • Assessment and care plan
  • Commence advance care planning
  • Request GP contribution to care plan
  • Disseminate information on GP services for RACF patients
  • Promote use of CMA and other MBS items including new chronic disease management items
  • Support advance care planning
  • Provide comprehensive continuing medical care to each resident:
  •  
  • prevention
  • disease management
  • optimising function
  • symptom control
  • palliative care
  • Practice staff support with liaison, recall, administration documentation, health records management
  • RAC patient register and recall/reminder system
  • Clinical resources/protocols
  • MBS items: new chronic disease management items, RACF visits, CMA, GP contribute to care plan, case conference, referrals for allied health and dental care
  • Case conference record
  • Discussions with resident and family/carer
  • Referral links with specialist services (aged care, psychogeriatric, acute, rehabilitation, palliative care)
  • Acute and after hours notification and call out protocols
  • Request GP contribute to care plan
  • Use case conference record
  • Reminder system
  • Clinical resources/protocols
  • Notify GP of available RACF services, health programs for residents
  • Acute and after hours protocols for GP attendance/hospital transfer
  • Discussions with resident and family/carer
  • Transfer arrangements with GP and other services for pathology and health reports
  • Disseminate information, resources and tools, eg. 'silver book'
  • Educational seminars in relevant clinical topics
  • Local service directory with eligibility, availability, waiting times
  • Promote use of MBS items, including new chronic disease management items
  • Aged care GP panels
  • Transfers between RACF and acute care
  • GP receive hospital discharge information
  • GP review resident, medication and care plan
  • Protocols for referral, notification of relatives/carers, GP notification, transfer and hospital discharge information, medication update, GP review of care plan
  • Promote hospital use of discharge summaries and exchange of information on medication, test results
  • Maintain facility based systems
  • Medication management
  • Infection control
  • Prevention of falls, flu
  • Physical and social activity groups
  • Guidelines (eg. Australian medicines handbook, RACGP Standards for general practices)
  • Legislation and regulations
  • Electronic software to print medication labels
  • MBS: Chronic disease management, RMMR, case conference
  • Discussions with resident and family/carer
  • Guidelines (eg. APAC), legislation and regulations
  • Medication Advisory Committee
  • MBS: RMMR
  • Commercial medication management systems
  • Audits (eg. pharmacy)
  • After hours medication arrangements with pharmacy, GP, hospital
  • Promote establishment of effective medication management systems with local GPs, RACFs and pharmacists including routine, after hours and on return from hospital
  • Educational seminars
  • Support local health programs into facilities (eg. falls)
  • Conduct continuous quality improvement activities
  • Use PDSA cycle to implement organisational tools
  • Use the Standards Agency Continuing Quality Improvement for Aged Care to implement organisational tools
  • Identify and promote strategies to address service gaps
  • Training and development
  • Aged care GP panels
  • Promote GP participation in quality activities with RACFs
  • Support local joint quality improvement projects

 

When people enter residential aged care, it is important that RACF staff seek consent from them (or their representative) for health information to be disclosed to all relevant service providers involved in providing their medical care (see Tools 9). Staff could also provide information about how to appoint an authorised representative and initiate advance care planning in anticipation of future changes that may occur in the resident's health and/or capacity to make decisions.

On admission to RACFs, staff members usually ask new residents whom they have or wish to have as their GP. It would be helpful for residents who do not have a local GP to be given information on local GPs (eg. practice brochures).

It is recommended that each RACF have a register of attending GPs with a record of their preferred work arrangements. The checklist in Tools 12 provides a useful starting point for clarifying and documenting work arrangements with each GP.

A recall/reminder system in the general practice and/or RACF can be used by staff to track when residents are due for a GP visit, comprehensive medical assessment, case conference, care plan review, or residential medication management review. Samples of recall/reminder systems with reminder letters and resident information sheets are available in the 'GP and residential aged care kit' produced by North West Melbourne Division of General Practice.258

RACF staff can facilitate GPs' input into multidisciplinary health assessments and care plans by:

  • nominating staff to liaise with the GP, resident, relatives/carers/representative and other health care providers
  • sharing information from the resident's records and care plan with the GP
  • supporting the use of Medicare items for GP comprehensive medical assessments, GP contribution to care plan (at request of RACF staff), GP involvement in case conferences, and the GP and pharmacist component of residential medication management reviews
  • facilitating or participating in case conferences where residents' issues, goals and management plans are discussed
  • offering standardised documentation to record the comprehensive medical assessment (see Tools 10), case conference discussions (see Tools 11) and care plans.
  1. Flicker L. Clinical issues in aged care, managing the interface between acute, sub-acute, community and residential care. Aust Health Rev 2002;25:136-9.
  2. Lewis G, Pegram R. Residential aged care and general practice. Workforce demographic trends 1984-2001. Med J Aust 2002;177:84-6.
  3. Gray L, Woodward M, Scholes R, Fonda D, Busby W. Geriatric medicine: a pocket book for doctors, nurses, other health professionals and students. 2nd ed. Melbourne: Ausmed Publications, 2000.
  4. Aged Care Association Australia (ANHECA). Aged care Australia: the future challenges. Canberra: ANHECA, 2004.
  5. Aged Care Standards Agency (ACSA). Accreditation guide for residential aged care services. Canberra: ACSA Ltd., 2001.
  6. Australian Institute of Health and Welfare (AIHW). Residential aged care services in Australia 2000-1. A statistical overview. Canberra: AIHW, 2002.
  7. Carers Australia. Submission to the House of Representatives Standing Committee on Ageing: inquiry into long term strategies to address the ageing of the Australian population, 2004.  [Accessed 19 April 2005].
  8. Johnson N, Iddon P, Pierce G. Outside looking in: a resource kit on carer friendly practices in aged care facilities. Carers Victoria, 2003.
  9. Flicker L, op. cit.
  10. National Aged Care Alliance (NACA). NACA issues paper. The aged care - health care interface, 2003. [Accessed 19 April 2005].
  11. Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C, Wegner N. Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc 2004;5:297-309.
  12. Australian Nursing and Midwifery Council (ANMC). ANMC national competency standards for the enrolled nurse. [Accessed 01 August 2005].
  13. Healy J, Richardson S. Who cares for the elders? What we can and can't know from existing data. Adelaide: National Institute of Labour Studies, Flinders University, 2003.
  14. Australian Pharmaceutical Advisory Council (APAC). Guidelines for medication management in residential aged care facilities. 3rd ed. Canberra: APAC, Commonwealth of Australia, 2002.
  15. Health Professional Council of Australia. Membership and member organisations, 2005.  [Accessed 23 May 2005].
  16. Whitehead C, Penhall R. Australian Society for Geriatric Medicine. Position statement no. 8. Geriatric Assessment and Community Practice, 2000.  [Accessed 19 April 2005].
  17. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  18. Care Australia. A guide to palliative care service development: a population based approach, 2005.  [Accessed 19 April 2005].
  19. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care. Melbourne: North West Melbourne Division of General Practice, 2004.  [Accessed 22 April 2005].
  20. Ibid.
  21. The Royal Australian College of General Practitioners (RACGP). Standards for general practices. 2nd ed. Melbourne: RACGP, 2000.
  22. RACGP and Committee of Presidents of Medical Colleges. Handbook for the management of health information in private medical practice, 2002. [Accessed 19 April 2005].
  23. Dorevitch M, Davis S, Andrews G. Guide for assessing older people in hospitals. Prepared for the Care of Older Australians Working Group and Department of Health and aged Care, May 2005 (in press).
  24. Gray LC, Newbury JW. Health assessment of elderly patients. Aust Fam Physician 2004;33:795-7.
  25. Siggins Miller Consultants and School of Population Health, University of Queensland. Executive summary. In: A report to the Brisbane North Division of General Practice (BNDGP). The residential care project. Queensland: BNDGP, 2002. [Accessed 26 April 2005]
  26. Dorevitch M, Davis S, Andrews G, op. cit.
  27. National Health Medical Research Council (NHMRC). Communicating with patients: advice for medical practitioners. Canberra: Commonwealth of Australia, NHMRC, 2004.
  28. Reuban DB, Herr KA, Pacala JT, et al. Geriatrics at your fingertips: 2005, 7th ed. New York: The American Geriatrics Society, 2005. [Accessed 17 June 2005].
  29. Ibid.
  30. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  31. Dorevitch M, Davis S, Andrews G, op. cit.
  32. Ibid.
  33. World Health Organisation (WHO). International classification of functioning, disability and health. Geneva: WHO, 2001.
  34. Mahoney FI, Bethel D. Functional evaluation: the Bethel Index. Maryland State Med Journal 1965;14:56-61.
  35. Dorevitch M, Davis S, Andrews G, op. cit.
  36. Pierce G, Nankervis J. Putting carers in the picture: Improving the focus on carer needs in aged care assessment. Melbourne: Carers Association Victoria, 1998.
  37. Doka DJ. Grief, loss and care giving. In: Doka KJ, Davidson JD, editors. Caregiving and loss. Washington, DC: Hospice Foundation of America, 2001;215-30.
  38. Boss P. Ambiguous loss: learning to live with unresolved grief. London: Harvard University Press, 2000.
  39. Darzins P, Molloy DW, Strang D, editors. Who can decide? The six step capacity assessment process. Adelaide: Memory Australia Press, 2000.
  40. Ibid.
  41. Ibid.
  42. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  43. Maas ML, Reed D, Myonghwa P, et al. Outcomes of family involvement in care intervention for caregivers of individuals with dementia nursing research. Nurs Res 2004;53:76-86.
  44. O'Shea M. An unrecognised grief: loss and grief issues for carers - a workers guide. Melbourne: Carers Association Victoria, 2001.
  45. Payda C, Draper B, Luscombe G, Erlich F, Maharja J. Stress in carers of the elderly - a controlled study of patients attending a Sydney medical practice. Aust Fam Physician 1999;28:233-7.
  46. Steinberg MA, Cartwright CM, Najman JM, MacDonald SM, Williams GM. Healthy ageing, health dying: community and health professional perspectives on end of life decision making: report to the Research and Development Grant Advisory Committee (RADGAC) of the Department of Human Services and Health. University of Queensland Department of Social and Preventive Medicine, February 1996.
  47. Cartwright CM, Parker MH. Advance care planning and end of life decision making. Aust Fam Physician 2004;33:815-9.
  48. Australian Medical Association (AMA) Committee on Care of Older People. Making decisions for later life: the medical profession's role. Working paper. AMA 2002.
  49. Ruth D, Wong R, Haesler E. General Practice in residential aged care: clinical information sheet: Advance care planning to improve end of life care, in Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005].
  50. Cartwright CM, Parker MH, op. cit.
  51. 51. World Health Organisation (WHO). National cancer control programmes: policies and managerial guidelines, 2nd ed. Geneva: WHO, 2002.
  52. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care. Canberra: Rural Health and Palliative Care Branch, Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  53. WHO. National cancer control programmes: policies and managerial guidelines, op. cit.
  54. Rousseau P. Spirituality and the dying patient. J Clin Oncol 2003;21(9 Suppl):54-6.
  55. Murray SA, Kendall M, Boyd K, Sheikh, A. Illness trajectories and palliative care. BMJ 2005;330:1007-11.
  56. Australian Government Department of Health and Ageing 2004. Guidelines for a Palliative Approach in Residential Aged Care, op. cit.
  57. Taylor A, Box M. Palliative Care Australia: multicultural palliative care guidelines, 1999. Accessed 31 May 2005].
  58. Writing Group for Therapeutic Guidelines: Palliative Care. Therapeutic Guidelines: Palliative Care, version 1. Melbourne: Therapeutic Guidelines Ltd, 2001.
  59. Jones J, Willis D. In search of a good death: what is a good death? BMJ 2003;327:224.
  60. Age Health and Care Study Group. The future of health and care of older people: the best is yet to come. London: Age Concern, 1999.
  61. Ellershaw J, Wilkinson S, editors. Care of the dying - a pathway to excellence. New York: Oxford University Press, 2003.
  62. Ibid.
  63. Liverpool Care Pathway, 2005. [Accessed 10 May 2005].
  64. The RACGP. Clinical audit: what is a clinical audit? 2002. [Accessed 10 May 2005].
  65. ACSA, op. cit.
  66. Liverpool Care Pathway project. Beacon resource pack September 2002 - August 2003. [Accessed 10 May 2005].
  67. Australian Pharmaceutical Advisory Council (APAC), op. cit.
  68. Australian Medicines Handbook. Australian Medicines Handbook: medication choice companion: aged care. Adelaide: Australian Medicine Handbook, 2003.
  69. Ibid.
  70. Wagerty D, Brickley R. American Medical Directors Association and American Society of Consultant Pharmacists joint position statement on the Beers List of Potentially Inappropriate Medications in Older Adults, 2005.  [Accessed 26 April 2005].
  71. Australian Medicines Handbook, op. cit.
  72. Swagerty D, Brickley R, op. cit.
  73. APAC. APAC national guidelines to achieve the continuum of quality use of medicines between hospital and community. Canberra: APAC, Commonwealth of Australia, 1998.
  74. Pharmaceutical Society of Australia (PSA). Professional practice standards. Pharmacy services to residential care facilities, in Australia Pharmaceutical Formulary and Handbook. 19th ed. Canberra: PSA, 2004.
  75. Brown TM, Boyle MF. Clinical review ABC of psychological medicine: delirium. BMJ 2002;325:644-7.
  76. Writing Group for Therapeutic Guidelines: Psychotropic. Therapeutic Guidelines: Psychotropic, version 5. Melbourne: Therapeutic Guidelines Limited, 2003.
  77. Ibid.
  78. Australian Medicines Handbook, op. cit.
  79. Innouye SK, Charpentier PA. Precipitating factors for delirium in hospitalised elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996;275:852-7.
  80. Ibid.
  81. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  82. Ibid.
  83. Australian Medicines Handbook, op. cit.
  84. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op cit.
  85. Brodaty H, Draper BM, Low LF. Behavioural and psychological symptoms of dementia: a seven tiered model of service delivery. Med J Aust 2003;178:231-4. [Accessed 29 April 2005].
  86. Alzheimer's Australia and Access Economics. Dementia estimates and projections: Australian states and territories. Report by Access Economics for Alzheimer's Australia, 2005.  [Accessed 29 April 2005].
  87. Scherer S. Getting ACROSS Dementia: A dementia management resource for general practice. Melbourne: Southcity GP Services and Alzheimer's Association Victoria, 2003.
  88. Bridges-Webb C, Wolk J. Care of patients with dementia in general practice guidelines. Sydney: The Royal Australian College of General Practitioners and NSW Health, 2003.  [Accessed 29 April 2005].
  89. Ibid.
  90. Pond D, Brodaty H. Diagnosis and management of dementia in general practice. Aust Fam Physician 2004;33:789-93.
  91. Folstein MF, Folstein S, McHugh PR. Mini-Mental State a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
  92. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
  93. Dorevitch M, Davis S, Andrews G, op. cit.
  94. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit
  95. Australian Medicines Handbook, op. cit.
  96. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T. A depression management program for older patients and their general practitioners. Melbourne: SPHERE: A national mental health project, 1995. 
  97. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  98. Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002;167:859-64.
  99. Bridges-Webb C, Wolk J, op. cit.
  100. Ibid.
  101. Scherer S, op. cit.
  102. Bridges-Webb C, Wolk J, op. cit.
  103. Kane RL, Ouslander JG, Abrass IB. Essentials of clinical geriatrics. 4th ed. New York: McGraw-Hill, 1999.
  104. Maas ML, Reed D, Myonghwa P, et al, op. cit.
  105. Rosen J, Mittal V, Mulsant BH, Degenholsz H, Castle N, Fox D. Educating the families of nursing home residents: a pilot study using a computer-based system. J Am Med Dir Assoc 2003;4:128-34.
  106. Scherer S, op. cit.
  107. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc 2003;51:1213-8.
  108. Ouslander JG, Simmons S, Schnelle J, Uman G, Fingold S. Effects of prompted voiding on fecal continence among nursing home residents. J Am Geriatr Soc 1996;44:424-8.
  109. Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester: Wiley.
  110. Scherer S, op. cit.
  111. Brodaty H, Draper BM, Low LF, op. cit.
  112. National Dementia Behaviour Advisory Service (Alzheimer's Australia). ReBOC: reducing behaviours of concern: a hands on guide. Canberra: Australian Government Department of Health and Ageing, 2003.
  113. Popplewell P, Phillips P. Is it dementia? Which one? Aust Fam Physician 2002;31:319-21.
  114. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease. NPS RADAR Review, December 2004. [Accessed 16 May 2005].
  115. Neal M, Briggs M. Validation therapy for dementia (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Chichester: Wiley.
  116. Australian Government Department of Health and Ageing. Decision making tool: responding to issues of restraint in aged care. Canberra: Australian Government Department of Health and Ageing, 2004.  [Accessed 10 May 2005].
  117. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  118. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  119. National Prescribing Service. Galantamine (Reminyl) prolonged release capsules for dementia in Alzheimer's disease, op. cit.
  120. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  121. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  122. Australian Medicines Handbook, op. cit, 5-8.
  123. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  124. Ibid.
  125. Brodaty H, Draper BM, Low LF, op. cit.
  126. Australian Medicines Handbook, op. cit, 5-8.
  127. Scherer S, op. cit.
  128. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  129. Australian Medicines Handbook, op. cit, p.5-8.
  130. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  131. National Prescribing Service. Resperidone (Risperdal) for behavioural disturbances in dementia. NPS RADAR Review, April 2005.   [Accessed 16 May 2005].
  132. Ibid.
  133. Australian Medicines Handbook, op. cit, 5-8.
  134. Ibid.
  135. Katona CLE, Livingstone G. Functional psychiatric illness in old age. In: Tallis RC, Fillit HM, editors. Brocklehurst''s Textbook of Geriatric Medicine and Gerontology, 6th ed. London: Churchill Livingstone, 2002.
  136. Teresi J, Holmes D, Ramirez M, Eimicke J. Prevalence of depression and depression recognition in nursing homes. Soc Psychiatry, Psychiatr Epidemiol 2001;36:613-20.
  137. Fleming R, editor. Challenge depression: a manual to help staff identify and reduce depression in aged care facilities. Sydney: The Hammond Care Group, 2001.
  138. Fleming R, op. cit.
  139. Snowdon J. Late-life depression: what can be done? Aust Prescr 2001;24:65-7.
  140. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington DC: American Psychiatric Association Press, 1994.
  141. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  142. Fleming R, op. cit.
  143. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  144. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  145. Khan F. Poststroke depression. Aust Fam Physician 2004;33:831-4.
  146. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  147. Khan F, op. cit.
  148. Fleming R, op. cit.
  149. Khan F, op. cit.
  150. Australian Medicines Handbook, op. cit.
  151. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  152. Snowdon J, op. cit.
  153. Scott E, Pesiah C, Hickie I, Ricci C, Davenport T, op. cit.
  154. Khan F, op. cit.
  155. Bird MJ, Parslow RA. Potential for community programs to prevent depression in older people. Med J Aust 2002;177:S107-110.
  156. Snowdon J, op. cit.
  157. Writing Group for Therapeutic Guidelines: Psychotropic, op. cit.
  158. Ibid.
  159. Australian Medicines Handbook, op. cit.
  160. Chan D, Phoon S, Yeoh E. Australian Society for Geriatric Medicine. Position statement no. 12. Dysphagia and aspiration in older people. Australas J Ageing 2004;23:198-202.  [Accessed 19 April 2005].
  161. Martino R, Pron G, Diamant N. Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia 2000;15:19-30.
  162. Australian Medicines Handbook, op. cit.
  163. Chan D, Phoon S, Yeoh E, op. cit.
  164. Australian Medicines Handbook, op. cit.
  165. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine, 5th ed. New York: McGraw-Hill, 2002.
  166. Scherer S, Jennings C, Smeaton M, Thompson P, Stein M. A multi-disciplinary practice guideline for hip fracture prevention. Australas J Ageing 2002 21:203-10.
  167. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra, ACT: Australian Government Department of Health and Ageing, 2005; in press.
  168. Ibid.
  169. Ibid.
  170. Ibid.
  171. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49:664-72.
  172. Australian Council for Safety and Quality in Health Care, op. cit.
  173. Writing Group for Therapeutic Guidelines: Therapeutic Guidelines: endocrinology, version 4. Melbourne: Therapeutic Guidelines Limited, 2004.
  174. Australian Council for Safety and Quality in Health Care, op. cit.
  175. Fonda D. Improving management of urinary incontinence in geriatric centres and nursing homes. Victorian Geriatric Peer Review Group. Aust Clin Rev 1990;10:66-71.
  176. Gardner J. Promoting continence in nursing homes: a national project. Urol Nurs 1992;12(2):83.
  177. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  178. The RACGP (West Australian Research Unit). Managing incontinence in general practice. Clinical practice guidelines. Perth: RACGP, 2002.  [Accessed 6 June 2005].
  179. Australian Medicines Handbook, op. cit.
  180. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  181. Ibid.
  182. Australian Medicines Handbook, op. cit.
  183. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  184. Australian Medicines Handbook, op. cit.
  185. Ibid.
  186. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  187. Sapsford R. Physiotherapy for pelvic floor dysfunction in the aged care setting. In: Nitz JC, Hourigan SR, editors. Physiotherapy practice in residential aged care. Edinburgh: Butterworth Heinemann, 2004.
  188. The RACGP (West Australian Research Unit), op. cit.
  189. Kalantar JS, Howell S, Tally MJ. Prevalence of faecal incontinence and associated risk factors: an underdiagnosed problem in the Australian community? Med J Aust 2002;176:54-7.
  190. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  191. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  192. Australian Medicines Handbook, op. cit.
  193. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  194. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  195. Ibid.
  196. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  197. Kamm MA. Faecal incontinence: common and treatable Med J Aust 2002;176:47-8.
  198. The RACGP (West Australian Research Unit), op. cit.
  199. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, 2004.  [Accessed 19 April 2005].
  200. Ibid.
  201. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  202. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting, op. cit.
  203. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  204. Australian Medicines Handbook, op. cit.
  205. National Health and Medical Research Council. The Australian immunisation handbook. 8th ed. Canberra: Commonwealth of Australia, 2003.
  206. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections. In: Residential Aged Care Kit. Melbourne: North West Melbourne Division of General Practice, 2004. [Accessed 19 April 2005]
  207. Ibid.
  208. Australian Government Department of Health and Ageing. Guidelines for a palliative approach in residential aged care, op. cit.
  209. Ruth D, Wong R, Haesler E, op. cit.
  210. Mater Hospital (Oncology and Palliative Care Wards). Authorised opioid conversion chart. Brisbane: Mater Hospital, 2005.
  211. Writing Group for Therapeutic Guidelines: Analgesic: Therapeutic Guidelines: Analgesic, version 4. Melbourne: Therapeutic Guidelines Limited, 2002.
  212. Ibid.
  213. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6.  [Accessed 6 June 2005].
  214. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  215. Stacey MC. Preventing pressure ulcers [editorial]. Med J Aust 2004;180:316.
  216. Prentice JL, Stacey MC. Pressure ulcers: the case for improving prevention and management in Australian health care settings. Primary Intention 2001;9:111-20.
  217. Australian Wound Management Association. Clinical practice guidelines for prediction and prevention of pressure ulcers. Perth: Cambridge Media, 2001.
  218. Queensland Health. Pressure ulcer prevention and management resource guidelines. Brisbane: Queensland Health, 2004.  [Accessed 6 June 2005].
  219. Ibid.
  220. Stacey MC, op. cit.
  221. Norton D, Exton-Smith AN, McLaren R. An investigation of geriatric nursing problems in hospitals. London: Churchill Livingstone. National Corporation for Care of Old People, 1975.
  222. Bergstrom N. A clinical trial of the Braden Scale for predicting pressure score risk. Nurs Clin North Am 1987;22:417-28.
  223. Waterlow J. Pressure sores: a risk assessment card. Nurs Times 1985;81:49-55.
  224. Joanna Briggs Institute. Pressure sores - part 1: prevention of pressure related damage. Best Practice 1997;1:1-6. [Accessed 6 June 2005].
  225. Dorevitch M, Davis S, Andrews G, op. cit.
  226. Norton D, Exton-Smith AN, McLaren R, op. cit.
  227. Queensland Health, op. cit
  228. Australian Wound Management Association, op. cit.
  229. Gray L, Woodward M, Scholes R, Fonda D, Busby W, op. cit.
  230. Ibid.
  231. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
  232. Queensland Health, op. cit.
  233. Ibid.
  234. Ibid.
  235. Guy RJ, Di Natale R, Kelly HA, et al. Influenza outbreaks in aged-care facilities: staff vaccination and the emerging use of antiviral therapy. Med J Aust 2004;180:640-2.
  236. Australian Medicines Handbook, op. cit.
  237. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  238. Guy RJ et al., op. cit.
  239. Australian Medicines Handbook, op. cit.
  240. Ibid.
  241. National Health and Medical Research Council, op. cit.
  242. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  243. Ibid.
  244. Australian Medicines Handbook, op. cit.
  245. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary Tract Infections, op. cit.
  246. Australian Medicines Handbook, op. cit, 5-8.
  247. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  248. Ibid.
  249. Australian Medicines Handbook, op. cit, 5-8.
  250. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  251. Australian Medicines Handbook, op. cit, 5-8.
  252. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  253. Australian Medicines Handbook, op. cit, 5-8.
  254. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  255. Ibid.
  256. Writing Group for Therapeutic Guidelines: Antibiotic, op. cit.
  257. Australian Medicines Handbook, op. cit, 5-8.
  258. Ruth D, Wong R, Haesler E. General Practice in residential aged care, partnerships for 'round the clock' medical care, op. cit.
  259. Australian Government Department of Health and Ageing. Medicare Benefits Schedule, 2005. Available atwww7.health.gov.au/pubs/mbs/index.htm [Accessed 10 May 2005].
  260. Aged Care Standards Agency. Continuous improvement for residential aged care: an education package, 2001.  [Accessed 10 May 2005].
  261. NSW Health Department. Easy guide to clinical practice improvement. A guide for health care professionals, 2002. [Accessed 10 May 2005].
  262. Dorevitch M, Davis S, Andrews G, op. cit.
  263. Flicker l, Loguidice D, Carlin JB, Ames D. The predictive value of dementia screening in clinical populations. Int J Geriatric Psychiatry 1997;12:203-9.
  264. Dorevitch M, Davis S, Andrews G, op. cit.