RACGP aged care clinical guide (Silver Book)

Silver Book - Part C

Services, systems and templates

Last revised: 20 Jul 2023

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

‘Integrated care’ refers to strategies that aim to overcome fragmentation between different services and sectors. It is a way to improve health and wellbeing, as well as satisfaction with services, and to establish efficient and sustainable health and aged care systems.

Some examples are provided in this chapter of organisation systems and tools to improve integrated care in aged care both in the community and in RACFs.

The Standards for general practice residential aged care (1st edition) (hereafter Standards for GPRAC) support and enhance the delivery of quality and safe GP care to residents in RACFs. The Standards for GPRAC focus on the clinical and systemic interface between the GP (and GP team, including other practitioners from the same practice) and RACFs. The Standards for GPRAC set out essential minimum requirements for GPs to provide quality and safe care in this setting.

The Standards for GPRAC support and facilitate RACFs and GPs to work collaboratively to provide care that is respectful, responsive and coordinated, while addressing some of the challenges facing GPs in delivering care in RACFs.

Organisational systems, strategies and tools can be applied to support service delivery for residents at the patient and facility level. 

Types of resources and tools include:

  • service systems and templates (eg work arrangements, registers, recall/reminder systems, checklists, electronic health records, My Health Record)
  • Medicare item numbers that remunerate GPs for multidisciplinary care of residents (ie case conferencing)
  • 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 Medicine advisory committees, PDSA cycle, working groups, audits).

This section contains examples of resources and tools that GPs and aged care services can use to improve communication between providers of clinical care. Information on strategies that PHNs can use to support GPs, RACF staff and aged care services to improve quality of care for residents is also included. 

Developing partnerships between service providers

Developing partnerships/collaboration between service providers not only builds relationships and trust between providers, but also supports older people’s experience and continuity of care within the aged care sector. 

GP systems, strategies and tools

GPs can use a variety of tools to establish partnerships between different aged care service providers. These can include:

  • designating a practice staff member as an aged care coordinator
  • establishing work arrangements with aged care providers, such as RACFs
  • providing practice information on GP services for aged care (including respite care)
  • providing practice details for after-hours arrangements, such as medical deputising/locum service
  • promoting staff skills and services in aged care that can be accessed by services and patients
  • accreditation and compliance with privacy legislation. 

Aged care services systems, strategies and tools

Aged care services can implement the following tools to develop partnerships with GPs, hospitals and other supporting aged care services:

  • have a designated GP/healthcare coordinator, including a virtual care coordinator
  • have a register of attending GPs and contact details
  • have a checklist of GP work arrangements available to RACF staff
  • have an understanding of medical deputising/locum service after-hours arrangements for patients
  • provide a list of local allied health and dental practitioners to GPs
  • provide a list of local specialist services to GPs
  • provide telehealth facilities for GP and specialist remote consultations
  • implement a medication advisory committee
  • ensure accreditation and compliance with privacy legislation. 

PHN systems, strategies and tools

PHNs have an important role in supporting systems to maintain partnerships between GPs, hospitals, RACFs and other supporting aged care services:

  • establish and maintain aged care GP panel in consultation with RACFs and other stakeholders
  • develop agreed goals for aged care services to work together
  • provide information on liaison for vulnerable populations (eg Aboriginal And Torres Strait Islander peoples, CALD people, people with disabilities)
  • establish a register of GPs working in RACFs
  • maintain up-to-date aged care HealthPathways
  • establish and support specific interest groups. 

Arranging care for the new resident/patient

The aged care sector can be overwhelming for new patients/residents; it is therefore important that they are provided with support by all aged care providers. 

GP systems, strategies and tools

When arranging care for a new RACF resident or older person, GPs can:

  • request the transfer of medical records for a new patient
  • review or conduct a CMA with the new patient
  • establish or review an advance care plan
  • provide practice information on GP services for new patient
  • hold discussions with the patient/resident and family/carer
  • arrange My Aged Care assessments to support the patient
  • use MBS items to support CMA, RACF visits, GP contribution to care plan and case conference. 

Aged care services systems, strategies and tools

It is important that aged care services use the following to support new residents/patients:

  • state-based RACF entry application
  • discussions with the resident and family/substitute decision maker about expectations for their care
  • consent form signed by the resident or their substitute decision maker for the exchange of health information
  • health assessment and care plan.

In addition, aged care services should:

  • identify a person’s substitute decision maker/s
  • identify person’s regular GP
  • commence and support advance care planning. 

PHN systems, strategies and tools

PHNs can support the care needs of older people during their first encounters with aged care services by implementing tools for GPs, hospitals and aged care services, including:

  • commencing and supporting advance care planning
  • requesting GP contribution to care plans
  • disseminating information on GP services for aged care
  • promoting the use of CMA and other MBS items, including new chronic disease management items. 

Providing comprehensive, continuing medical care to each patient to support optimal health and wellbeing

People aged 65 years and over are more likely to have two or more chronic conditions; therefore, the provision of comprehensive, continuing medical care to support optimal health and wellbeing between health services is very important. Comprehensive, continuing medical care can include:

  • preventive healthcare
  • disease management
  • optimising function
  • symptom control
  • palliative care. 

GP systems, strategies and tools

Providing comprehensive continuing medical care to patients is important for GPs, especially with older people, and can be supported by using the following tools:

  • practice staff support with liaison, recall, administration documentation and health records management
  • discussions with an older person and family/carer
  • aged care patient register (RACF and home visits)
  • recall/reminder system for follow-up care
  • clinical resources/protocols, including deprescribing guidelines
  • case conference records
  • referral links with specialist services (aged care, psychogeriatric, acute, rehabilitation, palliative care)
  • acute and after-hours notification and call-out protocols.
  • My Health Record health summaries
  • comprehensive health summaries
  • MBS items to support new chronic disease management items, RACF visits, palliative care visits, telehealth consultations, CMA, GP contribution to care plan, case conference, referrals for allied health and dental care.

GPs can also provide support by writing death certificates. 

Aged care services systems, strategies and tools

It is important that GPs have oversight of their patient’s continuing care needs. Aged care services can use the following tools to support or facilitate communication:

  • request the GP contributes to the care plan
  • use case conference records
  • use clinical reminder systems (eg GP follow-up, immunisations and medication reviews)
  • use clinical resources/protocols
  • notify the GP of available RACF services, health programs for residents, acute and after-hours protocols for GP attendance/hospital transfer
  • hold discussions with the resident and family/carer
  • have transfer arrangements with the GP and other services for pathology and health reports
  • inform GPs about funeral director arrangements, the resident’s next of kin and requests for death certification
  • provide information to patients, family/carers and staff on preventing heat stress and infection control. 

PHN systems, strategies and tools

PHNs can support comprehensive care by using the following systems, tools and education for GPs, hospitals, and aged care services:

  • disseminate information, resources and tools (eg ‘Silver Book’)
  • hold educational seminars in relevant clinical topics
  • provide a local service directory with eligibility, availability and waiting times
  • promote the use of MBS items, including chronic disease management items
  • establish aged care GP panels
  • establish and support specific interest groups (eg palliative care). 

Transfers between RACF, home and acute care

Transfers of care can occur between a person’s home, an RACF and acute care. Systems and protocols to support information continuity need to be established so that continuity of care is provided before, during and after transfers. 

GP systems, strategies and tools

GPs have an important role in assessing whether an older person needs to be transferred between care providers, and in managing and coordinating such transfers. This role can be supported using the following systems or tools:

  • a patient health assessment at home or in the RACF by the GP or delegate (ie deputising or locum service)
  • referring to patient advance care directives for information on transfers of care
  • collating information for transfer, including an up-to-date patient history, medication list, care plan and advance care plan
  • GP receiving hospital discharge information
  • GP reviewing resident medication and care plan
  • GP following up the patient
  • having acute care plans for the early recognition and management of recurrent acute symptoms (eg infective exacerbation of COPD, hypoglycaemia). 

Aged care services systems, strategies and tools

A person’s regular GP must have oversight of any transfers from an RACF. To support this, RACFs can implement the following systems and tools:

  • early recognition and assessment of acute symptoms
  • appropriate assessment of functional decline
  • reviewing advance care plans to identify patient needs/preferences
  • establishing protocols for referral to include:
    • notification of relatives/carers
    • notification of regular GP
  • GP case conferences
  • collating transfer information (health summary, medication chart observation notes, copy of care plan and advance care directive, medication update), communicating hospital discharge information to person’s regular GP
  • GP reviews of care plans
  • regular medication reviews
  • three-monthly reviews of psychotropic medication and other quality improvement activities, as determined by the Australian Commission on Safety and Quality in Health Care. 

PHN systems, strategies and tools

It is important that PHNs provide systems and tools for GPs, hospitals and aged care services to support patient continuity of care when transfers are made between services:

  • Promote hospital use of discharge summaries and exchange of information on medications and test results.
  • Provide follow-up support for patient discharge into community (ie geriatric outreach, hospital in the home). 

Maintaining aged care systems

It is important to establish and maintain aged care systems so that patients receive quality care across the aged care sector in areas such as:

  • medication management
  • infection control, prevention and outbreak management
  • falls prevention
  • physical and social activity groups
  • environmental monitoring (ie prevention and management of heat stress, bushfire smoke, flooding). 

GP systems, strategies and tools

Aged care services systems, strategies and tools

  • Guidelines (eg acute post-acute care), legislation and regulations
  • Medication advisory committee
  • Commercial medication management systems
  • Audits (eg pharmacy audits of antimicrobial medicines, number of medicines per resident, polypharmacy, psychotropic medicines, medication errors)
  • After-hours medication arrangements with pharmacy, GP, hospital
  • Imprest systems 

PHN systems, strategies and tools

  • Promote establishment of effective medication management systems with local GPs, RACFs and pharmacists, including routine, after-hours and on return from hospital
  • Provide educational seminars
  • Support local health programs into facilities (eg programs to manage falls) 

Conducting continuous quality improvement activities

There is scope for improving the quality of medical care for older people within RACFs and in the community by implementing systems and tools over the short and medium term. 

GP systems, strategies and tools

To improve care to older people within aged care facilities and the community, GPs can use PDSA cycles to implement organisational tools and support models for improvement. 

RACF systems, strategies and tools

Many RACFs use a continuous quality improvement cycle to implement changes, including the Aged Care Quality and Safety Commission’s Continuous improvement plan to implement organisational tools. 

PHN systems, strategies and tools

PHN’s can implement the following systems and tools to support continuous quality improvement activities in their communities:

  • identify and promote strategies to address service gaps
  • provide aged care quality improvement training and development
  • establish aged care GP panels
  • promote GP participation in quality improvement activities with RACFs
  • support local joint quality improvement projects.

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