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Medical care of older persons in residential aged care facilities (Silver Book)

Service systems and templates

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


  • • 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.

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