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We commissioned 6 aged care services across the region to support the lives of older people in our community
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Supporting improved medication management  for older people  

We continued to commission Drug and Therapeutic Information Service (DATIS) to coordinate the Quality use of Medicines Program which aims to engage and provide support for improved medication management of older people within the 6 Care Connections Practices.

 

The Quality use of Medicines priority areas include: Opioids and Benzodiazepines, Clinical Governance, Medicines, and weight with a focus on psychotropic medicines.

 

DATIS are also updating and educating local pharmacists on how to access HealthPathways and providing details about pathways that may be relevant to patients they might be supporting with Home Medicines Reviews.

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Supporting providers to identify, treat, and prevent frailty in their patients  

We commissioned AMPHEaT to liaise with the FORTRESS Project Team and deliver 5 FORTRESS Frailty education sessions to GPs, nurses, pharmacists, and allied health providers.

 

The sessions aimed to explore early identification, treatment, and prevention of frailty, and how all members of the multi-disciplinary team can work together to enhance patient outcomes.

 

Over 99 providers attended the 5 sessions, with more planned for the future.

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Care Connections – Good Health, Good Life Project  

We commissioned Simple Health Care Solutions to support 6 practices across the region with the continuation of our Care Connections - Good Health, Good Life project.

 

The project aims to assist community dwelling people aged 60 years and over to stay well and out of hospital through primary health care improvement activities. These activities included data quality improvement, risk stratification using the CSIRO Risk Stratification tool, and reviewing health assessment and care planning processes.

 

Each general practice involved in the project undertook community of practice activities, where they engaged with their local medical neighbourhood (pharmacists, dietitians, exercise physiologists, psychologists, and local councils) to establish programs supporting their over 60 patient cohort.

 

Some practices established group education and support sessions with patients, which included action plan setting by pharmacists, dietitians, and exercise physiologists. Other practices reviewed their Home Medicines Review and Case Conferencing processes, and established connections with local councils (Salisbury and Onkaparinga) to refer patients to their established wellbeing services.

 

Considering COVID-19 and the subsequent increase in social isolation, clinics focused on social connectedness and wellbeing.
 

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We supported 5 lead nurses and 21 residential aged care facilities as part of our Enabling Choice Program
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Our response to the Greater Choice for at Home Palliative Care Measure  

Enabling Choice for South Australia is our response to the Commonwealth’s Greater Choice for at Home Palliative Care (GCfAHPC) Measure.

 

The GCfAHPC Measure commenced in 2019 and with additional funding, will continue  until 2025.

 

This year, the project rolled into phase 2, which built upon the activity, achievements, and successes of phase 1 (2019-2020) including developing a process that could achieve an advance care plan for every resident and documenting their goals of care from admission through any change in their health status to their terminal phase of life.

 

In phase 2 (2020-2021), our Quality Improvement Coordinators engaged with 5 organisations and appointed 5 lead nurses to work across each organisation’s facilities, serving a total of 21 RACFs.

The project developed the following tools to assist RACFs in palliative care:

  • Activity workplans that reflect the quality improvement process, goals and expected outcomes to implement best practice advance care planning.

  • An advance care planning audit tool to identify process, gaps, and variance with required activity reflected through a quality improvement lens.

  • An Advance Care Planning Resource ensuring consistency of process and tools used for advance care planning. This resource has been adopted by all organisations involved in phase 2.

  • Each organisation developed policies, procedures, and pathways for a palliative approach supported through their clinical governance framework.

 

All organisations recognised the value of lead nurse roles and the impact they had on change and sustainability. One organisation reported that “staff have expressed how valuable it has been to have a dedicated palliative care nurse on the floor, providing support and direction to them and to the residents. Someone that they can go to for action around the deteriorating resident, for stress relief and support and for educational purposes. Staff stated that the bereavement project has been an incredible improvement in the care for all during end of life. Registered nurses have stated that providing a mentor approach to them has been invaluable”.

 

A RACF staff member also described how the project had helped her “I cannot explain the relief you feel as a worker to identify that someone has declined in their health suddenly, and to be able to immediately speak to the lead nurse and know that she would ensure things were in place and happening for the resident to ensure they were comfortable, and that she would speak to the family and be there as support the whole way through. This made palliative care a lot less daunting for me and other workers and meant that you do not suddenly face questions from visiting family who are confused and sad and unsure why their loved one had deteriorated, is in pain, or where they are at with their care. The lead nurse's ability to make such a daunting process smooth, coordinated and understood, and her ability to do so with genuine care clearly alleviates stress on families and workers in what is already a stressful time. She is invaluable.”

The project has led some organisations to invest in lead nurse positions moving forward to ensure sustainability of best practice advance care planning.

Find out more about our suite of aged care services