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Wrap-up: Northern Sydney Regional Forum, May 2021

Written by Rosanna Commisso, Home Support and Partnerships Coordinator

Our recent Northern Sydney Regional Forum focused on the important subject of Integrated Aged Care.

Due to an ageing population and a growing number of people with chronic or complex health conditions, people’s health needs are changing and demands on the health system are increasing.

To meet these rapidly changing and growing needs, it is vital that we as a sector understand and implement innovative models of integrated care, both within the community and in individuals’ homes.

Integrated care entails the provision of seamless, effective and efficient care that reflects the whole of a person’s health needs; from prevention through to end of life, across both physical and mental health, and in partnership with the individual, their carers and family.

It necessitates greater focus on a person’s needs; better communication and connectivity between healthcare providers in primary care, community and hospital settings; and better access to community-based services close to home.

The aim of integrated care is to achieve improved patient care through delivering person-centred, seamless, efficient and effective care, particularly for people with complex, long-term conditions.

Our Forum saw a range of aged care experts come together to focus on how we, as CHSP and HCP package providers, can work towards a more integrated approach, that encompasses the individual physical, mental and social needs of older people to remain at home longer.

  • Dr Caroline Rogers: GP – Osana
  • Dr Julie Bajic-Smith: Aged Care Psychology Consultant – WiseCare
  • Taylor Harrison: Chiropractor, Founder and Director- Active Seniors Health Centre
  • Richa Pathak: Senior Physiotherapist and Director – Figtree Health and Physiocorp
  • William Campos: Psychologist – Independent Community Living Australia
  • Sarah Kerr: Clinical Nurse Specialist – Uniting Northern Sydney Home and Community Care

Below is a summary of their recommendations, and what you can do to take the first step towards Integrated Aged Care within your organisation.

Top Ten Tips – What CHSP and HCP Providers Can Do

  1. Nutrition: ensure clients are eating healthy meals, undertaking regular strength and balance exercises, STOP smoking and their alcohol consumption is below safe limits
  2. Attention: focus on their goals and what really matters to them as this often gets lost. Report your concerns – if you are worried about their driving, or what they are (or are not eating), their deteriorating balance or their social isolation, etc.
  3. Organisation: register client with all appropriate government organisations, including social work services and chronic disease nurses if necessary. Establish a calendar of appointments on their wall that everyone can refer to, or a communications book. Find out who if anyone holds the delegated authority for their MyHealth Record, Power of Attorney for their medical affairs, if they have an Advanced Care directive?
  4. Medication: would your client benefit from a webster pack? All patients with chronic conditions or multiple medications are eligible for a home medication review by their pharmacist.
  5. Information: create an Emergency box or folder, containing ACD, medical summary, medication list, emergency contacts, ambulance plan, funeral director details with your client and their family/carers. Keep it on top of the fridge (that’s where the paramedics look first).
  6. Mental Health: older people are the least likely group to use mental health services, with less than 25% accessing support. In addition, the highest suicide rates are in men aged 85+ years. So as a service provider, you need to know:
    • How to support and engage clients who are experiencing changes to their mental wellbeing
    • When to escalate concerns to management and external health professionals, and how to work as a part of a multidisciplinary team
    • How to identify, and make the most of the individual strengths and abilities of your clients
  7. Know Your Strengths as an Organisation: know which clients you have the skills and capacity to help – don’t try to be all things to all people.
  8. Establish Strong Internal Systems: systems – both manual and technology based, are critical to your sustained success as they will enable continuity of care. Ensure that you have clear policies and procedures to support both your team and clients. Focus on systems that incorporate consumer’s perspectives. By establishing vigorous systems, you have a greater ability to improve care in a scalable fashion.
  9. Workforce: when hiring new staff, focus on their caring nature, as you can’t train someone to care, so hire based on applicant personality, above their resume.
  10. Screening: screen age-related challenges promptly as this will enable you to coordinate better proactive and restorative care. In addition to lifestyle modifications, consider environmental modification, such as home modifications, ADL analysis, Stressor analysis, safety, technology (alarms, non-slip mats, footwear, bed exit alarms, lamps).

We have listened to your requests and have compiled a list of valuable links to trainings and resources here. Feel free to contact Rosanna directly if you have any question.

Rosanna Commisso
Home Support and Partnership Coordinator