Aged Care After-Hours Toolkit
Background
Primary Health Networks (PHNs) are funded to support the Australian Government’s response to the Royal Commission into Aged Care Quality and Safety.
A key objective is for PHNs to bring greater awareness to residential aged care homes (RACHs) about the after-hours services provided by general practitioners and other health professionals.
These services can reduce hospital presentations for RACH residents, through providing appropriate care in the facility.
North Western Melbourne Primary Health Network and South Eastern Melbourne Primary Health Network have developed an after-hours toolkit, comprising 5 key resources to support RACHs in the after-hours period. These are intended to better prepare staff to identify which after-hours service is best to access depending on the nature of the incident.
Enhanced after-hours support for residential aged care homes
After-hours action planning
RACH residents can experience deterioration in their health during the after-hours period (defined as outside regular hours, ie the night time period and weekends), but immediately transfer to hospital is not always clinically necessary. Lack of awareness and utilisation of out of hours service provided by general practitioners (GPs) and other health professionals may result in unnecessary hospital presentations.
PHNs received funding to support the Australian Government’s response to the Royal Commission into Aged Care Quality and Safety. A key objective is for PHNs to bring greater awareness to RACHs about the after-hours services provided by GPs and other health professionals. These services can reduce hospital presentations for RACH residents, through providing appropriate care in the facility.
To assist RACHs to implement and maintain an after-hours action plan, a toolkit has been developed, comprising 5 key resources to support RACHs in the after-hours period.
How to use the after-hours toolkit
The after-hours toolkit has been developed following consultations with RACHs in metropolitan Melbourne about how to support after-hours processes in facilities to reduce emergency presentations.
The toolkit guide has instructions to help RACHs understand the importance of after-hours action planning, where to find after-hours resources, and how to use and keep them up to date.
After-Hours Action Planning Audit Tool
Helps assess your RACHs preparedness for the after-hours period as it relates to residents, systems and documentation, doing this audit every 12 months is recommended
Medical Support Checklist
This tool is a checklist, based on the ISBAR communication tool, to aid staff when a resident is unwell and support is required.
After-Hours Service Directory
This assists staff to identify services available in the after-hours period.
Person-Centred After-Hours Action Plan
This enables staff to summarise key information explaining a resident's after-hours care plans, for quick and simple reference during an emergency.
Family Factsheet
This is a fact sheet that informs family members and carers of RACH residents about:
- What happens if someone falls ill at night, or on the weekend.
- What families can do to help.
Implementation Support
For more information and support with implementing this Toolkit, contact agedcare@semphn.org.au
How to use the Toolkit
This video has been developed for RACH after-hours staff. It explains the toolkit and how it can be used in RACHs.
Additional after-hours resources
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Clinical Governance
Advance care planning is the process of planning for future health care. It relates to the health care an individual would or would not like to receive if they were to become seriously ill or injured and unable to communicate their preferences or make decisions. This can often relate to the care received at end of life.
Professional codes, standards, and guidelines. Nurses must be registered with the Nursing and Midwifery Board of Australia (NMBA) and meet the NMBA's professional standards to practice in Australia.
Advance Care Directive is a document that allows an individual to decide now, or to guide what health care and treatment they receive in the future, if they lose the ability to communicate and make decisions. The writer can also appoint a substitute decision maker who can make decisions on their behalf if they are not able to do so.
Medical Goals of Care Plans ensure that patients who are unlikely to benefit from medical treatment aimed at cure receive care appropriate to their condition and are not subjected to futile treatment including cardiopulmonary resuscitation and Medical Emergency Team calls. The Victorian Department of Health 3-phase model of goals of care can be found here.
Early recognition of clinical deterioration in aged care is a project by Safer Care Victoria that will help staff recognise clinical deterioration early and improve outcomes for aged care residents. .
Guidelines for provision of after-hours aged care services for GPs, Royal Australian College of General Practitioners (RACGP) Silver Book, offers guidance for GPs providing services to RACHs.
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Workforce
Comprehensive health assessment of the older person workshops are being offered by Latrobe University for nurses from all sectors, who provide care to older people.
Advance Care Planning Australia offers supports to health care practitioners, care workers, students, individuals and substitute decision makers to learn about advance care planning.
Aged Care and Community Provider Association has a range of learning and professional development options for those working in aged care services.
Palliative Aged Care Outcomes has developed a range of resources for clinicians, residents of RACHs and their families to systematically improve palliative and end of life care.
End-of-life Directions for Aged Care (ELDAC) provides information, guidance, and resources to health professionals and aged care workers to support palliative care and advance care planning to improve the care of older Australians.
ELDAC home care app has been designed to help home care workers to provide end-of-life and palliative care to their clients, whilst supporting their families and carers as their care needs change over time.
Education and training video resources for improved palliative care in aged care, developed by the Palliative Care Consortium, help build knowledge and capacity among aged care staff to better identify deteriorating residents, manage symptoms, improve dementia care, and set up medication imprest systems.
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Systems and Processes
Medical records at residential aged care facilities RACGP Silver Book.
McGeer’s Definitions for Healthcare Associated Infections for Surveillance in Long Term Care Facilities is a checklist that provides standardised guidance for infection surveillance activities and research studies in RACHs and similar institutions.
Pain assessment scales can be used to measure pain.
ISBAR is a clinical handover checklist that aims to improve patient safety and reduce adverse outcomes by improving communication. This form has been shown to improve clinician leadership and involvement and reduces the need for duplication in other clinical handover forms. Training in the use of ISOBAR can be organised by emailing admin@medecslearning.com.
Safer Care Victoria – Early recognition of clinical deterioration in aged care
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Meeting needs and accessing services
The after-hours service directory resource provides contact details of after-hour support services in your region, and/or national and state-wide services that may be of assistance for after-hours medical care to residents in RACHs. A template can be found here for your own RACH to keep its own locum after hours services up to date and will not be monitored by the SEMPHN.
Telehealth in Aged Care Homes - use of telehealth services can help to reduce unnecessary presentations emergency departments.
Safe-Life aged care equipment including CareWatch Alarm and Sensor Pads are devices ideal for residents at high risk of falls if they move by themselves. The function of these devices is to warn nurses if a patient gets up and starts moving around when they are alone.
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Infrastructure
A variety of person-centred digital clinical care systems are available that assist RACHs with administration and management tasks, including reporting, electronic care planning, medication management, communication, clinical analysis, mobile data entry, family communication, health monitoring, pathology and more.
Disclaimer: SEMPHN does not endorse or promote any particular digital solution.
Digital patient management solutions
Medication management
Medication management in residential aged care homes is based on evidence and advice from experts, providers and users of medicine in health and aged care services to promote the safe, quality use of medication management in RACHs.
RACH medicine storage and record keeping. Imprest systems are a resource RACHs can use to store medications in the after-hours period. You can have medications that are Schedule 2, 3, 4, 8 or 11 in your imprest stock.
Audit tool and checklist for a Medication Advisory Committee (MAC) in RACHs aims to assist RACHs implement or optimise a MAC.
Electronic National Residential Medication Chart Medication Management Systems is a guide for RACHs looking to implement electronic Medication Management Systems (eMMS).
eMMS that are compatible with My Health Record include:
MPS Medica EMM by MPS Connect
Other eMMS commonly used in RACHs but not compatible with My Health Record include:
Technology and innovation
The ELDAC Technology and Innovation team are developing service resources that can support services in implementing initiatives and building digital and technological capabilities.
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