Description of Division Programs

The ACTDGP has developed a GP Panels model, which has small working parties addressing priority activities that have been identified by stakeholders. These include:

Five GPs are on the GP Panels Steering Committee and meet regularly with RACF and Divisional staff. These same GPs are members of the working parties involved in the priority activities mentioned above.

An ACTDGP bi-monthly forum with members from all sectors involved in aged care in the ACT provides support and guidance for the GP Panels. Three members of the GP Panels also attend this meeting.

ACEDGP is working collaboratively with the ANEDGP on the ACGPPI. The Divisions are focussing on education and training initiatives, quality activities with RACF's and community groups and information and communication activities.

ANEDGP has been actively involved in the development of aged care resources and programs for several years. They have developed the following resources / programs.

Palliative Care Guidelines for Residential Facilities
Following two successful training sessions involving GPs and Residential Care Facilities it was identified that a brief set of guidelines useful for GPs and nurses working in residential care with palliative patients would be most beneficial.

The ANEDGP with assistance from Dr Mary Brooksbank, Dr Michael Kain, Dr Peter Ford and Nursing staff from residential care facilities within the Division has developed a Palliative Care Information resource. This document would compliment work being done on a national level in a project known as the APAC (Australian Palliative Aged Care Project) which the Division is also involved with on a local level. The resource does not replace evidence-based text but is designed to compliment it and makes extensive reference to these texts. The resource can be adapted to suit local needs by changing the phone contact and resource details.

Recently Adelaide North Eastern Division of General Practice (SA) undertook a project in conjunction with the University of South Australia and the Helping Hand Ingle Farm aged care home. This project has implemented computerised medication management with many positive outcomes including a 30% reduction in medication incidents in the first 12 months.

The Division has been involved in the development of a falls prevention program in metropolitan Adelaide, "Best Foot Forward". Attached is a zip file of resources developed as part of the program. Healthy Ageing & Falls Prevention Program

Contact: Ms Catherine Wohling CWohling@anedgp.com.au

The Adelaide Western Division of General Practice, through it�s Aged Care Program, is working towards improving GP access to Aged Care facilities. With Australia�s increasingly aging population, the Aged Care sector is predicted to grow dramatically in the near future. By implementing a range of projects involving GP's, Aged Care Facilities and Pharmacists, the Adelaide Western Division is helping to prepare the network that will be needed to support the increased demand on aged care services.

AWDGP has developed an innovative ACGGPI model, The GP - Aged Care Network. The Division and Network are focussing on a number of issues including owing scripts, medication charts, information management and technology, access and systems improvements.

BALLARAT AND DISTRICT DIVISION OF GENERAL PRACTICE

Ballarat & District Division of General Practice is participating in the Department of Health & Ageing Aged Care GP Panels Initiative. As of March 2005, the Division has established:

During 2005 - 2007 the Division aims to achieve the following:
1.To develop protocols around the establishment of a communications pathway with a consumer/carer advisory group
2.Exploration and option development for GPs wanting to rationalize the level of service they provide to individual aged care facilities
3.Facilitating the process of encouraging hostel residents to attend the GP in the Practice - to include developing protocols around transporting the medication charts and patient history to the GPs rooms
4.Reduction in hospital admissions -
   a.To facilitate the process for GPs to perform procedures in the aged care facility
   b.To set up triage systems for PCAs to access information - especially after hours
5.Managing after hours access to patient information by locum and rostered GPs
6.Comprehensive Medical Assessments (CMA) & Residential Medication Management Reviews (RMMR) - promotion of the process and value of the program to GPs & distribution of tools for use
7.Medication Charts
   a.Development of protocols around whether a discharge medication list from an acute care facility can be used as an administration order in the aged care facility for an interim period, until the GP can write up the medication chart
   b.AGON stickers - consistency of use and other difficulties
   c.Limitation to new drug availability after hours
   d.GP software and electronic medication charts
   e.Streamline medication chart usage, develop protocols, include communication issues re: medication

The Barwon Model will see local GP representatives and an overseeing GP Program Coordinator work collaboratively with Aged Care Facilities to address priority areas identified, with a view to these processes being adapted at other Aged Care Facilities where appropriate.

The Bendigo � Loddon Primary Care Partnership commissioned the �Ageing Strategy�. The strategy brings together a number of successful initiatives that the Bendigo and Loddon regions were implementing. The ageing strategy can be located at: /_assets/http/www.bgodivgp.org.au/download/BLAS%20Full%20Report4.pdf.

The BDDGP has been working with the aged care sector for a number of years examining process improvements including the use of information management and technology to address patient data exchange, medication management and prescribing issues. BDDGP is expanding on this work under the ACGPPI.

BMDGP has established a multidisciplinary advisory committee under the ACGPPI. The advisory committee is made up of directors of nursing from two RACF�s, GPs, an ACAT representative and the divisions aged care coordinator. The Division is trialling a virtual private network (VPN) between a general practice surgery and a RACF. the trial is to address data exchange, medication charts and prescription issues.

BDGP have established panels in Albury / Wodonga, Corowa, Holbrook, Howlong, and Jindera. The main focus has been on issues relating to medication management. The panel is examining the use of GP software available for use by GPs in the RACF's to assist in patient data exchange. The Division is focussing on the use of MBS items available in RACF's.

The Brisbane North Division of General Practice was funded under the Department of Health and Ageing National Innovations Funding Pool to carry out a project titled "The involvement of GPs in multi-disciplinary care planning and case conferencing in nursing homes". The Division was funded in June 2000. In November 2000 MBS introduced several new items in relation to case conferencing and care planning in residential aged care facilities. The project took a new focus to increase the number of GPs working in residential facilities by testing a GP Assessment of Resident's Health Forum. The project concluded in December 2002. This work was of significant value in developing the MBS Item Number 712 the Comprehensive Medical Assessment.

The BNDGP Residential Aged Care model encompasses multidisciplinary collaboration and peer to peer leadership as underlying philosophies. It demonstrates innovation in maximising resources across a large geographical urban area and a large number of GPs and RACFs. This model has been planned and will be implemented within a systematic project management related methodology. Click here for a diagramatic copy of the model.

Aged Care Taskforce
The Aged Care Taskforce consists of 6 GPs, 3 DONs and a Geriatrician which provides an overarching governance structure to the implementation of the Residential Aged Care Co-ops. The role of the Taskforce is to provide strategic advice and direction to the project, endorse the project proposal and project plan (including risk analysis) and to review progress of the project implementation.

Regionalised Residential Aged Care Co-ops
Six regionalised Residential Aged Care Co-operatives (RACCs) were established in February 2005. Each RACC consists of GPs and RACFs that currently have existing arrangements in place. They range in size from 6 to 18 representatives (GPs, DONs and RNs/CNs). RACCs are scheduled to meet for 1 / 2 hours per month (maximum of 9 meetings per year) and are chaired by a Taskforce GP (2 RACCs are chaired by GPs who are not on the Taskforce as there is no Taskforce GP in that group).

Interface between Taskforce and RACCs
In order to ensure continuity between the Taskforce and RACCs it was decided that a Taskforce GP or DON would act as a chair on each RACC. There is only one RACC without a Taskforce member (due to geographical spread of RACFs and GPs) and in this case BNDGP is working towards recruiting a GP in that group to participate in the Taskforce.

In order to address global issues and to reduce RACCs duplicating work, a communication plan has been established and implemented. Global issues can be referred to the Taskforce for consideration eg. Issues associated with Coroner's Act, IT limitations in RACFs. On a local issue level, resources that are developed by RACCs can be shared if appropriate to another RACC. For more information please see attached the communication plan.

BRISBANE SOUTH DIVISION OF GENERAL PRACTICE

Brisbane South Division of General Practice is using the government preferred encryption and encoding technology public key infrastructure (PKI) in order to improve the communication and information sharing links between all service providers including GPs, hospitals, nursing homes and respite care.

Contact: Mr David Gardner - CEO info@bsdgp.com.au

The CDGP has established a �panel� under the ACGPPI. The model implemented has an advisory committee and working panel. The Division is examining a number of issues including: after hours care, medication management and charts, discharge summaries from the acute sector and education and training opportunities for GPs, RACF staff and AHP.

The Division has provided training on Parkinson�s and aged care item numbers, psychiatry in aged care and is implementing a mentoring program for GPs wanting to improve their knowledge and skill set in aged care.

CANNING DIVISION OF GENERAL PRACTICE

The Canning Division have been actively involved in aged care programs for several years. They have worked collaboratively with other Divisions to develop useful and transferable programs and resources.

Canning Division in association with the Perth & Hills Division of General Practice, and the Western Australian Government Department of Health has developed a training program for General Practitioners and aged care industry workers.

The program "Managing Care in the Elderly: A Training Program for General Practitioners" has been developed as one of a range of strategies to support GPs providing care to the elderly and / or working in Aged Care Facilities. The program provides a focus is on multidisciplinary, holistic care and a pro-active approach to maintaining the independence of elderly people in the community. General Practitioners will further their skills in the management of elderly patients with complex care needs including those whose health may warrant a palliative approach to care.

Canning and Perth & Hills Divisions have agreed to make the learning objectives from the Managing Care in the Elderly: A Training Program for GPs available to divisions on request. Please contact: Bonnie Mist (Canning) bonnie@canningdivision.com.au or Liz Earnshaw (Perth & Hills) liz.earnshaw@phdgp.com.au.

Division Co-ordination

Divisions will be funded to appoint a dedicated staff member to provide coordination and support to GPs working in Residential Aged Care.

The Division Aged Care Coordinator will:

Aged Care Liaison GPs would be contracted by the Division on a sessional or hourly basis and attached to groups of geographically located Aged Care Facilities. The selection criteria for an Aged Care Liaison GP would include:

A pool of hours would be allocated to each Division based on the number of ACFs and attending GPs in the region. Remuneration would be at Division rates of $120 per hour indexed to CPI. The funding allocation would determine the number of Liaison GPs appointed and the number of sessions.

In conjunction with the local Aged Care GP network assist the Division to identify strategies to:

A multidisciplinary Aged Care Panel would be established for the region with membership consisting of Aged Care Liaison GPs, a Geriatrician nominated by the area health service, 2 Directors of Nursing nominated by the ACF network, a representative from the Carers Association, local representatives from both Aged and Community Care Services WA (ACCSWA) and Australian Nursing Home and Extended Care Association of WA (ANHECA). The role of the Aged Care Panel would include to provide strategic advice:

The Division Aged Care Coordinator will provide the secretariat to the Aged Care Panel.

Contact: Ms Bonnie Mist bonnie@canningdivision.com.au

The Central Bayside Division of General Practice (CBDGP) has developed a falls prevention program "Falls Prevention It's No Accident". It is a CDROM Training Resource. The evaluation of the program is due for completion in February 2005. Click here for a copy of the program poster.

The Central Coastal Division in collaboration with Central Coastal Health have produced a CD Rom - A Dementia Care Guide for General Practitioners. When GPs complete questions at the end of each section they can receive 6 CPD points. There is a limited number of CDs available for utilisation by Divisions. For a copy please contact the Alliance of New South Wales Divisions on (02) 6652 3866.

Prior to the implementation of the GP Panels Initiative the NSW Central Coastal Division in collaboration with Central Coastal Health's Department of Geriatric Medicine introduced an "Aged Care Attachment" program. The aim of the program was to provide geriatric skills and an understanding of the aged care services for individual doctors who could share this information with their practice partners. Each 13 week attachment included 2 GPs participating for 5 hours per week. A total of 10 GPs completed the program. GPs attended ACAT case conferences, were involved in in-patient consultations with the geriatrician, worked with the dementia care team and attended home visits with the geriatrician. In addition there were 6 education sessions, with topics nominated by the participating GPs.

The CCDGP surveyed the GPs, ACHs and ACAT teams within their catchment area to identify priority needs. As a result activities that will be undertaken as part of the GP Panels Initiative will examine medication management, communication including reducing inappropriate call outs, reducing duplicate documentation, and case studies.

The division is about to embark on a pilot program for the electronic transfer of specialist discharge summaries to GPs.

The Central Wheatbelt Division of General Practice believes that the Aged Care GP Panels Initiative fortunately coincided with a state run initiative: the 'MPS Leading Project' which aims to review the provision of aged care services, develop policy and implement best practice within the MPS environment.

The Division has developed relationships with key stakeholders in relation to this project, and as a result, has significant project representation on the 'Central GP Panel'. Stage One (Review) has been completed with the main findings as follows:

Contact:

DANDENONG & DISTRICT DIVISION OF GENERAL PRACTICE

The Dandenong Division has developed an Aged Care committee to examine pertinent issues affecting GPs, Aged Care Homes and specialist's integration / interface in the Aged Care Sector.

Fremantle Division have established a multidisciplinary GP Advisory Group and an GP Aged Care Management Group. The Management Group will address issues such as medication management, script management and developing streamlined consistent processes across the region.

The Great Southern Division has established a single panel model. They have also established an overaching multidisciplinary advisory group. Key areas include communication, medication management and development of best practice guidelines. A medication mangaement party has been formed.

The Greater Bunbury Division have established a single panel model. The panel is addressing three key areas through four partnerships. The are:
     Quality Improvement Programs
     Medication management
     CMA implementation

GP down south is establishing links with key stakeholders involved in providing care to the residents of Aged Care Facilities in the divisional area and is working with the GP Panels to achieve the aims of the initiative.

The GP North Division held a forum for stakeholders working in the aged care sector. Stakeholders included RCF's, GPs and Pharmacists. The forum was held in March 2002. Priority issues were identified from the respective parties.

The Greater South Eastern Division of General Practice (GSEDGP) has been running an Aged Care Program for five years. Initial planning meetings raised many and varying problems in aged care in the local area.

As a result of these meetings GSEDGP established a Regional Medical Advisory Committee (RMAC) and a Regional Medication Advisory Committee (ReMAC), in order to liaise, address and solve many of the problems, which were identified.

GSEDGP was of the opinion that the Aged Care Standards and Accreditation Agency, as part of the requirements of accreditation, insist that every facility have access to a RMAC and a ReMAC.

GSEDGP is working on a proposed model that will meet the criteria of the new MedicarePlus Aged Care GP Panels Initiative that will incorporate the RMAC and ReMAC. The division will also heavily focus on IM/IT issues.

CCA was an innovative project that utilised the services of a GP to approximately 500 patients in the Port Macquarie area in residential aged care homes. The GP was paid a retainer to visit patients without a full time or usual GP. The GP was also invited to be a member of the patient care review committee, the medication review committee and act as a liaison officer to the Division of General Practice and other GP colleagues.

This project was funded under the National Innovations Funding Pool program in 1999. The project sought to address an ongoing problem of the breakdown in communication between GPs and ACHs and thus improve the care of the residents.

The project worked with seven ACHs in the Division catchment area on issues of uniformity in documentation, establishment of a clinical service agreement, medication reviews and establishment of a continuation programme called the "Link Project" of the Nursing Home Liaison Project.

The Knox Division's Aged Care Panel seeks to address issues pertaining to the care of older people living in residential aged care facilities. One of the important areas being reviewed is the Discharge Protocols or Guidelines currently in place for elderly patients upon their discharge to an ACF. For more information contact Dr Ranjit Rasalam or Ms Simone Mitchell from the Division on (03) 9720 2044.

The Macarthur Division of General Practice instituted a collaborative approach to Aged Care early in 2003. The main aim was to enable relevant parties to share information and where possible address issues effecting the care of older people. To date this forum has achieved:

The next phase of this group is to address patient flow between Nursing Homes and Hospitals and develop strategies to address the issue of consistent documentation in Nursing Homes. These issues fall nicely under the Aged Care Panels initiative and will be warmly welcome by the committee. The Macarthur Division of General Practice would view this committee as the tool to drive / oversee the initiative.

The Mackay Division of General Practice has undertaken a range of consultation activities in preparation for the implementation of the Aged Care GP Panel. There is a dedicated Aged Care GP Panel page in the Divisional newsletter with monthly updates.

Implementation Process
The Implementation process for the GP Panel has been making steady progress since June. The Division is largely using the Aged Care GP Panels Handbook as a guide to the implementation process. The Division has maintained a collaborative approach for implementing the Aged Care GP Panels and has consulted with the Aged Care sector and GPs at every opportunity throughout the last 5 months.

The key elements of the implementation process for the Division have been:

Melbourne and Northern Divisions of General Practice are working collaboratively on the Aged Care GP Panels Initiative. NDGP and MDGP's GP Panels take the form of project teams, each made up of a small group of GPs focusing on process improvement activities in a particular area of need. GP panelists operate on a consultancy model, which means that they are paid an hourly rate plus travel time (where appropriate) for project work.

The Mid North Coast Division of General Practice runs a small project entitled Nursing Home Liaison. The aims of this project are:

The Division and UNE along with representatives from a consortium of government agencies have developed a new Network for providing aged care services. Utilising Division and University resources to coordinate and improve service delivery there has already been significant improvements in the care of older adults in the region.

The current pilot Network was developed to better understand the needs and service solutions for people in the community with early to moderate stages of dementia. The Network is a consortium including The New England Division of General Practice, The School of Psychology at the University Of New England, New England Area Health Services, Department Of Ageing Disability and Home Care, and The Armidale Dumaresq Council. The program was one of two pilot programs temporarily funded by NSW Health to investigate new models of linking services for aged care.

Through the program we provide comprehensive assessments and follow-up for older adults in the region who have early to moderate stages of dementia or who present with problems that look like dementia. This approach helps maintain the dignity and enhance the quality of life for the persons with dementia and their families. People with dementia are more successfully maintained at home because the reports generated by the Network inform in-home care.

The network links GPs and their patients with dementia to specialised medical and neuropsychological services and eliminates the need for patients to contact the many agencies who may provide services. As part of this program neuropsychological assessments are provided through UNE at no charge to the patients. Case conferences and follow-up will ensure the optimisation of aged care services through local agencies such as the Alzheimer's Association, home care, and respite and hostel providers. Post Graduate psychology students are also involved in this program as part of their training.

NORTH EAST VALLEY DIVISION OF GENERAL PRACTICE (VIC)

The North East valley Division of General Practice have developed numerous resources through the aged care program for the the use of GPs and for the information and use of aged care homes where appropriate. these resources can be located on the North East Valley Division website: http://www.nevdgp.org.au

   1. Paper-based Forms
   2. Medical Director templates
   3. Step-by-step guides for GPs
   4. MBS flowcharts
   5. Information kits
   6. How the Aged Care Home can help
   7. Transfer to hospital
   8. Urine Testing Protocol

Contact: Clare Chiminello clare@nevdgp.org.au

NORTH WEST MELBOURNE DIVISION OF GENERAL PRACTICE

GP RESIDENTIAL AGED CARE & AGED CARE HOME AFTER HOURS KITS

The Division was funded as part of the After Hours Primary Medical Care Trials by the Commonwealth Department of Health and Ageing. They developed two (integrated) kits, one for GPs and one for ACHs. The two kits will be revised, based on feedback during the project, and a final version produced for wider distribution in March 2005.

Purpose of the GP Kit

The GP Residential Aged Care Kit contains practical information and tools for GPs to:

Provide continuing medical care for their patients in aged care homes.
Work with ACH staff and other service providers to ensure delivery of timely and appropriate care after hours.
The kit is presented as a series of information sheets in a folder, which can be kept at the general practice, and updated as new materials become available. Each information sheet offers tools for incorporation into your practice systems.

Purpose of the ACH kit

The Aged Care Kit provides practical information and tools to assist staff in aged care homes (ACH) to develop more effective partnerships in medical care for their residents.

It is designed to:

Support ACH staff and general practitioners (GPs) to work together to provide continuing medical care for residents
Assist ACH staff and after-hours service providers to deliver timely and appropriate care across the pathway of care
Be readily incorporated into the continuous improvement cycle for residential aged care (RAC) accreditation requirements.

The kit is presented as a series of sections in a folder, which can be kept in the ACH office, and updated as new materials become available. Each section offers tools for incorporation into your practice systems. These tools have been developed in consultation with aged care home staff, GPs, medical deputising services, Metropolitan Ambulance Service, local hospital emergency departments and consumers. The project team is aware of the current problems of overwhelming paperwork and the tools are not intended to add to the paperwork maze. They have been designed to streamline communication and documentation, and can be adapted by a variety of low and high level care facilities.

The CD accompanying the kit contains an electronic version of each of the resources. These can be downloaded for use in the ACH, either as they are or adapted to suit the particular facility's need. The CD symbol used throughout the kit denotes the resource is included on the CD. The tool symbol denotes the resource is a tool available for use by the facility.

Benefits to ACH:
Entice GPs to attend residents
CQI tools for accreditation
Easy to upgrade and streamline documentation for medical care
More effective & efficient referrals
Support and skills for staff
Access to good practice guidelines
More timely and appropriate after-hours medical care for residents
Better discharge information

Benefits to the GP:
Optimise remuneration for residential care
Time saving tools for documenting and monitoring patient care
Better information from ACH staff on sick residents
Access to good practice guidelines
More timely and appropriate after-hours medical care for residents
Better discharge information

The North West Melbourne Division of General Practice would like to make available the GP Residential Aged Care Kit and associated tools. If utilising the attached resources please reference them appropriately. Please note that the GP Residential Aged Care Kit has recently been updated.The kit has numerous Information Sheets and GP Tools to support the kit. http://www.nwmdgp.org.au/web/doctors/after_hours/

The NWMDGP have identified four priority areas under the Aged Care GP Panels Initiative. They are:
1.   Identify and promote good service models: in order to improve the coordination of residents' primary care treatment within aged care facilities.
2.   Promote and educate on available funding / quality incentives: to facilitate the coordination of residents' primary care treatment between health care providers and increase GP involvment.
3.   Improve processes for the management of medication: to define the legalities influencing the various health professionals' roles and responsibilities in order to improve the medication pathway and to develop workforce initiated 'best practice' guidelines that accord with everyday practicalities.
4.   Identify specific models for the management of care to reduce preventable ambulance and Accident and Emergency hospital use.

The NWMDGP have developed a "Links for Coordinating Resident's Care with General Practitioners" brochure for consumers and ACHs. Click here for a copy of the brochure.

Contact: Ms Carolyn Searle admin@nwmdgp.org.au or Ms Rita Wong or Ms Sian Reilly sian@nwmdgp.org.au

NORTH WEST TASMANIAN DIVISION OF GENERAL PRACTICE

ULVERSTONE GP/AGED CARE LIAISON MODEL

The North West Tasmanian model allows contributing GPs to engage with Aged Care Facility (ACF) governance to improve service delivery processes and health outcomes of patients in ACFs.

Composition: DONs and section heads of the 4 Ulverstone ACFs, GPs attending ACFs, Pharmacists, invited guests (dementia support worker, ACAT, psycho geriatrician, acute care in the home program).

Mechanics: 3 monthly breakfast meetings lasting approximately1 hour. Chair and secretariat provided by DON. Minutes circulated. Funding of GP time by Division through dedicated program.

Examples of Issues:

Drug chart format, including transition to electronic format.
Drug chart renewal protocol.
Accessing authority scripts.
Electronic communication with practices to access database remotely.
Protocol for nurse initiated medications.
Assessment of the confused patient.
Admission procedures.
- Timelines for admission.
- Assessment protocol based on bests practice models.
- Surgery based assessment of new patients with their families wherever possible.
Death certification procedures
Emergency drug availability
Acute care in the home program (IV antibiotics and transfusions in the NH)
Improving care for patients with dementia:
- Assessment protocol in accordance with evidence based best practice care.
- Involvement of dementia support worker in training of staff, management of patients through case conferencing.
- Lobby ACF executives for increased staffing levels.
- Regular MMSE on patients to assist in RCF classification.
Trouble shooting any issues.

Comment:

Building relationships has been an important part of the success of this initiative, allowing a true partnership approach.
Vision of the Division has allowed this initiative to progress.
EPC does not currently stretch to covering this type of service delivery engagement.
This model provides a platform for the coordination of other initiatives such as DMMR, EPC.

Contact: Ms Patricia Aitken paitken@nwtasdgp.com.au

NORTHERN RIVERS (LISMORE) DIVISION OF GENERAL PRACTICE

Northern Rivers completed a community and residential aged care Outreach Speech Pathology Service project in conjunction with St Vincent's Hospital. The project has facilitated improved access to speech pathology services for RACFs and this service has continued as a self-funded program.

The division also ran a Dietetics Outreach Service pilot program.

Contact: Ms Judy Sheldon jsheldon@nrdgp.org.au

OSBORNE DIVISION OF GENERAL PRACTICE

After undertaking a needs assessment with funding from the WA Department of Health, Osborne Division has developed a model with the main purpose being to enhance existing service provision, co-ordinating service providers into a multidisciplinary team and enhancing communication with other sectors and agencies in the industry.

The Division commenced activities with a focus group for all GPs with an interest in aged care and those who are currently providing care to residents in aged care facilities. GPs attending were presented with an "Introduction to Strengthening Medicare Aged Care Panels Initiative and an Overview of Comprehensive Medical Assessments" by local members of the Department of Health & Ageing. Following the presentations, the group was asked to workshop Panel development, decide the arrangement and number of Panels, as well as the selection criteria for Panel members. GPs attending suggested that based on the size, scope and different needs throughout the Osborne Division a few Panels were needed however, interest and funding would drive the level of GP involvement.

As a result, three Panels were formed, allowing development of local solutions to local needs. Thirteen GPs have been officially appointed across these Panels. Simultaneously, a survey was distributed to RACFs, allowing them to identify gaps in GP services and on-site visits were scheduled with facility and nursing managers. A workshop has since been held for key aged care services providers and other healthcare professionals in order to further develop links and gain input into Panel activities. The Multidisciplinary Care Team (MCT) formed out of this workshop consists of a broad range of representatives and has input into care protocols, provides strategic advice and will assist with education opportunities to be implemented via the three Panels. Click here for a copy of the diagram illustrating the current structure of the Initiative for ODGP.

Contact: Ms Jay Wright jayw@odgp.com.au

PERTH CENTRAL COASTAL DIVISION OF GENERAL PRACTICE

The Division held its first Panel Meeting in October and at this meeting it was decided that PCCDGP would adopt a 'GP Liaison Officer Model'. In this model, each aged care home has a nominated Aged Care GP Panel member who liaises with the aged care home. The Aged Care GP Panel member reports back to Aged Care GP Panel meetings where protocols and strategies could be developed. Following the development of Division wide protocols and strategies, (initially agreed in principle by the aged care homes in the Division), the nominated panel member will liaise and work with the aged care homes to implement the Division wide strategies.

A community development approach will underpin the work of the Aged Care GP Panels Initiative. This approach will create a framework for planning and strategy development at a local level - identification of local issues and implementation of local solutions. This will be integral to the success and sustainability of the Panel Initiative.

Community development is about community building - the core elements of which are:

The grounding of problem and solution identification in reality as perceived by those most affected;
Relationship building; and
Working together.

Panel GPs have made contact with GPs working within particular aged care facilities to discuss the initiative and consult on pressures related to working in the residential aged care sector. As a result of consultation with aged care facilities and general practitioners the panel will be focusing on the following key areas:

* EPC/CMA promotion and streamlining
* Education for aged care home staff
* IT in aged care
* Communication protocols
* Advance Care Planning Project
* Falls prevention clinical trial

A Multidisciplinary Workshop is being organised in the near future as an introduction to the Panel Initiative, Comprehensive Medical Assessments and to share information. The results of the consultation with key stakeholders carried out over the last few months will be made available at this workshop and feedback will be invited. It is hoped that a key result of the workshop will be the formation of a multi-disciplinary advisory group which will be developed with the aim of being responsible for assessing the feasibility and viability of actions and make recommendations to assist the Panel in decision making.

Click Here for a copy of the PCCDGP Panel Model.

Contact: Ms Val Abery acp@pccdgp.com.au

ROCKINGHAM KWINANA DIVISION OF GENERAL PRACTICE (WA)

Rockingham Kwinana has established a single panel model with a membership of 11 GPs. The main focus of the panel will be on CMA implementation, education and quality assurance. The Division has employed a Practice Nurse to assist GPs to collate the non medical component of the CMA.

Contact: Ms Gretchen Lumsden Program Manager info@rkdgp.com.au http://www.rkdgp.com.au/

SOUTH EASTERN SYDNEY DIVISION OF GENERAL PRACTICE

South Eastern Sydney Divisions of General Practice have an Aged and Chronic Program currently operating. Services and activities include:

Provide educational opportunities and resources to GPs, practice staff/nurses
Established an Aged and Chronic Care Program Advisory Committee with reprsentatives of a GP, Program Officer, POWH Geriatrician, Community Health, Community Pharmacist, POWH Chronic and Complex Care Project Co-ordinators
Provide GPs with network opportunities by inviting Area Health Service and Community Health Providers to participate in Aged Care program's activities
Promote EPC items in corporation with other Divisional programs.

Contact: Chun Fang Yu cfyu@sesdgp.com.au

SOUTHERN HIGHLANDS DIVISION OF GENERAL PRACTICE

The Aged Care program has developed since 1999 with the initial implementation of a Falls Prevention Program. This has been refined over the years, key elements have been the development of an assessment protocol and audit for GPs in the assessment and management of falls risk. The development of Safety First Seniors program, whereby GPs can refer their patients living in the community as risk of falling to this education and information program. This program can be modified for use in a residential setting. Currently involved with providing advice on a whole of facility program at the largest Retirement Village in our area. I have also been involved at the Public Hospital developing a mechanism for referral back to the GP after a presentation of an older person who has fallen to the Emergency Department.

RACF Liaison Meetings - this is an avenue for discussion between the RACF, 2 nominated GPs and the Aged Care Program Officer. The Program Officer faxes all GPs in the Division requesting any issues they would like discussed at the meeting. This can include compliments and information of interest to the RACF staff. (One page fax back sheet). This information is then placed on an agenda with any issue requiring feedback from the previous meeting.

Medication Management Reviews involving the treating GP, a peer review GP, pharmacist, nursing staff member from the facility and the Aged Care Program Officer. These reviews are held monthly and payment to the GP uses the RACF Case conference item numbers, the Peer GP and the pharmacist are paid by the Division for their time. Consent is obtained from the resident/next of kin, relatives have occasionally attended the reviews.

Advanced Health Care Directives Presentations in the community, to hospital staff and information to RACFs. Assistance to GPs in organising EPC case conferences.

Contact: Margaret Mogg margaret@shdivgp.com.au

SUTHERLAND DIVISION OF GENERAL PRACTICE

Sutherland Division of General Practice initiated an Aged Care Program in July 2002, guided by an Advisory Committee. The program's first year focused on building relations with key partners to enable the opportunity to work collaboratively on issue identification and drive an integrated approach to implementation and evaluation of strategies.

The identify the areas for development the program undertook a needs analysis which included a literature review, focus groups with key partners, GP survey and networking with other industry partners.

Following the recommendations, resulting from the needs analysis conducted in 2002, the Division has commenced work on several key strategies. Already benefits of the Aged Care Program are emerging. Some of the strategies that have been undertaken include:

Developed best practice electronic generated medication charts for aged care homes.
Liaison with peak bodies.
Piloted Medical Director in ACHs.
Conducted annual combined education sessions with ACHs, GPs and the local hospital based community aged care team (Southcare).
Development of a services directory for GPs and ACHs about our local hospital based community aged care service (Southcare).
Distribute a biannual newsletter to all local ACHs.
Established communication network between the Division and ACHs.

Strategies currently being completed include:

Development of a generic Memorandum of Understanding between GPs and RACFs that will clearly outline roles and responsibilities of both partners to assist them to work better together.
Sectorising - this will provides an opportunity for GPs to streamline service provision. GPs will nominate the ACHs in which they wish to service in their area which will reduce the number of facilities that the GPs visit, thus reducing travel time, and provide opportunity for the GPs and ACHs to build better relations and develop efficient and effective systems and processes.

Sutherland Division's Aged Care Program is focused on or committed to

Achieving                                                                 Collaboration
Greater outcomes, through                                       Amalgamation, for
Enhanced                                                                 Residents and
Discussion,                                                               Enthusiastic aged care health professionals

The Sutherland Division in collaboration with the GP Panels and ACHs has identified 8 portfolios to focus on under the GP Panels Intiative. They are:

Sectorising
Regional Medical Advisory Committee
Implementation of MoU
Promotion
Information Management - including streamlining documentation for admission forms, respite admissions, aged care plans & EPC items
Hospital Liaison
After Hours Protocols
Clincal Care

The Sutherland Division of General Practice has launched an Aged Care Memorandum of Understanding. This document clearly defines the complementary roles and responsibilities of general practitioners and residential aged care facilities to facilitate quality outcomes for residents living in aged care homes.

The Aged Care MoU is an acknowledgement of the importance of integrated care and aims to strengthen partnerships between GPs and RACFs. Whilst the document is not a legal or binding contract, it provides a framework which sets out the expertise and mutual commitment of both parties in the following areas:

Communication
Clinical Assessment and Management
Medication Management
Documentation
Consent
Medical Care, After-Hours, Public Holidays and Periods of Leave
Advance Care Directives / Treatment Plans
Extinction of Life
Complaints / Conflict Resolution
Quality
Professional Ethics

The Aged Care MoU has been developed in consultation with local GPs, representatives from RACFs, Aged & Community Services Association of NSW (ACSA) and the Aged Care Association NSW, formerly ANHECA. The investment by these people in the development of the MoU has demonstrated the commitment of our local partners and has enabled us to make the most of our collaborative talents.

For further information contact Janine Lundie, Aged Care Program Officer at Sutherland Division of General Practice on (02) 9525 4011 or on the email below.

Health Communication Network is currently integrating the Nursing Home and PRN/Nurse Initiated medication charts developed by the Division's Aged Care Advisory Committee, in to Medical Director. These charts meet the requirements under the relevant legislation and best practice standards. John Paul Village and Pacific Heights will be trialing the charts in January. It is envisaged that these will result in improved legibility of medication orders, minimise transcribing, and be time saving.

Contact: Yvonne Rowling (CEO) rowlingy.sdgp@shiregps.org.au or Janine Lundie (Program Officer) jlundie.sdgp@shiregps.org.au

TOOWOOMBA & DISTRICT DIVISION OF GENERAL PRACTICE

The Toowoomba Division has been active in aged care programs for several years.

The Toowoomba Division assists and supports the Older Person's Interest Group (OPIG). OPIG aims to bring together individuals and services who have a common interest in the well-being and care of older person's in our community.

The group is an independent body, with shared / equal governance amongst participants, which will consider issues of relevance to older people including the provision of aged care services. Anybody is welcome to join the group, there are no official membership requirements, simply a desire to discuss and address issues that will promote the well-being of older person's in our community. It is hoped that the group will provide opportunities to network amongst services, improve communication, promote co-operation on shared issues and allow for the sharing of skills and knowledge. Meetings are to be held on a bi-monthly basis.

GP Connections is committed to advocating for improvements to aged care in the Toowoomba region. Specifically, they address the issues of step down, day only assessment, patient held records, aged care wards and holds an annual aged care event.

Contact: Mr Tim Wilke www.tddgp.com.au

TOWNSVILLE DIVISION OF GENERAL PRACTICE

The "Stepping Out Steering Committee" continues to meet every 3 months to overview the continuation of the Stepping Out Programme, which was completed in 1999. The committee is still involved with aspects of fall prevention in the community such as encouraging correct shoe wear, gentle exercise classes and home safety. Medication reviews are encouraged and this has been helped by the new enhanced primary care items. The issue of Incontinence has been addressed by ECCLI in NESB women and men, and by the shared care program of the Townsville Division of General Practice.

The Townville Division website contains:

Risk Factor Assessment
List of services available in Townsville
Safety products to help prevent falls

Contact: Dr Alison Hogg ahogg@tdgp.com.au

WEST VICTORIA DIVISION OF GENERAL PRACTICE

DIVISION-BASED MODEL OF QUALITY CARE COMMITTEE IN RESIDENTIAL AGED CARE PROJECT

This project is part of a larger joint venture, which seeks to improve the quality of care to residents through the active engagement of health professionals, aged care providers and staff in quality improvement activities.

In March 2001 the Department of Veterans' Affairs (DVA) and the Department of Health and Ageing (DoHA) agreed to jointly fund a consultant to research and advise on an appropriate strategy for piloting quality committees in aged care facilities.

The Objectives were to:

Develop a system to assist aged care facilities to minimize the risk of adverse events and improve safety and quality of care. This may involve an incident monitoring system that identified and reports incidents and implements appropriate processes with a view to preventing their re-occurrence.
Research and develop strategies that assist aged care facilities to meet accreditation processes through participation in incident reporting and quality committee programs.
Research and develop a multidisciplinary quality of care committee (RQCC) to discuss and develop recommendations.
Develop appropriate systems for dissemination of recommendations to participating aged high care facilities, including protocols and pathways for best practice.

The project outcomes:

A regional quality committee was established that included representatives from three aged care facilities, a local GP and a consumer representative.
The quality committee has met 5 times. The main focus being dementia management and medication management with case studies concentrating on these issues. The topics were:
Bench marking
Pain management
Dementia, including behavioural issues
RCS, accreditation and documentation demands
Medication management
Polypharmacy
Staff qualifications and training
Quality Improvement and risk management
Sharing case studies and brain storming strategies. Members were encouraged to present written case studies on quality issues and these were presented and the committee offered advice and links to expert knowledge.
Setting up a regional network for unit/middle managers. Peer managerial support emerged as an immediate need as many managers work in profession isolation and used their peers in the group to discuss issues around documentation, accreditation and staff management.
Provision of expert advice, for example pharmacists, GP and psychiatric services. The Division was able seek expert advice through email and resource and facilitate allied health, GP or consultant attendance at the meetings. This allowed local facilities to establish networking opportunities and discussions on quality free of the workplace and the sometimes complex relationships of local relationships. As a result the agencies reported improved health care for 3 residents following medication advice.
Trial of a quality assurance model for residents with dementia (ReBOC), as dementia was an area discussed. Agencies trialed ReBOC which promoted the quality improvement cycle.

The simplicity of the model acknowledges that the most important needs of these agencies is a network that can respond to immediate needs and one that provides a growing sense of a regional approach and is developing a culture of openly sharing areas that need addressing under a quality framework.

The challenge for the Division, throughout this project, was to provide

a professional environment that encourages the disclosure of concerns around patient care and
support to facilitate practical and relevant interventions.

Proposal
At the current proposed level of funding the project is expected to deliver the following;

A regional quality committee,
Broad based stakeholder input
Specific case based issue analysis
A platform for the sharing of common concerns and suggested solutions.

Further consideration is required for the refinement of the quality process, this includes;

incident and event detection,
data management,
process analysis,
intervention design and implementation.

Evaluation

Information was collected from each participating facility as in line with the work conducted by Elizabeth Percival. The methods of collection included an interview and pre- RQCC establishment questionnaire.

Contact: Ms Sally Philip (CEO) or Ms Jane Measday www.westvicdiv.asn.au

WIDE BAY DIVISION OF GENERAL PRACTICE

The Wide Bay Division of General Practice has had a specific aged care program since 2002 and has pursued a range of activities under this program. Some of the key activities are listed below.

Inter-facility Aged Care Forums
Forums have been established in Hervey Bay, Maryborough and Bundaberg to address issues related to GPs and provision of high quality health services to older people. The membership of these forums changes according to the issue being addressed at any given time. Issues addressed so far have centred around residential aged care facilities and in particular the timely provision of regular medications. As a result of discussion and negotiation between GPs, RACFs and Pharmacists a standardised system for prescription requests has been developed and implemented in Hervey Bay and Maryborough. It is anticipated that a similar system will be adopted in Bundaberg as well in the coming months.

Regional Dementia Forum
The Division is an active member of the Regional Dementia Forum and are currently working with this group in the final stages of development of a document that can be integrated into medical software to be printed out by GPs and given to patients or carers of patients who have been diagnosed with dementia. The document contains local information and contact details as well as general information and aims to encourage early contact with service providers so that support structures can be prepared rather than contact only during crisis.

Standardised Fitness to Drive Assessment Tool
We are currently working on a standardised fitness to drive assessment tool that can be incorporated into medical software and also used as a paper-based resource to assist GPs in addressing the problem of "doctor shopping" by people wanting to retain their license. The tool will also give the GP a standardised framework for a rigorous assessment and discussions are underway with local police as to provision of incident reports to GPs where a patient is having a medical assessment as the result of a traffic incident.

GP Call Out form for Residential Aged Care Facilities
In cooperation with GPs and RACFs we have developed a standardised call out form for RACFs to complete prior to calling out a GP to attend a patient. The form provides the basic information that GPs identified that they wanted to know and allows for recording of GP response / instructions. Originally designed to be used for after hours call outs, the form has been found to be useful during GP surgery hours as well. The form is also used as a communication tool as a copy of the completed form is forwarded to the patient's regular GP where another "on call" GP has attended.

The Wide Bay Division has developed two Pain Management documents. Elderly People and Pain and Good Practice Procedure: Pain Management for Aged Care Residents. Both are available in hard copy from the Division or via the net at http://www.widebaydgp.org.au/Resources/Pain.htm.

Aged care is also being addressed through theeducation and training and MAHS programs as well as through other project work and division activities. Wide Bay has a strong commitment to Aged Care and are very keen to be involved in the Divisions Aged Care Network and other aged care related activities.

Natalie Sell, Program Manager Aged Care, a 2004 Churchill Fellow, has written a report that presents her results of the research undertaken as part of the Vincent Fairfax Churchill Fellow. "New models of care for our ageing population" highlights innovative interventions that allow older people to remain living independently in their own homes and helps to reduce avoidable hospitalisation.

Contact: Ms Natalie Sell natc@widebaydgp.org.au

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