Section One: How to use this kit
Finding what you need
Privacy Statement
Acknowledgements
Disclaimer
Finding what you need
The 'GP and Residential Aged Care Kit' (Kit) provides a partnership approach and tools to assist general practitioners (GPs), staff in Residential Aged Care Facilities (RACF), and other service providers to provide medical care for residents.
The first edition of the Kit was published in December 2004. This second edition was completed in November 2006.
Although this Kit is written primarily for general practitioners and residential aged care nurses, all service providers who work in the residential aged care setting can use the integrated approach to residential health care. Service providers can quickly identify which systems and tools will be useful to them by referring to Table 1 in Section 2: Residents’ medical care.
Section 3 and Section 4 provide systems and tools for GPs and RACF staff, particularly for comprehensive medical assessment and chronic disease management. Section 5 provides 23 Clinical Information Sheets developed to assist with medication management, advance care planning, and the prevention and management of conditions that commonly occur in RACFs.
The resources are designed to help optimise medical care for residents within the current service system and funding arrangements.
The Kit has been developed in consultation with RACF staff, GPs, medical deputising services, Metropolitan Ambulance Service, local hospital emergency departments, local hospital medical staff and consumers in the northwest area of Melbourne.
The authors are aware of the current problems of overwhelming paperwork for RACF staff and GPs. The resources provided are not intended to add to the paperwork maze. They have been designed to streamline communication and documentation, and can be adapted across low-level and high-level care facilities.
The complete kit is available for downloading from Australian Divisions of General Practice website or can be obtained from the website or as a CD from North West Melbourne Division of General Practice. A CD version will be mailed to RACFs in Victoria and Divisions of General Practice nationally in November 2006.
List of terms
Terms may sometimes be used differently across health care sectors – residential aged care, general practice and hospitals. We have, therefore, defined common terms used in the Kit and Clinical Information Sheets.
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Accreditation* |
The process an aged care service must go through to become accredited by the Aged Care Standards and Accreditation Agency. A service must satisfy the Agency that it complies with the Accreditation Standards and other responsibilities under the Aged Care Act 1997. |
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After hours |
Hours which are outside of the normal opening hours of the medical practice. These hours are determined by the practice.
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Consumers |
People who are concerned about the performance of the organisation for themselves and other members of the community; the definition includes those who are users of the services provided by the health care organisation. (Australian Council of Health Care Standards 1996). |
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Continuous improvement* |
A total approach to achieving improvement in how a service operates, the care and services provided and the results for residents and other stakeholders. |
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General Practitioner (GP) |
A registered general practitioner, who is the resident’s usual general practitioner. |
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Health professional |
Broad term incorporating all persons caring for the resident in the RACF who hold registration with a health professional board (e.g. general practitioner, registered nurse, physiotherapist, etc.). |
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Improvement activities* |
The range of activities throughout a service that contribute to its overall program of continuous improvement. |
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Innovation* |
A new or different way of doing business that adds value to residents, representatives, staff or other stakeholders. |
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Key performance indicator* |
Information which shows the extent to which an anticipated result is achieved or the quality of the process leading to that result. It should focus only on the important and critical aspects of the process, output or outcome. |
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Locum GP |
A medical practitioner, from a medical deputising service, performing the duties of the resident’s GP when the resident’s GP is unavailable (e.g. after hours). |
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Medical deputising service |
Provides continuity of care to patients of GPs, registered with the service, primarily by a domiciliary visit when the GP is unavailable. |
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Medical practitioner |
A registered medical practitioner, e.g. GP, locum GP, palliative care physician, and geriatrician, who is attending the care of a resident in the RACF. |
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Patients |
Residents are called patients when they receive services from medical service providers, such as, GP, MDS, ambulance or hospital. |
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Qualified prescriber |
Any person qualified to prescribe medication under Victorian legislation (e.g. a medical practitioner, a register nurse practitioner, a dentist) |
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RACF staff |
All staff including, registered nurses, other health providers, personal care workers or other support staff (eg cook), etc. |
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Registered nurse |
Nurse registered under Division 1 or Division 2. |
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Registered Nurse Div 1 |
Nurse registered under Division 1. |
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Registered Nurse Div 2 |
Nurse registered under Division 2. |
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Resident |
A person who lives in a Residential Aged Care Facility. |
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Residential Aged Care Facility |
Term introduced by the Commonwealth Government to describe a ‘residential aged care service’, also referred to as a ‘facility’ in this kit. |
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Residential aged care service* |
An organisation that provides care and accommodation for aged people requiring a certain level of care. For the purposes of this kit, it refers to services that receive funding from the Commonwealth government. |
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Service providers |
Professionals or organisations that provide medical or other health services. |
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Stakeholders |
Groups or communities who have an interest in the health service organisation; these include government departments, professional organisations, consumer groups, non-government organisations and population groups. (Commonwealth Department of Human Services and Health 1995). In this kit, stakeholders include those with an interest in after hours medical care for residents of Residential Aged Care Facilities. |
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Sustainable* |
Describes continuous improvement or other systems that have become part of a service’s culture and will survive staffing or other organisational change. |
* Source: Adapted from Aged Care Standards and Accreditation Agency. Accreditation guide for residential Aged care services, Appendix 2, Dec 2001
Acronyms
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ACEBAC |
Australian Centre for Evidence-based Aged Care |
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ACP |
Advance Care Planning and/or the resulting Advance Care Plan |
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AHPMC |
After Hours Primary Medical Care |
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ANF |
Australian Nursing Federation |
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APAC |
Australian Pharmaceutical Advisory Council |
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APPG |
Australian Prescription Products Guide |
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CACP |
Community Aged Care Packages |
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CC |
Case Conference |
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CIS |
Clinical Information Sheet |
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CMA |
Comprehensive Medical Assessment |
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CR |
Controlled Release |
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DAA |
Drug Adminstration Aid |
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DL/MC |
Discharge Letter / Medication Chart |
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EACH |
Extended Aged Care Packages |
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EC |
Enteric Coated |
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ED |
Emergency Department |
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EPC |
Enhanced Primary Care |
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GPs |
General Practitioners |
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HIC |
Health Insurance Commission |
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IM |
Intramuscular |
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INR |
International Normalised Ratio |
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IV |
Intravenous |
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KPI |
Key Performance Indicator |
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MAC |
Medication Advisory Committee |
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MAS |
Metropolitan Ambulance Service |
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MBS |
Medicare Benefit Schedule |
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MC |
Medication Chart |
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MD |
Medical Director Software |
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MDS |
Medical Deputising Service |
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MH |
Melbourne Health |
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MX |
Management |
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NBV |
Nursing Board of Victoria |
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NGO |
Non-Government Organisations |
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NHMRC |
National Health and Medical Research Council |
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NOK |
Next of Kin |
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NWMDGP |
North West Melbourne Division of General Practice |
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PCA |
Personal Care Attendant (used interchangeably with PCW) |
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PCW |
Personal Care Worker (used interchangeably with PCA) |
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PDSA |
Plan, Do, Study, Act |
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QA |
Quality Assurance |
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RAC / RCF |
Residential Aged Care / Residential Care Facility |
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RACF |
Residential Aged Care Facility |
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RCS |
Resident Classification System |
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RMMR |
Residential Medication Management Review |
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RN |
Registered Nurse |
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SR |
Modified Release |
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TL |
Transfer Letter |
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WHO |
World Health Organisation |
Abbreviations used in writing prescriptions and medication charts are listed in Table 3 in the Clinical Information Sheet: Medication Management.
Useful Websites
National:
Aged Care Standards & Accreditation Agency: www.accreditation.aust.com
Aged Care Online: www.agedcareonline.com.au
Australian Divisions of General Practice: www.adgp.com.au
National Aged Care Alliance: www.naca.asn.au/publications
Compact Business Systems: www.compact.com.au
Victorian:
Aged & Community Care Victoria:www.accv.com.au
Melbourne Medical Locum Service: www.mmls.com.au
Metropolitan Ambulance Service: www.ambulance.vic.gov.au
North West Melbourne Division of General Practice: www.nwmdgp.org.au
The list is not complete. GPs, RACFs and Divisions of General Practice are encouraged to add local contacts.
Useful Clinical resources
General resources for clinical care of older people in RACFs include:
Privacy Statement
Contents of this kit comply with privacy legislation for use of health information in care of Residential Aged Care Facility patients.
Since December 2000, private health service providers are required to abide by the National Privacy Principles in the Privacy Act (Health Amendment) 2000 when collecting, using, disclosing and storing health information. Health service providers, in Victoria, are bound by the Health Records Act 2001 (Vic), which was enacted on 1 July 2001 and contains a similar set of principles.
This means, amongst other things, residents of Residential Aged Care Facilities:
Have more choice and control over their information. Should be told what happens to their health information. Should be told why and when a health service provider may need to share information, for example to ensure they receive quality treatment and care, from another provider. Can ask to see what is in their health record and, if they think it is wrong, ask for it to be corrected.
In practice, when a resident is admitted to a Residential Aged Care Facility, he or she is asked to sign a consent form (such as the sample one included in section 4 [adapted from the Royal Freemasons Homes]). This means that appropriate health information in the resident's record can be shared between RACF staff and health service providers involved in the provision of medical care. This includes the health information referred to in this kit, including the resident’s comprehensive medical summary, care plans, medication chart, pathology results, hospital transfer letter, and hospital discharge letter, where appropriate. Where practicable, residents should be advised when information is to be shared.
Acknowledgements
The first edition of the Kit was developed through the 'After Hours Primary Medical Care for Residents in Residential Aged Care Facilities Project', auspiced by North West Melbourne Division of General Practice (NWMDGP). The project was funded by a service development grant from the Commonwealth Department of Health and Ageing. Melbourne Health Human Research and Ethics Committee approved the project and its evaluation. The Kit was designed to help GPs and RACF staff work together, with other service providers to prevent unplanned events and better manage clinical events occurring after hours. Authors of the first edition of the Kit were Denise Ruth and Rita Wong with Emily Haesler (Clinical Information Sheets), Meg Storer (Reference Cards) and Noel Stewart (Using Medical Director for Residents' Care).
The second edition of the Kit was developed with funds from the Commonwealth Department of Health and Ageing, ‘After Hours Primary Medical Care Program’. Otway Division of General Practice funded the Osteoarthritis Clinical Information Sheet.
The second edition of the Kit includes:
An update of the content of the first edition of the Kit and Clinical Information Sheets (current as of November 2006); Nine additional Clinical Information Sheets; A chronic disease management sub-section in Section 2; Additional resources for using the residential aged care Medicare Benefits Schedule (MBS) items; and Inclusion of the Aged Care Standards and Accreditation Agency’s Accreditation Standards, where relevant.
To assist with implementation of the Kit, the North West Melbourne Division of General Practice has also produced:
An education module for GPs and RACF staff based on the Kit (compliant with the RACGP’s Active Learning Module framework); and A training package that will assist trainers to deliver the education module to GPs and RACF staff.
Authors of the second edition of the Kit were Denise Ruth and Sian Reilly, with Emily Haesler (Clinical Information Sheets) and Noel Stewart (Using Medical Director for Residents' Care). Authors of the additional Clinical Information Sheets were Denise Ruth and Emily Haesler, with Norma Jean Duncan (Elder Abuse Clinical Information Sheet). Dr Alison Sands, Dr Mary Belfrage and Ms Clare Chiminello from North East Valley Division of General Practice have authored various resources used throughout the Kit, and are referenced where appropriate. The editor was Denise Ruth. Proof reader was Carolyn Searle.
We thank members of the Project Advisory Group for generously making time to review the Clinical Information Sheets. Members were: Josie Adams, Dr Ralph Audehm, Olwyn Backhouse, Susannah Dax, Rosemary Fennech, Meni.Frawley, Dr Jenny Gowan, Dr Penny Harvey, Karen Kennedy, Jane Phelan, Rose Bushby, Dr Sam Scherer, Lee Stamford, Dr John Stanton, and Meg Storer. We also thank Josie Barbagallo, Dr Caroline Brand, Prof Rob Helme, Prof Edward Janus, Susan Koch, Dr Kylie Staggard, Katherine Utry and Dr Michael Vagg for reviewing various Clinical Information Sheets.
Sian Reilly and John Stanton developed the Active Learning Module and Training Package.
We thank all those who contributed to the development of this kit through the Project Advisory Group, Reference Groups, and directly in the design and piloting of the resources that are contained within the kit. Organisations and businesses involved included:
Aged Care Association of Victoria Australian Ambulatory Care Centre, Alfred Hospital Australian Centre for Evidence Based Aged Care, La Trobe University Australian Locum Medical Service Bell Street Clinic, Coburg Campbell Research & Consulting Carer’s Association Victoria Compact Business Systems General Practice Divisions Victoria Grantham Street General Practice, West Brunswick Melbourne City Mission Palliative Care Melbourne Division of General Practice Melbourne Health, including the Royal Melbourne Hospital and Melbourne Extended Care and Rehabilitation Service Melbourne Medical Locum Service Metropolitan Ambulance Service North East Valley Division of General Practice Northern Division of General Practice Northern Health, including Northern Hospital, Bundoora Extended Care and Broadmeadows Health Service
NWMDGP General Practitioner and Consumer Representatives Otway Division of General Practice. Palliative Care Australia. Residential Aged Care Facilities in the North West Aged Residential Care Network, particularly Wesley Aged Care, Holloway Hostel, Dorothy Impey Home, Anzac Lodge, Glengowrie Aged Care Facility, Plumpton Villa, North Western District Nursing Home, Emily Lenny and Cyril Jewell House Respecting Patient Choices Program, Austin Hospital St Vincent’s Hospital, Melbourne Victorian Association of Health and Extended Care
Contents of this kit comply with privacy legislation for use of health information in the care of Residential Aged Care Facility patients. We are grateful to Victor Harcourt, Partner of Russell Kennedy Solicitors, for his assistance in the medico-legal review of the earlier ‘Residential Aged Care After Hours Kit’.
The kit is supported by:
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Royal Australian College of General Practitioners
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Australian Nursing Homes and Extended Care Association
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Aged and Community Services Australia
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Australian Divisions of General Practice
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© North West Melbourne Division of General Practice Ltd and Department of Health & Ageing.
Intellectual property right of the Department of Health & Ageing.
This material may be used with acknowledgement of North West Melbourne Division of General Practice.
Disclaimer
The GP and Residential Aged Care Kit, including the clinical information sheets, is provided on the terms and understanding that:
The publisher, North West Melbourne Division of General Practice made every effort to ensure that this publication is free from errors and omissions, and that all opinions, advice and information have been provided by professionals in good faith. The authors and editors are not responsible for the results of any actions taken on the basis of any information in this publication, nor for any error in or omission from this publication. The publisher is not engaged in rendering medical or other advice or services. The publisher, and the authors and editors, expressly disclaim all and any liability and responsibility to any person, whether a reader of this publication or not, in respect of anything, and of the consequences of anything, done or omitted to be done by any such person in reliance, whether wholly or partially, upon the whole or any part of the contents of this publication. Without limiting the generality of the above, no author, consultant or editor shall have any responsibility for any act or omission of any other author, consultant or editor. To the extent that the information contained in this kit has been compiled using information from other sources any person having concerns about the contents of same should refer to those sources for more specialist information and advice. No person should rely on the contents of this kit without first obtaining advice from a qualified professional person.
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