Older persons health

Last updated 12 October 2023
Older persons health

Age care navigation and support

My Aged Care

The ‘My Aged Care’ website is the Australian Government’s online portal to support older people with their health care needs. It provides information about finding and accessing the government-funded services they need. 

Aged and Disability Care Australia (ADA)

Brisbane South PHN is partnering with Aged and Disability Care Australia (ADA) from 1 September 2021, to provide free specialist aged care support and navigation. 

ADA Australia’s Aged Care Navigator services are available to people residing in the Brisbane south regions, who need information about aged care options, or help to access aged care supports. This includes older people, their families, friends and others who want to link with aged care supports. 

Click here to find out more. 

To refer your patients to this service, send referrals via fax or secure email to the below address. Once a referral is received, contact will usually be made within 24-48 business hours. 

Frailty Care Coordination Service

Frailty is recognised as a key health issue among older people living in the community. However, frailty is not an inevitable consequence of ageing and is potentially reversible when identified and managed appropriately. 

Brisbane South PHN is supporting Footprints Community Limited to deliver a navigation service to support to older people who are frail (or are at risk of frailty) to access relevant health, social, and community care to prevent, reduce or manage their symptoms and adverse health consequences of frailty and improve quality of life and wellbeing outcomes. The Frailty Care Coordination Service will target older people living in the community in the Beaudesert and Logan area. 

Support for families and carers

The ‘Carer Gateway’ website is the Australian Government’s online portal to provide practical advice and access to supports for family members and friends caring for people with health conditions that demand a lot of support from their carer. These conditions include a disability, dementia, mental illness, chronic illness and life-limiting illnesses. Family and Carer services include assistance to connect with health services, free phone counselling, carer coaching and connection to other carers.

Advance care planning

The ‘My Care, My Choices’ website is the Queensland Government’s online portal promoting the important processes of advance care planning and providing information and resources to the health professionals and the community. 

Advance care planning involves informing and educating your patients about their ongoing health care options specific to their needs, then supporting their decision making. Advance care planning may be general or require specific advice about an Advanced Health Directive, Enduring Power of Attorney, Statement of Choices or forms to revoke these documents. 

General practice quality improvement (QI) measures for older patients

The following quality improvement toolkits are available to support your care of older people: 

The toolkits are designed… 

  • to support medical practices to make easy, measurable and sustainable improvements 

  • to provide best practice care for their patients  

  • to assist practice’s to complete Quality Improvement (QI) activities using the Model for Improvement 

  • to assist practices to meet the Practice Incentive Program Quality Improvement Incentive (PIP QI). 

For more information on how Brisbane South PHN supports quality improvement in general practice, click the button below.

Older People’s Health and Wellness Strategy

Brisbane South PHN and Metro South Hospital and Health Service are committed to working together to improve older people’s health and aged care journey. Both organisations are working in partnership and have developed the Older People’s Health and Wellness (OPHW) Strategy 2019–2024 to guide decision-making. 

The OPHW Strategy focuses on ensuring older people in the region experience a greater quality of life through safe, connected and coordinated person-centred health care in an age-friendly community. 

As part of the strategy, four key priorities have been identified: 

  1. facilitate connected person-centred care 

  2. enable evidence-based, safe and high-quality care 

  3. improve health outcomes for vulnerable communities 

  4. build an age-friendly community. 

These priorities have guided the subsequent development of programs to support the overall strategy.

Healthy Ageing and Frailty

Frailty occurs from a combination of de-conditioning and acute illness on a background of existing functional decline and is often under recognised. 

Frailty can affect up to 25% of people aged 70 and over, which equates to approximately 27,000 people residing in Brisbane South. 

People with frailty have 2 to 3 times the health care utilisation of their non-frail counterparts and experience higher morbidity and mortality, as well as lower quality of life. Their carers can also experience high levels of stress. 

Many of the causes of frailty can be managed and, in some cases reversed highlighting the importance of identifying older people who are living with frailty. 

It is important to identify frailty risk early to combat the condition and it effects. The use of a validated screening tool will ensure accurate, reliable, and consistent frailty identification. We recommend the use of the “The FRAIL Scale” to identify a level of frailty. A score of 1 to 2 indicates pre-frailty and a score of 3 or more indicates frailty. 

BSPHN is currently partnering with The University of Queensland/Mater Research Institute Centre for Health System Reform and Integration to determine: 
1) the impact of the Frail Scale Screening Tool on identifying frailty in general practice in Brisbane South; and 2) the services required in the community to support those who are pre-frail and at risk of frailty. 

For more information see resources below: 
1) Healthy Ageing and Frailty
2) Clinical resources
3) Referral options
4) Patient resources

Frailty Care Coordination Service

Frailty is recognised as a key health issue among older people living in the community. However, frailty is not an inevitable consequence of ageing and is potentially reversible when identified and managed appropriately. 

Brisbane South PHN is supporting Footprints Community Limited to deliver a navigation service to support to older people who are frail (or are at risk of frailty) to access relevant health, social, and community care to prevent, reduce or manage their symptoms and adverse health consequences of frailty and improve quality of life and wellbeing outcomes. The Frailty Care Coordination Service will target older people living in the community in the Beaudesert and Logan area. 

Download the referral form for the Medical Director and Best Practice clinical information systems here

Aged Care Workforce Strategy 

A capable aged care workforce has been identified as a critical enabler in our strategy for improving older people’s health care within the Brisbane South PHN region. 

The collaborative efforts of staff from Brisbane South PHN and Metro South Health, together with the local health and aged care sectors, have led to the development of the Brisbane South Aged Care Workforce Strategy 2020–2024. 

This strategy serves to highlight further our strategic commitment to enhancing health outcomes for older people in Brisbane south and identifies six priorities to guide further action. 

  • Upskilling residential aged care facility and in-home care workforce. 

  • Attracting and rewarding General Practitioners. 

  • Improving elderly-specific content in clinical training. 

  • Attracting professionals skilled in providing health care to older people. 

  • Increasing the capacity and capability of primary care health professionals. 

  • Improving the interface between care settings. 

A report has been developed to outline the current state of the aged care workforce in the Brisbane south region and describe the key findings that informed the strategy development process. 

This report will aid in monitoring the achievement of the objectives outlined in the Workforce Strategy, and help to assess the effectiveness and impact of programs and activities being delivered as part of the Workforce Strategy and guide future planning and commissioning. 

Supporting older family carers

In 2019, Brisbane South PHN facilitated community conversations and workshops with older people and their carers across the region. The purpose of these activities was to hear first-hand about the lived experience of these informal, older family carers and identify how we can facilitate better support for them. 

The findings of these community conversations and workshops have been collated into a Project Outcomes Report. The findings will be used by our organisation to guide our planning and decision-making to ensure appropriate supports are in place for older family carers, especially as their patient’s needs become more complex and support-intensive. 

Additionally, we have made the findings of these activities available to health professionals and other community organisations with the view to improving carer support and service integration across the region. 

Click on the links below to access the full suite of assets:

Watch our Carer Support video:

Care Finders

Care Finders Supplementary Needs Assessment

Brisbane South PHN is delivering the national care finder program through the Department of Health and Aged Care from January 1 2023. 
The Supplementary Needs Assessment was approved on 25 November 2022 and outlines the priority areas for older people in our region.

Aged Care Navigator Trials

As part of the national Aged Care Navigator trials, Brisbane South PHN is working with community organisations to deliver different types of services and activities across the region to help older people learn more about government-supported aged care programs and how to access them. 

Services and activities Brisbane South PHN have delivered during the trials include seminars, phone support, and group and individual sessions to almost 7000 older people across the region in partnership with a number of local services: 

  • Aged and Disability Advocacy (ADA) Australia 

  • Donald Simpson Community Centre, Cleveland 

  • Inala Community House (ICH) 

  • LACOTA at Logan Central Community Centre 

The Aged Care Navigator trial is delivered by Brisbane South PHN as part of a consortium led by COTA Australia and funded by the Australian Government. 

AHA has completed an evaluation of the aged care navigation trials across Australia from October 2018 to June 2021. The final report can be found here. 

Brisbane South PHN understands that some older people require additional support to navigate the aged care system. From 1 September 2021, Brisbane South PHN has partnered with ADA Australia to provide free specialist support for your clients who are aged 65 years and over (Aboriginal & Torres Strait Islander people 50 years and over), socially isolated, at risk of homelessness and/or have complex health or mental health issues. They do this in several ways, including: 

  • identifying appropriate and available local services and how to access them 

  • connecting them to the Federal Government’s ‘My Aged Care’ information portal via website or telephone 

  • assisting them with choosing a service or provider, and facilitating access (e.g. completing relevant forms for access) 

  • helping break down any barriers the older person is experiencing accessing aged care services, including referring them to alternative or support services. 

Please send referrals via fax or secure email to: 

ADA Australia Intake Team 
Fax: 07 9637 6001 
Secure email to: intake@adaaustralia.com.au 
Contact time: once referral is received and based on workload, contact is made within 24-48 business hours. 

Healthy Ageing Hubs

Brisbane South PHN is supporting community organisations in the region to pilot Healthy Ageing Hubs. Healthy Ageing Hubs create local links to primary health care and empower older people, their families and carers, to confidently manage their own health and wellbeing in the community. 

A number of organisations are currently involved in the Healthy Ageing Hubs pilot: 

This pilot was designed to allow older people, their families and carers to access health information and support in convenient and familiar places that are culturally safe and appropriate. Through our Healthy Ageing Hubs, we aim to provide more opportunities for older people to make the most of existing services in their own communities and help them to access reputable health and aged care information. 

Yellow Envelopes 

The Yellow Envelope is a communication tool used in clinical handover when residents of aged care facilities are transferred to and from hospital. Its aim is to improve patient safety and the quality and continuity of care.


Residential aged care services and hospitals can order a supply of Yellow Envelopes on 1300 467 265 or email agedcare@bsphn.org.au. 

Alternatively, you can also download the yellow envelope template here

Support materials 

Flow chart 

The clinical information flow chart illustrates how the Yellow Envelope supports clinical handover between settings of care and between care providers. 

A copy of the flowchart can be downloaded here

Online module for residential aged care 

An online module is available to support the implementation and adoption of the Yellow Envelope in practice. 

Residential Aged Care staff can access the module through DiscoverPHN

Alternatively, if you would like to embed the module into your own facility’s online professional development or Learning Management System, please contact us at agedcare@bsphn.org.au

Online module for hospital services 

An online module for hospital staff is currently being developed. Please check back for more information soon or contact us on agedcare@bsphn.org.au. 

Improving patient experience

Metro South Health has led the “What Matters to Bill and Betty – Frail Older Person Project” to better understand the older person’s health care journey and use this knowledge to co-design an improved patient experience for older people with Brisbane South PHN.

The project delivered a series of recommendations to improve the integration and provision of, high quality, health care services that accommodate the specific needs of the elderly.

Several research activities were undertaken with stakeholders throughout the project, including a number of community workshops. These activities helped us to collect information to understand the older-patient health care journey better and identify the barriers to quality and safe patient care.

Outcomes of these activities included the development of an Experience Map that identified what matters most in an older person’s health care journey and identified gaps in care. Recognising the value of the community contribution to our research, we also recorded some members’ stories sharing their first-hand health care experience.

Watch What Really Matters – an interview with consumers