Older people

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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.

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. These 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.

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.

Upon completion of the trials, outcomes will be independently evaluated by Australian Healthcare Associates (AHA) to inform future policy considerations and guide the implementation of long-term models of aged care support.

Services and activities Brisbane South PHN have delivered during the trials include seminars, phone support, and group and individual sessions (including by our Specialist Support Worker) 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
  • Institute for Urban Indigenous Health (IUIH)
  • 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.

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 pilot

Brisbane South PHN is supporting community organisations in the region to pilot five Healthy Ageing Hubs. The 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.

Five 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 the 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

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.

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.

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.

End-of-life care in residential aged care facilities

In 2017, the Improving End-of-Life Care Residential Aged Care Residents Initiative was developed by Brisbane South PHN in partnership with the Metro South Palliative Care Service (MSPCS). The initiative aims to support Residential Aged Care Facilities (RACFs) to embed evidence-based practice in their routine clinical care to support high-quality end-of-life care for residents and their families.

The recent Productivity Commission’s Report, ‘End-of-life care in Australia’, agrees that end-of-life care should be core business for RACF’s. However, it acknowledges this will require a coordinated approach in supporting the upskilling and ongoing education of aged care nurses to ensure they have the necessary skills to lead and coordinate end-of-life care in RACFs.

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.

More information

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