On this page:
- Older People’s Health and Wellness Strategy
- Healthy Ageing and Frailty
- Aged Care Workforce Strategy
- Supporting older family carers
- Care Finders Supplementary Needs Assessment
- Aged Care Navigator Trials
- Healthy Ageing Hubs pilot
- Yellow Envelopes
- End-of-life care in residential aged care facilities
- Improving patient experience
- More information
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:
- facilitate connected person-centred care
- enable evidence-based, safe and high-quality care
- improve health outcomes for vulnerable communities
- 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.
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. 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.
- Principles card set
- Principles poster
- Transitions and opportunities map
- Links to video interviews
- Video interview posters
- ‘Rich picture’ posters of carers
- Additional insights
- Map of our research methodology
Watch our Carer Support video
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: email@example.com
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:
- Logan East Community Neighbourhood Centre (LECNA)
- Inala Wangarra Inc.
- Amputees and Families Support Group QLD Inc (AFSG) – Logan Central
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.
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 firstname.lastname@example.org.
Alternatively, you can also download the yellow envelope template here.
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 email@example.com.
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 firstname.lastname@example.org.
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.
Watch What Really Matters – an interview with consumers
Learn about person-centred care