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.

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.

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.

Care finder service

The national care finder program commenced 1 January 2023. The program is a free service that exists to support eligible vulnerable older people- who have no one else who can support them – to learn about, and apply for and access aged care services.

Who is eligible to use the care finder service?

To receive care finder support, a person must:

  • have no carer or support person that can appropriately assist them
  • need help with one or more everyday tasks
  • be aged 65 years or older (50 years or older for Aboriginal or Torres Strait Islander people) OR 50 years or older (45 years or older for Aboriginal or Torres Strait Islander people) on a low income and homeless or at risk of being homeless
  • be eligible for government funded aged care support.

The care finder service is not available for everyone. Learn more about eligibility here.

What help can care finders provide?
Care finders can help vulnerable older people navigate the aged care system and find support services to improve their quality of life.

Who do I refer to a care finder in the Brisbane South region?
Check the map and accompanying list of service providers in the Brisbane South region.

You can refer your client directly to a care finder organisation by completing a referral form via the links below.

For more information, visit the My Aged Care website.

Healthy Ageing Hubs

Brisbane South PHN is supporting community organisations in the region to deliver the Healthy Ageing Hubs program. 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 program:

This program is 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 community 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

Online module for residential aged care

Online module for hospital services

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

More information