Aged Care

Our Integration and Priority Populations Programs Team supports GPs in our region providing care to residents of South Western Sydney. 

The following areas have been highlighted as priorities within Aged Care:

Advance Care Planning

Palliative Care

Healthcare for aged care residents

Seasonal Influenza Vaccination 2022

Advance Care Planning

Advance care planning is a process of planning for future health and personal care, whereby the person’s values and preferences are made known, so they can guide decision-making at a future time if the person cannot make or communicate his or her decisions.

Advance Care Planning promotes the autonomy and dignity of an individual, an important part of providing high quality, person-centred care. It has the potential to improve care and decision-making during times of impaired capacity.

SWSPHN is supporting advance care planning by:

  • Linking GPs and Practice Nurses to education and training
  • Providing access to resources and tools to implement advance care planning as a part of usual practice
  • Encouraging uploading of Advance Care Directives to My Health Record for storing and access by treating Health Professionals

Tools and Resources to assist Advance Care Planning


HealthPathways is designed and written for use during a consultation providing clear and concise guidance for assessing, managing and referring a patient in the local health system.

Advance Care Planning and Completeing an Advance Care Plan including Best Practice and medical Director templates.

Supporting patient fact sheets for patients are available on the companion site Health Resource Directory in Arabic, simplified Chinese and an audio version in Vietnamese. 


Advance Care Planning and Directives NSW a guide for health care professionals is an infographic highlighting the difference between an Advance Care Plan and an Advance Care Directive. It was produced by Sydney North Health Network and is displayed here with their permission.


Advance Care Planning Australia (ACPA) is a national program that provides information and resources to healthcare professionals, individuals, and care workers. ACPA provides an advisory service Monday to Friday during business hours to answer Advance Care Planning questions.

Advance Care Planning Advisory Service


Capacity Toolkit produced by the NSW Attorney General’s Department assists in correctly identifying whether a person has the capacity to make their own decisions. Section 5.2 of the toolkit is specific to making and using an Advance Care Plan and other health related decisions.

Palliative Care Australia provides discussion starters that may assist patients to begin to think and talk about their health care wishes. These can be completed online or downloaded. There are two toolkits. Dying to Talk Discussion Starter and Dying to Talk Aboriginal and Torres Strait Islander Discussion Starter


The Advance Project following completion of the appropriate online training module, access is given to the project’s practical, evidence-based toolkit of screening and assessment tools, specifically designed to support Australian general practices. The project also provides one-on-one telephone mentoring from a palliative care nurse to provide individual mentoring and coaching to assist implementing the skills learned into practice.

The NSW Ministry of Health have developed the package Making An Advance Care Directive that  provides information and a form to assist in completing an Advance Care Directive in New South Wales.

Making an Advance Care Directive

Advance Care Planning Learning opportunities

Advance Care Planning Australia – free online modules for Health Care Professionals. You will need to register and sign in to access the modules.

Queensland University of Technology - End of Life Law for Clinicians– free online modules for clinicians and medical students. Registration required to access modules.

The Advance Project – Register and sign in to access The Advance Project training package, of practical, evidence-based training specifically designed to support Australian general practices. The training package includes:

  • a free online module specifically for GPs that has been accredited with RACGP Qi&CPD;
  • a free online module specifically for General Practice Nurses endorsed by the Australian Primary Health Care Nurses Association (APNA);
  • a free online module for General Practice Managers.

Palliative Care

Palliative care provides relief from pain and other distressing symptoms, helps patients remain as active as possible and supports family members to cope throughout the process. Endorsed by the World Health Organisation, palliative care affirms life, recognises death as a normal process and neither hastens nor delays death.  
SWSPHN is supporting palliative care by:
  • Linking GPs and Practice Nurses to education and training;
  • Providing access to palliative care tools and resources;
  • Encouraging uploading of Advance Care Directives to My Health Record for storing and access by treating Health Professionals;

Our Projects

Palliative care for people with Dementia

We are working on the Peace of Mind project to increase access to palliative care for people with dementia. The project has three elements:

  1. Development of a HealthPathway for Palliative Care for people with dementia
  2. Education for community members and health professionals
  3. Palliative care quality improvement

Having commenced in January 2018, phase one of the Peace of Mind project is complete, read the below Peace of Mind Project Report presenting a summary of the work undertaken, successes and learnings of the project to 30 June 2021 here. The report also contains appendices of factsheets aimed at assisting:

  • PHNs new to the expanded Greater Choice for At Home Palliative Care measure, page 39
  • Clinicians providing care to people with dementia, page 49

Peace of Mind Project Report 2021 [PDF | 71 pages | 1.2mb]


Aboriginal and Torres Strait Islander Resources

A Journey Into Sorry Business is an informative booklet that has been created as part of the Peace of Mind project to support Aboriginal people to journey into their wishes and preferences through 'Sorry Business'.

Tools and Resources to assist Palliative Care

Supportive and Palliative Care Indicators Tool (SPICTTM

A popular tool often used by clinicians in combination with the "surprise question" to identify someone that may need palliative or end of life care. The SPICT Tool has two sections, General Indicators and Clinical Indicators. A positive response to one of the six general indications and one of the clinical indicators would be indicative of need for palliative or end of life care.

A second version of the tool is designed to be completed by everyone for example people with a life limiting illness or frailty, family or carers. SPICT-4All can make it easier to identify and discuss signs of deteriorating overall health and plan for the care needed in a timely manner. 

The role of NSW Ambulance paramedics in palliative care

NSW Ambulance expanded the paramedic scope of practice in the 2020 Protocol and Pharmacology update to incorporate medications administration for the management of distressing palliative care symptoms. This protocol enhancement provides further flexibility and broadens the paramedic skillset, to respond to and manage patient needs at the point of care. Now that palliative care medications are within the paramedic scope of practice, doctors do not need to submit a NSW Ambulance Authorised Care plan for patients to receive palliative care medications.

NSW Ambulance have produced factsheets for health professionals and community members to provide further information. 


Healthcare for aged care residents

Our Projects

  • Primary health care in residential aged care - collaborative development of Communication Manual to enhance quality healthcare. To date a manual has produced and successfully trialled in the Wingecarribee local government area. The manual contains useful information, clinical flowcharts for aged care nurses and locally developed communication tools which can be downloaded below. We are currently working with representatives from aged care, NSW Ambulance and SWSLHD to adapt the manual for use within the Campbelltown, Camden and Wollondilly local government areas.


Community Outreach Geriatric Service (COGS)

The Community Outreach Geriatric Service (COGS) to residential aged care aims to maintain the health and independence of older people living in residential care. The COGS will provide rapid access to medical and nursing care for older people experiencing rapid decline or acute changes in their condition while remaining in their Residential Aged Care Facility (RACF). In preparation for the COVID-19 Pandemic Response Plan, the COGS will provide a seven (7) day service to all residential aged care facilities (RACF).The SWSLHD Community Outreach Geriatric Service  to residential aged care aims to maintain the health and independence of plder people living in residential care. The service provides rapid access to medical (Geriatrician) and nursing care (CNS2 and CNC) for older people experiencing rapid decline and acute changes in their condition while remianing in their RACF.  

Inclusion criteria - Any conditions that relate to:


Sepsis Tube Management Cognitive Decline End of Life
Comprehensive Assessment Delirium Challenging Behaviours Teleconsultation Simple Fractures
Ambulance Board Monitoring

Family Conferencing

Hydration Capacity Building Post Fall Management


Service operating hours and clinician contact details click below. 

Fairfield Geriatric Flying Squad - COGS updated details

Community Outreach Geriatrics Service this includes Bankstown, Camden & Campbelltown and Bowral.

GPs attending aged care facilities are able to refer to the COGS service in their LGA by phoning the clincians. 


Aged care services

My Aged Care is the entry point for older Australians to access aged care. Health professionals play a key role in supporting patients to access these services. If you believe your patient may need aged care services, you can make a referral. GPs can refer their patients to My Aged Care from their electronic practice management systems via the e-Referral form. 

GPs can access the e-Referral form from Best Practice, MedicalDirector and Genie practice management systems. The form is secure, easy to use and accessible through the patient’s electronic medical record. By pre-populating patient information, the focus is on screening the patient. This makes it the quickest and easiest way for GPs to refer patients to My Aged Care.

Alternatively, GPs can refer patients by:

There are specific circumstances where health professionals may need to refer directly to a service provider. These circumstances are where there is an urgent need for a service based on the patient’s circumstances which, if not met immediately, may place the patient at risk. The services where this is likely to happen are:

  • nursing
  • personal care
  • meals
  • transport

These services would be of a time-limited duration (two weeks) with a longer-term commitment only occurring after assessment. 

For further information refer to the My Aged Care website.


Medication Management Reviews

Department of Health (DoH) details information regarding Medication Management Reviews on referral for patients in the community and in Residential Aged Care Facilities (RACFs).

Domiciliary Medication Management review (DMMR) a medication review for people in the community (MBS item number 900)
Residential Medication Management review (RMMR) a medication review for residents in aged care facilities (MBS item number 903)

Domiciliary Medication Management Review (DMMR):

The DMMR may only be initiated by a patient’s GP after assessing the patient’s need for the service. The goal of the DMMR is to maximise benefits of their medication regimen for individual patients, and reduce medication-related problems through a team approach. This process draws on the specific knowledge and expertise of each of the health care professionals involved. In collaboration with the GP, a pharmacist comprehensively reviews the patient’s medication regimen in a home visit. Subsequently, a report is issued to the patient’s GP to review and consult the patient to agree on a medication management plan. Payment for the review under the MBS will not occur until after the second patient consultation.

More information can be found at:

Medical Benefits Schedule (MBS item descriptor)
Sample DMMR plan
Sample DMMR referral form

Residential Medication Management review (RMMR):

The RMMR is for permanent residents of a Residential Aged Care Facility (RACF), who are at risk of medication misadventure due to a significant change in their condition and or complicated medication regimen. The resident’s doctor must assess the resident and decide whether an RMMR is clinically necessary. In collaboration between a GP and a pharmacist the medication management needs of a resident is then reviewed. As is the payment process for a DMMR, payment for the RMMR under the MBS will not occur until after the second patient consultation.

Medical Benefits Schedule (MBS item descriptor)
Information for GPs
Information for Pharmacists: Guild Clinical-HMR and QUM
Information for Aged Care Homes
Sample RMMR plan
Flow chart  


Health Assessments for People Aged 75 and Older

The over 75 years aged health review is a comprehensive medical review structured to identify health issues and conditions that are preventable or amenable to interventions to improve health and or quality of life. Please click here for the Pro-forma-Health Assessment for People Aged 75 and older form.


Seasonal Influenza Vaccination 2022

Key messages:

  • All residents should receive seasonal influenza and, as appropriate, pneumococcal and zoster vaccine.
  • Fluad® Quad is an enhanced QIV, registered for use in adults aged 65 and over.
  • Pre-order influenza vaccine online at: