Aged Care


Our Integrated Health 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


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; 
  • Supporting local research activities in collaboration with SWS Local Health District


Our Projects 

SWSPHN is working in collaboration with South Western Sydney Local Health District (SWSLHD) to trial the Community CriSTAL Toolkit. The Criteria for Screening and Triaging to Appropriate aLternative Care (CriSTAL) tool is a validated prognostic tool that can assist in identifying elderly clients who are at risk of deteriorating health and flagging that discussions about those implications could be sensitively conducted. It is used within the acute hospitals and has been modified for use within the General Practice setting. The tool is easy to complete and suitable for use by GPs and nurses.

The toolkit being trialed contains the CriSTAL tool, in electronic or paper form, and documentation for discussing and recording goals of care and Advance Care Directives. The toolkit can be incorporated into everyday practice through linkage with the 75+ Health Check or chronic disease management such as GP Management Plan and Team Care Arrangements preparation or review with eligibility to claim MBS Level C and D consultations with GP sign off on Advance Care Planning documents.

Thus far, the Toolkit has been trialed in two practices and a third trial is underway. There is capacity remaining for one more practice to be involved in the trial.

Advantages for participating practices:

·        An opportunity to work in collaboration with a specialist nurse and receive coaching in how to identify patients at risk of deteriorating health;

·        Receiving training in how to use the Community CriSTAL toolkit to initiate discussions with patients around goals of care;

·        Upskilling in the use and implementation of Advance Care Planning documents;

·        Receiving additional support for practice staff to identify the care needs of elderly patients;   

·        Initiation of Advance Care Planning conversations, a process that is acknowledged as difficult for patients, families and health care providers;

·        Collaborating with colleagues to advocate for patients wishes as they progress to End of Life using the tool;

·        Eligibility to claim MBS Level C and D consultations with GP sign off on Advance Care Planning documents.

 If you have questions about the project or would like to participate in the trial, please contact Anne Harley on 4632-3027 or Vitor Rocha on 4632-3019. 


Tools and Resources to assist Advance Care Planning 


HealthPathways - 

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. 


                ACP in a nutshell  


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


Advance Care Planning (ACP) Talk –  CALD Advance Care Planning in a searchable easy to navigate website   

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.

ThinkGP offers a one hour online learning activity Advance Care Planning in Primary Care accredited for 2 category 2 points with RACGP and 1 point with ACRRM.


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; 
  • Supporting local research activities in collaboration with SWS Local Health District

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 four elements - development of a Model of Care and HealthPathway for Palliative Care for people with dementia, education for community members and health professionals, palliative care quality improvement in residential aged care in partnership with the Palliative Care Outcomes Collaborative and compassionate communities.
  • Palliative care in the home - development of an electronic medication chart to ensure safe use of medicines


Tools and Resources 


NSW Ambulance Palliative Care Plans - NSW Abulance have advised of Authorised Care Plan changes effective from Monday, 30 March 2020.

This form is specifically designed for people who have a diagnosed life-limiting illness. It provides the clinician with the opportunity to: 

  • Document resuscitation plans, 
  • Prescribe treatment for specific symptoms, 
  • Guide where the patient should be admitted if care at home becomes difficult (providing there is a bed available) and how the paramedic can negotiate direct admission preventing unplanned, unwanted presentation to the nearest ED. 
  • Inform the paramedics the details of the medical practitioner who has agreed to complete the Medical Certificate of Cause of Death in the instance where the paramedics have completed the Verification of Death procedure.
  • Contact numbers of services involved in the patients care to facilitate communication with the known service providers.


1) NSW AMBULANCE Authorised Palliative Care Plan Adult 

  • If this form is held paramedics are not required to call police.

  • Paramedics will assist the family to call a funeral director

  • Paramedics are able to leave the deceased person’s body with the family

2) NSW AMBULANCE Authorised Palliative Care Plan Paediatric 

- Clinicians Information booklet

Authorised Care Plan Factsheet - Indigenous


Triple I GP Referral Form  


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.



Macarthur Community Geriatric Service

The Community Geriatric Service (CGS) based at Campbelltown Hospital has geriatricians available weekdays between 8.30am and 4.30pm except public holidays.
The CGS aims to assist in managing acute and complex medical conditions occuring in people living in residential aged care facilities. The service can also review complications of chronic comorbidities including dementia with the consent of the resident’s GP. The service maintains close contact with the GP and the RACF when attending a resident.

GPs attending aged care facilities are able to refer to the service using the Community Geriatrics Service Referral Form.

Further enquiries
Call 0437 117 349 or email


My Aged Care


The Department of Social Services ‘Aged Care Reforms’ came into effect on 1 July, 2015, which have been described by some as the ‘biggest reforms to confront Aged Care in over 30 years’. The reforms brought significant changes and challenges right across the health spectrum. As the Department of Social Services strives to improve health outcomes for older populations the My Aged Care portal emerged as the centre of a strategy to provide access to services based on assessed need. Services are packaged and tailored to individual needs to restore function and maintain the highest possible levels of independence.

Department of Social Services have comprehensive Information about My Aged Care on their website. Contact centre: 1800 200 422.

*About My Aged Care   *Service Providers   *Assessors   *Hospital staff   *Health Professionals   *Referral Tip Sheet


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.