Aged Care

Usually, older people have a mix of medical and non-medical care needs ranging from acute to chronic. It is widely accepted that a multidisciplinary approach to Aged Care is best drawing from the knowledge and skills of a range of health care professionals to assist individuals reach their highest levels of physical, functional and cognitive health.

South Western Sydney PHN aims to promote collaboration, innovation and integration of services in primary, secondary and community health care settings to enhance access for all residents to the right care, at the right time, by the right people, and at the right location.

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

*My Aged Care   *Advanced Care Planning   *Palliative Care   *Health Pathways   *Medication Management Reviews   *Health Assessments for people 75 and older


Macarthur Community Geriatrics Service

The Community Geriatric Service (CGS) based at Campbelltown Hospital has being expanded during winter, 2018. The service now covers nine of the 10 residential aged care facilities (RACFs) in the Campbelltown and Camden LGAs. The Frank Whiddon Masonic Home in Glenfield will be covered by the Liverpool Geriatric Service.

The service has geriatricians and a senior community nurse available weekdays between 8.30am and 4.30pm except public holidays. The CGS aims to assist in managing acute and complex medical conditions in nursing homes and 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 can be directed to the service by phoning on 0437 117 349 or by 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


Advance Care Planning 

The My Wishes website is hosted by South Western Sydney Local Health District in collaboration with General Practitioners, residential aged care providers and members of the general community.

Advance Care Planning (ACP), is planning for the future which includes: making a will, appointing a power of attorney and an enduring guardianship. All healthcare and community health care staff may need to explain ACP to their patients. Depending on your role this could be a general discussion or more formally as part of a treatment plan. General Practitioners (GPs) have a central role in ACPs given the frequency and nature of care provided as well as typically the long term trust inbuilt in the relationship that develops between Doctors’ and their patients.

The Ambulance Authorised Palliative Care Plan aims to support paramedic decision making in meeting the needs of individual patients with specific medical conditions.The plan allows paramedics responding to a Triple Zero (000) call to treat palliative patients in their own home, on the instructions of their GP when a detailed plan is in place, rather than transfer them to hospital.

NSW Ambulance Adult Palliative Care Plan

GP information booklet

The My Wishes website contains important information and helpful resources including: 

Advanced Care Planning
*Basics   *Health Care staff   *GPs   *Initiate and conduct discussions   *ACP Competencies   *Documenting an ACP   

Information Sheets for chronic and end of life care
* Patterns of illness   *Family expectations   *Levels of care   *CPR


All enquiries about My Wishes should be sent to


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 or delays death.

*Palliative Care NSW   *Service directory   *Fact sheets   *Access   *Anorexia   *Coping with dying   *Fatigue   *Nausea and vomiting (Nutrition)   *Pain   *Principles   *Planning ahead   *Triple I GP Referral Form   



HealthPathways are currently being localised to provide support local health providers in delivering the best practice care to their patients. For more information see our HealthPathways page.


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.

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.