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 healthcare 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 healthcare 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 

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 by  community members to My Health Record for storing and access by treating Health Professionals; 
  • Supporting local research activities in collaboration with SWS Local Health District


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


                ACP in a nutshell  


Health Professional Education and Training 


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.


Advance Care Planning Resources


HealthPathways - 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 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








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 (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.