ACI Building Partnerships: A Framework for Integrating Care for Older People with Complex Health Needs

Project activity so far:

Previous work: Assessing risks associated with waiting for older people with complex health needs attending TTH ED. Data revealed the majority (86%) of these patients live in the community and not RACF, as perceived by TTH ED staff. 70% RACF residents leave TTH ED within 1 hour of treatment cessation. Nil significant adverse incidents have been reported when patients wait for transport. This predominantly reflects an effective partnership between ED staff and PTV / Ambulance. Discharge summaries from ED were very timely, but not from wards. This issue has been elevated & now addressed. TTH reinstated Yellow Envelope to improve communication between TTH and RACF.

Current project. A community based approach to improving care for the older person with complex health needs experiencing early cognitive decline. A delay in receiving best practice care has been identified for people living in the Tweed region who experience cognitive impairment. The delay is understood to be 2 fold: from when a person first acknowledges cognitive impairment to when they seek medical attention; A further delay is documented after first seeing a medical practitioner to diagnosis. Additionally, Health & Service provider organisations have limited processes to share cognitive information about a consumer. This can have a negative impact upon the consumer’s health care.


Community consultation- NCPHN 2016 Needs Assessment

Partnership consultation – Focus groups 8th and 15th March 2016

Data collection- ED admission data, Health Record audits

Consumer / Carer stories, Process mapping

Literature search to best practice / 2016 Clinical Guidelines


Solution design workshop 14th June 2016 and Solution Report drafted. Next step: conduct smaller working groups to draft Implementation Plan.

Sample activities:

Improve health literacy – Education message to community and stakeholder forums on benefits of early identification.

Cognitive screening training including a range of screening tools to community providers e.g. EPIC, HCP; and NNSW Health – Aboriginal Health, ASET, CDMP

Engage with GPs: GP forum, promote Health Pathway, benefits of progressive screening results for high risk group, navigating aged care.

Populate progressive scores in GP Summary and cognitive scores in discharge summaries; community Yellow Envelope to service providers.

Implementation and Evaluation Plan

Implementation planning to commence August 2016

Sustainability of Framework process and project


Identifying on going roles

Stakeholder consultation and linking of Stakeholder forums

Support suggested

GP forum November 2016

Health literacy printing

IT support, space to populate progressive cognitive scores in GP summary and in discharge summaries and letters from Acute to Primary health care.