0 Executive Sponsors: Aged Care Stream Director and Stream Manager Guided and written by: Strategy and Planning Unit, Directorate of Planning, Population Health and Equity South Eastern Sydney Local Health District Locked Mail Bag 21 TAREN POINT NSW 2229 Phone: (02) 9540 8181 Fax: (02) 9540 8164 This work is copyright. It may be reproduced in whole or in part to inform people about the strategic directions for health care services in the South Eastern Sydney Local Health District (SESLHD), and for study and training purposes, subject to inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the South Eastern Sydney Local Health District. 1 Contents Foreword ........................................................................................................................................... 3 Executive Summary ........................................................................................................................... 4 1. Introduction .................................................................................................................................... 5 2. Aged Health Demographics ............................................................................................................ 6 2.1 Ageing Population .................................................................................................................... 7 2.2 Drivers of demand .................................................................................................................... 7 2.3 Recent Activity for people aged 70+ in SESLHD ....................................................................... 9 2.4 Activity Projections.................................................................................................................. 11 3. What we have achieved ............................................................................................................... 13 4. Current SESLHD Aged Care Services .......................................................................................... 17 4.1 Prince of Wales Hospital and Community Health Services ...................................................... 18 4.2 St George Hospital and Community Health Services ............................................................... 23 4.3 The Sutherland Hospital and Community Health Services ....................................................... 27 4.4 The Sydney and Sydney Eye Hospital .................................................................................... 32 4.5. War Memorial Hospital Waverley ........................................................................................... 34 4.6 Calvary Health Care Kogarah ................................................................................................. 37 4.7 The Garrawarra Centre ........................................................................................................... 41 4.8 Aged Care Programs supported by Primary Integrated & Community Health ........................... 42 5. Looking ahead: Key Areas of Focus for the Future ....................................................................... 44 5.1 Community Innovation and Integration .................................................................................... 44 5.1.1 Working with Consumers and Carers and Family Members, .............................................. 45 5.1.2 Central and Eastern Sydney PHN (CESPHN) ................................................................... 46 5.1.3 Integrating Care with Our Partners ................................................................................... 46 5.2. Aged Care Wellbeing ............................................................................................................. 47 5.2.1 Dementia and Delirium ..................................................................................................... 47 5.2.2 Mental Health ................................................................................................................... 49 5.2.3 Falls and Falls Injury Prevention ....................................................................................... 51 5.2.4 Frailty ............................................................................................................................... 53 5.2.5 Social Isolation and Loneliness ......................................................................................... 54 5.2.6 Older Aboriginals .............................................................................................................. 54 5.2.7 Medicines Safety .............................................................................................................. 56 5.3. Care of the Older Surgical Patient .......................................................................................... 57 5.4 Advance Care Planning .......................................................................................................... 59 5.5 Research ................................................................................................................................ 60 5.6 Teaching and Education ......................................................................................................... 61 5.7. Infrastructure ......................................................................................................................... 62 6. Next Steps- Implementation and Evaluation ................................................................................. 63 Implementation Plan ..................................................................................................................... 64 7. Draft Aboriginal Health Impact Statement ..................................................................................... 71 References ...................................................................................................................................... 77 2 Foreword Fuelled largely by a growing aged population and increasing costs in health care, the Aged Care sector in Australia has undergone a series of reforms over recent years. While containing costs is critical, an integrated, coordinated system should continue to be the main driver of change in aged care. Integration recognises the value and need for close connection and collaboration between health, social and other relevant sectors (public and private) to support better outcomes for aged care patients. The need to better invest in primary and secondary prevention and wellness activities to reduce the need for increasing acute health care among the elderly, is also extremely important. Providing efficient, comprehensive care for older persons is one of the most important issues currently facing the South Eastern Sydney Local Health District. The development of various service improvements, innovations and models of care to better support older people has occurred incrementally across the District over recent years. Highlighted in this plan are further service and program developments that have one or more of the following goals: Extend the period in which older people are well and independent Reduce the number and length of periods of ill health in older people Build the capacity of communities to address health issues Increase the time before an older person becomes frail and increasingly dependent on care Increase services and programs that keep older people out of hospital Continue to shift the balance of care to community and home settings Increase services that are integrated across the continuum and forms of care Create better linkages between different parts of the aged care and other sectors Ensure cost effective care for older persons Ensure the wishes of each aged care patient is understood and respected Optimise the exchange of patient information between providers and settings of care. Aged Care services across the South Eastern Sydney Local Health District will continue to recurrently evaluate their services to determine the quality of care being provided to older people and identify opportunities for improvement in line with new and emerging best practice models and approaches to care delivery. A continuous system improvement approach to ensure that best practice is shared among our facilities, services and beyond will also be maintained. Associate Professor Peter Gonski, Director Aged Care and Rehabilitation Stream, South Eastern Sydney Local Health District. 3 Executive Summary The Aged Care Services Plan 2019-22 is one of an important suite of South Eastern Sydney Local Health District (SESLHD) Clinical Stream plans, and builds upon the key priorities outlined in the Aged Care Services Plan 2015-2018. The Plan is consistent with NSW Health’s vision of delivering high quality services responsive to consumer and community needs. The Plan also aligns with the SESLHD Journey to Excellence Strategy 2018-20211 and its 5 key strategic themes: safe, person-centred and integrated care; better value; community wellbeing and health equity; workforce wellbeing; and fostering research and innovation. The Plan was developed in consultation with aged care clinicians, services and external stakeholders. The service needs identified in this Plan are based on this advice, international and national evidence, and aged care strategies, plans and policies at local, state and national levels.