Older Adults & those living in Residential Aged Care

Referral to Palliative Care for People Living in Residential Aged Care Facility

The GRPCC is partnering with the Gippsland Primary Health Care Network (GPHN) in a review project to continue to improve access to specialist palliative care services for people with complex palliative care needs residing in Residential Aged Care Homes (RACH) and developed a referral pathway from RACHs in Gippsland to their local palliative care services.

Click the relevant link below to view the Palliative Care referral pathway for your area or explanatory video.

Palliative Care Referral Pathway for RACHs in Bass Coast (2024)  - (explanatory video
Palliative Care Referral Pathway for RACHs in West Gippsland (2024) - (explanatory video
Palliative Care Referral Pathway for RACHs in East Gippsland (2024)  - (explanatory video) 
Palliative Care Referral Pathway for RACHs in Latrobe (2024) - (explanatory video
Palliative Care Referral Pathway for RACHs in South Gippsland (2024) - (explanatory video)
Palliative Care Referral Pathway for RACHs in Central Gippsland (2024)  - (explanatory video) 


Planning for Care

  • The Abbey Pain Scale was developed to measure pain in patients who cannot verbalise.

    Click here to download the Abbey Pain Scale.

  • What Matters Most Discussion Starter includes questions about the older person, their health and what they might want at the end of their life. The questions can be used by the health or aged care worker to guide the conversation with the older person as they explore What Matters Most to them.

    Download here

  • The Inclusive Service Standards were developed by the Centre for Cultural Diversity in Ageing to assist aged care providers in the development and delivery of inclusive services to all consumers.

    Click here to access the Inclusive Service Standards.

  • An imprest system serves as a stock management process to enable timely access to palliative care and end of life care medicines by appropriate clinical staff in a Residential Aged Care Home (RACH). Medication is held within the stock management system in accordance with legislative requirements of Victoria.

    In 2022-23, the GRPCC undertook a project in collaboration with the Gippsland Primary Health Network ( PHN) to support 11 RACH in Gippsland to establish and implement a palliative care and end of life care medicines imprest system.

    Click here to view the Guiding principles for medication management in RACH 2022

    Click here to view the Step by step guide to establish and implement a palliative care and end of life medications imprest system into RACH in Victoria

  • PalliAGED is the palliative care evidence and practice information resource for the Australian aged care sector.

    Click here to be directed to to PalliAGED website

  • My Aged Care is the entry point for older Australians to access aged care. For patients who need health-related support, such as after a hospital stay or due to a sudden change in their health status, more appropriate health-specific services may be available through post-acute care, state or privately funded rehabilitation.

    Click here to visit the My Aged Care website.

  • This document provides information about the relevant symptoms and care for people living with Parkinson’s Disease. It also includes an example care plan that can be used as a guide for what should be addressed in a care plan.

    Click here to view the booklet

  • The ELDAC Residential Aged Care Toolkit (replaces the PA toolkit.)

    Provides information and guidance to support palliative care and advance care planning for people living in residential aged care and for their carers.

    Click here to access the ELDAC Residential Aged Care Toolkit.

  • The SPICT™ is used to help identify people at risk of deteriorating and dying with one or multiple advanced conditions for holistic, palliative care needs assessment and care planning.

    Click here to view the SPICT Tool.

  • Talking about DEMENTIA and Dying is a discussion tool for residential aged care facility staff. It is a resource to help people working in facilities to openly communicate with people with dementia and their families and friends about death and dying.

    Click here to view the Talking Dementia and Dying tool.

 

End of Life Care

  • CareSearch provides trustworthy and practical resources for General Practitioners for the management of the last days of life.

    Click here to visit the CareSearch End of Life Care Resources.

  • The Residential Aged Care End of Life Care Pathway (RAC EoLCP) is a care plan that guides the provision of good quality end of life (terminal) care in residential aged care. It incorporates evidence and consensus-based best practice clinical management and care coordination for dying residents in residential aged care facilities.

    Click here to view the RAC EoLCP care plan.

  • Many people from different backgrounds face similar barriers to talking about dying. PalliAGED provides a list of some resources that can be useful for everyone as well as resources developed for specific population groups

    Click here for PallAGED ‘Talking about dying’ resources.

 

Webinars

  • Click here to view the Care of the dying person in Residential Aged Care webinar

  • Click here to view the webinar

  • PalliAged has a range of education video for for aged care workers

    • What to say to family when a resident dies

    • How to do a soft towel wash

    • The role of benzodiazepines at end of life

    • Recognising the signs of dying

    • Recognising deterioration in a resident

    • Pain management

    • Non-pharmacological and pharmacological interventions for breathlessness

    • Mouth care

    • How does culture impact on care

    • Communicating with families

    Click here to view the videos

  • The Short and Sweet webinar series consists of five short education sessions for Residential Aged Care workers. They were developed in 2020 in response to the ongoing requests for palliative care education and the restrictions in residential aged care from COVID.

    These 15-minute sessions are available to watch on the GRPCC youTube channel and cover topics including (click to watch):

    Advance Care Plans.... why are they so important in aged care?

    Why is it so difficult to recognise decline in aged care?

    Advanced Dementia.... how will we know?

    Care of the dying person

    Frailty in Aged Care

  • Having an Advance Care Plan and current Goals of Care support timely and effective communication with residents and families and, sound decision making ensuring the resident has a comfortable, dignified death.

    This video provides a guide for Residential Aged Care staff when discussing advance care planning and goals of care with family and carers.

    Click here to view the video developed by the North West Metro Palliative Care Consortium.

 

Palliative Aged Care Outcomes Program (PACOP)

  • The Palliative Aged Care Outcomes Program, or PACOP, is dedicated to significantly improving the outcomes of all Australians in aged care homes with a particular focus on those who are approaching the end of their life

    Click here for more information

  • Included in this video is TWO special guests, one with expertise in the development and trial of the AN-ACC model and one with expertise in its use during the shadow AN-ACC assessment period.

    Click here to view the video

  • The PACOP YouTube Channel hosts videos for & about our program to inform & educate all who are interested - from consumers to resident's living in aged care & their families & staff working in aged care.

    Click here to be directed to the PCOP youtube channel

  • This PACOP 'Clinical Bite' takes you through a quick look at a clinical assessment tool called the Australia-modified Karnofsky Performance Status (AKPS).

    Click here to view the video

 

Grief, loss and bereavement in older people

  • This booklet provides information on what is likely to happen over time from entry into aged care through to the end of life. It includes suggestions, practical resources, and supports for families.

    Click here to download the When someone dies in Residential Aged Care - Grief and Loss for Families booklet.

 
 

Dementia

  • Click here to download the booklet.

  • Dementia Australia is the source of trusted information, education and support services. They exist to support and empower the estimated more than 400,000 Australians living with dementia and the more than 1.5 million people who are involved in their care.

    Click here to be directed to the Dementia Australia website

  • Which cognitive assessment tools for which patient and why…

    Whether it’s part of an over 75 health assessment or fitness to drive assessment, investigating patients’ concerns about impairment, or tracking progress over time, cognitive screening is important.

    Click here to be directed to the HealthEd website for more details on Cognitive testing for dementia

  • Weight Loss in Advanced Dementia is an information booklet discussing the many reasons why a person with advanced dementia might lose weight.

    Click here to download the booklet.

  • Talk with Ted is a realistic online simulation designed to support respectful communication with people living with dementia. It is a safe and effective way to practice communication skills. Participants who have experienced Talk with Ted were able to recall their learnings up to eight weeks following the training, and say it has improved the overall quality of care they give.

    Click here to be directed to the dementia learning website

 
 

Useful websites

  • The ACPC ‘Highway to Help’ is for residential aged care staff and managers caring for residents living with a life limiting illness, showing signs of deterioration or at end of life. It provides information on quality assessment, monitoring or communication tools, external support services, educational materials, resources and bereavement support for residents, their families and friends, or self-care tips

    Click here to be directed to the Aged Care Palliative Care website

 
This document was last updated on Mondau 13 June 2022.