Working Together in Residential Aged Care. a practical Guide for GPs, Staff and Practice Nurses

Transcription

1 Working Together in Residential Aged Care a practical Guide for GPs, Staff and Practice Nurses

2 Table of contents Acknowledgements Why do we need a Manual? Working Party Objectives The Principles of Quality Care Overview of BHS Residential Services BHS Facility Contact Details Other Facility Contact Details BHS Facility Map Access to BHS Facilities Aged Care Assessment Service Residential Admission Coordinator Levels of Residential Care Respite Care Medical Management of Residents Engaging a GP Consent Form GP Details Doctors Folder Geriatrician Access In Reach Program Advance Care Planning Medications & Prescriptions Compact Business Solutions Medication Charts Telephone Orders Immunisations Use of icare GP Orientation to BHS facilities Allied Health Services Utilising Private Allied Health Services Medicare Rebates

3 GP Consultations In A Residential Facility Optimising Medicare Rebates Aged Care Access Incentive Program Routine GP Consultations Multiple Consultations Urgent & After Hours Consultations Definition of After Hours Definition of Urgent Consultation Levels Health Assessments, GP Management Plans & Resident Care Plans Steps to Utilizing MBS Health Assessments Definitions Benefits Flow Chart GP Management Plans What is a GP MP? Residential Medication Management Reviews What is a RMMR? Who should have a RMMR? Who is responsible for undertaking a RMMR? Benefits Medicare Rebate Flow Chart Resident Care Plans What is a Resident Care Plan Benefits Medicare Rebate

4 Case Conferences What is a Case Conference Organising a Case Conference Medicare Rebate Aged Care Funding Instrument (ACFI) Impact on the GP Additional Information Role of the Practice Nurse GP Reminder & Recall System After hours & acute care referral Return from Hospital Aged Care & GP Services Helpful Contacts Appendix Request for Medical Records Transfer Form GP Register Template Health Assessment Form Residential Medication Management Review Form Transfer Form

5 ACKNOWLEDGEMENTS Ballarat Health Services GP Liaison Unit has worked closely with the Ballarat District Division of General Practice (BDDGP) and other key Clinicians in the public sector to develop the Working Together in Residential Aged Care Manual a Practical Guide for GPs, Staff and Practice Nurses. The purpose of the Manual is to provide strategies and guidance to both Residential Aged Care Facilities and to General Practitioners with the aim of providing better and more efficient healthcare delivery to the Residents of Residential Aged Care Facilities. A team care approach and effective communication channels between all healthcare providers are essential in the provision of high quality medical care within Residential Aged Care Facilities. Sincere thanks are extended to the following for their support and dedication to the development of the Manual: Residential Aged Care Facilities Working Party Dr. Malcolm Anderson GP Liaison Consultant, BHS Professor Joseph Ibrahim Geriatrician Sub Acute Services, BHS Dr. Jim Sutherland General Practitioner Ms. Jannine Rigby GP Liaison Manager, BHS Ms. Pat Erwin Director of Nursing Hailey House and Queen Elizabeth Village, BHS Ms. Wendy Burgener Manager Geoffrey Cutter Centre, BHS Mr. Claudio Dellore Quality Manager Residential Care, BHS Ms. Heather Campbell Ballarat District and Division of General Practice Ms. Angela Aldred Ballarat District and Division of General Practice Ms Colleen Fryar Manager Steel Haughton Centre Ms. Cathy Caruso Quality and Safety Manager Allied Health, BHS GP Reference Group Dr. Rob Campbell General Practitioner Dr. Dianna Jefferies General Practitioner Dr. Sue Lyons General Practitioner Dr. Alison Miller General Practitioner Project Advisors and Support Dr. Linda Danvers Deputy Medical Director, BHS Ms Sue Gervasoni Executive Director Residential Services, BHS Mr Andrew McPherson CEO, Ballarat District and Division of General Practice Dr Colin Crook Ballarat District and Division of General Practice For further assistance or to access this document on line please go to We would like to acknowledge Peninsula GP Network and their Working Smarter not Harder in RACFS Manual for providing information and the use of this document as a template for this publication. First Published April

6 WHY DO WE NEED A MANUAL? Our population is ageing and many more people will spend their last years in supported accommodation or a Residential Aged Care Facility. It is also known that the medical needs of this population, and the proportion of the medical budget to provide for their care will increase dramatically. The Australian Bureau of Statistics predicts that by 2041, one in five people will be over 65 and 7% of the population will be aged over 80 (the fastest growing sector of the population in Australia). General Practitioners have an integral role in the provision of medical care to these Residents and it is because of this that this Manual has been produced. The Ballarat Health Services GP Liaison Unit consulted with those involved in Aged Care and established a Working Party to review current information and practice within the 11 Residential Facilities that they manage. This Manual is the result of the Working Party and we have great pleasure in making it available to all GPs, their Practices and to BHS Residential Aged Care Facility staff. RESIDENTIAL AGED CARE FACILITIES WORKING PARTY After detailed discussion, the Working Party had three (3) main objectives to achieve in the formulation of this Manual. These were: 1. To improve access to appropriate medical and primary care for all Aged Care Residents through: The utilisation of comprehensive assessments of medical needs for new and existing Residents as required; Supporting a multidisciplinary approach for the care of Residents; Promoting an understanding of the requirements of care from the perspective of both the Resident and the GP; Ensuring the adequate provision of emergency and After Hours Care. 2. To increase the participation of GPs in the provision of Aged Care through: Promoting an understanding and awareness of quality care protocols; The participation of GPs in quality care initiatives. 3. To ensure GPs, Practice staff and GP Divisions are working more effectively with Residential Aged Care Facilities by: Identifying key areas of concern and implementing measures to address these concerns; Enhancing methods of communication and developing appropriate strategies; Reducing barriers to the involvement of General Practitioners and their Practice Staff in Residential Aged Care Facilities. We hope that the development and publication of this Manual will greatly assist GPs and their Practices, and Residential Aged Care Facility staff. 6

7 THE PRINCIPLES OF QUALITY CARE FOR RESIDENTS OF AN AGED CARE FACILITY Both the Residential Facility and GPs have mutual responsibilities in providing care for Residents. These responsibilities are different for both disciplines but together will work to ensure a high standard of care. LIST OF MUTUAL RESPONSIBILITIES FOR GPs AND AGED CARE FACILITIES Aged Care Facilities agree to: 1. The provision of appropriately trained and well informed staff to care for Residents and to discuss their medical needs with visiting GPs. 2. The provision of effective communication tools to enable GPs to address any ongoing issues relating to a Resident. 3. To ensure GPs are contacted appropriately, and in a timely manner regarding important or serious matters relating to a Residents health and wellbeing. 4. The provision of a satisfactory work space and the accessibility of an appropriate records system including an electronic database. General Practitioners agree to: 1. Regularly attend the Facility to visit Residents and maintain appropriate records, planned visits to the Facility being preferred; 2. Maintain and update the Medication Chart, including to confirm telephone orders and provide prescriptions as necessary; 3. Ensure the provision of Urgent and After Hours care for Residents. 4. Provision of alternative arrangements for cover when on leave. 5. Maintain Medical Registration and appropriate Indemnity Insurance. 6. Participate in the provision of a multidisciplinary approach to chronic and complex care needs. 7

8 OVERVIEW OF BALLARAT HEALTH SERVICES RESIDENTIAL AGED CARE SERVICES Ballarat Health Services Residential Aged Care Service is comprised of 11 separate Residential Facilities accommodating approximately 500 residents. These Facilities can provide a range of levels of accommodation from Low Level Care to High Level Care, as well as for Psycho Geriatric and Dementia Specific Care recipients, and are available on either a respite or permanent basis. This care is provided in a safe and caring environment and the needs of the Resident determine the level of care required. The 11 Facilities are located at five separate suburbs within a radius of 8 kilometres around the City of Ballarat, and the following is a Quick Reference Chart together with a Map locating all Ballarat Health Services Residential Aged Care Facilities in the area. BHS Residential Services Contact Details FACILITY NO. OF BEDS HIGH / LOW CARE STAFF Eureka Village Hostel (RACS ID 3369) Balmoral Drive Windsor Gardens, Ballarat East Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: Ph: Low Level Care (House 1 Dementia Specific) Hostel Registered Nurses and/or Enrolled Nurses Personal care workers (PCA) Geoffrey Cutter Centre (RACS ID 3515) Kenny Street Windsor Gardens, Ballarat East Ward Clerk: 40 High Level Care Nursing Home Registered Nurses and Enrolled Nurses Ph: Fax: Nurse Unit Manager: Ph: High Level Care Dementia Specific Talbot Place Aged Care Facility (RACS ID 3518) 1205 Dana Street, Ballarat Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: High Level Care Nursing Home Registered Nurses and Enrolled Nurses 8

9 FACILITY NO. OF BEDS HIGH / LOW CARE STAFF Bill Crawford Lodge (RACS ID 4442) 1101 Dana Street, Ballarat Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: W.B Messer, Q E Village (RACS ID 3224) 302 Gillies Street, Nth Wendouree, 3355 Ward Clerk: (9am 1pm) Ph: Fax: Nurse Unit Manager: Ph: P S Hobson Nursing Home Q E Village (RACS ID 4459) 302 Gillies Street, Nth Wendouree, 3355 Ward Clerk Ph: Fax: Nurse Unit Manager: Ph: Ph: Hailey House Hostel (RACS ID 3262) 701 Norman Street, Ballarat Ward Clerk: (9am 1pm) Ph: Fax: Nurse Unit Manager: Ph: High Level Care Dementia Specific Nursing Home 45 Low Level Care Hostel 60 High Level Care Nursing Home 60 Low Level Care Hostel Registered Nurses and Enrolled Nurses Registered Nurses and/or Enrolled Nurses Personal Care Workers (PCA) Registered Nurses and Enrolled Nurses Registered Nurses and/or Enrolled Nurses Personal care workers (PCA) 9

10 FACILITY NO. OF BEDS HIGH / LOW CARE STAFF Jack Lonsdale Lodge (RACS ID 4414) 232 Spencer Street, Sebastopol Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: (Diosma) Ph: (Boronia) Jessie Gillett Court (RACS ID 3263) 117 Morgan Street, Sebastopol Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: James Thomas Court Hostel (RACS ID 3273) 117 Morgan Street, Sebastopol Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: High Level Care Nursing Home 42 Low Level Care Dementia Specific Hostel 44 Low Level Care Hostel Registered Nurses and Enrolled Nurses Registered Nurse and/or Enrolled Nurse Personal Care Workers (PCA) Registered Nurses and/or Enrolled Nurses Personal Care Workers (PCA) Steele Haughton Unit (RACS ID 3422) Dana Street Ballarat PO Box 199, Ballarat VIC 3353 Ward Clerk: Ph: Fax: Nurse Unit Manager: Ph: High Level Care Psycho Geriatric Registered Psychiatric Nurses Division 2 Psychiatric Endorsed Nurses 10

11 Other Residential Services Contact Details The following list of other Residential Aged Care Facilities in the Ballarat area is provided for reference, as many GPs will have patients in both Ballarat Health Service and Private Facilities. This Manual refers specifically to procedures and processes in those run by Ballarat Health Services, but many of the systems will be similar and it is suggested that GPs check with each organisation regarding any specific or differing requirements. FACILITY NO. OF BEDS HIGH / LOW CARE HOSTEL / NURSING HOME Kelaston 2 4 Park Street, Wendouree High and Low Level Care Nursing Home Ph: Fax: kelaston@acsagroup.org.au Kirralee Aged Care Facility Richard Street, Ballarat 3350 Ph: Fax: High and Low Level Care Nursing Home John Curtin Memorial Hostel PO Box 173, Creswick 3363 Ph: Fax: High and Low Level Care Hostel Skipton Nursing Hostel 9 Low Level Care Nursing Home Blake Street, Skipton 11 High Care Ph: Fax: Beaufort Nursing Home Havelock Street, Beaufort Ph: Fax: Beaufort Hostel Burton Street, Beaufort Ph: Fax: High Care Nursing Home 12 Low Level Care Hostel 11

12 FACILITY NO. OF BEDS HIGH / LOW CARE HOSTEL / NURSING HOME Nazareth House 218 Mill Street 45 High Level Care Nursing Home Ballarat 3350 Ph: (Clinical Care Coordinator Serenity (SE) / Tranquillity (TR) Ph: Charisma (CH) / Shalom (SH) Ph: (Shalom) Secure Dementia Unit Holy Family/St Anne s Ph: Low Level Care Hostel Ballan Hostel 168 Inglis Street, Ballan 3342 Ph: Fax: Low Level Care Hostel Ballan Nursing Home, 33 Cowrie Street, Ballan 3342 Ph: Fax: High Level Care Nursing Home Hepburn Health Services Creswick Hospital Calembeen Lodge PO Box 66 Creswick 3363 Ph: Fax: High Level Care, including 1 respite bed Nursing Home 12

13 Residential Facilities Map 13

14 ACCESS TO BALLARAT HEALTH SERVICE RESIDENTIAL CARE FACILITIES How does my patient get into Aged Care? Aged Care Assessment Service (ACAS) All individuals seeking accommodation within Residential Facilities are required to have an Aged Care Assessment completed. The Aged Care Assessment Service Team can be contacted on A GP Referral into the Service is desirable, but anyone in the Community can refer a Patient, for example, a Carer, a Relative, or indeed an individual person may refer him or herself for assessment. A valid Consent Form is always required for this process. Residential Service Admissions Co ordinator The Residential Services Admissions Co ordinator oversees the admission process and can be contacted on The Co ordinator can assist families with pre admission details and appropriate Waiting Lists for Facilities following the Resident s ACAS assessment. Levels of Residential Care The Commonwealth Government regulates and partly funds the provision of Residential Care. Although they are officially called Low Level Residential Care and High Level Residential Care, they are still widely known and referred to as "Hostel" and "Nursing Home" type accommodation, respectively. What is Low Level Residential Care ( Hostel Care )? Low Level Residential Care is that provided to people assessed as requiring general accommodation and personal care service in a Residential Facility. What is High Level Residential Care ( Nursing Home )? High Level Residential Care is that provided to functionally dependent people requiring 24 Hour Care, and provided by either a Registered Nurse, or under the supervision of a Registered Nurse. What is Respite Care? Respite Care is understood to mean, residential or flexible care (as the case requires) provided as an alternative care arrangement, with the primary purpose of giving a Carer or Care recipient a shortterm break from their usual care arrangement. ACAS documentation is required prior to a person entering Respite Care in a Residential Facility. Residential Respite Care may be used on a planned, or on an emergency basis to help with Carer stress, illness, holidays, or the unavailability of the Carer for any reason. Respite Care is not intended for rehabilitation following an acute episode of illness, unless there is a genuine respite element involved. It cannot be used as a waiting facility for people seeking a permanent bed. 14

15 MEDICAL MANAGEMENT OF RESIDENTS Engaging a GP and requesting Medical Records As the needs of a patient change and evolve, and they move from independent living to Residential Care, their need for regular Medical Care continues, and indeed may escalate. In general, GPs provide the bulk of care to Residents of Residential Aged Care Facilities, and ideally, this would continue to be provided by their regular GP. However, for a variety of reasons, not all GPs are able to provide this care, and this is especially the case if the Resident has moved away from their original locality. The Charter of Residents Rights includes their right to choose their treating GP. The Royal Australian College of General Practitioners Practice Accreditation Standards require that Practices inform Residents of their services, and of their availability to provide care in a Residential Aged Care Facility. Prior to admission, an incoming Resident is asked to inform the Residential Aged Care Facility of the details of the GP they have engaged, and who has agreed to provide their medical care at the Facility. If this is not their usual GP, a request for the Patient s History should be made by the Resident or their representative, using a Medical Records Transfer Form, a sample of which is in the Appendix. Practices will usually have access to their own form via their Medical Software. The Resident, or their family or Carer are asked to take responsibility for obtaining the Medical Records from their previous GP. Consent Form With the increase in complexity of privacy laws, it is important that the Residential Aged Care Facility ensures that a valid Consent Form is used in the admission process to allow for a Resident s Health Information to be disclosed to all those involved in providing medical care to the Resident. This ensures the continuity of their medical care, and especially during After Hours or other acute episodes, when the Resident s GP may not be available and other Service Providers are called to assist, e.g. another GP, an Ambulance crew or Hospital Emergency Departments. GP Details and Doctors Contact Folder To assist the staff of the Residential Aged Care Facility in contacting the Resident s GP, and especially in an emergency, it is imperative that accurate contact details for the GP, for both In and Out of Hours (Appendix 2) are readily available at all times. These details will be placed in the Doctors Contact Folder. This is especially helpful should a Resident require medical care for an acute event After Hours, when support for Residential Aged Care Facility Staff dealing with such an episode may be limited. Geriatrician Access Ballarat Health Services is fortunate to have Geriatricians on staff. They are available to speak with GPs to discuss medical and management issues relating to Residents, or if necessary, to see patients in Residential Care. 15

16 This service can be organised by contacting the Aged Care Assessment Service on , or by contacting Medical Services at the Queen Elizabeth Campus on Referrals can also be faxed to Medical Services on In Reach Program The Residential Aged Care In Reach Program is an acute In Reach service operating through the Hospital In The Home program. The program works closely with the Resident s General Practitioner and Residential Care Staff with the aim being to: Reduce avoidable Emergency Department presentations by caring for Residents with acute illness in their Aged Care homes Minimise functional decline in the elderly by avoiding hospital admissions where possible Reduce the length of stay of Residents admitted to acute services by facilitating earlier discharge with Residential In Reach support For further information contact the Nurse Unit Manager of Hospital In The Home on Advance Care Planning (ACP) The concept of Advance Care Planning is designed to facilitate the ability of a Resident to participate in self determination, and to clarify their choices for End of Life decisions. It aids in reducing both unwanted and unwarranted medical treatments, as well as reducing unnecessary hospitalisation. Alternatively, it ensures that a Resident s wish to continue treatment is acknowledged. Considerable skill is required in formulating a Plan, and GPs are well placed to perform this task in assisting Residents and their families to make their wishes known. GPs are encouraged to participate in a guided discussion with the Resident and the family in determining their preference for both providing and/or withholding treatments under certain situations. The Plan would preferably be completed prior to the Resident entering Residential Aged Care. Completing an Advance Care Plan would normally be undertaken as part of the preparation of a GP Management Plan and for further details of this process, please refer to page 28. Medications and Prescriptions Most, but not all Residents of a Residential Aged Care Facility will require medication, and for those who do, their safe administration is of paramount importance. Indeed, dispensing and administration of pharmaceutical agents is tightly regulated by Governmental Agencies, and all Residential Aged Care Facilities are bound to comply with these Regulations. 16

17 The ways in which these Regulations most directly affect GPs attending Residential Aged Care Facilities are in both the provision of Prescriptions for the supply of Medications, and in the completion and maintenance of a valid Medication Chart. All Ballarat Health Services Facilities utilise Medication Charts produced by Compact Business Systems and which last for a maximum of six months If there have been no changes over that time, a new Chart will then need to be written. However, GPs are encouraged to review the Resident s Medication Chart each 6 8 weeks, and to signoff on any changes. Facility Staff will regularly identify Residents requiring new Medication Charts and will notify the GP in advance, giving at least 2 weeks notice. Again it must be stated that the stringent regulations prohibit Staff from administering any medications from a Medication Chart that has expired, and GPs are asked to refrain from post dating or forward dating charts Residential Facility Staff are required and obliged to commence using a new Medication Chart on the day it has been written by the GP. Use of the Compact Business Systems Medication Chart Ballarat Health Services Residential Aged Care Facilities use the Compact Business Systems Medication Chart and many Medical Software suites provide for the printing of prescribed medication items onto a sticky label sheet, which can then be placed into a new chart. GPs are encouraged to explore their software to check for this facility. Compact Business Systems also produce an adhesive sheet with 2 pre cut labels per page for this purpose and providing labels of the correct dimensions for the Chart. The Product Code is: LTMC MD1 and can be ordered directly through them.. Their web address is: and the Phone Number is: Of course, an A4 Label Sheet can be used and cut into two. Telephone Orders Telephone Orders for medication changes are regularly required, but it is requested of GPs that they complete a Confirmation of Telephone Order (CTO) slip, which must then be faxed and also posted to the particular Facility. The use of multiple medications for Residents of Aged Care Facilities is constantly under review by the Department of Health. A quarterly report of the Incidence of Residents using nine (9) or more different medications is required to be provided to the Department from all Public sector Residential Aged Care Facilities. In general, unless there are multiple complex medical issues, it is generally considered that the majority of patients should require no more than eight (8) medications. GPs are asked to regularly review their Resident s Medication List with this in mind and to inform the Residential Aged Care Facility staff of any changes and variations. 17

18 Immunisations All people over the age of 65 are eligible for free Annual Seasonal Influenza Vaccination as well as 5 yearly Pneumovax. All Residents are offered these vaccinations. For their administration, GPs are asked to prescribe the required Immunisation in the Medication Chart, together with an order for Adrenaline in the event of an allergic reaction. This requirement applies whether the GP or the Residential Aged Care Facility Staff are to administer the vaccination. All administrations of course must be signed for. As stated, the vaccination may be given by either the GP, or by a member of the Residential Aged Care Facility Staff, and stocks of vaccinations will be ordered and supplied by the Residential Facility once quantities are known. To ensure the Cold Chain is not broken, GPs are asked not to provide stock from their community supply. Documentation and use of icare All Residential Facilities within Ballarat Health Services use a software package called icare to electronically manage all documentation relating to each Resident. This documentation includes: Personal information Next of Kin and Contact Details Medical history Progress notes Assessments Forms & Charts Care plans Aged Care Funding Instrument reports and level of funding icare incorporates specific measures to maintain security and confidentiality. Each Staff Member or GP has a unique Login and Password which can be obtained from any Residential Aged Care Facility Manager. The same Login and Password can be used in any Facility once a GP has been logged on to the system. Quick Guides for operating icare are available within each Facility. Every page used in icare, has a photograph of the Resident at the top as a visual identification check to ensure the correct file is being used. For reasons of security, every entry made into icare is annotated with the name and designation of the person making the entry, together with the date and time of that entry. Any documents not entered directly into icare can be scanned and attached to the Residents icare file. This would include Pathology and Radiology reports, handwritten letters or other Progress Notes not able to be directly entered into icare. 18

19 ORGANISING GP ORIENTATION TO BHS RESIDENTIAL FACILITIES Familiarity with the Facility and with their Staff is a very important component of developing an effective and healthy working relationship between GPs and the Residential Aged Care Facility and new and existing GPs are encouraged to make a tour of the Facilities they attend. Such a tour will provide an opportunity for GPs to familiarise themselves with the Facility, to meet Staff and to gain an understanding of the policies and procedures involved within Residential Aged Care. It is hoped both parties will gain a better understanding of the issues with which they are each faced in their aim of providing optimal care to the Residents of the Facility. To organise a tour at a convenient time, please contact the Nurse Unit Manager within each Facility (please refer to the Residential Contact List located on pages 8-12 of this Manual). ALLIED HEALTH SERVICES Ballarat Health Services Directorate of Allied Health provides a full range of Allied Health services and disciplines for Residents. Services available include Dentistry, Dietetics, Occupational Therapy, Podiatry, Prosthetics and Orthotics, Physiotherapy, Psychology, Social Work and Speech Pathology, and may be arranged as required. There is no fee for services provided by BHS Allied Health. Residents or their family, as well as GPs and Nursing Staff, are all able to initiate a request for an Allied Health Assessment. Referrals for BHS Directorate of Allied Health services may be sent by Fax to the Residential Care Central Intake Service on Utilising the Services of a Private Allied Health Practitioner Residents are supported and encouraged to choose their preferred therapist, and Private Allied Health Practitioners can also provide services to Residents in Ballarat Health Service Residential Facilities. However, they must be accredited with Ballarat Health Service, and charges will apply. Medicare rebates are available for services provided to eligible Residents by a Private Allied Health Professional, as long as a GP Management Plan is in place, and the Practitioner is working in a private capacity and registered with Medicare Australia. To be considered as eligible, Residents must be suffering from a chronic condition, or have complex care needs that are being managed by their GP, and that are identified in their Resident Care Plan. Where a Resident s GP has contributed to a GP Management Plan, and Medicare Benefits Schedule Item number 731 has been claimed for that contribution to the Care Plan, the Resident may be eligible to access certain Medicare rebated items for Allied Health services on referral from their GP, provided it is part of a Multidisciplinary Care Management Plan for treatment of a chronic condition. 19

20 Services eligible for the Medicare rebate, followed by the relevant Item numbers, are: Aboriginal Health Worker (MBS 10950) Occupational Therapist (MBS 10958) Audiologist (MBS 10952) Osteopath (MBS 10966) Chiropractor (MBS 10964) Physiotherapist (MBS 10960) Diabetes Educator (MBS 10951) Podiatrist (MBS 10962) Dietitian (MBS 10954) Psychologist (MBS 10968) Exercise Physiologist (MBS 10953) Speech Pathologist (MBS 10970) Mental Health Worker (MBS 10956) In the first instance, the GP must refer the Resident using the Chronic Disease Management Referral Form for Allied Health Services. Where the GP is referring a patient to more than one Allied Health Professional, a separate Chronic Disease Management Referral Form for each Allied Health Provider is required. A copy of the Referral form can be found in the Appendix, and is available using the following link: C6222/$File/Referralformindividual.pdf After the service has been provided, the Allied Health Professional should provide a written report to the referring GP. High Care Residents, are only eligible for rebates if the service to which they are referred is not already funded by the Residential Aged Care Facility. For example, Aged Care Facility funding usually covers a basic Physiotherapy assessment, but may not cover ongoing treatment, for which the Allied Health rebates could be used. A maximum of five Allied Health Service rebates are available to a Resident per calendar year, and services can be delivered by more than one type of Allied Health Provider. 20

21 GP CONSULTATIONS IN A RESIDENTIAL AGED CARE FACILITY OPTIMISING THE USE OF THE MEDICARE BENEFITS SCHEDULE ITEMS Despite some improvements in the Medicare Benefits Schedule allowing for better remuneration for GPs providing care to Residents in Residential Aged Care Facilities, it is known that GPs generally undercharge for their services and do not take advantage of the full range of Medicare Benefit Schedule items available. One reason for this is probably the complexity of the Schedule, and this section is written to try and clarify the steps and processes involved. The Medicare Benefits Schedule (MBS) lists the Item descriptors and Medicare rebates available for GPs providing services to people living in Residential Aged Care Facilities. The Medicare Benefits Schedule items available cover the following range of services: GP consultations in an Aged Care Facility; Health Assessments; Chronic Disease Management and GP Management Plans Residential Medication Management reviews; Case Conferences; GP contributions to a Resident s Care Plan. Aged Care Access Incentive Program Practice Incentive Program Payments In addition, through the Practice Incentives Program, further payments are available to GPs who see patients in a Residential Aged Care Facility. There are 2 tiers of payment, being $1500 at a Qualifying Service Level of 60 services, and an additional $3500 after 140 services. The services must be claimed through Medicare by a Practitioner with a Provider Number linked to a PIP Practice, and in a financial year. The following is a link to the Medicare Australia website with specific details of this Incentive: aged care access incentiveguidelines.pdf Additional Services available through the Aged Care Access Incentive Program Services such as those from a Psychologist or a Diabetes Educator can be provided through this program and further details may be obtained through the Ballarat and District Division of General Practice. Claims for payment to the Provider are made through the Division, rather than from the Resident. 21

22 Routine GP Consultations The purpose of the Medicare Benefits Schedule items for GP consultations at a Residential Aged Care Facility is to reimburse the GP for routine medical care, including a component for travel time. As with consultations in the rooms, Medicare reimbursement per patient increases with the length and complexity of the consultation. A number of measures have been introduced to improve the remuneration for GPs working in Residential Care as the rebate levels have not previously included components to reflect the value of some elements that are essential and substantial aspects of the routine medical care of a Resident. Some of the issues which needed to have been addressed included: seeing multiple Residents at the Facility, the complexity and time spent during consultations, time spent with Staff and Residents family members, management of Medication Charts and Prescriptions, and the writing of clinical notes. Medicare has gone some way towards addressing and correcting these inadequacies. What are the consultation levels? The base consultation fees follow the MBS descriptors for Brief (Item 20), Standard (Item 35), Long (Item 43) and Prolonged (Item 51) for a Consultation at a Residential Aged Care Facility. GPs will be familiar with this categorisation. Clarification of Charging for Multiple Consultations during the one visit. To cover the situation where multiple patients are seen during the one visit to the Facility, there is an additional component which may be charged and which depends on the number of Residents seen by the GP. This component decreases from a maximum for 1 patient down to a minimum amount for 7 or more patients. As from November 2010, this component is: $44.05 divided by the number of patients seen, up to a maximum of six patients. For seven or more patients, an amount of $3.15 per patient is added to the base fee. Please note that this figure is revised each year. Consultation levels follow the standard time based plus complexity format, (Levels A, B, C & D) and Full descriptors and a further explanation on the most appropriate item number to use, see Benefits Schedule MBS 1 Urgent and After Hours Consultations in a Residential Aged Care Facility Provisions have been made in the Medicare Benefits Schedule to address GP consultations for medical care provided outside normal business hours. There are 4 categories of Visits to Residential Aged Care Facilities. They are: Routine Visits, Urgent Visits, After hours Visits, and After hours Visits during Unsociable Hours. 22

23 What is the definition of 'In and After Hours? In Hours is defined in the Medicare Benefits Schedule as the hours between 8am and 6pm on weekdays and 8am and 12 noon on a Saturday. After Hours Consultations are those performed outside of these hours, or on a Public Holiday, and attract appropriate consultation fees. After Hours visits are further broken down into After Hours Unsociable Hours, being those between the hours of 11pm and 7.00am, and those classified as After Hours Urgent. What is the definition of Urgent? To qualify for an Urgent After Hours Consultation, the request for the GP to attend must be made by the patient or the responsible person during, or no more than two hours before the beginning of an unbroken after hours period. The urgency of the patient s condition is to be identified by the attending GP; however, their opinion regarding the patient s condition must be acceptable to the general body of Medical Practitioners. What are the Consultation levels? After Hours Consultations, but excluding those for Urgent or Urgent in Unsociable Hours (597 & 599), are divided into the same four levels (A, B, C & D) to acknowledge the complexity of the consultation and the time involved in providing appropriate care for the patient. (N.B. Items Numbers 597 & 599 are not time based) A complete listing of all After Hours MBS Item Numbers and descriptors for Residential Care is at the following website, and below it is a Reference Chart for clarification: ours Attendance Period Urgent After Hours Attendance Urgent After Hours in Unsociable Hours Non Urgent After Hours at a Residential Aged Care Facility Monday to Friday* Between 7am 8am and 6pm 11pm Between 11pm 7am Before 8am or after 6pm Applicable Time Saturday* Between 7am 8am and 12pm 11pm Between 11pm 7am Before 8am or after 12pm Sunday and/or Public Holiday Between 7am 11pm Between 11pm 7am 24 hours Items 597, 599, 5010, 5028, 5049, 5067 * With the exception of Public Holidays which fall on a Saturday 23

24 HEALTH ASSESSMENTS, GP MANAGEMENT PLANS & RESIDENT CARE PLANS The following table is a Flow Chart to present the 10 Steps that can be followed to develop a Total Management Plan for a Resident, incorporating all of the various MBS Item Numbers applicable to Aged Care, and thereby optimising the potential income available for GPs working in this sector. A detailed explanation follows this chart. TEN STEPS TO RESIDENTIAL CARE USING THE MEDICAL BENEFITS SCHEDULE Step 1 Step 2 GP Step 3 GP Step 4 GP / Pharmacist Step 5 GP & RACF Step 6 Allied Health Step 7 RACF Step 8 GP Step 9 RACF / GP Step 10 RACF / GP Assessment and initial Care Plan. GP undertakes Health Assessment (HA) within two weeks of Admission. Summary of the HA provided to the RACF. GP initiates Residential Medication Management Review (RMMR) with referral sent to the accredited Pharmacist. Pharmacist undertakes review, providing a report to the GP, including recommendations. GP prepares a Medication Plan. GP contributes to eligible Resident s Care Plan. Referral to Allied Health following consultation with RACF and submission of Item 731 claim. Up to 5 Allied Health services provided for eligible Residents as detailed in Resident s Care Plan. Finalise Resident s Care Plan with GP input. GP organizes or contributes to Case Conference for eligible Residents for reasons other than to which a Medicare claim has been made. Undertake HA RMMR review. GP contributes to Care Plan at the 12 monthly review (or 3monthly if applicable) Refer to Allied Health. HA MBS Item RMMR MBS Item 903 Contribution by a GP to a GP Plan MBS Item 731 Various MBS Items depending on the service MBS Items: (to organise); (to participate) HA MBS Item & RMMR MBS Item 903 Contribution by a GP to a Plan MBS Item 731 Admission 2 weeks 4weeks 6 weeks 12 months Routine Medical Care Residents with a chronic medical condition (present or likely to be present for 6 months) or terminal illness and complex care needs are eligible for a Care Plan contribution by GP Allied Health & Dental Care Services and Case Conference Items.

25 A Health Assessment, previously known as a Comprehensive Medical Assessment, is an overall summary of a Resident s History and Examination and Treatment Plan. A GP Management Plan, previously known as a Chronic Disease Management Plan covers the involvement and contribution from a GP in the development of a Multidisciplinary Care Plan. A Resident Care Plan is an overall summary of a Resident s Total Management Plan from a Nursing Care perspective and is undertaken by the Residential Aged Care Facility staff. All Residents of a Residential Aged Care Facility will, as a matter of course, have a Resident Care Plan undertaken as part of their admission procedure, and the information from the Health Assessment, as well as the GP Management Plan, if applicable, would be incorporated into the Resident Care Plan. HEALTH ASSESSMENTS What is a Health Assessment? Eligibility for patients to be able to obtain a Medicare Rebate for a Health Assessment applies to patients falling within a number of target groups. In this instance, the appropriate category is for Patients who are permanent Residents of a Residential Aged Care Facility and the applicable Item Numbers are 701, 703, 705 and 707, depending on the time and complexity involved. A person is considered to be a Resident of a Residential Aged Care Facility if they have been admitted as a permanent Resident of that Facility. A rebate for a Health Assessment is available to all new Residents on admission and, whilst not a formal requirement for the GP s management and care of the Resident, the completion of a Health Assessment is a Practice Accreditation Standard. It is recommended that an assessment should be undertaken as soon as possible after admission, and ideally within 2 weeks. A rebate is available providing that a Health Assessment has not already been undertaken in another Residential Aged Care Facility within the previous 12 months. It can be repeated at 12 month intervals thereafter. The Health Assessment requires assessment of the Resident's health and physical and psychological function, and must include making a written summary of the Medical History and Examination, and developing a list of diagnoses and medical conditions. A copy of the Summary should be provided to the Residential Aged Care Facility, and also offered to the Resident. The Health Assessment complements normal Aged Care Consultation Items and other Medicare Items such as Case Conferences, contributions to a Multidisciplinary Care Plan and Residential Medication Management Reviews. 25

26 What are the benefits of Health Assessments? Health Assessments enhance the quality of medical care provided to Residential Aged Care Facility Residents by enabling the GP to undertake a detailed review of a Residents medical conditions and to identify their medical needs. The information from a Health Assessment can be used to:. Assist the GP in planning medical management, including preventive care, treatment of chronic conditions, acute events, medication monitoring, palliative and Advance Care Planning. Discuss goals of care and Advance Care Planning with the Resident and their Relatives. Establish closer working relationships between the GP and the Residential Aged Care Facility Staff. Provide medical information to Residential Aged Care Facility Staff and other Service Providers to assist in the preparation of a Resident Care Plan and for referral to a Consultant Pharmacist for a Residential Medication Management Review The Residential Aged Care Facility may be able to assist the GP by identifying those Residents requiring a Health Assessment, by obtaining their Consent, and by making all Documents and Clinical Information available to the GP for the appointment time. Practice Nurses may also assist the GP in performing the Health Assessment and their role is further clarified later in this document. Further information is available in Section A24 & A29 in the MBS Schedule: Benefits Schedule MBS 1 Included in this Guide is an example of a Health Assessment Form (Appendix 3) and following is a Flow Chart for conducting a Health Assessment. 26

27 HEALTH ASSESSMENT FLOW CHART NEW RESIDENT Resident admitted to Aged Care Facility EXISTING RESIDENT Significant change in Medical Condition or psychological / physical function GP notified of new admission Potential need for HA identified by GP, Aged Care Staff or Resident GP notified GP assesses Resident s need for HA Resident s Consent obtained for HA HA Consultation conducted with Resident Full Medical History taken Physical Examination conducted List of Diagnoses and Problems prepared from the Medical History and Examination A written summary of the HA is prepared and a copy is filed with: The RACF for planning and provision of care The Resident s Medical Record 27

28 GP MANAGEMENT PLANS What is a GP Management Plan? There is only one GP Management Plan MBS Item Number applicable to Residents of Residential Aged Care Facilities, being Item Number 731. This Item covers a contribution by the GP to the preparation of, or a review of a Multidisciplinary Care Plan for a patient in a Residential Aged Care Facility. The Resident must have at least one medical condition that has been present for at least 6 months, or who is a terminal patient, and who requires ongoing care from at least 3 collaborating Health Care Providers, one of whom is a Medical Practitioner. The patient must be a care recipient in a Residential Aged Care Facility. This rebate is claimable no more frequently than once every 3 months, unless there is a change in circumstances requiring a new contribution to the Multidisciplinary Care Plan. An important component of a GP Management Plan is the preparation of an Advance Care Plan and GPs are encouraged to discuss this issue with the Resident and their Relatives or Carers, and to complete a Plan. The following is a link to the Medicare Benefits Schedule webpage giving an explanation of a patient s eligibility for a GP Management Plan: 28

29 RESIDENTIAL MEDICATION MANAGEMENT REVIEWS What is a Residential Medication Management Review? A Residential Medication Management Review is a collaborative service available to Residents of a Residential Aged Care Facility. A Residential Medication Management Review provides an opportunity for GPs and Pharmacists to assess medication related information so as to identify and resolve any issues or needs. Who should have a Residential Medication Management Review? A Residential Medication Management Review is available to all permanent Residents of a Residential Aged Care Facility on admission to the Facility, and on a 12 monthly basis, as well as for existing Residents on an as needs basis where, in the opinion of the treating doctor it is required because of a significant change in the medical condition or treatment regimen. Where a Resident has had a Health Assessment, the Residential Medication Management Review should preferably be performed after the results of the Health Assessment are available. Residential Aged Care Facilities can assist GPs in identifying those Residents who need a Residential Medication Management Review and by advising the GP. Who is responsible for undertaking a RMMR? Residential Medication Management Review are undertaken as a collaborative effort between a Resident s GP and a Consultant Pharmacist and in doing so, can help to establish closer working relationships between the GP and the Pharmacist. What are the benefits of Residential Medication Management Reviews? Residential Medication Management Reviews can enhance the quality of medical care provided to a Resident. It can be used to assist the GP in developing, or revising a Medication Management Plan, thereby optimising the therapeutic effectiveness and management of the Resident s medication regimen and minimising possible adverse effects. A copy of the Review should be provided to the Resident, as well as to the Residential Aged Care Facility staff. Is there a Medicare rebate for a Residential Medication Management Review? An MBS rebate is available to permanent Residents of a Residential Aged Care Facility receiving either High or Low Level care and the MBS Item number is 903. The Residential Medication Management Review complements the normal Aged Care Consultation items and other Medicare items such as for Health Assessments, GP Management Plans and Case Conferences. The following link provides the MBS descriptor for Item Number 903: For further information on how to organise a Residential Medication Management Review, the following Flow Chart is provided on the next page, and included in this Manual is an example of a Residential Medication Review Template Form (Appendix 4) 29

30 RESIDENTIAL MEDICATION MANAGEMENT REVIEW FLOW CHART (MBS Item 903) NEW RESIDENT Resident admitted to Aged Care Facility EXISTING RESIDENT Potential need for RMMR identified due to significant change in Medical Condition or Medication Regimen GP notified of new admission GP notified of potential need for RMMR Consultation with Resident GP discusses the RMMR and seeks Consent Consultation with Resident GP makes assessment to determine whether RMMR is required and seeks Consent GP consultation with the Pharmacist GP initiates the RMMR and discusses the pharmaceutical component of the Review. Pharmaceutical component of RMMR Pharmacist reviews the Resident s medication, considering both prescription and non prescription medication. Post Review Consultation between GP and Pharmacist GP and pharmacist discuss the outcomes of the RMMR and create a Medication Management Strategy for the Resident. Consultation with Resident GP discusses the outcomes of the RMMR and the proposed Medication Management Strategy with the Resident and obtains their approval. GP finalises the RMMR GP documents the outcomes and the Medication Management Plan. The GP then provides the Aged Care Facility with a copy to file with the Resident s Medical Record. Resident is billed for the RMMR in accordance to standard MBS procedure. 30

31 RESIDENT CARE PLANS What is a Resident Care Plan? A Resident Care Plan is a comprehensive individualised nursing assessment compiled so that each Resident s physical and mental health is promoted and optimised, in partnership between each Resident (or representative) and the Health Care team. Following admission to a Residential Aged Care Facility a series of comprehensive assessments are conducted over a four week period. From this information a Plan of Care is compiled by the Residential Facility Staff outlining the social, personal and nursing needs each Resident requires. What are the benefits of a Resident Care Plan? There are many benefits in collaborating with the Resident s GP when creating a Care Plan. Contributing to a Resident Care Plan provides an opportunity for the GP to view the plan and to add relevant medical care information, such as: Information from the Health Assessment. Information from the Residential Medication Management Review. Information from Case Conferences. Referrals needed for Allied Health services. Arrangements and instructions for After Hours and Acute Care. Is there a Medicare rebate related to a Resident Care Plan? A Medicare rebate is available for the GP to contribute to, or to review, the Resident s Care Plan prepared by the Residential Aged Care Facility. This rebate appears as MBS item 731. A period of at least three months must pass between each claim. Item 731 may also be claimed if a contribution was made to a Care Plan developed by a Hospital from which the Resident has been discharged. Where a Resident s GP has contributed to a Care Plan, and MBS item 731 has been claimed, the Resident may be eligible to access certain Medicare rebated items for allied health and dental services provided by Private Practitioners, on referral from their GP. For more information regarding these referrals, please see the Section on Allied Health Services. The following also provides more information: 31

32 CASE CONFERENCES What is a Case Conference? A Case Conference, better known as a Multi disciplinary Case Conference is available for patients who have at least one medical condition that has been (or is likely to be) present for at least 6 months, or who is terminal, and who requires ongoing care from a Multidisciplinary Case Conference Team which includes both a Medical Practitioner and at least two other members (one of whom may be a second Medical Practitioner), and each of whom provides a different kind of care to the patient. Case Conferences provide the opportunity to plan for urgent or short term Health Care needs in a coordinated fashion, or to coordinate Medical Care for specific aspects of a Resident s condition. For the purposes of the Medicare Benefits Schedule Item descriptors, a Multidisciplinary Case Conference is a process by which a Multidisciplinary Case Conference Team discusses the patient s history, identifies the patient s multidisciplinary care needs, thereby identifying outcomes to be achieved by members of the team and services to the patient, and identifying tasks that need to be undertaken to achieve these outcomes. Tasks are then allocated to members of the team, and an assessment is made whether previously identified outcomes (if any) have been achieved. Participation in a Multidisciplinary Case Conference must be at the request of the person who organises and coordinates the Conference. A GP may either organise and coordinate a Conference, or simply participate in the Conference, and different Item numbers apply. A Case Conference may be held without the attendance of a GP, but of course, there is no MBS rebate available in these circumstances. Alternatively, the Conference may be organised by Residential Aged Care Facility Staff. Conferences may be held over a period of several days, or over the course of say, a year, and a maximum of 5 Conferences can be claimed in any 12 month period. It is recommended that the Resident, or their Relative or Carer is involved in the discussions in the conference process, but they are not counted as participants in the Conference for meeting the Medicare Benefits Schedule requirements. The following is a list of some of the Health Care Providers who may participate in a Multidisciplinary Case Conference: Aboriginal Health Workers Asthma Educators Audiologists Dental Therapists Diabetes Educators Dietitians Directors of Nursing Mental Health Workers Occupational Therapists Optometrists Orthotists and Prosthetists Personal Care Worker Pharmacists Physiotherapists Podiatrists Psychologists Registered Nurses Social Workers The following charts provide further information on how to organise a Case Conference. 32

33 PROCEDURE FOR ORGANISING A CASE CONFERENCE GP and/or Facility Staff member to identify Residents in need of a Case Conference Nominate potential dates and times It is recommended to give all parties involved at least four weeks notice when scheduling potential Conference dates GP/Care Co ordinator to set the Agenda for the Case Conference Fax request with Agenda to appropriate Health Professionals who will participate Conduct the Case Conference Record the outcome of the Case Conference Report to be disseminated to participants and placed in the Resident s File 33

34 MEDICARE BENEFITS SCHEDULE GP coordination of Case Conference of 15 to 30 minutes Item Number GP coordination of Case Conference of 30 to 45 minutes Item Number GP coordination of Case Conference of 45+ minutes Item Number GP participation in Case Conference of 15 to 30 minutes Item Number GP participation in Case Conference of 30 to 45 minutes Item Number GP participation in Case Conference of 45+ minutes Item Number

35 THE AGED CARE FUNDING INSTRUMENT (ACFI) The ACFI is the method now used for determining the subsidies for Residential Care, and has been in use since March Principles of the Aged Care Funding Instrument The Aged Care Funding Instrument has been designed to focus on the core measurable needs that best explain the differences in Residential Care costs and involves an assessment of the person s usual care needs It does not look at care plans or ongoing care documentation and is considered to be a more objective instrument. There are more tightly specified assessment and documentation requirements Structure of the Funding Model Three Funding Domains Activities of Daily Living determined by questions 1 5 Behaviour Supplements determined by questions 6 10 Complex Health Care Supplement determined by questions 11 & 12 There are twelve questions as stated above to cover these three domains. Each question has an assessment stage to determine a rating of A, B, C or D for that question and these ratings have different values for each question. The values are then used to classify the Resident s needs as Low, Medium or High in each of the three domains The Impact on the Medical Practitioner Some criteria within the ACFI are very specific and complex, and so that a Resident may attain the maximum and appropriate level of funding, it may be necessary to provide some quite specific details and information, especially regarding diagnoses and their verification. For example, to achieve the highest level for the Behavioural Supplement, a Dementia, Psychiatric or Behavioural Diagnosis is required. In the case of diagnoses covering Depression, Psychotic and Neurotic disorders, the Diagnosis, Provisional Diagnosis or re confirmation of the Diagnosis must have been made within the past 12 months. From time to time, the Residential Aged Care Facility staff may ask the Treating Doctor to provide more specific documentation when the ACFI tool is used. GPs are asked to show some understanding towards the Facility in its need to optimise its income. For those interested in more information regarding the Funding Model, the following link may be useful: 1 The following is a link for the User Guide to the ACFI: ser%20guide.pdf 35

36 ADDITIONAL INFORMATION The Role of the Practice Nurse and their Involvement within Residential Aged Care Facilities Working within a Residential Aged Care Facility, the General Practitioner s Practice Nurse is able to assist in the conduct of a Health Assessment, much the same as would occur in the setting of the GP s Office. A Protocol for the involvement of Practice Nurses in Ballarat Health Services has been developed and is on the BHS GP Access website. Practices are asked to provide a document to Ballarat Health Services to state that the Practice Nurse(s) employed by them are Registered with the Australian Health Practitioner Regulation Agency, have Indemnity Cover (usually part of the GP s Cover), and have had a Police Check. A copy of this document is available on the GP Access website. GP Reminder and Recall System The setting up of a Recall System using the GP Medical Software is another valuable tool to be utilised for such reminders as investigations to be scheduled, timing of Medication Chart updates, Immunisations due, and of course, a reminder of when the next Health Assessment is due. After Hours and Acute Care Referral When a Resident is unwell and the Staff of the Residential Aged Care Facility decide that the Treating Doctor should be notified, the most senior person on duty should be the person to make that contact. The assessment of the Resident may be influenced by a number of factors, including the Staff Member s qualifications and confidence, workload, protocols or equipment at the Facility. The Resident s current Medical and Nursing Documents should be accessible at the time of the discussion and following direction from the GP this information will be included within the Resident s Medical history. Arrangements for After Hours Care should be noted on the Resident s Medical Care Plan and the Aged Care Facility s GP register. It is a requirement that GPs make arrangements for After Hours primary Medical Care for their patients, either providing this themselves or by sharing on call arrangements with other GPs. If a Residential Aged Care Facility Staff Member completes their shift prior to the GPs attendance, they should ensure that another member of Staff is aware of the reason for the impending visit. Continuity of Care after Return from Hospital The GP should review the Resident and their Medical Care Plans as soon as practical and, ideally within seven days of the Resident returning to the Facility. Ballarat Health Services uses the BOSSNET system for scanning the patient s Electronic Medical Record, and Staff members within each Facility have access to this system. A GP review can be undertaken and remunerated as a Residential Aged Care Facility consultation, or as a Health Assessment (MBS item 731). 36

37 AGED CARE FACILITY AND GENERAL PRACTICE SERVICES Ballarat and District Division of General Practice CONTACT / WEBSITE Tel: Fax: ADDITIONAL INFORMATION 105 Webster Street, PO Box 36W Ballarat, Victoria 3350 Aged Care Assessment Service Tel: Fax: Dana Street, Ballarat, Victoria 3350 Rural Ambulance Victoria Emergency: 000 Non Urgent Transfer: Tel: Australian & New Zealand Society for Geriatric Medicine Public Advocate Office Ph: ACCV Aged and Community Care Victoria The National Aged Care Alliance (NACA) Ph: Ph: PO Box 4239 Kingston ACT 2604 Drug Choice Companion: Aged Care Geriatrics at Your Fingertips Medical Care of Older Persons in Residential Aged Care Facilities Medicare Benefits Schedule Online ips.org konline /mbsonline/publishing.nsf/content /Medicare Benefits Schedule mbspublications May08 Australian Medicines Handbook Subscription Required American Geriatrics Society Royal Australian College of General Practitioners Therapeutic Guidelines Subscription Required The Merck Manual 37

38 REQUEST FOR MEDICAL RECORDS TRANSFER FORM (Appendix 1) (Example Only) Date: From: Facility: Address Telephone: Facsimile: To: Practice: GPs: Address: The Practice Manager Re: Name: D.O.B: Address: Please note that the above mentioned patient is now attending: GPs: Practice: Address: Telephone: Facsimile: Argus Would you kindly forward their Clinical Records or an accurate Health Summary, with the relevant correspondence and results, to assist in the future management of this patient? These records can be forwarded by mail or to the Practice specified above. Resident signature: Date: REPRESENTATIVE Yours sincerely, 38

39 BHS Residential Aged Care General Practitioner Register Template Name of Facilities you are prepared to attend (please tick) and if possible nominate day/s and times of attendance Eureka Village Hostel W.B Messer Hostel, QE Village Talbot Place PS Hobson, QE Village Steel Haughton James Thomas Jack Lonsdale Jessie Gillett Hailey House Bill Crawford Geoffrey Cutter Are there any Facilities you do not attend: GP s Name: Practice: Address: Telephone: Facsimile: Mobile: Preferred Method of Communication: Routine Communication (e.g medication reviews) Phone: Mobile: Fax: Urgent Matters Phone: Mobile: Fax: After Hours Service Provided: YES: NO: Phone: Arrangements for Medication Reviews: GP to complete: Pharmacy to complete: Arrangements for Rewriting Drug Charts: Please note current drug chart/s will be faxed to GP Contact staff member at Practice when you are on leave: Name: Title/Position: GP Completing Health Assessment of Residents: YES: NO: PN Completing Health Assessment of Residents: YES: NO: Will Attend Case Conferences: YES: NO: Will Contribute to Care Plans: YES: NO: GP s Signature: Date: / / Please return this form to: GP Liaison Unit BHS PO Box 577, Ballarat 3353 Please inform Residential Aged Care Facility if your details change. Please note that all information will be stored in a secure environment