Section Two: Residents' Medical Care
Residential aged care
Residential health care
Medical management of RAC patients
The number of older people living in a Residential Aged Care Facility (RACF) is increasing as the population ages. The number of people in Australia aged 65 years or over is estimated to rise from 2.5 million, representing 12.7% of the total population in 2002, to 5.4 million people, representing 22.3% of the total population by 2031. The estimated increase is even more marked in those over 85 years1.
Currently, 6% of people aged 65 years or over live in Residential Aged Care Facilities. Of people aged 85 years or over, 29.5% are in residential care or receiving an aged care package or service. The average age of people living in RACFs is 83 years. Proportions of males and females aged 65-74 in RACF are relatively equal, however, by age 85 they are predominantly women2.
Admission to residential aged care is usually from home due to functional decline associated with falls, dementia, incontinence, or on discharge from hospital after an acute episode. Following admission to a RACF, any new or progressive illness may be associated with loss of independence in self-care and mobility, and lead to increased dependence on RACF staff.
Residential Aged Care Facilities (RACF) provide residential care to eligible older people who have been assessed by an Aged Care Assessment Team. Residential care combines the provision of accommodation with personal and/or nursing care and other supports. RACF may also offer extra services and respite care within their overall service provision.
The Resident Classification Scale (RCS) is the tool used to assess the care and support needs of the individual resident, and determine the level of the Commonwealth Government subsidy paid per resident per day. People entering a RACF are income-tested with some residents expected to pay additional fees. An accommodation bond and and charge also apply3.
As of 2007 the Aged Care Funding Instrument (ACFI) will replace the Resident Classification Scale. The ACFI is a resource allocation instrument, which focuses on the main areas that discriminate care needs among residents. The ACFI measures a person’s assessed care needs, e.g. the person’s ‘core’ impairments. This is a more objective and informative approach than measuring the care provided (what is done to support the person). The ACFI, while based on the differential resource requirements of the individual, delivers funding to the financial entity providing the care environment. This entity for most practical purposes is the residential aged care facility. At the time of producing this second edition of the GP and Residential Aged Care Kit, the ACFI was not in its final version. For up to date information see the Department of Health and Ageing Website at www.health.gov.au/
In 2000/01, there were about 140,000 government subsidised RACF beds; about 74,000 high care and about 66,000 low care. The proportion of residents classified as high care is increasing, due to community care packages and services enabling people to stay in the community longer, before entering residential care at a more dependent level4.
Providers of residential aged care services may be charitable (not for profit) organisations, private (for profit) organisations, local government, and state government. In 2000/01 the residential care industry employed over 131,200 people assisted by over 32,600 volunteers, representing about 1.3% of the Australian workforce 5.
The Aged Care Act 1997 (Commonwealth) provides the basis for regulation of the residential aged care industry as well as some community based care, e.g. EACH and CACP programs. The Aged Care Standards and Accreditation Agency manages the accreditation process. There is an expectation of continuous improvement of services, and a RACF must be accredited to receive subsidies. Certification regulates building and upgrades with a set of standards to ensure that upgrades meet standards. The Department of Health and Ageing regularly audits homes and RCS (or ACFI) claims and may upgrade or downgrade resident care beds 6.
Residential health care
An integrated approach
The frailty and complexity of medical needs of residents, combined with their social context of dependency on relatives and residential care staff, necessitates an integrated approach to health care provision.
Figure 1 presents a map for integrated residential health care. The map shows three levels of care in a service system illustrated as a series of concentric layers.
The resident and his or her relatives are in the centre. They are served by the three levels of care, which are shown as pie segments involving services across the system layers.
Level 1 is residential care. Quality residential care includes accommodation that is safe and promotes wellbeing, personal care including food and support services, and in some instances nursing and allied health care. It is mainly provided by staff of the facility (RACF), with extra input if required from other service providers.
Level 2 is primary medical care. Primary medical care includes prevention, e.g. vaccination, falls reduction, management of chronic diseases and geriatric syndromes, rehabilitation, palliative care and end-of-life care. It is mainly provided by the general practitioner (and practice staff) working closely with the resident/relative, staff of the RACF and pharmacist, with extra input if required from other service providers.
Level 3 is specialist medical care. Specialist medical care includes acute, geriatric, rehabilitation and palliative care that may be provided externally, e.g. at hospital, or as shared care with GPs and staff at the facility.
The outer layer represents the wider system and community that sets the context for residential health care and includes:
Population demographics, family and social structures and community attitudes. Government funding, regulation and monitoring of residential care and health service sectors (federal, state and local level). Industry peak bodies, unions, employer groups and professional organisations that support providers’ conditions, education, standards and practice. Consumer groups eg Council of the Aging, National Seniors, Carer’s Association. Non-government organisations (NGO), eg Alzheimer’s Association.
Residents and their relatives are central in the provision of quality medical care. See the RACGP Silver Book for discussion of their role, including rights, advocacy, complaints and control over decision making, and privacy and confidentiality of health information7.
Figure 1: A map for integrated residential health care
The provision of quality health care to residents requires a multidisciplinary team approach with strong emphasis on effective relationships between the resident, their relatives, RACF staff, GP and other service providers. It also needs clinical resources (such as guidelines and training) and organisational tools (such as protocols, information management and quality improvement processes) for delivering services.
Figure 2 shows the three essential elements in an integrated service system for delivering medical care to the resident.
Figure 2: Three essential elements in an integrated service system
All three elements are necessary to ensure that the resident receives care that is timely and appropriate, whether in hours or after hours.
To implement an integrated approach:
Identify the health care needs of the residents in your care. Identify service providers needed for partnerships. Identify clinical resources required to deliver care, such as:
23 Clinical Information Sheets in Section 5; RACGP Silver Book Medical Care of Older Persons in Residential Aged Care Facilities8; Australian Medicines Handbook, Aged Care Drug Choice Companion9; Therapeutic Guidelines10; and Geriatrics At Your fingertips .Geriatrics At Your fingertips11.
Select organisational tools to help develop and maintain partnerships to deliver health care:
Table 1 lists organisational strategies and tools that GPs, RACF staff and other service providers can use for partnerships between services, providing care for the new resident/patient, routine medical care, medication management, and after hours and acute care. The following two Sections present tools for GPs (Section 3) and RACFs (Section 4), including use of current MBS items to help organise and remunerate multidisciplinary service provision, and use of Medical Director to help streamline practice systems. Other useful tools can be found at:
North East Valley Division of General Practice has templates and tools for aged care and enhanced primary care; many are adapted for use in Medical Director12. Northern Rivers Division of General Practice has templates that can be adapted for residential aged care patients, including a general template called GPMP and TCA, plus disease management plans for Asthma, CAD, CHF, COPD, Diabetes, Depression, Dementia, Hepatitis C, Pain, Palliative, Renal, Renal Diabetes, Schizophrenia and Warfarin13.
Use a quality improvement cycle to implement changes in your practice and RACF for care delivery and accreditation:
Continuous improvement process widely used as part of accreditation in residential care. PDSA cycle (plan, do, study, act) widely used in health service organisations and general practice. The Tools of the Trade Active Learning Module can help you to implement this kit. Located at www.nwmdgp.org.au Working through a Division of General Practice Aged Care GP Panel to develop joint quality improvement activities with RACF, GP and other services. Local Divisions of General Practice Aged Care GP Panels can help develop joint quality improvement activities with RACF, GP and other services to facilitate:
Improved access to GP services, Increased involvement of GPs in RACFs’ quality improvement activities, e.g. GP participation in a Medical/Medication Advisory Committee of RACF, and Effective partnerships and collaboration between the Division, local RACFs and other groups for addressing identified health needs of residents.
Table 1: Organisational strategies and tools for residential medical care
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MEDICAL CARE |
SERVICE PROVIDERS |
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GP |
RACF |
Resident &
Relative |
Pharmacist &
Allied health |
Medical Deputising Service (MDS) |
Hospital |
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Partnerships between services |
Designate a practice RACF coordinator
RACF work arrangements
Medical Deputising Service arrangement
Tool: RACF patient register/recall/reminder system
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Designate a health care coordinator
Tools:
- Resident consent for exchange of health information
- GP Register
- GP work arrangements
- Reminder system
- Organising a Case Conference with GP, GP letter and agenda, resident/relative letter and information sheet
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RACF Tool: Resident consent for exchange of health information
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|
Service arrangement with GP |
|
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Providing care for the new resident/patient |
Practice information on services for RACF patients
GP request for transfer of medical record
Comprehensive Medical Assessment
CIS: Advance Care Plan
MBS: CMA, RACF visits, GP contribute to care plan, case conference
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Tool: Resident consent for exchange of health information
Admission assessment
GP contribute to care plan
CIS: Advance Care Plan |
RACF Tool: Resident consent for exchange of health information
GP information on services for RACF patients
CIS: Advance Care Plan information sheets |
|
|
|
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Routine medical care |
Tool: Case Conference record
Clinical information sheets
MBS: RACF visits, GP contribute to care plan, case conference, CMA |
GP contribute to care plan
Case Conference
Tools:
- Organising a Case Conference with GP, GP letter and agenda, resident/relative letter and information sheet
- Reminder system |
RACF tool: Case Conference information sheet |
Participate in case conference
MBS: Allied health and dental services on GP referral |
MBS: RACF visits, after hours visits |
|
|
Medication management |
CIS: Medication Management
MD: print medication labels
Discharge letter/ medication chart on return from hospital
MBS: RMMR |
CIS: Medication Management
Medication Advisory Cx
Discharge letter/ medication chart on return from hospital
RMMR |
|
CIS: Medication Management
Discharge letter/ medication chart on return from hospital
MBS: RMMR |
CIS: Medication Management
Discharge letter/ medication chart on return from hospital
MBS: RACF visits, after hours visits |
Tool: Discharge letter/ medication chart |
|
After hours and acute care |
Instructions to RACF
Instructions to MDS
CIS (prevention and MX of after hours events)
CMA
Advance Care Plan
Discharge letter/ medication chart on return from hospital |
Tool: After hours and acute referral reference card
Instructions from GP: resident’s care plan
Relevant CIS for prevention and MXof after hours events
CMA
Transfer letter
Advance Care Plan
Discharge letter/ medication chart on return from hospital |
Advance Care Plan |
Discharge letter/ medication chart on return from hospital
|
CMA
Advance Care Plan
Instructions from GP: resident’s care plan
Relevant CIS for prevention and MXof after hours events
Available medical equipment & supplies at RACF
Discharge letter/ medication chart on return from hospital
MBS: RACF visits, after hours visits |
CMA
Transfer letter
Advance Care Plan
GP/MDS letter
Tool: Discharge letter/ medication chart |
Medical management of RAC patients
Principles
The RACGP states the following principles of quality medical care for people living in residential aged care facilities14.
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Quality medical care for persons living in residential aged care facilities
Is of the same standard as applied to the community generally. Respects the rights and responsibilities of residents. Acknowledges the various levels of dependency among residents, including their functional status and capacity to make decisions. Acknowledges groups with special needs, such as Aboriginal and Torres Strait Islanders, people from culturally and linguistically diverse backgrounds, people with disabilities and veterans. Includes information, education, and support for relatives / carers / representatives involved with the health care of residents. Meets the specific health and quality of life needs of residents in relation to diagnostic evaluation, disease management, optimising function, symptom control, palliative care, psychosocial and spiritual wellbeing. Is multidisciplinary with collaboration between GPs, residential aged care staff, pharmacists, allied health and specialist service providers. Uses available evidence-based clinical and organisational practices. Maintains continuous quality improvement through collaboration and systems development by general practice and residential aged care providers.
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Residents have complex medical needs related to chronic illness, physical disability and dementia15. The prevalence of medical conditions among residents in high care is estimated to be: over 80% sensory loss, 60% dementia, 40-80% chronic pain, 50% urinary incontinence, over 45% sleep disorder, and 30-40% depression16. In a twelve-month period, 30% of residents have one or more fall, and 7% fracture a hip17.
This medical complexity, combined with residents’ dependency on relatives and residential care staff, necessitates a more complex process of care than can be provided within routine consultations.
The medical care provided by GPs for RAC patients involves (as shown in Figure 3):
Comprehensive Medical Assessment and problem list; Discussion of goals of care, and Advance Care Planning with the resident and relatives, based on the problem list; Medical management planning for identified medical problems, plus GP contribution to resident’s care plan; Referrals, and care coordination, including for RMMR, allied health and specialist services; and Ongoing medical care.
Figure Three: Process of Medical Care for Residential Aged Care (RAC) Patients
The Reference Cards for Section Two contain a copy of Figure Three to print for easy reference.
Comprehensive medical assessment and problem list
Health assessment is the cornerstone of quality care of older people, as it leads to improved identification and management of health care needs18. It is a multidimensional assessment, often using standardised tools, and incorporating physical, psychological and social function as well as medical health. In RACFs, comprehensive health assessment includes a RAC staff component plus GP component:
RACFs are required and funded to assess needs and produce care plans for all residents. The assessment and care plans have a strong focus on personal and nursing care. An up to date medical summary for patients, including in residential care, is a general practice accreditation standard19. Medicare rebates support GPs’ participation in multidisciplinary assessment for residential aged care patients through the Comprehensive Medical Assessment (Item 712) and Contribution to residents’ care plan (Item 731) items.
Accurate diagnosis of disease and geriatric conditions is essential for formulating a list of medical problems and developing medical management plans.
Comprehensive medical assessment of a resident may include:
Review of background documents, including investigations, specialist letters and allied health provider assessments; Detailed history, including medication; Full physical examination; Functional assessment, including mental state examination, and assessment of capacity to make decisions; and Formulation of a list of medical problems
Information can be gathered from documents, resident, resident’s relatives, RACF staff and other service providers. Multiple sources of information are particularly important if the resident has cognitive impairment.
If possible, talk to, and examine the resident in a quiet location with good lighting and privacy, and at a time the resident is most rested, alert and comfortable with glasses and hearing aids in place.
A detailed history includes identifying the current main medical problems and health concerns, past medical history, systems review, medication review, smoking, alcohol and immunisation status (tetanus, influenza and pneumococcus).
The systems review helps to identify conditions commonly associated with ageing that may otherwise be unrecognised. Ask about20:
Loss of appetite; Weight loss or gain (amount, time period); Oral health (mouth, teeth, gums and presence of dentures); Fatigue; Poor exercise tolerance; Pain (location, character, intensity); Dizziness (postural, vertigo, dysequilibrium);
Falls (number in past 6 months, location, time of day, mechanism: slip/trip, overbalancing, legs giving way, dizziness or syncope); Cardio-respiratory symptoms (including chest pain, palpitations & shortness of breath); Musculoskeletal symptoms (including arthritis, stiffness & weakness); Neurological symptoms (including loss of sensation or power); Nutrition; Hearing (including availability & use of aids); Vision (including availability, use & type of glasses, when vision last tested);
Feet and usual footwear; Swallowing (solids & liquids); Communication (speech, handwriting); Sleep habits (including pattern, duration, use of hypnotic medication); Elimination (including usual pattern of bladder & bowel function, continence, use of aids); Sexual function (including libido, symptoms of dysfunction); and Mood.
Review functional assessments of physical, psychological and social function, which have been done by RACF staff and allied health providers to identify needs for support and prevention of further decline.
Assess cognition early, e.g. Mini Mental State Examination, as recognition of cognitive impairment has a significant impact on how information is obtained and from whom.
Increasingly, GPs are being asked to assess residents’ capacity to make decisions such as granting a power of attorney, making an Advance Care Plan, or choosing a health care investigation or treatment. It is relatively easy to judge capacity of someone who is clearly capable or incapable. When a person has partial understanding, undertake a more systematic assessment or refer to a psychologist or geriatrician.
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Assessment of capacity to make decisions
Capacity and the lack of capacity are legal concepts. Capacity is determined by whether a person can understand and appreciate information about the context and decision, not the actual outcomes of choices made, and not whether they can perform tasks. A capable person can demonstrate that he or she21:
Knows the context of the decision at hand; Knows the choices available; Appreciates the consequences of specific choices; and Does not base choices on delusional constructs.
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For further information on assessing capacity see the Clinical Information Sheet on Advance Care Planning for End-of-Life Care, including the Reference Card: Assessing a Patient’s Legal Capacity.
Further details on medical assessment and standardised tools are available in the RACGP Silver Book22.
The problem list from the Comprehensive Medical Assessment provides the basis for:
Annual GP contribution to the resident care plan; Medicare rebates cover GP review of the resident care plan 3 monthly at the request of RACF staff; Discussions of goals of care and Advance Care Planning with the resident and relatives; and Arranging further investigations, referrals and detailed medical management plans for specific medical problems.
Goals of care and Advance Care Planning
Some residents will have full capacity to provide information, understand and make decisions, and be able to discuss their wishes and goals of care. However, many residents will need to have relatives and/or others help decide care as their condition progresses. It is recommended that residents, if capable, appoint a representative, e.g. an Enduring Power of Attorney (Medical Treatment) to make decisions on the resident’s behalf, if in the future the resident becomes incapable (See Clinical Information Sheet on Advance Care Planning for End-of-Life Care).
GPs have a significant role in supporting residents and relatives/carers with information about the condition, its management and likely course. This includes sensitivity to the different cultural needs of families and how they care for their older relative, and responding to expressed feelings or concerns. Involvement of relatives/carers in the resident’s care can improve clinical outcomes, reduce feelings of loss and captivity, and increase satisfaction with care23.
The resident’s wishes and goals of care should be discussed for current care and also for future care (See Clinical Information Sheet on Advance Care Planning for End-of-Life Care). Ask what they consider the main problem and goals for care. Goals of care will vary depending on the stage of illness, co-morbidities and wishes of the resident.
The resident’s problem list and goals of care will help determine medical management plans and what emphasis is placed on:
Medical management planning
To meet the complex medical needs of residents, general practitioners must plan care taking into consideration:
Goals of care and wishes of the resident; Number, type and interaction of co-morbidities, including dementia; and Number, type and interaction of medications and their effect on the condition they are prescribed for, as well as on co-morbidities and the aging person.
This requires knowledge of ageing, chronic diseases and geriatric syndromes; as well as a high level of clinical skill to manage polypharmacy, balance active treatment of medical conditions with symptom control, and care for the whole person.
In effect, a medical management plan is required to address:
Chronic conditions: Treatment tailored to stage of illness (often advanced stages); Acute exacerbations and events: Prevention, early detection and treatment; and Medication monitoring: Benefits and adverse effects.
For chronic conditions such as COPD, cardiac failure and diabetes the GP should plan maintenance care, and then monitor the resident’s progress and adjust treatment as appropriate at scheduled visits. To assist with this, GPs may adapt the chronic disease guidelines and tools that they use in their general practice.
Acute care plans may be needed for residents who have acute exacerbations of chronic conditions (e.g. COPD, cardiac failure, chest pain, seizure), or recurrent illness (e.g. asthma, delirium, UTI). Acute care plans are designed to help RACF staff to promptly recognise acute events or exacerbations and to quickly put acute care measures in place. An acute care plan may include:
Usual severity of condition and usual management (baseline information); Usual frequency and pattern of acute/worsening signs and symptoms (for early recognition of acute event); and Action for RACF staff (or locum doctor) to initiate when resident develops acute signs and symptoms, including medication, investigations, and notifying GP.
Medication monitoring is an integral part of medical management of RAC patients. This includes arranging annual medication reviews (RMMR), and monitoring for beneficial and adverse effects of treatment. When prescribing, consider the resident’s renal function, mental status, other medications and co-morbidities. Consider: Is the drug having the desired effect? Are there adverse effects? Is the outcome optimal? Assess relevant symptoms, physical signs and investigations at baseline and after an appropriate period. See the Clinical Information Sheet on Medication Management or specific conditions for details and examples.
Further details of management goals and medical management planning for specific conditions are given in the Clinical Information Sheets in Section 5, for:
Important aspects of medical care of residents: Medication Management, Advance Care Planning, End-of-Life care; Chronic diseases: Diabetes, heart disease (Cardiac Chest Pain, Cardiac Failure), Osteoarthritis, respiratory disease (Asthma, COPD, Inhalation medication delivery devices); Epilepsy and Seizures; Common infections: Urinary Tract Infections, Pneumonia, Cellulitis; Geriatric conditions: Behavioural and Psychological Symptoms of Dementia, Delirium, Elder Abuse, Falls, Pain; and Procedures in RACF: Gastrostomy Tube Management, Urinary Indwelling Catheter Management, Subcutaneous Hydration.
Whilst there are MBS items for GP management plans for patients living at home in the community with complex chronic medical conditions, there are currently no MBS items for medical management plans for frail elderly patients living in a RACF with complex chronic medical conditions. Consider using a combination of item 51 (prolonged consultation) and case conferences, when applicable, for developing medical management plans for RAC patients.
The medical management plans together with the resident care plan can help the GP, RACF and practice staff to organise appropriate referrals and ongoing care.
Referrals and medical care coordination
Medical management plans provide the basis for co-ordinating the resident’s medical care, with referrals as required. Commonly used services include:
Consultant pharmacist for Resident Medication Management Reviews (RMMR); Allied health providers (physiotherapist, dietician, optometrist, podiatrist, occupational therapist) who may be on RACF staff, in hospital outpatients, or private practitioners registered with Medicare (to be eligible for allied health rebates); Specialist multidisciplinary services such as aged care, aged psychiatry and palliative care; Specialist medical practitioners in hospital outpatients or private rooms; and Emergency departments.
Consider referring each resident for a RMMR on admission and annually. Findings can identify medication issues and help in the development and revision of the medication management plan. For further information see Section 3 and the Clinical Information Sheet on Medication Management.
Ongoing medical care
When providing ongoing medical care, GPs undertake a range of tasks including24:
Evaluate patients for interval functional change at scheduled visits; Check vital signs, weight, laboratory tests, consultant reports since last visit; Review medications (correlate to active diagnoses); Revise problem list as needed; Write medication chart; Write prescriptions; Address RACF staff concerns; Update residents; and update family member(s) as needed; Liaise with RACF staff, pharmacist, and other service providers; Write medical notes in resident record at the RACF; Record patient notes at the general practice; and Update CMA, RMMR and Advance Care Plan annually; and contribute to resident care plan 3 monthly (if requested by RACF staff).
A unique feature of ongoing medical care for RAC patients is that a large proportion of GPs’ time is required to be spent in activities other than face-to-face consultations and is not funded through Medicare benefits. Currently, GPs are not renumerated for their time and services for:
Writing medication charts, prescriptions, referrals, and patient notes at the RACF and practice; Liaison in person or by telephone with the resident’s relatives, RACF staff, pharmacist, and other service providers (unless it meets criteria for a case conference).
Ongoing care can be more efficiently provided and remunerated by proving most care at the time of seeing the patient at the facility, e.g. by having regular GP sessions and having a practice computer with medical records and software at the facility. Details of the use of practice tools and MBS items available for RAC patients are discussed in Section 3.
References
Australian Bureau of Statistics, (ABS) (2003). Australian Social Trends 2003. Canberra, ABS. Australian Nursing Homes and Extended Care Association, (ANHECA) (2004). Aged Care Australia:
The Future Challenges. Canberra, ANHECA Australian Institute of Health and Welfare, (AIHW) (2002). Residential aged care services in Australia 2000-1. A statistical overview. Canberra, AIWH Flicker, L. (2002). "Clinical issues in aged care: managing the interface between acute, sub-acute, community and residential care." Australian Health Review 25: 136-139. Australian Institute of Health and Welfare, (AIHW) (2002). Residential aged care services in Australia 2000-1. A statistical overview. Canberra, AIWH. Aged Care Standards Agency, (ACSA) (2001). Accreditation Guide for Residential Aged care services. Canberra, DHAC Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Pharmaceutical Society of Australia, (PSA). Royal Australian College of General Practitioners, (RACGP), Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT). Australian Medicines Handbook. (2006): At URL http://www.amh.net.au eTG. (2005). Therapeutic Guidelines. At URL http://www.tg.com.au Reuben, D; Herr, K. et al (2006) 2006-2007 Geriatrics at your Fingertips 8th edition. At URL: http://www.geriatricsatyourfingertips.org See North East Valley Division of General Practice at URL www.nevdgp.org.au for more information. See Northern Rivers Division of General Practice at URL www.nrdgp.org.au for more information. Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Scherer, S (2001). "Australian Society for Geriatric Medicine. Position Statement No. 9.
Medical Care for People in Residential Care Facilities." Australian Journal on Aging 20: 204-208. National Aged Care Alliance, (NACA) (2003). The aged care - health care interface. Issues Paper.
www.naca.asn.au/publications.html. NACA Pocock, NA ;, NL; Culton, et al. (1999). "The potential effect on hip fracture incidence of mass screening for
osteoporosis." Medical Journal of Australia 170: 486-8. Dorevitch M, Davis S, Andrews G. Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Dorevitch M, Davis S, Andrews G. Darzins P, Molloy DW, Strang D (Eds). Who can decide? The six step capacity assessment process. Adelaide: Memory Australia Press, 2000 Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Royal Australian College of General Practitioners ‘Silver Book’ National Task Force (RACGP) (2005) Medical care of older persons in residential aged care facilities (The Silver Book), 4th edition, Melbourne, RACGP. Reuben, D; Herr, K. et al (2006) 2006-2007 Geriatrics at your Fingertips 8th edition. At URL: http://www.geriatricsatyourfingertips.org
Reference Cards for Section Two
The following reference cards are designed to be used in conjunction with the information provided in Chapter 2 of the GP and RAC Kit. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised.
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Reference Cards:
Process of Medical Care for Residential Aged Care (RAC) Patients
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