Section Four: Residential Aged Care Facility - systems and tools
Arranging medical care for a new resident
Working with GPs
Using MBS items for medical care
Medication Management
After hours and acute care
RACF Tools
The complexity of medical needs of residents, combined with their social context of dependency on relatives and residential care staff, presents a major challenge for the provision of 'round the clock' medical care. This requires a strong emphasis on effective working relations between RACF staff, the resident's relatives, GP and other service providers.
From the RACF perspective, arranging routine medical care for residents involves 'round the clock' arrangements for working with several different GPs and practices, as well as pharmacists, allied health and other service providers. After hours, acute and specialist care require the RACF staff to develop working arrangements with additional relevant service providers.
This section presents systems and tools for working with GPs, and for arranging timely appropriate after hours and acute care. Additional systems and tools can be found in the Clinical Information Sheets for medication management, Advance Care Planning, and care of specific conditions.
Arranging medical care for a new resident
Patients have the right to choose their GP, however, not all GPs visit RACFs and some RACFs have reported that new residents have difficulty accessing a GP, particularly if they have moved away from their previous locality and GP. The RACGP practice accreditation standards require practices to inform patients, including those living in RACFs, of their services.
As part of the health assessment on admission, RACF staff will ask a resident who they have or wish to have as their GP. It would be helpful to have a copy of the local GPs' practice information to give to new residents so they can approach practices available to visit them at the facility. The local Division of General Practice may have information on availability of GPs visiting RACF.
Consent for use of health information
With the increase in complexity of privacy laws, it is important that the RACF ensure that the consent form used in the admission process allows for a resident's health information to be disclosed to all the relevant service providers involved in providing medical care to the resident. This allows the resident to receive continuity of medical care, especially during after hours or acute episodes where the resident's GP is not available and other service providers are called to assist, e.g. locum, ambulance crew, hospital emergency departments, etc.
RACF tools include a Resident consent for exchange of health information form so that residents can permit service providers, involved in their medical care, to have access to appropriate health information.
The Resident consent for exchange of health information could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care, and Expected Outcome 3.9 Choice and decision-making: each resident participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people.
Advance directive
Producing an ‘Advance Directive’ for future care, also known as a ‘Living Will’ or ‘Advance Care Plan’, is generally part of the admission process for residents entering a RACF. General information and a form about resident’s wishes are usually given to the resident’s relatives to fill in and return to the RACF.
The Advance Care Planning for End of Life Care’ clinical information sheet included in this kit is a systematic guide to advance care planning for RACF staff and GPs consulting with residents and their relatives. It includes ‘Steps to advance care planning’, Advance Care Plan document, information and documentation for competent and incompetent person, fact sheets, who to involve and how an Advance Care Plan should be used. The information is based on the Respecting Patient Choices Program and relevant legislation in Victoria, Australia.
The Advance Care Planning for End of Life Care’ clinical information sheet could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.9 Palliative care: The comfort and dignity of terminally ill residents is maintained and Expected Outcome 3.9 Choice and decision-making: each resident participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people.
Working with GPs
GP work arrangements
There are many differences between general practice and the residential aged care sector in their structure, funding, regulations, codes of practice and culture. Good working relationships can be built from understanding the differences in language and perspective, keeping a ‘resident’ or ‘patient’ centred focus, and accommodating differences in professional practices between the two sectors.
RACF staff can work more effectively with GPs and their practice staff by:
Discussing arrangements for how the GP and RACF staff will work together, Ensuring that clear roles and responsibilities are agreed, and Setting up systems within the RACF that compliment and work in synch with those in the general practice.
GPs have reported more satisfaction working with Residential Aged Care Facilities where they can get to know the staff and systems of care. This can be fostered through discussion of eg communication, attendance times, Case Conferences, use of MBS items, after hours arrangements, medication reviews, reminders for patient reviews, GP involvement in advisory groups, and the nominated contact person at the RACF and general practice.
The Reference Cards include a GP work arrangements checklist/form , as a starting point for clarifying and documenting work arrangements with each GP.
As well as being a tool to assist in partnership development and formulating partnership arrangements, the GP work arrangements form assists with collecting information on visiting GPs. Thus, it could be used as a source/example of evidence in relation to the Accreditation Standards, Expected Outcome 1.8 Information systems: Effective management systems are in place, and Expected Outcome 1.9 External services: all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals.
GP register
It is important that information on GP contact numbers and instructions is available to staff at all times. This is necessary especially if a resident requires medical care for an acute event after hours, when support for RACF staff dealing with such an episode may be limited.
The Reference Cards include a GP Register. It is a template for a list of attending GPs, and provides prompts for RACF staff on what to do during an acute episode, GP contact numbers and instructions for after hours for each resident in the facility. RACF staff may enter data directly, or alternatively modify it to suit the way the facility works.
The GP Register ccould also be used as a source/example of evidence in relation to the Accreditation Standards, Expected Outcome 1.8 Information systems: Effective management systems are in place, and Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care.
RACF reminder system
The Reference Cards include a RACF reminder system as a simple and effective way to track when residents are due for review by their GP. If the date the medical care plan was reviewed is entered in this document, a formula will automatically calculate the next review date. This document requires very little effort to maintain and will save considerable time.
The reminder system will prompt you to notify the GP when the next review or immunisation is due. It can be used in combination with a GP letter and the MBS items to improve medical care for residents and ensure that the GP receives adequate remuneration for their role in care.
The RACF reminder system could also be used as a source/example of evidence in relation to the Accreditation Standards, Expected Outcome 1.8 Information systems: Effective management systems are in place, and Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care.
Using MBS items for medical care
Until November 2000 Medicare rebates were available only for GP consultations in the RACF. Since then, the other types of items have been introduced progressively to support GP participation in multidisciplinary care for people living in RACFs. These items include, Comprehensive Medical Assessment (CMA), Residential Medication Management Review (RMMR), contribution to RACF care plan, and case conferencing.
Use of the MBS items by GPs, with or without assistance from the RACF, could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.4 Clinical care: Residents receive appropriate clinical care, and Expected Outcome 2.7 Medication management: Residents’ medication is managed safely and correctly.
Consent
A resident’s consent should be obtained by the GP, using normal procedures for obtaining consent for provision of a medical service, before proceeding with any of these residential aged care MBS items.
RACF staff can assist the GP in obtaining consent from the resident or relative/power of attorney, by distributing and collecting the Consent to Medical Care for Aged Care Home Resident (see RACF tools), which may be included in the admission process.
The Consent to Medical Care for Aged Care Home Resident could be used as evidence in relation to the Accreditation Standards, Expected Outcome 3.9 Choice and decision-making: Each resident participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people.
Comprehensive Medical Assessment
An up to date medical/health summary for patients, including those in residential care, is a general practice accreditation standard [The Aged Care Standards and Accreditation Agency (2006). Accreditation Standards. Accessed at URL: http://www.accreditation.org.au/AccreditationStandards].
A Comprehensive Medical Assessment (CMA) enhances the quality of medical care provided to RACF residents by enabling the GP to undertake a comprehensive review of residents’ medical conditions, identify their medical needs and provide important medical information, including diagnoses and problems.
The information from a CMA can be used to:
Assist the GP in planning medical management, including preventive care, treatment of chronic disease and geriatric syndromes, medication management, palliative and end of life care; Establish closer working relationships between the GP and RACF staff; Refer to the consultant pharmacist for a RMMR; Inform the GP contribution to the resident’s care plan (and subsequent referral for dental and allied health services, if required); and Provide medical information to RACF staff and other service providers, eg on referral for after hours and acute care etc.
The CMA Medicare rebate is available to permanent residents of RACFs receiving either high or low care. There is no age limit for a resident to be eligible for a CMA. Veterans in RACFs are eligible for CMAs. A CMA is available to new residents on admission into a RACF, but only if a CMA has not been undertaken for the resident in the previous 12 months. Existing residents can have a CMA where it is required in the opinion of the resident's general practitioner, eg a significant change in the resident's medical condition and/or physical and/or psychological function, but only if a CMA has not been undertaken for the resident in the previous 12 months. A maximum of one Medicare rebate is payable for a CMA for a resident in any twelve month period.
There is no requirement for RACF staff to contribute to the preparation of a CMA. However, the RACF may assist the GP by:
Identifying residents requiring CMA and alert GP; Assisting in obtaining consent to CMA from resident or relative; Encouraging the GP to ‘book’ a time for CMA; Making the progress notes, care plan, assessment charts, medication chart, and clinical information such as weight, urinalysis etc., available to the GP; and Documenting a recall for 12 months time.
The checklist below provides a guide for RACF staff to assist GPs in conducting a CMA.
CMA checklist
Following is a checklist for RACF staff to use when considering a resident for a CMA:
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Comprehensive Medical Assessment Checklist for Residential Aged Care Facility Staff
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Has the resident recently been admitted to the facility, or had a significant change in medical condition, physical and/or psychological function eg discharge from a hospital in the previous 4 weeks, significant change to medication regimen in the last 3 months, falls in the last 3 months, etc.
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Ensure the resident has not had a CMA within the last 12 months. |
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Discuss with the residents’ GP, the resident’s eligibility for a CMA. |
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If it is agreed that a CMA will be held:
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Schedule a time for the CMA. |
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Explain what a CMA is to the resident/carer/relatives and ensure consent is given. |
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Ensure the resident’s record as up-to-date as possible prior to the CMA being conducted, check:
Resident details including DOB, Pension No., Medicare No., NOK, Current medications, allergies and drug intolerances, immunisation status, Available results from previous assessments, tests, investigations, Information on previous health/medical assessments if available, and Nursing care plan.
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GP Tools includes a Comprehensive Medical Assessment form (December 2004 version) to use for the CMA consultation with the resident. Medical Director has a CMA template built in.
CMA and ACFI
Under the Aged Care Funding Instrument (ACFI) for RACFs the CMA can be used as a source of evidence for meeting ACFI 14: Medical Diagnosis [Department of Health and Ageing. (2006). ACFI 14: Medical Diagnosis. Accessed at URL: www.health.gov.au/internet/wcms/publishing.nsf/Content/ageing-acfi-userguide.htm~ageing-acfi-userguide16.htm on 17/11/2006.]. See the Department of Health and Ageing Website at www.health.gov.au for further information.
GP contribution to a Resident’s Care Plan
Residential aged care facilities are required and funded to produce a Care Plan for every resident. The Resident’s Care Plan has a strong focus on personal and nursing care rather than medical care.
MBS Item 730 is for the GP to contribute to, or review, the Resident’s Care Plan prepared by the RACF. It can be claimed at > 3 monthly intervals. (Refer to the ‘Medicare Benefits Schedule Book – A.21 explanatory notes’ for more detail.)
The GP contribution must be at the request of RACF staff. This should involve collaboration based on two-way communication (in person, by phone or in writing). The GP contribution should be documented in the Resident’s Care Plan and a copy kept in the resident’s medical record.
It provides an opportunity for the GP to view the plan and to add relevant medical care information, eg:
Information from the CMA, including medical diagnoses and problems; Medication management issues; Information from Case Conferences; Referrals needed for RMMR, allied health and dental services; and Arrangements and instructions for after hours and acute care.
Referral to allied health and dental services
Where a resident’s GP has contributed to a Care Plan for a resident and item 730 has been claimed, the resident is eligible to access certain Medicare rebated items for allied health and dental services on referral from their GP. These services can be provided at no cost to the resident if the service provider bulk bills (or a small gap may be charged). Up to 5-allied health services per year in total (not 5 per service type) and 3 dental services are available. The allied health or dental service provider must be a private service registered with Medicare AUstralia.
Eligible service providers are:
Aboriginal Health Worker (10950) Chiropodist (10962) Dental Practitioner (10975) Dietitian (10954) Mental Health Worker (10956) Osteopath (10966) Podiatrist (10962) Speech Pathologist (10970) |
Audiologist (10952) Chiropractor (10964) Diabetes Educator (10951) Exercise Physiologist (10953) Occupational Therapist (10958) Physiotherapist (10960) Psychologist (10968)
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All residents are eligible for the allied health and dental care rebates. However, high-care (as classified by the Residents Classification Scale) residents are only eligible for rebates if the service they are referred for is not already funded by the RACF (for example, the RACF funding usually covers a basic physiotherapy assessment, bot not ongoing treatment, which the allied health rebates could by used for). RACF staff can assist the GP in determining which services would be most beneficial to the resident, to support the care already provided by the RACF.
Refer to Section 3: General Practice systems and tools for further details on how to refer.
Residential Medication Management Review
A Residential Medication Management Review (RMMR) is a collaborative service available to residents of a RACF who are likely to benefit from such a review. This includes residents for whom quality use of medicines may be an issue or who are at risk of medication misadventure because of a significant change in their condition or medication regimen. A RMMR provides an opportunity for GPs and pharmacists to assess medication-related information so as to identify and resolve any medication-related issues or needs.
Current arrangements provide for contracted medication review services by pharmacists. The RMMR Medicare item provides a Medicare benefit for a service provided by a GP in collaboration with a reviewing pharmacist. It enables doctors to provide clinical information to inform the pharmacist's component of the review. It also enables the pharmacist to provide input from the outcomes of the review to inform the doctor's decision on the appropriate medication management strategies for the resident.
The information from a RMMR can be used to:
Assist the GP in developing or revising a medication management plan; Establish closer working relationships between the GP and accredited pharmacist; and Provide a medication management plan to resident and RACF staff.
The RMMR Medicare rebate is available to permanent residents of RACFs receiving either high or low care. There is no age limit for a resident to be eligible for a CMA. Veterans in RACFs are eligible for CMAs. A RMMR is available to new residents on admission into a RACF. Existing residents can have a RMMR on an `as required’ basis, where in the opinion of the resident’s medical practitioner, it is required, because of a significant change in medical condition or medication regimen. A maximum of one Medicare rebate is payable for a RMMR for a resident in any twelve month period, except where there has been significant change in medical condition or medication regimen requiring a new RMMR.
RACF can assist GPs by identifying which residents might need a RMMR and alerting the GP. A resident who has had a significant change in their medical condition or medication regimen may be eligible for a RMMR. Some examples where a referral may be appropriate (but not limited to) include:
Discharge from an acute care facility in the previous 4 weeks; Significant changes to medication regimen in the last 3 months; Change in medical conditions or abilities (including falls, cognition, physical function); Prescription of medication with a narrow therapeutic index or requiring therapeutic monitoring; Presentation of symptoms suggestive of an adverse drug reaction; Sub-therapeutic response to treatment; Suspected non-compliance or problems with managing drug related therapeutic devices; or At risk of inability to continue managing own medications (eg due to changes with dexterity, confusion or impaired sight).
The RMMR could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.7 Medication management: Residents’ medication is managed safely and correctly.
Organising Case Conferences with GPs
What is a case conference?
RACFs may hold meetings without GPs, as Case Conferences between RACF staff, the resident’s relatives and other service providers. This kit refers only to Case Conferences, as per the Medicare Benefits Schedule (MBS), that must involve a resident/patient’s GP and at least two other health care providers (eg RN, PCW, pharmacist, allied health), each of whom provide a different kind of service to the patient.
The purpose of Case Conference MBS items is to support multidisciplinary management of the health care needs of a patient with a chronic or terminal condition requiring complex care. 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. The GP or RACF staff can initiate a Case Conference.
Eligible residents are those who suffer from at least 1 medical condition that has been, or is likely to be present for at least 6 months or is terminal, and requires care from the GP and at least 2 other formal health care providers. Refer to ‘Medicare Benefits Schedule Book – A.22 explanatory notes’ for more detail.
It is recommended that the resident and a relative be included in discussions, although they are not counted as participants for meeting requirements of the item numbers.
Service providers who, in addition to GPs, may be included in a multi-disciplinary Case Conference (but not limited to) are:
GPs can claim for a maximum of 5 Case Conferences per patient per 12 month period, either as the organiser or a participant.
GP tools include a GP RACF Case Conference record and template.
Benfits of Case Conferences
Some RACFs have regularly conducted Case Conferences with GPs and reported benefits for residents and their relatives, facilities and GPs:
Residents:
Improved medical/nursing care as all parties involved in the care of the resident, (including the resident themselves), clearly understand the reasoning behind the type and importance of care being given. This results in a team effort and a better standard of care. The care is focused back on the resident who can make an informed choice on the type of care they receive. The resident can feel more confident in the type of care they are receiving and will therefore be more likely to comply.
Relatives:
Improved understanding of the health care needs of the resident and the reasoning behind the treatment/care plan. Therefore relatives are less likely to take up RACF staff/GP time in wanting to discuss the general health status of the resident. Feel more involved in health care planning and more likely to work with the RACF staff/GP on implementing the plan and discussing any further issues. Increase confidence in the RACF staff/GP. Improved relationship between RACF staff and GP. Reassurance that the RACF and GP are ensuring that the resident is receiving the best treatment possible.
RACF staff:
A better understanding of the residents’ treatment plans. Comply with the accreditation standards. Can be used as an education session for the RACF staff. Can be used as input to the RCS review if the timing is appropriate. Allows the RACF staff to discuss with the GP and other team members the concerns they may have with the resident in a structured conducive manner and not while the GP is in a hurry. Allows a good working partnership to develop between RACF staff and GP. Can identify communication breakdown between RACF manager and staff, e.g. are staff correctly documenting aggressive behaviour, RACF and relatives, e.g. relatives are welcomed to visit the resident at any time, even during meal times, RACF staff and GP.
GPs:
Allows the GP a good opportunity to review the medications. If this is to be done effectively it requires input by the RACF staff. It can decrease the number of calls, both in hours and out of hours, received from the facility. Allows better planning of the residents’ medical problems. It is a very effective way to utilise GP time as they can discuss the residents health problems and develop a treatment plan with RACF staff, relatives, and allied health professionals, review medication, discuss advance care plans within a single meeting.
Two models for scheduling Case Conferences
Case Conferencing can be set up in a number of ways to suit the working relationship between the RACF, GPs and other service provider/s. Below are examples of 2 different models that can be adapted and used. Alternatively you might invite GPs to participate in the family case conference conducted by the RACF.
Model 1 – Scheduling Case Conferences over a short period of time (2-3 days)
This model involves scheduling Case Conferences for the majority of residents over a few days once or twice a year.
Benefits of using Model 1:
Care Co-ordinator needs to be involved organising and co-ordinating Case Conference for only 4 weeks. GPs may prefer to ‘get it over and done with’ in one afternoon rather than coming back every couple of weeks. Better suited to RACFs that have a lot of GPs with only a few residents each.
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Suggested Steps for Case Conferencing
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Tips
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Allocate the task to a Care Co-ordinator.
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The designated Care Co-ordinator should also be the Single Point of Contact for the GPs and relatives.
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Identify residents for Case Conference and select date/s and time/s.
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It is advised that the GP, Pharmacist and residents are given at least 4 weeks notice when scheduling Case Conferences.
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Liaise with Pharmacist and/or other allied health professional.
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Confirm attendance with Pharmacist and/or other allied health professionals prior to sending a letter to the GP. Determine if the Pharmacist or allied health will be charging costs that the resident will have to pay.
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Send letter and agenda to GP.
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Advise the GP that the facility will be conducting the meetings and provide agenda so the GP understands what will be discussed.
GP letter and agenda are in RACF tools.
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Care Co-ordinator to confirm dates and times.
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Some liaison with the Practice Manager/staff, or GP, if no Practice Manager, may be required. Confirm with the GP if the patient will be required to pay an additional fee for the Case Conference.
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Advise the residents’ relatives/carers and gain their verbal consent.
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This can be done when the residents’ relatives/carers visit or sent via mail.
Provide the residents/relatives with a copy of the Case Conference information sheet and obtain verbal consent. When obtaining consent, advise the resident that they have the right to specify what medical and personal information they want withheld from the other case conference team members. Advise them if there will be any additional costs.
RACF tools includes a Resident/relative letter and Case Conferencing information sheet.
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Conduct Case Conferencing
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Complete the GP RACF Case Conference record, available in GP tools.
This meets requirements to claim the MBS item. You can advise GPs that this document is also available as a Medical Director Template and available from:
http://nwmdgp.org.au/pages/after_hours/GPRAC-GPRACK-03.html#tools
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Copy of Case Conference documentation to GP, resident and/or carer and RACF staff
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It is recommended that the RACF file the information at the front of the resident’s medical file so it can be easily accessed by RACF staff, locum, ambulance officers during an after hours or acute medical episode.
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Model 2 – Scheduling Case Conferences for a whole year
This model involves scheduling Case Conferences for the majority of residents over the course of the year.
Benefits of using Model 2:
Flexibility in that residents times and dates can be changed; Scheduling can be arranged to coincide with the residents Aged Care Funding Instrument (ACFI) Review; Relatives will have ample time to make arrangements to allow them to attend the case conference; Better suited to RACFs that have fewer GPs with a greater number of patients at the facility; Better suited to GPs who have regular days/times for visiting the RACF.
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Suggested Steps for Case Conferencing
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Tips
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Allocate the task to a Care Co-ordinator.
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The designated Care Co-ordinator should also be the Single Point of Contact for the GPs and relatives.
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Review residents and prioritise list for case conferencing.
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When prioritising the list for case conferencing, consider the residents’ general condition, when the RCS is due, when the relatives are due to sign the Care Plan.
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Liaise with Pharmacist and/or other allied health professional to confirm availability.
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Confirm attendance with Pharmacist and/or other allied health professionals prior to sending a letter to the GP. Determine if the Pharmacist or allied health will be charging costs that the resident will have to pay.
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Send letter and agenda to GP.
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Advise the GP that the facility will be conducting the meetings and provide agenda so the GP understands what will be discussed.
GP letter and agenda are in RACF tools.
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Care Co-ordinator to confirm dates and times.
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Some liaison with the Practice Manager/staff, or GP, if no Practice Manager, may be required. Confirm with the GP if the patient will be required to pay an additional fee for the Case Conference.
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Advise the residents’ relatives/carers and gain their verbal consent. .
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This can be done when the residents’ relatives/carers visit or sent via mail.
Provide the residents/relatives with a copy of the Case Conference information sheet and obtain verbal consent. When obtaining consent, advise the resident that they have the right to specify what medical and personal information they want withheld from the other case conference team members. Advise them if there will be any additional costs.
RACF tools includes a Resident/relative letter and Case Conferencing information sheet.
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Conduct Case Conferencing
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GP tools includes the GP RACF Case Conference record to complete.
This meets requirements to claim the MBS item. You can advise GPs that this document is also available as a Medical Director Template and available from:
http://nwmdgp.org.au/pages/after_hours/GPRAC-GPRACK-03.html#tools
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Copy of Case Conference documentation to GP, resident and/or carer and RACF staff
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It is recommended that the RACF file the information at the front of the resident’s medical file so it can be easily accessed by RACF staff, locum, ambulance officers during an after hours or acute medical episode.
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Continue to liaise with GPs & relatives and review Case Conference list as required.
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There may be times when a resident may need to be scheduled in earlier for a Case Conference if their condition changes significantly.
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The Reference Cards include a resident/relative letter and Case Conference Information Sheet. These could be adapted for use by the practice nurse if the GP is organising the case conference.
The Case Conference Information Sheet could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care, and Expected Outcome 3.9 Choice and decision-making: Each resident participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people.
Medication Management
Medication Management is very complex, as each RACF has their own procedures; different laws and legislation exist across the States and Territories; the legal requirement differs between high and low care facilities and on the qualification of the staff at the RACF; it involves and relies upon a number of other services providers to understand and adhere to their roles and responsibilities in the process from prescribing, dispensing and administering medications.
Establishing Medication Advisory Committees (MAC) is an excellent way of establishing good working relationships and processes with the other parties involved in medication management. It provides a forum where medication management issues can be raised, discussed and resolved with input from all stakeholders. The expertise within the MAC should also be used to set policy for the RACF e.g. Nurse Initiated Medications, medication administration, etc. The Medication Management clinical information sheet can be used as a resource for setting up a MAC; and then used by the MAC as a reference when deciding on medication management policies and procedures.
After hours and acute care
Having an up to date CMA and medical care plan means that the resident can have their medical information available when and where it is needed for their medical care.
This section presents additional tools to improve communication and decision-making, particularly after hours, by staff of the Residential Aged Care Facility, medical deputising service, ambulance and hospital.
RACF tools are provided to:
Assist staff to refer to the appropriate service provider, and have information needed when calling a locum doctor or ambulance, Send appropriate information when transferring a resident to hospital, and Provide continuity of care, including medication, on the resident’s return from hospital.
Assessment and referral
The RACF staff assessment of the resident is influenced by their own qualifications and confidence, workload, protocols and equipment at the facility; and availability of the resident’s medical information. The staff person may be a Division 1 registered nurse who knows the facility, its procedures and residents, or may be agency staff without nursing qualifications and unfamiliar with the facility or resident.
The Acute Care & Emergency Referral reference card has been produced to guide staff on what factors to consider when assessing the resident’s need, and possible actions to take when a resident requires after hours medical attention. How the staff person uses the reference card will be determined by their training and the facility.
The reference card is designed for use with patient information provided by the CMA and RACF medical care plan, and to be supported by Clinical Information Sheets and protocols used in the facility. The decision as to which after hours service is the most appropriate service to contact may vary across facilities depending on the support level of staffing and protocols within the facility.
As part of implementation of the Acute Care & Emergency Referral reference card, each facility should review the examples of care in each box and customise them to compliment the existing protocols in the facility.
The Acute Care & Emergency Referral reference card could be used as evidence in relation to the Accreditation Standards, Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care, and Expected Outcome 2.6 Other health and related services: Residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences.
Referral to a Medical Deputising Service
It is an accreditation requirement for GPs to make arrangements for after hours primary medical care for their patients. They may do this themselves, by sharing on call arrangements with other GPs or a Medical Deputising Services (MDS) that provide locum doctor visits. The GP’s arrangement for after hours care will be noted on the resident’s medical care plan and the RACF GP Register. Some local GPs are available by phone after hours.
When RACF staff call a Medical Deputising Service, the CMA and medical care plan, and RACF GP Register should be on hand so the call can be triaged quickly and accurately.
If you complete your shift prior to the locum doctor arriving, ensure that another member of staff is aware of the reason for the impending locum doctor visit.
Information on what information is required when calling the MDS is on the back of the Acute Care & Emergency Referral reference card.
Calling an Ambulance
When placing a '000' call to the Metropolitan Ambulance Service (MAS) a series of questions will be asked in order to triage the call. Depending on the response to the questions, an ambulance may be despatched. In Melbourne, if an ambulance is not required, the caller may be put through to a second operator who will ask another series of questions and direct you to an alternative service provider, e.g. MDS or domiciliary nursing service.
The information required when calling the MAS is on the back of the Acute Care & Emergency Referral reference card.
Transferring a resident to hospital
If a resident requires transfer to a hospital Emergency Department, the following documents need to be sent with the patient.
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Document Type |
Sent |
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Transfer Letter |
Original sent, copy filed in resident record |
|
CMA and/or medical care plan |
Copy sent and original kept in resident record |
|
Medication Chart or Webster Sheet/Pack |
Copy sent and original kept in resident record |
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Advance Directive |
Copy sent and original kept in resident record |
It may also be useful to include the following information when sending a resident to hospital:
Reason for transfer / letter from GP or locum if available; If CMA not available, relevant medical history and summary of usual condition and functioning, e.g. alertness, mobility, continence; Next-of-Kin and/or Medical Enduring Power of Attorney contact details; Telephone contact details at RACF including after-hours telephone number; An indication of the level of care and support available to and needed by resident, including level of training of staff at RACF; and Health insurance status, i.e. Medicare only/ Department of Veterans’ Affairs / Private health insurance.
Some divisions of general practice have developed ‘Transfer Envelopes’ to transport this information from the RACF to the hospital, which include a checklist of information to be included, similar to that provided above. Contact your local division of general practice for further information.
RACGP need to remember to:
Advise the resident’s GP of the transfer and to which hospital and fax the transfer letter and any other relevant information to the general practice. Advise the next of kin as soon as possible of the transfer.
The reference cards include a Letter for transfer to hospital. It has been designed so it can be filled in on the computer by using the ‘checkboxes’, or alternatively it can be printed out and filled in manually. It may be modified to suit each Residential Aged Care Facility.
The Letter for transfer to hospital could also be used as a source/example in relation to the Accreditation Standards, Expected Outcome 1.8 Information systems: Effective management systems are in place, and Expected Outcome 2.4 Clinical care: residents receive appropriate clinical care.
Continuity of care after return from hospital
When a resident is transferred from hospital back to the RACF, a discharge summary and medication list or chart should be forwarded to the GP and RACF before the resident returns.
Upon return of the resident from hospital, immediately fax to the resident's GP the discharge letter and medication chart from the hospital and request the GP to review the resident.
The GP should review the resident and their medical care plan as soon as practical, approximately within 7 days of the resident returning to the facility. GP review can be done and remunerated as a RACF consultation or case conference.
If the interim medication chart is filled out and signed by the hospital doctor, it can be used legally for up to 7 days by an RN in the RACF for administering medications, until the GP attends for review. If an RN is not available and a doctor is called to rewrite the medication chart and prescribe medication, the interim medication chart provides a clear statement of changes in medication.
RACF tools include the sample Hospital Discharge Letter and Medication Chart, developed for the first edition of this Kit, by the NWMDGP and piloted with The Northern Hospital in Melbourne. We encourage Division of General Practice Aged Care GP Panels to consider working with local hospitals to adapt the Hospital Discharge Letter and Medication Chart into their routine hospital discharge processes for RACF patients. Since the first edition of the Kit, some divisions of general practice have worked with their local hospitals to further this work, such as North East Valley and Melbourne Divisions of General Practice.
RACF Tools
The reference cards for this Section contain tools can be used as they are or adapted for use in any residential aged care facility. Some tools may be suitable for use in the general practice setting. The sample Hospital Discharge Letter and Medication Chart has been designed and piloted for incorporation into routine hospital discharge processes.
Reference Cards and Tools for Section Four
The following reference cards are designed to be used in conjunction with the information provided in Chapter 4 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.
Viewing Reference Cards
To view the reference cards, click on the link and select open with.... The document will open in Microsoft Word (for .doc) or Adobe Acrobat for (.pdf).
Printing Reference Cards
To print the reference card, select follow the steps for viewing a reference card, then select print in either Microsoft Word or Adobe Acrobat.
Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards:
Acute Care & Emergency Referral
Resident consent to exchange of health information form.
GP work arrangements checklist.
GP Register.
RACF reminder system.
GP letter and agenda for Case Conference.
Resident/relative letter and Case Conference information sheet.
After hours and acute referral reference card.
Letter for transfer to hospital.
Consent to Medical Care for Aged Care Home Resident Form.
Download and Printing
See note on viewing and printing documents.
Individual clinical Information Sheets and the Reference Cards designed for use alongside them are available for downloading at the specific sites. To download Section Four of GP and Residential Aged Care Facility Kit use the buttons below. Click on the link and select save to disk. You will be asked to select a folder in which to save the document. Downloads are in printable formats.
To print, download the document and use the options in Microsoft Word or Adobe Acrobat.
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