Request number: 2024-86

About this Opportunity:

WA Primary Health Alliance (WAPHA) is seeking submissions from Aged Care organisations with a minimum of two Residential Aged Care Homes within the metropolitan area of Perth to apply for a grant that will fund them to employ a dedicated Case Coordinator as part of their team.

The Case Coordinator will be a Registered Nurse and will facilitate case coordination, decrease administrative burden on visiting General Practitioners (GPs) and increase efficiency to deliver quality primary care and end of life and palliative care to people living in these Residential Aged Care homes (RACHs).

The Case Coordinator will implement the Palliative Care Outcomes Program (PACOP) in both RACH sites. PACOP is funded by the commonwealth and provides Aged Care organisations with a systematic approach to routine assessments that support the identification of deterioration and palliative care needs (PACOP for clinicians – University of Wollongong – UOW).

The Case Coordinator will support the development of end-of-life care capacity and capability with RACH staff.

Background information

This is Phase 2 of the “NPA: Optimising primary care coordination for people living in RACH’s”.

Following the successful completion of Phase 1 which delivered a number of positive outcomes for residents, staff and each organisation, the project has been refined and the following activities have been identified:

1. Coordinating case conferencing within participating RACHs, through activities such as:

• Identification of residents who would benefit from case conferencing.
• Liaising between the resident and their family/carer, GP, RACH health care team, specialist palliative care provider and other clinicians according to the needs to set-up and participate in case conferencing.
• Increase RACH staff capability to facilitate routine case conferencing.
• Promotion and utilisation of applicable MBS items to support GP service delivery.

2. Facilitating resident and GP access to specialist care, including integration of existing specialist palliative care providers such as:

• Health Service Providers (HSPs).
• Metropolitan Palliative Care Consultancy Service (MPaCCS).
• Other specialist palliative care providers.

3. Delivery of quality improvement activities to build the capability of RACH staff and GPs to deliver quality generalist palliative care, including:

• The coordination of care and health services for residents.
• The proactive management of resident health care, including residents’ access to timely and appropriate medication.
• Integrating and supporting existing care planning resources such as ACP, RGoC and PACOP to recognise and respond to deterioration.
• Coordinate targeted education via existing providers and provide / facilitate opportunistic education responsive to RACH workforce needs.

4. Developing and integrating improved processes in RACHs, such as:

• After-hours planning and escalation pathways.
• GP engagement pathways (when to call).
• Effective utilisation of in-hours and out-of-hours health care services.
• Supporting GPs and RACHs to increase availability and use of telehealth care for their residents.
• Palliative care needs round models

WAPHA will provide support to each of the Case coordinators through a combination of site visits and online monthly project meetings.

Reporting requirements:

1. Baseline and end-point ELDAC Advance Care Planning and Palliative Care Organisational Audit (Quality Improvement – Residential Aged Care)
2. Monthly data submission via an electronic template provided by WAPHA
3. Completion of monthly After Death Audits (ELDAC – After Death Audit Residential)