Education and Training
ACAT Age Care Assessment Team
If you need some help at home or are considering moving into an aged care home, you may first need a free assessment by an Aged Care Assessment Team
(ACAT, or ACAS in Victoria). A member of an ACAT will talk to you about your current situation and work out if you are eligible to receive government-subsidised aged care services.
Dying To Talk – Discussion Starter Kit
The Dying to Talk Discussion Starter
will guide you through that discussion. It will help you prepare, so that you know what you want to say and it will provide you with tips about how to start talking.
Statement of Choices
The Advanced Care Planning Statement of Choices Document
focuses on a person’s wishes and choices for their health care into the future. It is used to guide management of care if a person is unable to communicate their decisions.
Advance Care Planning Australia
If a person ever becomes seriously ill or injured and cannot communicate, an advance care plan
makes sure that the person's beliefs, values and preferences for treatment are understood and respected. The plan only comes into effect when a person loses the ability to make decisions or express their choices.
Ideally, an advance care planning
conversation will result in written plan. This helps make sure that a person's preferences will be respected.
Caresearch GP Hub
The Caresearch GP Hub
reflects the reality of palliative care for GPs. As well as providing prescribing and symptom management advice, the GP Hub specifically addresses challenging topics such as psychosocial complexity and refractory symptoms, as well as clinical decision-making for the deteriorating patient, emergencies, and planning for a home death.
Provides GP Tools:
- Printable Patient Resources
- Resources by Topic
- Literature and Evidence
Palliaged Palliative Care in Age Care
is a smartphone app that helps GPs who are caring for older palliative patients living at home or in residential care. As most deaths are expected, death can be planned for and the required care delivered in a pre-emptive fashion. General practitioners (GPs) have a central role in planning and providing for that care. palliAGEDgp
can help them in this role.
The app was designed and developed following a review of available apps relevant to palliative care and aged care. It recognises that GPs make use of mobile technologies in managing and providing care.
is now available for free download from iTunes and PlayTM
online app stores
For those GPs who may not have a smartphone, have a phone that does not meet current software standards, or who may prefer to use web-based resources or view content on their tablet - for optimal user experience, we would recommend viewing the palliAGEDgp content online through your web browser
A desktop shortcut can be created using Internet Explorer which will display the palliAGEDgp
icon on your desktop, this will give the appearance of the app whilst providing rapid access to web version of palliAGEDgp.
Instructions on creating a desktop shortcut
are now available (222kb pdf).
GP RACF work arrangements form Page 81
Email and Specialist Advice Services
Dementia Training Australia
A National Approach to Dementia Training
Funded by the Australian Government, Dementia Training Australia (DTA) is a consortium of experts in dementia care and workforce training.
Applying a ‘hub and spoke’ model to enable national delivery of training, DTA comprises a network of teams, with leadership provided by six organisations:
- University of Wollongong (Consortium lead and Central Coordination)
- Alzheimer’s Australia
- La Trobe University
- Queensland University of Technology
- University of Western Australia
- Wicking Dementia Research and Education Centre (University of Tasmania)
DTA is a service established to provide dementia-specific training to aged care, health care professionals, undergraduate trainees, and a range of other professionals and community service providers.
Our goal is to improve the care and wellbeing of people with dementia.
We will achieve this goal through a range of services, events, and resources to ensure that up-to-date dementia knowledge and skills training are within reach of anyone who has a professional contact point with people who have dementia.
In addition to education and training - resources include:
General practitioners often provide care for patients with lifelimiting conditions. Being able to more effectively participate in this care can be personally and professionally rewarding and has the potential to substantially improve patients’ quality of life. There is now a great opportunity for GPs with an interest in palliative care to further increase their skills and learn from palliative care specialists in a supported environment through PEPA - the Program of Experience in the Palliative Approach.
PEPA is a national educational project to enhance confidence, experience, knowledge and skills in the palliative approach through: funded and supervised clinical placements and interactive workshops; integration of learning into the workplace; and establishing networks of support. There is financial support available for successful PEPA applicants, including contributions towards backfill and travel
To access more information about the PEPA programme and the application process click here
To discuss PEPA or the different ways in which you or your practice could become more involved in palliative care, contact Dr Andrew Broadbent. Andrew is the clinical director of palliative
care for the GCHHS and can be contacted on 07 5687 2702 or email Andrew Broadbent.
To enhance the provision of palliative care and advance care planning services to the aged nationally, the Australian Government has funded the Specialist Palliative Care and Advance Care Planning Advisory Services (Decision Assist) Project.
Black Dog Institute Education and Training
Black Dog Health Professionals Education and Training provides GPs, psychologists, social workers and mental health professionals with the latest research on common mental health conditions, applied to their professional setting. Our interactive, case-based workshops, webinars, online training and podcasts are available around Australia, for individual and group enrolment.
Flow Chart - Residential Aged Care
Gold Coast Health - Supportive and Specialist Palliative Care Service
Specialist Community Palliative Care Team
Palliative Care Consultation Liaison Service
Palliative Care Inpatient Unit
- Gold Coast University Hospital Phone: 1300 744 284
- Robina Hospital Phone: 5668 6000
- Phone: 07 5668 6021
- Fax: 07 5668 6049
- Hours: 24 hours / 7 days a week
- Location: Level 1, H Block South, Robina Hospital
** GPs can join the process at point in the cycle
||Commence time based RACF CMA
in consultation with RACF.
MBS Item Numbers 701 - brief, 703 - standard, 705 - long or 707 - prolonged
Plan Case Conference, including the GP, Resident, Resident's support network, RACF staff and Allied Health Professional or other Multidisciplinary Care team members involved in the care of the resident
Provide Palliative Care Australia "Discussion Starter" for Resident/Substitue Decision Maker to enable Advance Care Plan (ACP) discussions
RACF MBS Item Numbers for VR GPs
Including, but not limited to
Pathology as required
Send a copy to RACFs for Resident File
Upload to eHealth Record
|GP Contribution to Care Plan
MBS Item Number 731
||Refer resident for
Residential Medication Management Review
MBS Item Number 903
Review sample form here
Review service description flowchart here
MBS Item Numbers 735 to 758
Advanced Care Plan (ACP) - Utilising QLD Health Statement of Choices Documentation (upload to eHealth Record, Send to Hospital ACP data base)
Multidisciplinary Care input re: ADLs., Mobility, Posdiatry, Psychosocial and psycholigical support of the resident
Agreed Care Plan within the team re: Goals
My Care, My Choices
Other Useful Multilingual Information
We recommend to start with a discussion with your GP regarding all health issues around yourself or the ones you care for. Before contacting the myAgedcare service – prepare the following information:
- Medicare card
- Full name, address, date of birth
- Allergy - medication/food/environmental
- GP details name and contact details
Have you heard of ACAT? They are the Aged Care Assessment Team
ACATs are teams of medical and allied health professionals who assess the physical, psychological, medical, restorative, cultural and social needs of frail older people and help them and their carers to access appropriate levels of support. Assessments are free of charge.
An assessment may show the older person may be able to remain at home with support. However, if this isn’t possible, the team will help the client access residential aged care facilities for either permanent or respite residential care (at both low and high levels).
If a referral to ACAT is not appropriate, the team can also refer older people on to other available services that may be more suitable.
Referral can be made by self, family, carer, GP or health worker.
Finding the Aged Care Services that are right for you
The Assessment Process
If you are seeking assistance to access aged care services, contact centre staff will register you with My Aged Care. The My Aged Care contact centre staff member will ask you a series of questions in order to understand your needs.
They will ask you questions about:
The My Aged Care website provides you with information about:
- any support you are currently receiving
- if you have any health concerns
- how you are managing with activities around the home
- some questions relating to your safety in the home.
To perform these activities, the contact centre will seek your consent to create a personalised client record. This will hold up to date information on your needs and any services you receive. The client record will reduce the need for you to retell your story to the contact centre, assessors and service providers. This initial contact will set-up the person in the system and myAgedcare staff will add information as the progression of the assessment/application/query continues.
- the different types of aged care services
- eligibility for services
- how we understand your aged care needs and help you find local services to meet your needs - you are able to select your own service provider
- the cost of your aged care services, including fee estimators.
Telephone: 1800 200 422
Hours: Mon-Fri 8am–8pm Sat 10am-2pm
Resources in other languages
The Australian Government’s My Aged Care website
and phone line can help you access aged care services in different languages to support you.
Patient Information available via the My Aged Care website
There are many different services that may support you to stay in your own home for longer, including:
Staying in your own home – Do you require assistance with day to day living in your home?
The Dying to Talk - Discussion Starter Tool Kit will assist with planning for your health care in the future. Speak with your family/significant other and your GP to understand and put plans in place for the future. This plan may be adjusted or altered at any time if there is a change in your health.
Planning ahead can be helpful and it is easier to do this planning when you are well. Talking about the type of health care you might prefer will help others to understand your wishes and help them to make decisions for you if they ever need to. Even though you might find this discussion a bit hard now, it will make their decisions less stressful later.
Dying to Talk - Discussion Starter Tool Kit
The Queensland Statement of Choices focuses on a person’s wishes and choices for their health care into the future.
It is used to guide management of care if a person is unable to communicate their decisions.
Statement of Choices
Advance Care Planning
The Queensland Government Website provides information on Advanced Care Planning
for people to assist them with making their decisions known before they cannot make or communicate any longer. For more information on what the Advanced Care Planning process includes and for assistance with understanding and undertaking the process please visit the Queensland Government Website
or contact the Office of Advance Care Planning
Metro South Health PO Box 72, Corinda Qld 4075
Phone: 1300 007 227
Fax: (07) 3710 2291
Advance Health Directive
An Advance Health Directive (AHD) —sometimes called a living will—is a formal way to give instructions about your future health care. It comes into effect only if your cognitive health deteriorates and you become unable to make your own decisions (i.e. lose capacity to make decisions).
Aged Care Complaints
1. Contact Age and Disability Advocacy Australia (ADA Australia)
2. If you are unable to resolve your concern directly with your aged care home or service
Free Call 1800 818 338
Aged and Disability Advocacy Australia (ADA Australia) is a not-for-profit, independent, community based advocacy and education service with more than 25 years’ experience in supporting and improving the wellbeing of older people and people with disability.
Headquartered in Brisbane we provide advocacy services to older people and people with disability in metropolitan, regional, rural and remote communities across Queensland. Our services are free, confidential and client focused.
ADA Australia offers a range of services in the following areas:
You can contact the Aged Care Complaints Commissioner
(Complaints Commissioner). The Complaints Commissioner provides a free service for people to raise concerns about the care and services they are receiving through an Australian Government-subsidised aged care service.
The Complaints Commissioner will select one or more approaches to resolve the issues in your complaint. If your aged care home is not providing acceptable care or services, the Complaints Commissioner can direct them to make changes. A direction requires the service provider to demonstrate how they have met or will meet their responsibilities under the Act.
3. Aged Care Home - Non-Compliance
If an aged care home doesn’t give you the care and services you need, the Department of Health (the Department) may investigate the situation and give them a Notice of Non-Compliance. The Notice will let them know there are problems that need to be fixed within a certain time period. Notices of Non-Compliance are most commonly sent out if a home does not comply with:
4. Rights and Responsibilities – Home Care
- the residential aged care Accreditation Standards detailed in the Quality of Care Principles 2014 covering areas such as management, staffing, health and personal care, resident lifestyle, living environment, catering, cleaning, continuous improvement, and safety and security
- the Charter of Care Recipients’ Rights and Responsibilities – the rights and responsibilities of care recipients living in an aged care home
- the financial obligations of an approved provider, including:
- financial management
- reporting requirements
- the management of accommodation payments (these include refundable deposits and refundable accommodation bonds)
- the publishing of refundable deposit prices.
- Specified Care and Services that an aged care home must provide to residents.
You have a right to be looked after properly, treated well and given high-quality care and services. To make sure you get the best care, all service providers have responsibilities and must meet certain standards. https://www.myagedcare.gov.au/financial-and-legal/rights-and-responsibilities-home-care
5. Making a Complaint on the My Aged Care Website
If you’re concerned about the care or services you receive from an aged care home, Home Care Package
or the Commonwealth Home Support Programme
service, there are two ways you can make a complaint:
6. Rights and responsibilities – Residential Care -Registered Aged Care Facilities
No matter which aged care home you live in, your rights and responsibilities are the same. To protect these rights and responsibilities, there is legislation that all Australian Government-subsidised aged care homes must follow, such as the Aged Care Act 1997 (the Act).
‘Residential care’ refers to the care and services you receive when living in an aged care home.
'Active and Healthy' Seniors
With our climate, enviable parks, pristine beaches and love of the outdoors, there is no better place to stay active and healthy.
City of Gold Coast (City) offers a wide variety of activities and recreation facilities for seniors at your doorstep. So get involved and live life to the fullest!
Feros Care - Celebrating ageing
|Feros Care helps people to remain living independently, socially connected, healthy and fulfilling lives for as long as possible.
Feros Care Provides services for seniors to live a connected life. Their services cover Home Care, Residential Villages, Health and Wellness programs, NDIS Local Area Coordination, and more.
My Health Record
Having a My Health Record
means your important health information like allergies, current conditions and treatments, medicine details, pathology reports or diagnostic imaging scan reports can be digitally stored in one place. Healthcare providers like doctors, specialists and hospital staff can see these details online from anywhere at any time when they need to, such as in an accident or emergency.
Help line: 1800 723 471
Elder Abuse Prevention Unit
The Queensland Government through the running an Elder Abuse Awareness Campaign
to raise awareness of the issue in Queensland.
is a no-cost, 24-hour telephone and online service funded by Queensland Health. PalAssist
can assist patients, carers, family and friends with accurate information on Palliative Care.
My Care, My Choices
The My Care, My Choices
website is a Queensland Government Initiative that provides information on Advanced Care Planning here you will also find the Statement of Choices form
Information available on the My Rights Qld website:
- My Rights Qld: information about your rights as a person with disability in Queensland Australia.
Referrals can be made My Aged Care via the following methods:
Via Phone -
Call My Aged Care on 1800 200 422
. Contact centre staff are available from 8am to 8pm on weekdays and between 10am and 2pm on Saturdays, local time Australia wide. The patient does not have to be present for a phone referral, however you will need your patient’s consent before you provide information on their behalf. You can also promote the number to your patient or family member and encourage them to call.
Use the Make a referral
page on the My Aged Care website and enter details into the online form. You can add attachments to the information that you enter into the online form.
Via Fax -
Send a fax to the My Aged Care contact centre on 1800 728 174
. You can use the Make a Referral page from the My Aged Care website as a template.
More information for healthcare professionals on making referrals to My Aged care can be found on the My Aged Care Website.
Allied Health 731 Form
Referral Form for Individual Allied Health Services under Medicare for patients with a chronic medical conditions and complex care needs.
Every day, 133 older Queenslanders have a fall requiring medical attention with 75% of hospitalisations among people over 65 years due to falls.
You are at increased risk of a fall if you:
- Are over 65 years of age
- Have a history of falls or a fear of falling
- Are female
- Have a chronic medical condition such as arthritis, stroke or Parkinson’s disease
- Are on multiple medications
- Have impaired balance or mobility, or reduced muscle strength
- Wear inappropriate footwear
- Wear inappropriate spectacles
- Suffer from dizziness, depression, incontinence or impaired cognition
- Do not get sufficient exercise for good health
Falls have a big impact on mobility and independence, but they can be prevented by:
- Staying healthy and active
- Maintaining strength and balance
- Identifying falls risk factors and addressing them
- Improving home safety to avoid hazards
Are you at risk of a fall?
The causes of a fall can usually be identified and the sequence of events leading up to a fall can be predicted. Look after your wellbeing and stay on your feet by:
- being active
- managing your medications
- reducing hazards
- wearing safe footwear and caring for your feet
- improving your balance
- eating good nutritious foods and drinks
- using assistive technology
Here are some more ways to prevent falls
See your GP
- Talk to your GP about any concerns you have regarding dizziness, blood pressure, circulation, foot problems, incontinence or medications.
- Ask your GP for assistance to make your home safer and to support you at home.
- Check with your GP about the best measures to improve your overall health, including what physical activities could suit your abilities to improve your balance and coordination.
- Increase the amount of light in your home.
- Decrease glare e.g. put net curtains in windows.
- Increase contrast e.g. put a light strip on edge of dark steps.
- Make sure light switches that are easy reach and easy to get to.
- Use the lamp or light when getting up at night.
Reduce Trip Hazards
- Keep all walkways clear.
- Tuck electric cords under furniture or around skirting boards.
- Fit a draft excluder rather than use a ‘sausage’ type at the bottom of the door.
- Remove small changes in floor levels or mark them with contrasting colour so they are easy to see.
- Have bed spreads and curtains neatly tailored so that they don’t spread over the floor.
- Remove mats and rugs or have them well tacked down.
- Wear appropriate footwear.
Reduce Slip Hazards
- Use non-slip flooring surfaces.
- Remove rugs and mats on slippery surfaces (or put non-slip backing on them).
- Use a non slip mat or strips in the shower/bath.
- Clean up spills immediately.
- Keep outdoor pathways free from obstacles, moss and leaves.
- Don’t have highly polished walking surfaces.
Remove or Manage Structural Hazards
SOURCE: Modified from Queensland Health Stay on Your Feet®
- Have bathroom and toilet doors re-hung to open outwards rather than inwards.
- Have soap holders recessed.
- Install rails in the bathroom, toilet and near the front and back door.
- Eliminate dangerous lips in to the shower.
- Have outdoor paths that are smooth.
Mental Health for Older Persons
Resources for Aboriginal and Torres Strait Islander people
- fact sheets
- print advertisements
- radio advertisements
- a poster (in English only)
A new video for Aboriginal and Torres Strait Islander audiences is also on the My Aged Care website. It provides an overview of My Aged Care, including the services available and how to access them.
Residential Aged Care Facilities
Older Persons Mental Community Mental Health Service
Robina Gold Coast Hospital
What they do
- provide early intervention to prevent escalation of mental health issues
- mental health assessment – in the person’s home, or Aged Care Facility
- short/long term case management depending on individual client needs
- collaborate with significant others, community care agencies and primary care (i.e. GP, Hospital)
- link people with organisations (i.e. for support for participation in daily activities, Dementia care, Carer support).
- older persons mental health services website
P: 07 5635 7000| F: 07 5635 7099
Mental Health for the older person
works to improve the mental health
of older Australians by raising awareness of depression
, and overcoming barriers to care within the needs of an ageing population.
CNAP Complex Needs Assessment Panel for 65yrs+
The Complex Needs Assessment Panel (CNAP)
brings government, community and private organisations together. The intention is to create pathways to support older people with complex needs and mental illnesses, where all past and current services have identified unmet needs. The CNAP aims to:
- assist coordination of appropriate care and services
- support older people and their families to remain independent in the community
Other Mental Health Resources
Unpaid Care Givers
DBMAS Qld- Dementia Behaviour Management Advisory Services
The Dementia Behaviour Management Advisory Service
(DBMAS) is a free, nationwide service funded by the Australian Government. This service is provided by highly skilled multidisciplinary teams to support family and health and aged care professionals to better understand and respond to individual changes in behaviour and emotions, and enhance quality of life.
DBMAS services are free of charge and include:
- Assessment of the person with dementia
- Clinical support, information and advice (face to face and via telephone or email);
- Care planning, case conferences and short term case management;
- Mentoring and clinical supervision;
- Education and training;
- Referral to the Severe Behaviour Response Teams; and
- Referral to other support services as needed.
- Family carers and health care professionals can contact the service on 1800 699 799 at any time of the day or night.
This app helps nurses working in residential aged care, community care and general practice to care for older people with palliative care needs. The app highlights a care framework built around three care processes – advance care planning, palliative care cases conferences and a care plan for the dying person. Nurses can navigate quickly to the three care processes. More specific information relevant to their practice setting can also be found.
palliAGEDnurse is now available for free download from iTunes and PlayTM online app stores.
If you don't have a smart phone or just prefer using a computer, you can view the content online through your web browser at apps.caresearch.com.au/palliAGEDnurse/home.
The Department of Health - Information for Aged Care Providers newsletters
The Department of Health provides information and resources to the Aged Care industry via its online e-newsletters. You can view past issues and sign up
to their email campaigns online.
Advance Care Planning
Advance care planning (ACP) has been defined as:
"... a process enabling a patient to express wishes about his or her future health care in consultation with their health care providers, family members and other important people in their lives. Based on the ethical principle of patient autonomy and the legal doctrine of patient consent, advance care planning helps to ensure that the concept of consent is respected if the patient becomes incapable of participating in treatment decisions."
(Singer, Robertson, Roy 1996)
The advance care planning process can include:
- discussing and deciding future health and personal care choices
- discussing views, values and beliefs
- individuals documenting their choices and substitute decision-maker(s) in an advance health directive, enduring power of attorney or Statement of Choices
- medical officers documenting clinical recommendations regarding resuscitation
- providing copies of the documents to substitute decision-maker(s), carers, family, GP and any other healthcare providers as appropriate
- reviewing decisions
- updating legal documents.
As a part of the End of Life Strategy, Qld Health recognises the pivotal role of individuals being empowered to undertake Advance Care Planning and to make informed decisions about their own healthcare, and the role of all health professionals in the identification of patient needs and supporting the delivery of high-quality end-of-life care.
This will ensure that everyone is included in the efforts to improve care at the end of life for residents of the Gold Coast.
Advance Care Planning Australia
Advance Care Planning information for health and care workers
has online resources to assist health and care workers.
Topics on their website include:
Search for the nearest Gold Coast JP or Cdec
Justice of the Peace (JP) or Commissioner of Declarations (Cdec) Services
Justices of the peace (JPs) and commissioners for declarations (Cdecs) volunteer to serve the public by signing documents that need a qualified witness. Use this search to find a JP or Cdec at shopping centres, courts, and a variety of other locations, or search for an after-hours JP
JPs and Cdecs are trained Queenslanders who can witness and certify your routine legal documents.
Compulsory Reporting for RACFs
It is required by law (the Aged Care Act 1997
) that all residential aged care service providers report certain incidents to both the local police and the Australian Department of Health.
More information on how to make a report including links to forms and contacts can be found on the Queensland Government’s Website.
Caresearch Pallative Care Knowledge Network
Clinical Resources for Nurses - Nurses Hub
What is the Nurses Hub?
The Nurses Hub is a collection of information, tools and resources developed to form a ‘hub’ of knowledge. These pages will help to link the specialist and academic evidence base to the information and care needs of those nurses providing practical support to palliative patients in any setting of care.
As information is needed at different levels and nurses have different palliative care information needs at different times, a variety of information and resources have been provided. For example, all pages include links to relevant: GP pages; Clinical Practice pages; PubMed Topic Searches and CareSearch
Review Collection topics. All pages also link to content within the patients and families pages.
A certain level of nursing knowledge and experience is assumed, as the pages are not intended to teach nurses how to nurse, or specifically how to be a palliative care nurse.
The sections within the Nurses Hub cover the following areas:
Medical Care of Older Persons in residential aged care facilities (Silver Book)
Videos and Presentations
Related Links and Information
is a national online and phone service that provides practical information and resources to support carers. The interactive service finder helps carers connect to local support services.
Aged Care Resources and Links
Articles and Journals
QCAT Queensland Civil & Administrative Tribunal (EPOA reversal)
can make decisions about decision-making for adults with impaired capacity, including financial decisions administration
and personal and health decisions guardianship
. There focus is always the wellbeing, needs and interests of the adult.
Dementia Behavior Management Advisory Service (DBMAS)
provide tailored professional support for people caring for a person with dementia where a change in behavior impacts their care and quality of life.
Their role is to improve the quality of life of people living with dementia and their carers by understanding the causes of change in behavior in the person and to support care workers, carers and service providers. 24 hour helpline 1800 699 799
Continence Foundation of Australia
Resources for patients with continence issues.
Phone: 1800 33 00 66
is a national program providing education, resources and advisory services to support aged care staff and general practitioners in palliative care and advance care planning.
Organ and Tissue Donation
The below resources will provide legal information, details on how to register on the Australian Organ and Tissue Register and best practice guidelines for offering organ and tissue donation in Australia.