Principles

Twelve core principles underpin the Improving care for older people policy. These principles form the basis of practices and processes that address the fundamental issues for Victorian Health Services in providing care for older people.

Principle 1: Specific care issues for older people

Health Services apply practice based on best evidence to the care of older people, including specific attention to the risk of malnutrition, decreased functional mobility, loss of skin integrity, incontinence, falls, the development of delirium, problems with medication, poor self-care and depression.

Key objective

1.1 That older people under the care of Health Services receive care that is based on best evidence.

Principle 2: Clinical governance responsibility

Health Services take clinical governance responsibility for the care of older people.

Key objective

2.1 That Health Services give specific attention to clinical effectiveness, risk management, education and training, and consumer participation in the care of older people.

Principle 3: Involving older people and carers

Treatment and care provided by Health Services places the person at the centre of their own care and considers the needs of the older person’s carers.

Key objectives

3.1 That older people and, where appropriate, their carers, are actively engaged in care planning processes.
3.2 That older people and their carers are given the opportunity to provide feedback that is used for quality improvement purposes.

Principle 4: Identifying people with additional care needs

Health Services identify older people at risk of adverse health outcomes and/or having existing or potential supportive care requirements.

Key objective

4.1 That the validated Risk Screening Tool be used to screen every person presenting to a Health Service.

Principle 5: Assessing care needs

Treatment and care provided for older people with a positive risk screen includes the completion of a comprehensive assessment.

Key objectives

5.1 That every person over 70 years of age who is identified by the screen as at risk of adverse health outcomes and/or having existing or potential supportive care requirements has a comprehensive assessment, including identification of carer needs.
5.2 That Health Services take an interdisciplinary approach in assessing the care of older people.

Principle 6: Planning care

Treatment and care provided for older people includes interdisciplinary care planning that is founded on evidence-based care pathways.

Key objectives

6.1 That Health Services use evidence-based care pathways for major clinical conditions.
6.2 That a coordinated care plan is developed for all people whose risk screen has identified existing and potential supportive care and transition issues.
6.3 That older people who have undergone a comprehensive assessment will have an interdisciplinary care plan developed. This care plan will be based on the person’s and, where appropriate, their carer’s goals and bridge the person’s transition from hospital to the community.
6.4 That older people participate in their care planning as part of an interdisciplinary team. The person’s general practitioner, existing ongoing community support provider and carers are included in the interdisciplinary team.
6.5 That care planning includes discussion with the older person and their carers regarding their future care and palliation wishes.

Principle 7: Transition planning and coordination of care

Treatment and care provided for older people is coordinated to achieve integrated care across all settings.

Key objectives

7.1 That people assessed as having complex care needs have a single person coordinate their care by working with them and their carers.
7.2 That care coordination for older people is provided in both the hospital and the community to facilitate the older person’s return to their usual residence, with ongoing support as required.

Principle 8: Hospital inpatient care

Older people receive treatment and care in the setting that best meets their needs and preferences where it is safe and cost effective to do so.

Key objectives

8.1 That older people receive appropriate care in the appropriate setting.
8.2 That the hospital setting provides appropriate physical, social and environmental features to meet the special needs of older people.

Principle 9: Health Service community-based programs

Health Services integrate their community-based programs to provide the appropriate treatment, therapy and supportive care to meet the needs of older people.

Key objectives

9.1 That community rehabilitation centres accommodate an expanded role as providers of integrated sub-acute community-based services.
9.2 That community-based programs provided by Health Services are integrated to provide appropriate treatment, therapy and supportive care, with a single entry point and referral system.

Principle 10: Relationships between Health Services and ongoing community support services

Robust protocols and agreements developed between Health Services and ongoing community support providers ensure that older people continue to receive the care they require in a coordinated and integrated manner.

Key objectives

10.1 That older people experience integrated care (and case management where required) through coordination between Health Services and ongoing community support providers.

10.2 That Health Services arrange supportive care services, where required, for a maximum of 28 days to enable the person to return home. (There may be exceptions and a degree of flexibility needs to be maintained to ensure that a person receives the level of care they require).
10.3 That post-discharge, ongoing community support providers continue to provide up to the level of service that the person received prior to their hospital episode. Health Services will facilitate this by notifying providers when a client of theirs has been admitted and indicating a likely discharge date.
10.4 That Health Services ensure their time-limited supportive care programs have similar processes and protocols to ongoing community support providers to enable the older person and their carer to move smoothly between providers.
10.5 That Health Services participate in the service coordination work of their local Primary Care Partnership.

Principle 11: Older people awaiting long-term care options

An adequate level of support for people awaiting long-term care options is provided in the setting that best meets their needs.

Key objectives

11.1 That people who have been assessed in hospital as requiring residential aged care continue to receive appropriate care from Health Services.
11.2 That Health Services assist people and their families to obtain timely access to long-term care.

Principle 12: Promoting health independence

All people across Victoria have access to Centres Promoting Health Independence.

Key objectives

12.1 That existing extended care centres and some major sub-acute facilities are refocused into Centres Promoting Health Independence, with at least one designated centre in each departmental region.
12.2 That Centres Promoting Health Independence:

• provide a significant sub-acute inpatient service, with the size dependent on the catchment population
• provide or facilitate access to a range of sub-acute community-based services to enable people living in regional and remote areas to access clinical expertise, including centre-based and home-based services, cognitive, dementia and memory services, continence clinics, falls and mobility clinics and mobile outreach services
• are a focus for the development of statewide specialist services that provide health care professionals with additional skill levels and access to a wider support network for the management of people with complex needs
• where possible, co-locate with Aged Care Assessment Service (ACAS), aged psychiatric and mental health services and community support programs (such as community aged care packages) to provide a recognisable facility that supports people, particularly older people, to remain in their community
• provide access to a hydrotherapy pool
• are a recognised point of access (from the community or from acute services) to services for the prevention, treatment and management of disabling conditions
• are outward-focused community resources that provide information, services and facilities to older people and people with a disability