Aged Care Program

WA Primary Health Alliance is taking on an enhanced role in supporting the health and wellbeing of older Australians


Under the Aged Care Program 2021 – 2025, WAPHA will undertake the design, commissioning, and delivery of new activities to support the wellbeing and access to primary care and aged care services for older Australians.

Funding under the Australian Government Aged Care Reform Package to Primary Health Networks (PHNs) is focused on initiatives with the overarching goal of delaying entry into Residential Aged Care Facilities (RACFs) and reducing avoidable hospitalisations for older Australians.

The Final Report: Royal Commission into Aged Care Quality and Safety identified several areas that affect aged care residents and our health system including limited access to general practitioners (GPs) and allied health professionals in aged care facilities, difficulties accessing out of hours services and unnecessary hospital transfers.

To help us understand the community needs, aged care system capacities and areas for investment, stakeholder consultations are taking place throughout 2022. Stakeholder engagement will leverage the strength of existing relationships, and the opportunity to build new ones by working with:

  • General practitioners
  • peak bodies
  • senior Australians, their families, friends and carers
  • Health Service Providers – Metropolitan (North, South, East) and Country WA
  • state government departments
  • aged care providers.

This simultaneous investment in primary health aged care is a once in a generation change; providing better health for older Australians through an integrated system-wide improvement to healthy ageing.

WA Primary Health Alliance (WAPHA), as the operator of the three PHNs in Western Australia, will improve outcomes for older Australians in the state by:

  • commissioning services for older people which address identified needs and gaps in our PHNs’ local primary health and aged care systems
  • enhancing access to general practitioners and other primary care providers
  • improving co-ordination, integration and continuity of care that contributes to improvements in the health and wellbeing of older people and promotes healthy ageing in place
  • supporting access to aged care services and other relevant supports in the community and building the capacity of health and aged care professionals to deliver high quality care.

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        October 2018

        The Royal Commission into Aged Care Quality and Safety

        May 2021

        Australian Government response to the Royal Commission: Aged Care Quality and Safety

        December 2021

        PHN Policy Guidance for Aged Care Funding Schedule released


        WAPHA Aged Care activities planning, development and consultation period

        June - July 2022

        Care Finders and Telehealth in RACFs needs assessments

        HealthPathways topics review in collaboration with GP Aged Care Panel

        August 2022

        Telehealth for residential aged care facilities implementation

        January 2023

        Care Finders Program

        Coming soon

        Targeted program schedule

        The Australian Government has provided Aged Care Funding Guidance and Dementia Guidance to support PHNs to design, commission and deliver these activities from late 2021 onwards:

        GP MBS Training -PHN Allied Health Aged Care COVID Response – COVID Allied Health Package GP Education

        From 10 December 2020 until 30 June 2022, temporary Medicare Benefits Schedule (MBS) items are available for care recipients in residential aged care facilities (RACFs) during the COVID-19 pandemic.
        The new items apply to RACF residents referred for allied health services under the following treatment, management or care plans:

        • Multidisciplinary Care Plans; OR
        • GP Management Plans; OR
        • Shared Care Plans; OR
        • Team Care Plans; AND/OR
        • Aboriginal and Torres Strait Islander Health Assessments.

        These temporary MBS items are applicable for non-admitted patients that reside in a RACF and cannot be claimed as part of hospital treatment. Further information is available at Practice Assist, where regular GP Webinar Series and recording for online training can be found for general practice.

        Greater Choice for at Home Palliative Care (GCfAHPC) Expansion

        Greater Choice for at Home Palliative Care Expansion

        The Greater Choice for At Home Palliative Care (GCfAHPC) measure aims to improve awareness of local palliative care options and improve coordination of care across the health, aged care, primary care and palliative care sectors.

        WAPHA has received funding from the Australian Government to develop and implement new and innovative projects, or expand and build on existing activities implemented through the 2017-18 GCfAHPC Great Southern pilot in Country WA PHN, to achieve the following objectives:

        • improve access to palliative care at home and support end-of-life care systems and services in primary health care and community care
        • enable the right care at the right time and in the right place to reduce unnecessary hospitalisation
        • generate and use data to support continuous improvement of services across sectors
        • use available technologies to support flexible and responsive palliative care at home, including in the after-hours.

        Who will GCfAHPC support?

        The initiative will support access to palliative care services for people approaching the end of their lives. GCfAHPC will increase patient and carer awareness of palliative care options, including Advanced Care Planning, to facilitate greater community interest in home care support.

        WAPHA will also work closely with general practitioners to meet primary care needs and education to increase awareness and access to safe palliative and end-of-life care. Scoping of service provisions and needs has commenced.


        In 2017-18, the Australian Government provided funding to 11 PHN trial sites to pilot the GCfAHPC measure, which included a pilot program in the Great Southern Region of Country WA PHN. The pilot focused on the implementation of Compassionate Communities, a community-based model to build palliative care awareness and capacity within the community. The successful outcomes of the GCfAHPC Great Southern pilot resulted in the City of Albany establishing a “Compassionate Communities” Charter.

        Resources developed during this pilot are available through Palliative Care WA for other Local Government Agencies (LGA’s) or community groups who are interested in developing a Compassionate Communities model. In the 2021-22 Budget, the Australian Government has expanded the GCfAHPC funding to all PHNs in Western Australia for four years to 2024-2025.

        RACF Telehealth - Support RACFs to increase use and availability of telehealth for aged care residents

        RACF Telehealth

        The Australian Government has provided funding to WAPHA to support Residential Aged Care Facilities (RACFs) with training and equipment to deliver telehealth consultations for residents.

        New telehealth packages will be introduced across the three PHNs through a needs assessment, with the activity expected to be implemented from late 2022.

        This initiative will:

        • provide timely access to specialist telehealth for older people receiving care in RACFs – further information about specialist video consultations under Medicare can be found here
        • equip RACFs with the necessary equipment and training for staff to support telehealth services
        • encourage a GP-led model of care.

        Who will this initiative support?

        Timely access to primary health care  professionals,  whether  through  face-to-face  consultation  or telehealth, is  recognised  as  an  issue  for  many  RACFs. This initiative will support RACFS to have access to adequate telehealth to support access to virtual consultations with GPs and other health professionals. This will also support people who are resident in RACFs to have improved access to telehealth consultations as appropriate to their needs.

        RACF Out of Hours- Enhanced out of hours support for residential aged care

        WAPHA will support RACFs to guide and implement after-hours plans and to educate staff on appropriate healthcare planning for residents who require after-hours care.

        WAPHA is engaging with RACFs and primary care to achieve the following objectives:

        • provide guidance to assist participating RACFs to have appropriate after-hours plans in place
        • educate participating RACF staff on the after-hours health care options and processes for residents
        • encourage participating RACFs to implement procedures for keeping residents’ digital medical records up to date, particularly following an episode where after-hours care was required
        • support engagement between RACFs and their residents’ GPs (and other relevant health professionals), as part of after-hours action plan development.

        Who will this initiative support?

        RACF residents can experience deterioration in their health during the after-hours period, but immediate transfer to hospital may not always be clinically necessary. Lack of awareness and utilisation of out of hours services provided by GPs and other health professionals may lead to unnecessary hospital presentations.

        Early Intervention- Commissioning early intervention initiatives to support healthy ageing and ongoing management of chronic conditions

        Some older Australians are entering aged care earlier than they may otherwise need to due to a lack of support for healthy ageing or ability to manage their chronic conditions in the community. WAPHA will lead the commissioning of early intervention services and models for chronic conditions management that support healthy ageing and reduce avoidable hospital admissions.

        Improving health outcomes for older Australian’s (particularly those at risk of poor outcomes) through early intervention programs will be guided by the following objectives:

        • expand existing healthy ageing programs where relevant
        • support older Australians to live in the community for longer (including those not currently receiving aged care services) through commissioning early intervention initiatives that promote healthy ageing, slow decline, and support the ongoing management of chronic conditions
        • increase awareness in the primary health care workforce of the needs of the population and the availability of these initiatives.

        Who will this initiative support?

        This measure will seek to support older adults (65 years and over for non-Aboriginal people and 50 years plus for Aboriginal people) who are living in the community with one or more diagnosed chronic conditions and would benefit from being better connected to psychosocial, health and welfare supports.

        Care Finders

        WAPHA is commissioning care finders to support improved integration between the health, aged care and other systems at the local level within the context of the care finder program.  CoTA Australia will support the transition to the PHN led Care Finder program to be implemented from January 2023, with knowledge sharing from the navigator trials across PHNs nationally.

        The care finder program forms part of a significant investment in aged care reform in response to the recommendations of the Royal Commission. PHN Commissioned care finders will provide specialist and intensive assistance to help people within the care finder target population to understand and access aged care and connect with other relevant supports in the community.

        Care finders will further support older Australians to interact with My Aged Care to find the aged care supports and other services they need. They will also provide client check-ins and follow ups periodically once services have commenced to check that the persons care plan continues to support their changing needs.

        Who will this initiative support?

        Care Finders is designed to provide intensive support for older Australians to access My Aged Care and community support into the future. The care finder service is aimed at helping people who:

        • Are vulnerable, isolated, homeless, disadvantaged or impaired;
        • Have dementia or mental health problems;
        • Are unlikely to seek aged care support without assistance from others
        • Have limited access to the internet or other technologies;
        • Live in rural or remote areas.


        In response to the Aged Care Royal Commission, the Australian Government committed $7 million through the 2021-22 Budget to extend the Aged Care System Navigator trial. The trials, delivered by COTA Australia and partner organisations, will continue until 31 December 2022 when the longer-term PHN led Care Finders Program and specialist navigation supports for Aboriginal and Torres Strait Islander people have both begun. See  Pillar 1 Commitment for further information. PHNs are required to commission current Assistance with Care and Housing (ACH) Providers as Care Finders organisations from January 2023 onwards.

        Aged Care Clinical Referral HealthPathways

        WAPHA will work to increase the awareness, engagement, and utilisation of aged care Clinical Referral HealthPathways by local health care practitioners (including GPs, allied health and practice staff) and engage local clinical practitioners, and experts in their development.

        WAPHA will review currents pathways, identify gaps and renew Clinical Referral HealthPathways topics, health services and assessments for inclusion in localised clinical pathway guidance fit for the care of older Australians.

        WAPHA is currently reviewing the Aged Care Clinical Referral HealthPathways guided by the PHN Aged Care Activity Expansion 2020-2021

        Who will this initiative support?

        The WAPHA Clinical Referral Pathways are designed to be used at the point of care, primarily by GPs but is also available to hospital specialists, nurses, and other health professionals.

        Dementia Clinical Referral HealthPathways

        In February 2022, WAPHA received new Dementia Guidance, including specific information on Dementia Clinical Referral HealthPathways. The commitment by WAPHA will be to progressively update existing and implement new Dementia specific Clinical Referral HealthPathways from 1 July 2022.

        Who will this initiative support?

        The WAPHA Dementia Clinical Referral HealthPathways are designed to be used at the point of care, primarily by GPs but is also available to hospital specialists, nurses, and other health professionals.

        Dementia Consumer Pathway Resources

        The PHN Dementia Guidance document outlines the requirements for both the Dementia Clinical Referral Pathways and Dementia Consumer Pathway Resources.

        WAPHA will work closely with Dementia Australia to identify and develop suitable digital and print resources for those living with dementia, their families and carers.

        Current clinical tools and resources can be found on the Dementia Australia website, including the Building Dementia Practice in Primary Care Practice Guide.

        National Partnership Agreement (NPA) Project - WA Department of Health funded

        More information coming soon

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