Aged Care Program

We are taking on an enhanced role in supporting the health and wellbeing of older Australians


Under the Aged Care Program 2021 – 2025, WAPHA will design, commissioning, and deliver nine new activities to support 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. We will continue to build relationships and hear from the WA aged care sector, general practitioners through the care of the older person specialist interest panel, community members and state government departments.

Through the PHN Aged Care Program initiatives, WAPHA 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 coordination, 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.

      Stay informed on the progression of the Aged Care Program by subscribing to one of our regular news updates. For questions or to provide feedback on the Aged Care Program, email us at

      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:

      Greater Choice for at Home Palliative Care (GCfAHPC) 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

      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 finder program

      WAPHA has commissioned care finder service organisations to form part of the national network of care finders who will support improved integration between the health, aged care and other systems at the local level. Visit our Service Directory to find a provider in your region.

      CoTA Australia were involved in the transition to the PHN led care finder program, 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.

      Who will this initiative support?

      The new service will support eligible vulnerable older people who would not be able to arrange services without intensive support and who do not have family members or friends who can help them with connecting to aged care services and support. The service is available to people 65 years or older (50 years for Aboriginal or Torres Strait Islander people or people) or 50 years or older (45 years or older for Aboriginal or Torres Strait Islander people) on a low income and homeless or at risk of being homeless who:

      • need intensive support to understand and access aged care services as well as to connect with any other supports they need, such as health, housing services, and social supports, and
      • could otherwise fall through the cracks due to isolation, communication or cognitive issues, or a history of past experiences with institutions or government.


      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. Through funding under the national Primary Health Network (PHN) Aged Care Program 2021-2025, WA Primary Health Alliance conducted a care finder program Needs Assessment for Perth North, Perth South and Country WA PHNs in July 2022 to inform an open tender request  and service specifications.  

      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

      Collaborating with Dementia Australia, WAPHA is working to identify and develop suitable digital and print dementia consumer resources for those living with dementia, their families and carers. By consulting with WA dementia advocates for the dementia consumer resources project, WAPHA sets out to achieve the shared aims of Dementia Australia to affirm the voice of people living with dementia, families and carers and improve community understanding of dementia through access to clear information. WAPHA will also leverage local relationships with WA organisations such as Alzheimer’s WA, ConnectGroups, Carers WA, local government and age friendly strategy supporters to accumulate feedback on the format consumers would like to receive information at the point of care from their GP.

      National Partnership Agreement (NPA) Project - End-of-Life and Palliative Care

      WAPHA is engaging with participating residential aged care facilities (RACFs) to establish and fund a dedicated clinical coordinator role within RACFs to liaise with GPs, co-ordinate case conferencing and engage GPs in RACF quality improvement.

      The intended outcomes of the project will be to:

      • Improve resident and family/carer access to primary care and quality end-of-life and palliative care
      • Improve coordination of primary care in RACFs
      • Manage residents’ end-of-life and palliative care health needs to include access to timely and appropriate medication
      • Implement systems and processes to support the sustainable delivery of primary care coordination for general practice and RACFs.

      The  RACFs funded for the project are expected to be announced early 2023 (grant opportunity available until June 2024, made possible through the WA Department of Health NPA Grant).  A summary of the 2021 GP consultation key themes: current interaction with palliative care, case conferencing, additional GP support and funding recommendations that informed the project is available here

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