Leanne Wells (Facilitator)
Welcome to the second discussion in the General Practice in Aged Care Incentive series on how the incentive can better enable joint working and team-based care for the benefit of people living in residential aged care homes.
This discussion drills down into the principles of effective teamwork in a residential aged care context. Panellists consider the roles and responsibilities of various team members within the primary care team, opportunities for strengthening team collaboration and integration across general practice and aged care services for the benefit of people who live in residential aged care homes.
Let's start with some perspectives on what's different, how the General Practice in Aged Care Incentive strengthens team-based care.
Anthony Marrinuci (GP)
So I think, ahh, the first thing to realise when answering this question is the fact that, umm ah, care of people living in residential aged care homes is complex, it’s very complex by definition, umm, they are often multi-morbid, they have many different pre-existing medical conditions and therefore their care needs are complex.
Umm, so to deliver appropriate care plans for these people, we, by definition, need input from many different practitioners, not just medical. Umm, and further to that, I think we all know that when all of this whole bunch of different practitioners are talking to each other, the care outcomes are improved.
[Clears throat] So I think the major, the main concept here of what the incentive is trying to do, is remunerate practitioners, practices in order to be able to establish those good, strong lines of communication between different practitioners in order to create that multipli, multidisciplinary care plan, which is the ideal that we all think about.
Karen Booth (Nurse)
Building on what Anthony said, I think the more set of eyes on a person, the wider the view, the wider the opinions, the different perspectives help to build a bigger picture of care for that person. I think teamwork helps also to build relationships with the patient, with their family, much better support for the very stretched, umm, care services in aged care facilities. So how do we support them?
So, I think the abil, the ability to share ideas and knowledge, and ahh, of what might be best for that person, then to help organise the right care. Now the right care might be the GP at the time. The right care might be, ahh, some intervention by the pharmacist to review the medications. I think making sure teamwork is big picture thinking. We're looking at, you know, how we come at it from different angles, how we best support the person and then, umm, and then look at making them comfortable.
Ann Davies (Consumer)
I think it's very important in aged care, ahh, to have, ahh, team-based care. It's always been there. It's the way they operate in aged care. But I think that, ahh, it's got to be holistic and it, it's got to outline best practice. And the team approach involving, ahh, professionals can create a sense of unity, because they all have a different background of knowledge, and ability, and that increases the work quality.
It also means a sharing of goals with effectiveness in mind. And there's less stress, there's a shared responsibility and accountability and, ahh, shared problem-solving skills.
Leanne Wells (Facilitator)
What I'm hearing is that there is a consensus across the GP and practice team and consumers on what high quality primary care means for people living in residential aged care homes.
I'm now interested in how the General Practice in Aged Care Incentive enables better team-based care, both within general practice and better team collaboration and integration across general practices and residential aged care services.
Let's start with a GP perspective.
Paresh Dawda (GP)
The role and responsibility of the GP under the incentive is to be the responsible provider. Ahmm, it's one of the requirements of the incentive. What that, for me, what that means is the clinical governance, umm, sits with, umm, the general practitioner who’s the responsible provider. Ahmm, that general practitioner, umm, will be supported by the team, umm, involved in the proactive, umm, approach to the care of that person around whatever you know, is, is important to them and, and what their, their goals are.
So, I think the role of the responsibility is first and foremost, umm you know, being accessible and available and consulting with, ahmm, with, with, with that patient. Ahmm, being there to support the other members of the team where and when that's happening.
So, I, I think, umm, that's the role of, of the GP. I kind of see this as being, and imagine an orchestra and you have the conductor, and I imagine the general practitioner as being the conductor of the orchestra in this team.
Anthony Marrinuci (GP)
So, I like to, look I, I sort of mirror Paresh's sentiments, that I think definitely the, the GP should be one of the clinical leaders of, of the MDT. Umm, I like to think of it, maybe even a little bit more broadly, that the, the sort of the primary medical care team. And that's what the incentive looks to do in the sense of it allows the, the regular GP, also, other health practitioners in the, in the, in the, ahmm, in the practice to, sort of umm, be part of that care team too.
So for me I, I, I look at three really key important variables of what, umm, the GP can bring. Umm, one is, umm, good communication, the other is support and the third is education. I really think of those three sort of variables, umm, to empower the care team, umm, and with all, within those three you have other variables, like availability, et cetera, et cetera.
But if, if your availability is not backed up by excellent communication, good support, and, you know, carry on education to the rest of the care team, I think it is where it falls flat.
So, I think the, the, what an excellent multidisciplinary care team looks like is having all of those variables there, led by good clinical governance from the primary medical care team. Umm, and ahh, ahh, ultimately, that's what's going to end up with those really, really good patient outcomes.
Ann Davies (Consumer)
I think, erm, incentive GPs need to be encouraged to take an explicit role in leadership in team-based care, with the focus on quality, assurance and improvements in addition to the clinical care.
Leanne Wells (Facilitator)
Thinking about what we've heard about the role and responsibility of the GP under the incentive, what's the role of nursing in the context of a multidisciplinary aged care team?
Karen Booth (Nurse)
There's lots of people in the care team, and so it's not just GP care. Lots of patients come in and they think they're not getting care if they don’t see the GP. But letting people know that actually we're all connected. We're in the team. So, anything I do with you today the GP will also know about because we use the same record, we're in the same team, we talk to each other. And I think the better involvement through this incentive with aged care and collaboration, being part of the care plan, ahmm, builds a better understanding of how each team works.
And I think it also will build confidence for the aged care team as well, actually, the general practice team’s got your back, we're back up for you. And, umm, and you'll have that connection, you'll know who to contact, you know where to get support. So I think they're all positives coming out of, out of the incentive.
Being able to, umm, be part of the team, doing some, umm, hands on care, not quite as hands on as the, the, the team in the aged care facility, but to be able to be, ah, to participate in things like the health assessments, to help to organise medication reviews, to follow up results and help gather that information ready for, umm, ready for the GP then to move straight into that higher level decision making, and change of treatment, change of therapies, I think it's really important.
It's much more time efficient, I think, umm, as part of the team, for the nurse to do some of those things and, ahh, and that way the GP can still continue seeing acute patients as well as then have more time to actually review and reflect on the care that needs to be given. Not just to one person, but you know we're talking about population health activities in aged care as well - that the nurses can help to organise some of those activities in, in aged care, for the GP. To look at how you link other team members together, making sure again you've got everyone's reports in so that you can, if needed to, you can case conference, you can liaise with family members.
So I think they're all the main support roles that nurses would, would do to support GPs, umm, in aged care.
Leanne Wells (Facilitator)
Sophie, I'm keen to understand the role of the practice team in supporting the GP and the broader care team in fulfilling their roles.
Sophie Piron (Practice Manager)
I think it's really important from a practice point of view, that the residents of the aged care facility that a GP is visiting, are seen as patients of that practice. So, they're not seen as, you know, something that, that's a bit of a side hustle for that GP, but they are, as with every other patient, patients of that practice. Umm, I think that sets the scene for, umm, a really positive interaction when, umm, either the aged care facility is calling the practice, umm, needing to contact that GP or contact a practice nurse, umm, it sets the scene for a really positive interaction when family members might be contacting the practice, umm, because you know, as I've said, fundamentally they are a, a patient of the practice and, and things can move from there in, in, in a really positive way.
From, from, from our point of view as a practice, umm, I guess, umm, in relation to the General Practice in Aged Care Incentive, umm, our role is to make sure that, umm, from an administrative point of view, all the boxes are ticked. That, umm, you know, we, that the patients are, are registered with the practice for MyMedicare, that they are regis, that we are registered for the incentive, that the, that the providers are allocated, umm, to those patients, umm, that, you know, the patients got the tick, tick box for, umm, the General Practice in Aged Care Incentive.
Umm, and then we also have a really strong role in, in making sure that, umm, on a quarterly, annual basis all of the requirements of that incentive are met, umm because we're putting the work in, you know, so it's really important that we don't just miss out, umm, because of a, a small timing error or administrative error. So, the general practice has a really strong role to play.
I think also, umm, it's really important for the general practice, umm, to have a relationship with the aged care facility so that from a management point of view that the manager of that facility can ring me and, umm, and we can just troubleshoot some issues that, that we might be having. And for us that often happens when the general practitioner is away. Umm, in the same way that when a, a general practitioner on site is going on leave we need to make sure that we've got steps in place that we know who's going to be taking on those visits. That, in fact, we have a plan so that there are, as we've talked before, that there is always more than one person who has a relationship with those patients and, and is able to step in and provide that continuity of care in a, in a reasonably seamless way.
Laila Hallam (Consumer)
Umm, I think that whole team-based thinking is actually, umm, it will be a different way of thinking about how services are provided in aged care. And I think the comment that was made earlier about a GP being a facilitator, I think it gives it a lot more resonance.
So it allows, umm, a lot, a lot of other things that previously probably didn't get touched on, things like depression, things like, you know, hip pain, things like a whole lot of things that otherwise we just assume it's just part of being old.
I think, umm, the team-based approach gives the, umm, GP an opportunity to think more broadly about the services that are being provided. And I think that's a big win for the patients.
Leanne Wells (Facilitator)
As a representative of the peak body for private and public aged care providers, Andrew, how can staff within the residential aged care home engage with a multidisciplinary team-based care approach? Be they nurses, lifestyle coordinators or administrators?
Andrew Hayward (Aged & Community Care Providers)
Ahh, I think it's really important that we build a culture of respect, err, and that person-centred, or person-driven care, umm, is actually enhanced through the represent, reputation of the aged care providers and, and aged care services.
I think, umm, the role from the, ahmm, residential aged care teams, ahh, are one of, umm, offering that direct care support, daily activities, ahh, and then looking at, umm, how they become the bridge, so the conduit between the resident and the GP, and, and the GP practice. So, and that's enhancing and, and ensuring there's access, ahh, and, umm, making sure that, umm, the residents are aware of the GP services, ahmm, and umm, and that the GP is aware of the resident’s health needs as well. And, and it's really facilitating the access to, ahh, from the GP to the resident, ahh, and then working as a team to ensure that, umm, whatever they need is, umm, is being provided.
Umm, so, I think that liaison, sort of acting as a bridge um between residents, families and healthcare providers is really important. Ahh, and then managing, so facilitating operational support, umm and umm, enabling that team collaboration, ahh, and communication.
Ahh again, I think we can’t bang on too much about relationships. It's relationship, relationship, relationship.
Leanne Wells (Facilitator)
Ann and Laila, the main game here is clearly about consumers and carers. You've heard the views of the care team, how can people living in residential aged care homes, their families and their carers be better recognised and supported to be part of the team to ensure they receive person-driven and high quality primary care enabled by this new incentive?
Ann Davies (Consumer)
I think this is very important, that at all times the willingness, or the unwillingness, of the consumer to participate must be respected.
It must be recognised, and it really isn't, that today the majority of consumers are admitted to residential aged care facilities with an average age of 85, 86, and with the diagnosis of dementia and/or debilitating serious illness.
So basically, and maybe in the majority of times, they cannot be, ahh, part of the team. And of course, then the, the representatives take over in that case. However, umm, they are welcomed, enabled, encouraged to be involved as much as possible.
Laila Hallam (Consumer)
I have to, umm, reinforce what Ann said.
I think, from a resident perspective, I think they should always be the locus of control. I think regardless, whether they have dementia or anything else, the relationship is always with the, with the, resident. And I think that's really important because what we don't want to do is further disempower people.
Umm, but what I will say is, with regards to family members, I think they have such a critical role to play in also supporting the resident be that locus of control. Umm, often it’s the family members who can support the enablement of residents to participate. They may not be able to necessarily make decisions, but they can certainly participate. And I think having the family as core, as core, to the team, I think you know when I think about team-based care, I can only think that family and residents are part of that team. So even though within the incentive we're talking specifically about, umm, the general practice I think that, umm, if we go down the mindset of understanding that the residents and the, and their families are actually part of that team, they will do enormously more work together than they will be able to do separately. That also goes to, building that level of trust and relationship that enables that communication to flow.
Leanne Wells (Facilitator)
Kate, given what you've heard, I'm now keen to understand how the Primary Health Network, as the ‘system enabler’, can work with consumers and carers, GPs, practices and aged care staff to enhance team-based care, within general practice and across primary care/residential aged care interfaces, and strengthen the system so that patients receive person-driven, proactive, planned and coordinated care enabled by the General Practice in Aged Care Incentive.
Kate Tye (PHN)
Thanks, Leanne. Umm, that's a really good question. And I think, umm, one of the foundations of team-based care is having an understanding of the environment in which you're working, and which that team's working.
So, one of the key roles of Primary Health Networks is helping, umm, general practice and GPs to understand, umm, what, how aged care works and how the aged care home operates broadly. And then helping them to also understand the nuances and the variability across each of those aged care homes.
And the way that we do that is that we, umm, facilitate and connect between the general practice and the GP and the aged care home and help them to be able to commence that relationship.
As part of that process, umm, we assist them to, umm, to go through a bit of an orientation process, umm, to help the GP and the general practice team, as a whole, to understand the, umm, team that actually is within that particular aged care home. What resources are there? Where do they find equipment? How do they access, umm, medical records? What does that look like? Are they digitally enabled? So, all those key enablers that sit underneath and support, umm, the team to work and to actually function.
So, one of the key roles that PHN's play is that connector role. And also that education role, and making sure that there's an opportunity for that relationship between the general practice and the GP and that home to be facilitated.
Leanne Wells (Facilitator)
Presumably that includes working with allied health, such as pharmacy, physiotherapy and psychologists, to name a few.
Kate Tye (PHN)
Yes, absolutely Leanne and that's really critical, umm, in being able to understand what that looks like as well. And in some cases, PHNs fund some of those roles within residential aged care as well. And so being able to connect up those players and who those, who those team members are, and, umm, and making sure that they're part of that conversation.
The other core component as well, umm, is case conferencing, and we've mentioned that a little bit this afternoon. Umm, case conferencing is a mechanism that enables teams to come together with the patient, with their loved ones, to be able to have conversations around their goals. And it's critical that the aged care home team as well as the general practice team are all involved in those conversations and that it's very clear around how each are going to work, umm, to support that patient’s goals and hear particularly from the patient and what they actually want.
Leanne Wells (Facilitator)
This brings us to the close of our second session on the General Practice in Aged Care Incentives series. I'm sure you'll agree our panellists have left us with many valuable takeaway messages about what good team-based primary care looks like in the residential aged care home setting.
Key standouts included -
- The centrality of consumers and their family and carers as active partners in care, and the contribution they can make to personal goal setting and decision making. Their presence needs to be considered and planned for in all GP and te, team care visits.
- The benefits that arise from proactive, quality focused, team-based care and opportunities to enhance joint working between GPs, general practice and aged care providers.
- The critical role of the GP as care team lead stood out. As Paresh said, their job is to serve as the ‘conductor of the orchestra’.
- And finally, the importance of a culture of mutual respect among primary and aged care providers.
Clearly, collaboration can't be left to chance. It is stronger when enabled through good communication, multidisciplinary education, and systems such as shared clinical records.
Join us in our third discussion where our expert panellists will consider how the General Practice in Aged Care Incentive can be implemented in a way that works for diverse care team arrangements and regional settings.