ISBAR Training 

Effective clinical handover of Residents in Aged Care Facilities 

Research shows that using a standardised format assists the transfer of information for Residents in Aged Care Facilities and improves patient outcomes. ISBAR (Introduction – Situation - Background – Assessment - Recommendation) organises a conversation into the essential elements for transferring information from one source to another.

Western NSW PHN is providing ISBAR training to the 74 residential aged care facilities  and Multipurpose Facilities across the region, covering 3098 aged care beds.

The Program launched on 5 February 2018 in various Residential Aged Care Facilities and Multi-Purpose Services in the Far West and Western Local Health Districts. As at May 2018, over 300 staff have already been certified.

The Aged Care Channel’s (now re-branded as Altura Learning) Bridge Learning Management System is being used to deliver and manage the online ISBAR training module. The courses align to the Australian Aged Care Quality Agency’s 4 standards and 44 outcomes.

For more information please download the RACF ISBAR Framework Document.

Contact: Rekha Pillai, Aged Care Programs Coordinator: or (08) 8005 8364.

Aged Care Resources for Health Professionals 

The Aged Care resources contained in the below drop-down menu are available to assist health professionals with accessing services, current evidence-based information or best practice guidelines to support patients in Aged Care.

Email & Specialist Advice Services

Aged Care 

My Aged Care - Information for Service Providers to navigate and improve access to information 

Far West Local Health District – Supportive and Specialist Aged Care Service

Western NSW Local Health District - Supportive and Specialist Aged Care Service

Specialist  Community  Aged Care Team

Contact No.

Specialist  Community  Aged Care Team

Contact No.

Supportive and Specialist Aged Care Service

Broken Hill Health Service

Far West Local Health District

176 Thomas Street, Broken Hill New South Wales 2880

(08) 80801656

Western NSW Aged Care Service

2 Morrissey Way

PO Box 103

Parkes NSW 2870

(02) 6861 2555

Aged Care Consultation Liaison Service

Aged Care Consultation Liaison Service

Aged Care Consultation Service

Broken Hill Health Service

Far West Local Health District

176 Thomas Street, Broken Hill New South Wales 2880

(08) 80801656

Western NSW Aged Care Service

2 Morrissey Way

PO Box 103

Parkes NSW 2870

(02) 6861 2555

Aged Care Quick Reference Guide
Resources for Health Service Professionals

ACAT Age Care Assessment Team 

Advance Care Directives

An Advance Care Directive (ACD) is a statement,  written in advance, setting out what medical treatment  you want or do not want if you are not able to communicate  because of illness or injury.  It is sometimes called a "Living Will".  It is not used as a substitute for your decisions  at the time of medical treatment  if you can communicate your own wishes.

Using Advance Care Directives,

Advance Care Planning (ACP) – General Practice Resources 

Advance Care Planning (ACP) supports people’s preferences  for future healthcare  being known and respected if they can no longer communicate  their wishes.  The following resources are designed to assist general practitioners  and practice nurses in implementing advance care planning into general practice. 

For further information  regarding  Advance Care Planning in general practice, a telephone based advice service has been established to enable delivery of advisory services to general practitioners  and aged care staff in all areas of Australia, 24 hours per day, 7 days a week via national

Phone : 1300 668 908

Advance care planning advice Mon-Fri 9am-5pm AEST Palliative care advice 24/7 

Allied Health 731 Form

Referral Form for Individual Allied Health Services under Medicare for patients with a chronic medical conditions  and complex care needs. 

Clinical Guidelines

Continence Foundation of Australia Resources

For patients with continence issues. National Continence Helpline

Phone: 1800 33 00 66

Decision Assist Tool

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. 

Dementia Behaviour Management Advisory Service (DBMAS)

The DBMAS provide tailored professional support for people caring for a person with dementia where a change in behaviour impacts. 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 

Drivers Licence Information

See Rehab on Road website.

Drivers Licence cancelation for the elderly: 

Dying To Talk – Discussion Starter Kit

Download the discussion starter

GP RACF work arrangements form Page 81

Palliaged Palliative Care in Age Care 

palliAGEDgp  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. 

palliAGEDgp is now available for free download from iTunes and PlayTM online app stores. 

Apple iTunes App Store 

Play Store for AndroidTM 

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 at: 

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 at: How to create a desktop shortcut for palliAGEDgp 


Medical care of older persons in residential  aged care facilities (Silver Book)

Medicare Benefits Schedule MBS 

Mental Health for the older person -  Resources

beyondblue  works to improve the mental health of older Australians  by raising awareness  of depression, anxiety and suicide, and overcoming  barriers to care within the needs of an ageing population. 

Black Dog Institute fact Sheet: Depression in older people


My Aged Care, established by the Australian Government, can help you find information about aged care services and what you need to do to receive them:

GP Referral  - 

NCAT NSW Civil & Administrative Tribunal (EPOA)

NCAT can appoint a guardian under the Guardianship Act 1987 for a person with a decision making disability.  

VR GP Med Items & NON VR GP Med Items  

Staying Active, myMoves for Seniors and NSW Falls Prevention Network

Following links can be accessed by older adults to access physical activity programs and falls prevention information to assist them.

myMoves for Seniors

myMoves Program for Seniors Flyer

NSW Falls Prevention Network

The NSW Falls Prevention Network activities are part of the implementation of the NSW Falls Prevention Policy funded by the NSW Ministry of Health.

Patient 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 & Contact details
Have you heard of ACAT? - 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: 

  1. any support you are currently receiving
  2. if you have any health concerns
  3. how you are managing with activities around the home
  4. some questions relating to your safety in the home. 

The My Aged Care website provides you with information about: 

  1. the different types of aged care services
  2. eligibility for services
  3. 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
  4. the cost of your aged care services, including fee estimators.

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.

Telephone:    1800 200 422

Hours:    Mon-Fri 8am–8pm   Sat 10am-2pm 

Here is a list of the information provided on the website to assist your individual needs:

Personal stories give examples of others experiences to share:

Carers need support and this information assists their needs:

Assistance with staying in your home:

Help in your home:  

Eligibility and assessment:

How assessment works:

Information for people that identify as Indigenous or Torres Strait Islander:

Information for older people from a culturally and linguistically diverse (CALD) background:

Information for Veterans:  

Information for older people living with a disability:

Information for older people that are financially disadvantaged:

A ‘Care-Leaver’ is an adult who spent time in care as a child (that is, under the age of 18). This care could have been foster care, residential care (mainly children’s homes) or another arrangement outside the immediate or extended family. The care could have been provided directly by the state through a court order or voluntarily or by the private sector.

Information for older people of a diverse sexual orientation:

Information for people facing unstable housing arrangements or homelessness:

Rural and regional Service delivery: 

Staying in your own home – Home Care Packages 

Do you want general information about home care packages, hae had an assessment and want to access home care packages or already have a home care package and want to manage or change services? Please check all related information on MyAgedCare: 

Discussion Starter Tool Kit

This document 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. 

Advance Care Planning

Advance care planning is a process of planning for future health and personal care. The person's values, beliefs and preferences are made known so they can guide decision-making  at a future time when that person cannot make or communicate his or her decisions. Have the discussion with your family/carer and your GP to assist in understanding of the document. 

Advance care planning is usually undertaken within a health or aged care setting and with the assistance of trained professionals after an individual has been diagnosed with a life-limiting condition. It requires respect for the individual and their autonomy. 

The advance care planning process can include:

  1. discussing and deciding future health and personal care choices
  2. discussing views, values and beliefs
  3. individuals documenting their choices and substitute decision-maker(s)  in an advance health directive, enduring power of attorney or Statement of Choices
  4. medical officers documenting clinical recommendations  regarding resuscitation
  5. providing copies of the documents to substitute decision-maker(s),  carers, family, GP and any other healthcare providers as appropriate
  6. reviewing decisions
  7. updating legal documents 

NSW Aged Care Services

Aged Care Service Providers 

End of Life Law in Australia

End of Life Law in Australia provides accurate, practical and relevant information to assist you in navigating the challenging legal issues that can arise with end of life decision-making. 

Their website is an initiative of the Australian Centre for Health Law Research. It is designed to be used by patients, families, health and legal practitioners, the media, policymakers and the broader community to access information about Australian laws relating to death, dying and decision-making  at the end of life. These laws are very complex, particularly in Australia where the law differs between States and Territories, and where areas of uncertainty about the law exist. This website provides you with a broad introduction to these laws. It can also help you stay up to date with Recent Developments in the end of life area.

End of Life Law in Australia 

Phone: 3138 5345 -Telephone Helpline

Opening Hours

Service available 24 hours a day 365 days a year 

Target Groups Healthcare  Professionals Parents / Families, Elderly, GP's 

000' Emergency Service

000' is an emergency hotline service to contact the police, fire or ambulance in life threatening or urgent situations. '000' calls are answered by a Telstra Operator who will ask which service you are after. 

Phone: 000 -Telephone  Helpline

Opening Hours

Service available 24 hours a day 365 days a year 

Note on public holiday hours: We are open as normal

Fees & Charges

Free services 

Asthma Australia 

As part of the Community Support Program, Asthma Australia is offering health professionals the opportunity to refer patients with asthma, or their carers, to their local Asthma Foundation for Helpline asthma education, resources and support. 

Following referral your local Asthma Foundation will phone your patient, or their carer, to discuss their asthma. The call will be tailored to each individual and may include topics such as: 

What is asthma?

  • Signs and symptoms
  • Checking their Asthma Control Score* Goal setting to improve asthma control
  • Asthma medications and how they work, and how to use devices
  • Asthma action plans
  • How to tell if your asthma is worsening and Asthma First Aid 

*The Asthma Control Test™ a validated self-assessment  tool that determines level of asthma control. By answering five simple questions, your patient will be provided with their Asthma Score. This can be used to discuss asthma management and strategies to improve asthma control. 

After the initial phone call, your patient will be offered the opportunity  to be contacted six weeks post education. 

The purpose of the follow-up call is to provide further education, check whether agreed recommendations  were acted upon and revisit their Asthma Control Score. 

At follow-up, six weeks after the initial intervention, nearly two-thirds of patients showed an improvement in asthma control with an average improvement of 5.5 in their Asthma Control Test Score. 

Upon completion of the initial phone call, an Asthma Education Summary will be sent to you for inclusion in your patient’s medical record. This documents recommendations,  Asthma Control Score and education provided to your patient. 

A referral form has been developed for this service, which can be returned to your local Asthma Foundation via fax or email. A Patient Information Sheet has also been developed which informs patients about the service, and what they will receive.

Phone: 1800 278 462 -Telephone Helpline

Opening Hours

Monday 9:00am - 5:00pm
Tuesday 9:00am - 5:00pm
Wednesday  9:00am - 5:00pm
Thursday 9:00am - 5:00pm
Friday 9:00am - 5:00pm
Saturday -
Sunday - 

Notes on public holiday hours: We are closed on public holidays 

Contact Details 

Target Groups: Chronic Disease General Public 

View our Website

View our Facebook  page 

Aged Care Complaints 

Aged Care Complaints  Commissioner Website 

Free Call 1800 550 552 

The Aged Care Complaints  Commissioner provides a free service for anyone to raise their concerns about the quality of care or services being delivered to people receiving aged care services subsidised  by the Australian Government. 

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. 

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:

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 includes: 

  • 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. 

Rights & Responsibilities – Home Care 

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. 

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:

  1. let your service provider know about your concerns
  2. make a complaint  to the Aged Care Complaints Commissioner (Complaints Commissioner). 

How to make a complaint via my aged care: 

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 & Healthy 

Active and Healthy is expanding  to include a broader range of physical activity programs and information  on the benefits of physical activity for people aged 50 years and older.  For more information,  please visit:

Residential Aged Care Facilities (RACF)

Dubbo Residential Aged Care Facilities Folder 

This Aged Care Folder is a clinical support tool for Residential Aged Care Facilities and General Practices located in Dubbo.

DBMAS NSW Dementia Behaviour Management Advisory Services

Phone 1800 699 799

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 Care planning, case conferences and short term case 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. 


palliAGEDnurse now 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 retrieved. An online-offline capacity means they can use the app anywhere in Australia. As the app is web-based,  it can be updated as new evidence and resources are released. palliAGEDnurse is free to download.

For those nurses 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 palliAGEDnurse content online through your web browser at: 

A desktop shortcut can be created using Internet Explorer which will display the palliAGEDnurse icon on your desktop, this will give the appearance  of the app whilst providing rapid access to web version of palliAGEDnurse. 

The Palliative Approach Toolkit is a comprehensive, step-by-step  guide to implementing  a palliative approach in residential aged care facilities (RACFs). 

The PA Toolkit includes policies and procedures  and education for staff, as well as resources for friends and relatives of residents in RACFs.

Mental Health for the Older Person 

beyondblue  works to improve the mental health of older Australians  by raising awareness  of depression, anxiety and suicide, and overcoming  barriers to care within the needs of an ageing population. 

Black Dog Institute fact Sheet: Depression in older people 

Telehealth in Residential Aged Care Facilities Program 

The Telehealth in Residential Aged Care Facilities Program (TRAC) operates in Broken Hill and Dubbo to improve access for Residents in aged care facilities to health professionals through video consultations. Services that can be accessed include GPs, allied health professionals and specialists through the following organisations:


Rekha Pillai, TRAC Program Administrator 
Phone 1300 699 167


Referrals can be made to 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. 

Online - 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.

Make a Referral 

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.