<strong>Aged</strong> <strong>Care</strong> & <strong>Rehabilitation</strong> <strong>Clinical</strong> Service <strong>Plan</strong> <strong>2007</strong> - <strong>2012</strong>1. INTRODUCTIONSydney South West Area Health Service (SSWAHS) was established in January 2005 following theamalgamation of the former Central Sydney Area Health Service (CSAHS) which is in Sydney’sInner West, and is also known as the Eastern Zone (EZ), and the former South Western SydneyArea Health Service (SWSAHS) which is part of Sydney’s south west, and is also known as theWestern Zone (WZ). A map of SSWAHS is provided as Figure 1.1.Figure 1.1 Map of SSWAHS showing facilitiesThe SSWAHS area comprises 15 Local Government Areas (LGAs) and covers a geographic area of6,380km². The eastern part of SSWAHS comprises the LGAs of City of Sydney (part), Leichhardt,Marrickville, Canterbury, Canada Bay, Ashfield, Burwood and Strathfield and is comparativelydensely populated. By contrast, the south west, which accounts for over 95% of the geographicarea of SSWAHS, comprises the LGAs of Bankstown, Fairfield, Liverpool, Campbelltown, Camden,Wollondilly and Wingecarribee. Settlement patterns in the south west are varied, including oldercentres, scattered rural townships, and new release areas.The <strong>Aged</strong> <strong>Care</strong> and <strong>Rehabilitation</strong> Service (AC&RS) is a complex group of services provided in arange of settings including hospitals, community health centres, homes and residential aged carePage 10
<strong>Aged</strong> <strong>Care</strong> & <strong>Rehabilitation</strong> <strong>Clinical</strong> Service <strong>Plan</strong> <strong>2007</strong> - <strong>2012</strong>facilities. Some services are provided on a consultative basis, whilst others are designatedspecifically as aged care or rehabilitation. <strong>Services</strong> provided in the full range of settings and tomembers of the identified target groups will be discussed in this <strong>Plan</strong>.1.1 The Structure of <strong>Aged</strong> <strong>Care</strong> and <strong>Rehabilitation</strong> <strong>Services</strong> in SSWAHSDue to its history as two separate organisations, the AC&RS has operated under differing structures.In the eastern part of SSWAHS, AC&RS have been managed since 1993 through the General,Geriatric and <strong>Rehabilitation</strong> Medicine (GGRM) <strong>Clinical</strong> Stream with a single Area Director. In thesouth west of the SSWAHS, both <strong>Aged</strong> <strong>Care</strong> <strong>Services</strong> and <strong>Rehabilitation</strong> <strong>Services</strong> have beenmanaged through the Complex <strong>Care</strong> and General Practice Stream, via an Area Director <strong>Aged</strong> <strong>Care</strong>and Area Director <strong>Rehabilitation</strong>. This structure has been in place only since late 2005 andconsiderable work is required to reorient the service away from its previously sectorised model.With the development of clinical streams across SSWAHS, a single AC&RS clinical stream will beimplemented in 2008. It is anticipated that AC&RS services will be grouped into three clusters: aSouthern Cluster (Wingecarribee and Macarthur areas); Central Cluster (Liverpool, Fairfield andBankstown areas); and Northern Cluster (Canterbury, Concord and Camperdown areas). AnAC&RS organisational chart will be developed in 2008.Further work has also been required to clarify the role of General Medicine across the south west,and relationships between AC&RS, Allied Health <strong>Services</strong> and Community Health <strong>Services</strong>.Across SSWAHS, the Specialist Mental Health Service for Older People (SMHSOP) is to be jointlymanaged by AC&RS and the Area Mental Health Service. Further work is required to delineateroles and responsibilities across services, particularly in relation to the management of older peoplewith complex co-morbidities and/or dementia with challenging behaviours.1.2 Scope of the <strong>Aged</strong> <strong>Care</strong> and <strong>Rehabilitation</strong> <strong>Clinical</strong> Service <strong>Plan</strong>This <strong>Plan</strong> is focused on ensuring equity of access and outcomes for the elderly patient with multiplesystem medical, functional and psychosocial problems ie “the aged care client” and for all adults whorequire rehabilitation services. These target groups are defined in Section 4.The <strong>Plan</strong> addresses in detail services managed by <strong>Aged</strong> <strong>Care</strong> and <strong>Rehabilitation</strong> <strong>Services</strong>. Partnerservices are identified and briefly discussed in the context of the overall aged care and rehabilitationservice system, but this <strong>Plan</strong> does not project future needs for these services.It identifies the service delivery model for AC&RS from <strong>2007</strong> and beyond. The model includesservices across the continuum of inpatient, non-inpatient and community based services, includingassociated specialist services. The model recognises current clinical structures and service models,particularly in relation to the availability of general medicine, whilst also outlining a consistentapproach for the future.In respect to aged care, this <strong>Plan</strong> has used as its basis the NSW Health Framework for IntegratedSupport and Management of Older People in the NSW Health <strong>Care</strong> System 2004-2006.<strong>Rehabilitation</strong> is described in accordance with current guidelines produced by the AustralasianFaculty of <strong>Rehabilitation</strong> Medicine (AFRM).This <strong>Plan</strong> does not have a population health focus, with strategies to maintain and improve thehealth status of the well elderly addressed in other SSWAHS plans. In addition, the <strong>Plan</strong> focuses onpeople requiring multidisciplinary assessment and treatment, rather older patients with a singlehealth problem or disease treated by other specialties.Implementation of this <strong>Plan</strong> is dependent on factors including the external funding, policyenvironment and internal structures. As such, the <strong>Plan</strong> will be regularly monitored and reviewed toensure it remains consistent with the operating environment of the services.1.3 Principles Guiding the <strong>Aged</strong> <strong>Care</strong> & <strong>Rehabilitation</strong> <strong>Clinical</strong> Service <strong>Plan</strong>The provision of aged care and rehabilitation services in SSWAHS will be guided by a clear set ofprinciples. These principles (following) are consistent with National and State policy.Page 11
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