Aged Care & Rehabilitation Clinical Services Plan 2007 – 2012

Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012EXECUTIVE SUMMARYBackground to the PlanThe Sydney South West Area Health Service (SSWAHS) Aged Care and Rehabilitation ClinicalServices Plan provides direction for the development of Aged Care and Rehabilitation Services(AC&RS) across Sydney South West in the period 2007 – 2012, with a broader view to 2016.The Plan has been developed to ensure SSWAHS is able to comply with the policies guiding thedelivery of AC&RS at a national and state level, meet the growing demand for AC&RS, and providean equitable and accessible service system across the Area. A set of principles has been describedwhich outline the basis for this Plan and the future delivery of AC&RS across SSWAHS.Plan development was overseen by a small steering committee comprising senior AC&RS managersand clinicians. Commencing early 2005, various consultative and participation opportunities havebeen arranged for clinicians and community members across SSWAHS (Refer Appendix 2).The Target GroupsThe population of Sydney South West, along with that of most developed countries, is rapidlyageing. In 2001, approximately 10.6% of the population were aged over 65 years and approximately1% aged over 85 years. By 2016, the population over 65 years is projected to rise to almost 13%and the population aged over 85 years to almost 2%. Although these percentages appear small,projections indicate that there will be approximately 200,000 people over the age of 65 years inSydney South West by 2016. People in this age group are the highest users of health, particularlyhospital, services and will place extensive demands on all services over time, particularly if currenthealth service utilisation patterns continue.The Aged Care component of this Plan does not address the health needs of all older people, buthas focussed rather on those who specifically require aged care services. This is based on thepremise that older people with a single system disease are best treated by that sub-specialty, and donot require a comprehensive multi-disciplinary approach to treatment. Aged care clients are definedin this Plan as those with either an acute or chronic illness, who have particular physical or mentaldisabilities, issues with care, accommodation and support, or with multiple medical or polypharmacyproblems. Particular attention is given to people with dementia and people who have experiencedfalls or are at risk of falling.The Rehabilitation component focuses on adult rehabilitation only, giving particular attention to theneeds of people who have had a stroke, have a chronic disease, an intellectual disability, braininjury, spinal cord injury or severe burns. Clients of the Rehabilitation Service have unique physicalor mental disabilities and are also often in need of assistance with care, accommodation and/orsupport. Services for people with disabilities are also being addressed through the SSWAHSDisability Plan.Given that both Aged Care and Rehabilitation clients usually have a strong reliance on carers, theneeds of carers are also considered. Carers’ needs are considered in greater detail in the SSWAHSCarers Action Plan.The Aged Care and Rehabilitation Service SystemThe AC&RS system is complex from both a service design and delivery perspective, with fundingand guidance for the delivery of programs coming from multiple sources at an Australian and Stategovernment level, as well as direct from the Area and through other partnership arrangements. Thesystem includes a range of health promotion initiatives (particularly focused on injury prevention),through to early intervention and diagnosis, community care, acute care and residential care. Arange of providers operate within the system including public services, non-governmentorganisations and private providers, such as General Practitioners. Both generalist and specialistservices are provided in inpatient, outpatient, community and home based settings.Within SSWAHS, inpatient AC&RS are provided at Royal Prince Alfred Hospital (RPAH), Balmain,Concord Repatriation General Hospital (CRGH), Canterbury, Bankstown/Lidcombe, Liverpool,Page 3