LMS -SGO for RACFs (Suite 198, 1 Barratt Street, Hurstville NSW 2220)
Service Model
Definition
Longevity Medical Services (LMS)-SGO is a geriatrician led community services which provide medical service for the patients in multiple Residential Aged Care Facilities (RACFs) in Sydney and surrounding areas. We provide the acute and subacute model. Subacute model involves providing medical and mental health consultation services including management of behavioural and psychological symptoms of dementia (BPSD). Acute medical services involves intervention which normally the patients will receive in hospital such as intravenous antibiotic, subcutaneous fluids or any other intravenous medication. LMS-SGO also provide palliative care services in the facilities should the patients not respond to treatment or if the patients/families opted for no acute treatment. The main aim of the service is to treat the nursing home patients in their facilities safely and effectively.
Aims: Acute
- To reduce patient’s presentation/representation to the Emergency Department and potential admission to hospital, by treating suitable patients in the aged care facilities early and efficiently.
- To potentiate early discharge from hospital by continuing the treatment in the community setting.
- To support the health system primarily by reducing the pressure on the Emergency Department and inpatient teams. This hopefully might lead to reduction in the health care cost.
Aims: Subacute
- To support the nursing home staffs and the Local Medical Practitioner in these areas in managing the elderly patients in the community setting
- To support the patients and their families by delivering hospital like care at RACFs and reduce the need to transfer patients to hospital
- To manage palliative care aged care patients in the aged care facilities so the patient might remain in their familiar environment and pass away there, rather than admitting them to hospital
- To ensure that patient’s safety and care are not compromised during the delivery of care.
- Complementary Nurse Practitioner services towards complex wound care and complex nursing; including staff education, behaviour management strategies for dementia.
- Provision of telehealth services between clinicians.
- Provision of medical consultation services for different RACFs.
- Conducting family conferences and resolving any complex medical and family issues.
- Ready access to provision of Allied Health services; dieticians, physiotherapist, podiatrists where required.
- Medication and psychotropic medication review
- Advance care Planning
Expected benefits of Acute & Subacute Service for RACFs:
- Increased capability of RACF to identify a deteriorating resident to enable prompt medical management.
- Providing clinical support for the General Practitioners to manage complex medical and family issues.
- Managing complex Mental Health issues and Behavioural Psychological Symptoms of Dementia (BPSD) and geriatric syndromes including falls, weight loss, incontinence, pain management and functional/cognitive decline.
- Ensure safe prescription of medications including antibiotics and antipsychotics
- Improving the quality of service to residents in RACFs
- Reduce avoidable and unnecessary patient transfers to ED and therefore relieving pressure on the nursing staff and distress to the families/residents, thus ensuring patient satisfaction.
- To manage aged care patients in the RACF so the patient might remain in their familiar environment and reduce risk of delirium, pressure sores and falls.
- Reduce burden of straining healthcare resources at ED due to influx of unnecessary referrals from RACF.
- Improve partnership and coordination between multidisciplinary community services in the local areas.
- Reduced health care costs as a result of decreased rate of patient transfer from RACF
- Ready access for Specialist Geriatric services.
Quality assurance
LMS assists patients to achieve their maximum level of physical, functional and cognitive potential, whilst promoting positive attitudes towards the care of the elderly. Residents’ safety is important to us. Participating staff at LMS-SGO maintains improved practice efficiency by keeping abreast of evolving worldwide developments in Aged Care and Rehabilitation by attending relevant Australian accredited courses, seminars and conferences. All staff are obligated to fulfill Continuous Professional Development standards and requirements. All our staff are Fellows of Royal Australasian College of Physicians, affiliated to many reputable learning institutions.
Current Team Structure:
Dr Frank Liu FRACP, geriatrician
Dr Deni Irwanto FRACP, geriatrician
Dr Manoj Kumar FRACP, geriatrician
Dr Natalia Rezai FRACP, geriatrician
Other accredited participating clinicians available.
What we do in the Residential Aged Care Facilities (RACF)
- Do a rapid and effective geriatric medical assessment of the aged care patients in the RACF.
- Identify the geriatric medical issues and do early intervention and investigations. This might include ordering appropriate tests and commencing appropriate patients on medications which might include intravenous medications and subcutaneous fluids/medications. This will also include commencing palliative approach for the patients with poor premorbid function who is unlikely to benefit from hospital presentation and admission, after discussion with the family.
- Liaise with the family and Local Medical Practitioner regularly about the management and progress
- Regularly maintain constant patient follow up.
- Refer patients to allied health as required such as speech pathologist, dietician, physiotherapist, etc.
- Provide written instruction for the patient upon discharged from the service with future plan and recommendation
- Do in-service session as required in the aged care facilities to familiarize the staff with the program as well as empowering the staff with the skills needed such as initiating and managing subcutaneous fluid or possibly giving IV antibiotics
- Discuss the palliative option for appropriate patients with the family.
- Quarterly mortality meeting, which will be held within the geriatric service team for the service quality and safety.
We have Specialist Geriatricians to cover a wide spectrum of geriatric services in RACFs:
- All geriatric syndromes including pressure ulcers, incontinence, falls, functional decline, weight loss and delirium.
- Dementia & cognitive impairment assessment
- Medication, psychotropics and poly-pharmacy review
- Elderly mental health issues such as Depressive and anxiety disorders
- Behavioural and psychological symptoms of dementia (BPSD)
- Parkinson’s disease & Parkinsonism.
- Falls; syncope
- Chronic pain, frailty, reduced mobility
- Comprehensive geriatric assessment including patients with multiple co-morbidities, or chronic illnesses.
- Rehabilitation and restorative care
- Advanced care planning and palliative care managements.
- Acute medical illness including chest infection, urinary sepsis, cellulitis and dehydration which require IV antibiotics and SC hydration…
Hours of Operation:
8:00 am to 8:00 pm, 7-days a week service including direct emergency telehealth.
Who could make the Referral
- Local Medical Officer
- Staff at the aged care facilities (ideally after consulting with the LMO)
- Inpatient geriatric teams when discharging if the consultants are happy for the patients to be referred to the service.
- Emergency Department of the local hospital.
- Ambulance service
How to refer
- Two direct phone numbers available to contact the on-call geriatrician for acute service.
0466885511
0413712151
- A standard referral form provided to facility for referrals by the LMO.
- Direct Fax number: 1300664528
- Email: referral@longevityms.com
- No cost for patient and facility with GP referral
At present LMS-SGO caters for;
70 RACFs