Shifting the focus on ageing

Patient-centred approach makes a difference to people at risk of frailty

Source: APNA Primary Times Spring 2020 (Volume 20, Issue 2)

A nurse-led healthy ageing clinic is helping to keep people well and at home in suburban Adelaide.

Among those to benefit are elderly couple Brian and Gaynor Stanford, who have been married for 56 years and are keen to remain at home with support.

The Stanfords are patients at the Allenby Gardens Family Practice, where APNA member Jane Bollen is working with local GPs on the federally funded project.

Jane, a Registered Nurse with more than 30 years’ experience, is hopeful that lessons from the clinic can be applied more broadly throughout Australia to deliver better health outcomes for older people, particularly those at risk of frailty.

“If we can use the general practice team to delay aged care and avoid hospitalisations, everybody wins,” says Jane. “Patients lead happier lives, the Government saves money and doctors get to use their time more effectively.”

The aim is to identify over-75s at risk of frailty and better support them with structured, holistic health care that takes account of their individual needs.


It all starts with a search of the practice database, seeking out patients in the target age group who have visited the practice in the last six months, are prescribed eight or more medications and who have a chronic condition.

This is followed by an initial nurse visit to the patient’s home where a health assessment is performed including a 4-metre walking speed test, home safety check and nutritional assessment. Finding a person who walks slowly and improving their speed has better outcomes than blood pressure management at this age.

Jane says a key driver is to find out what the patient wants – which may be as simple as being able to water the garden, attend a grandchild’s wedding or feel confident in walking the dog. Those motivators are then used as part of an overall health plan which can include screening for chronic kidney disease, osteoporosis, dementia and depression.

The plan is usually finalised two weeks later during a three-way conversation between the patient, nurse and doctor at the practice. Appointment reminders are set up at 3-month or 6-month intervals for care-plan review to keep the patient on track. More regular phone calls can be factored in if required.


The nurse will also complete relevant referrals such as a pharmacist for home medication review, podiatry, exercise, continence, pathology and Commonwealth home care packages. In the case of the Stanfords, Jane was able to refer the couple to physiotherapy and resistance exercise programs, as well as discuss the importance of more protein in their diet.

“This relies on nurse skills to help the patient navigate the system,” says Jane. “Ageing is a normal process which is just as much about the social needs as it is the medical needs. Above all, we need to find out what matters to them. Without engaging like this to discover people’s goals, referrals to other providers are likely to fail.

“The nurse is at the heart of it all. We’re the caring role that brings it all together, rather than just focusing on particular diseases. We contact aged care organisations that manage their home care needs. We use our nursing eyes to see how they manage at home – is the house messy, what’s in the fridge, how they move, how many tablets they have on the table.

“We see how they’re managing their lives so we can put systems in place to help them fulfil their wishes. We can also help families navigate the system on behalf of their parents.”


"We use our nursing eyes to see how they manage at home...what's in the fridge, how they move"


When Jane first started this project, she realised that the practice had a large number of older patients with chronic and complex needs. There are 280 patients aged over 75 on the books, with many requiring education in diet and exercise to improve not only their life goals but overall health and wellbeing.

The two practice GPs were finding it challenging to follow up on the social-care needs of these people. They were also experiencing a lot of ad-hoc visits from elderly patients. By providing more structured care, the project seeks to minimise unnecessary visits by elderly patients to the practice.

Summing up, Jane says: “I’ve been listening to the Royal Commission on Aged Care. It surprises me that no one has been talking from a general practice perspective. We could avoid so much suffering by doing more intervention and prevention at a general practice level. Nurses are the obvious way of linking all these services together for the benefit of the patient.”


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