This plan will outline priority actions to improve and integrate care for older people in Northern NSW.

We acknowledge that everyone ages differently, and “older” is not easy to define.

In this plan, older people are defined as people aged 65 years and older, and Aboriginal people aged 50 years and older. We’ve also included actions for younger people that support healthy ageing.

“Integrate” means that all health services work together, so care information is passed between health providers and patients don’t miss out on any care they need.

As well as new priorities, it considers:

• Work already happening to improve care for older people

• Work that is funded or planned to start soon

• Other relevant plans and work from partner organisations and NSW Health

Services this plan covers include:

• Services that specialise in caring for older people (e.g. NSW Health aged care services, geriatric inpatient medical and mental health services)

• Services that care for large numbers of older people (e.g. rehabilitation, chronic disease services, palliative care, and others)

• Community health services (e.g. Hospital in The Home, Aged Care Outreach Service)

Things that are not included in this plan include:

• Actions for other organisations not part of Northern NSW Local Health District. We will look for opportunities to work with other organisations wherever possible. However, we cannot assign actions to other organisations unless they have agreed to them.

• Detailed operational plans. This plan is “high-level”; it provides a broad overview of all work happening or planned in this space. It does not include detailed service designs or work plans.

The population of older people in Northern NSW is growing, and older people now have more long-term health conditions, making their care more complex. Populations that experience inequity have poorer health outcomes as they age.

The health pathway of older people takes place across a range of settings over many years, including:

• Hospitals

• Community health services

• Primary care services

• Aged care providers

• In the home.

There are many factors that put pressure on the healthcare system, including:

• not enough residential aged care beds in the area to meet demand

• longer hospital stays for older people

• healthcare workforce shortages.

With higher care needs, a growing older population, a strained healthcare system, and many different healthcare providers and settings, care can become complicated and disjointed. We need a system-wide response to ensure that people receive quality, integrated care at the right time, in the right place, from the right professional.

A lot of work is already happening across our region. However, much of it is happening in isolation. This plan is an opportunity to bring this work together and see where the gaps are. Some examples of current work include:

• Setting up expanded Hospital in the Home services

• Programs to reduce risks for older people while in our hospital units

• Nursing roles specialising in care for older people across many disciplines