The document discusses the importance of documenting social history for older patients in general practice. It found deficits in documenting key details like living arrangements, mobility aids, carers, and language barriers that negatively impact care. A social history checklist was found to help practice nurses and increase collaboration between general practice and aged care providers. The conclusion advocates for improved social history documentation to enhance care coordination and quality of life issues for older patients.

1. Are we chasing our aging tail?
Results of the CHASE project-Connecting Health and Aged
care Systems Effectively
Documentation of the social history for community
dwelling older people in General Practice
- why is it important for integration?
3 points for clinical practice
1. Sharing information about an older person’s social
history can have a positive impact on care in the
community
2. Deficits in documentation of the aged and community
care provider types and contact details, mobility aids,
living arrangements, carer name, cognition status,
advance directive status, and language barriers have
a negative impact for older people when referred
across the health system.
3. Use of a social history checklist has been found to
be a useful aid for practice nurses when working
with older people, and has increased collaboration
between general practice and community aged care
providers
Introduction
• According to the BEACH study, people aged 65+
make up 32% of all consultations in Australian General
Practice. (Britt et al 2014, http://ses.library.usyd.edu.au//
bitstream/2123/11882/4/9781743324226_ONLINE.pdf)
• Many of this group have functional decline and frailty, which
is under recognised and is a core factor for admission
to hospital and premature entry to residential aged care
facilities.
• Documentation of “social history” in the appropriate section
of the patent’s electronic medical record is a fundamental
part of safe and quality care requirements for this group of
people and is recognised as being an important part of the
RACGP Standards (4th edition).
• ACH Group is a leading provider of community aged
care services in South Australia and Victoria. It is the lead
organization which successfully applied for project funding
via the Commonwealth Department of Health Better
Health Connections program to develop a project called
Connecting Health and Aged care Services Effectively
(CHASE).
The project
• The CHASE project’s initial task included an audit of 50
medical records of people aged 75+ attending the emergency
department of a large public hospital in the western suburbs of
Adelaide as well as auditing the medical record of the general
practice which provided the majority of long term care. An
experienced GP audited the hospital case notes and the same
GP audited the General Practice case notes,
• The CHASE project data has shown suboptimal documentation
of the social history in referral letters from GPs, on letters back
to GPs from hospitals (Emergency Department and Discharge
summaries), in the general practice medical record and on care
plans and/or health assessments. And this is despite the older
person having multiple visits each year to the general practice.
• Additionally it noted the suboptimal communication between
aged and community care providers and general practice with
very few letters of introduction, provider generated care plans
and case manager details found in general practice medical
records.
Conclusion
• Improved GP and Practice Nurse understanding
of the importance of social history documentation
in patient records can improve the quality of care
of older people not just based on medical issues
but on functional and social issues. It can also
increase collaboration between general practice and
community service and aged care providers.
• Annual health assessments and care plans and
reviews every 3-6 months are ideal opportunities for
Practice Nurses to update the social history as they
assess and review the function of an older person.
• Surveyors of General Practice accreditation can
support improvements by advocating for the social
history check list recommendations at practice visits
• Remember the care of an older complex person is
far more than a single disease being treated to a
guideline!
Creating a checklist is useful to improve the overall documentation of care needs/alerts for all older people. It is appropriate to put this
information in the “social history” field of the medical software, and to ensure the referral letter template, health assessment templates
and care plan templates all have the social history as an automatic download field in order for this important information to be
transferred between health care providers.
Check list for Social History to
be included in the electronic
software field, with examples:
1. Name of person/people who live with older person
2. Name of carer/other family members + contact phone number
3. Name of person being cared for if a carer
4. Living in own house/unit/rented/supported hostel
5. Community package provider name, case manager, contact
number
6. Pharmacist details/medication management used eg Webster
7. Involvement of other support organizations such as RDNS,
Domiciliary Care, Meals on Wheels, council, community aged care
provider etc
8. Mobility status/aids required such as stick, 4 wheel walker,
wheelchair, scooter/gopher, has drivers license
9. Cognition status- Age related memory loss, Mild Cognitive
impairment, dementia (Even a MMSE score and year could be
helpful here)
10.Continence status/aids-urinary incontinence and wears pads/has
IDC
11.Language issues-eg stroke and has aphasia, speaks Spanish and
requires interpreter
12.Advance Directive status- has Enduring Power of Guardianship
(EPOG)/ Enduring Power of Attorney (EPOA)/Medical Power of
Attorney (MPOA)/Good Palliative Care Order
Chris Bollen
BMP Consulting
chris.bollen@bmpconsulting.com
0412 952 043