For older people living in the Whitsundays, getting the right care at the right time can make all the difference to staying healthy, independent and out of hospital.  

Over the past 3 years, the Mackay Hospital and Health Service (MHHS) General Practice Liaison Unit (GPLU) has been working with local healthcare providers to strengthen support for older people across the MHHS region.  

With an ageing population and increasing rates of dementia and cognitive impairment, the focus has been on creating proactive, community-based care pathways that support earlier diagnosis and intervention.   

Early identification allows people and their families to plan ahead, access services sooner and receive coordinated care that can help prevent health crises and hospital presentations.  

The GPLU identified a strong need for improved frail aged services in Bowen and Proserpine, particularly due to limited access to geriatricians and ongoing general practitioner (GP) workforce shortages affecting residential aged care homes (RACHs).   

To address these challenges, the GPLU partnered with Northern Queensland Primary Health Network, local GPs and aged care providers to establish two innovative programs.  

The first is the Frail Aged Nurse Practitioner Service (FANPS) in Bowen. The service provides safe, timely and culturally appropriate care aimed at keeping older people well and living safely in their community for longer.  

Working alongside local GPs and supported by geriatricians from Geriatric Care Australia (GCA), FANPS delivers rapid frailty assessment clinics and regular visits to RACHs, particularly when GPs are unable to attend. The service helps identify health concerns early and intervene before conditions worsen.  

The impact has already been significant, with reductions in falls and hospital admissions, alongside improvements in frailty management and medication optimisation. Access to specialist geriatric support through GCA has also strengthened cognitive assessments and delirium management for older people with complex health needs in Bowen.  

Building on that success, the MHHS GPLU this year launched the Proserpine Bridging Recovery, Independence and Discharge Guidance for the Elderly (BRIDGE) program. The BRIDGE program delivers patient-centred geriatric care with a strong focus on supporting the relationship between GPs and their patients. It was developed in partnership with the Proserpine Hospital Emergency Department (ED), nurse practitioners, geriatricians and allied health professionals. The service provides specialised assessment in the ED, coordinated referrals to GCA, structured communication with GPs and follow-up care at 2, 5 and 14 days after discharge.  

The MHHS GPLU continues to work closely with both programs to strengthen models of care, support GP engagement and improve health outcomes for older people across the region.