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Positive steps for a healthy ageing journey.

Have you or a loved one discovered you are frail or at risk of frailty? The upside is you can start taking steps to reduce your risk of becoming frail, limit the impact of frailty, or even reverse it in some cases.

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Understanding the results

The journey starts with awareness and understanding your frailty score.

If you complete the positive ageing tool – either for yourself or on behalf of a loved one – you’ll receive results indicating your risk for poor health outcomes. Claire Fletcher, Community Health and Care Regional Business Manager at Benetas, says PAT provides a guide for where to start because it identifies which risk factors are at play.

If you elected to receive a report, it describes simple strategies that support healthy ageing, including advice for:

  • improving your sleep
  • managing pain
  • managing shortness of breath
  • increasing your exercise
  • building a diet that serves you, and
  • getting the support you need to remain independent.

You can find out some simple coping strategies, exercises and diet tips in the Positive Ageing Tool website.

The report also includes a letter you can take to your GP outlining your results and recommending ways they can support your positive ageing journey.
Many therapy and support services are available to help you live your best life into your advanced years.


Screening for frailty

The next step is a comprehensive assessment. After you’ve received the results, we recommend seeking advice from your GP, or another health practitioner (such as a nurse, dietitian, physiotherapist, or occupational therapist) who can provide a holistic assessment of your functional capacity and work with you to overcome any identified issues.

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Where to start

Dietlind Schutte, occupational therapist at Benetas Macedon Ranges Health Centre, agrees a comprehensive assessment is the crucial next step, and your GP is a great place to start.

Your assessment should be focused on your needs. “We don't just manage the health crisis,” she says. “We also address the underlying vulnerabilities. For example, if somebody has had a fall, we address the reason why they had a fall, but the assessment looks at the overall person and their goals.

“Our initial assessment revolves around what the person wants to do that they currently have difficulties doing. It could be anything from getting dressed, to being able to play golf, to feeding the chickens when you live on four acres. Then we look at ways the person can do that safely. This might mean a different strategy to perform a task or using equipment or assistive technology to allow that person to be safe in the home, if that is their goal.”

Start as early as possible to optimise positive ageing

She explains that it’s important to get assessed as soon as possible, so you can quickly start taking the steps to optimise healthy active ageing. She describes frailty care as an end-to-end journey. The sooner you get support, the better that journey can be.

As she explains: “The earlier you start having a relationship with your local team the better, because then you can be in control of letting your team know when you need help. I've worked with a lot of people in the community over the years, but I don't see them on a regular basis. But they know where we are, and we do what we can to support them through the process.”

Get connected to the right services

Once you’ve been assessed, the next step is accessing appropriate therapies and services. This may include referral to a geriatrician or specialist physician as well as therapists, support workers and community services.

This will also revolve around what your goals are, Dietlind says. “If someone reports they want to continue or get back to playing bowls, for example, then that's what we'll be working towards. We know that people who have the opportunity to participate in meaningful activities are more likely to age well.”

A wide range of care and therapy services are available. These include, but are not limited to:

  • care support planning – to help tailor a package that addresses your needs and goals (link to article four)
  • social care support – to address issues such as social isolation and loneliness
  • community support – to help you access your community and attend activities such as exercise classes, social groups and medical appointments
  • personal care – for assistance with personal activities such as showering and toileting
  • occupational therapy – to assess and support your ability to function safely and independently at home and in the community
  • social work or case management – to assist you with completing applications and paperwork (such as forms required by Centrelink and My Aged Care), and advocate on your behalf
  • podiatry – for regular foot care and assessing and managing concerns with your feet and legs
  • physiotherapy – to assess and treat a range of conditions that may be impacting your health, function and independence
  • pharmacy reviews – to monitor your medications, ensure they don’t overlap or interact adversely with each other, and that you’re not taking medicines you no longer need
  • dietetics and nutrition support - to help you make dietary choices that support healthy ageing and assess and manage any nutritional or dietary concerns.

Your GP can refer you to appropriate services and is likely to know what supports are available in your local community, such as exercise and social groups.

Dietlind adds that community health services (including Benetas Macedon Ranges Health) and allied health professionals may accept direct referrals from patients or their families, and from hospitals.

Support for what matters to you

Benetas take a person-centred approach that gives you choice and control, Dietlind explains. Your needs and goals are at the heart of planning and decision making. The people who play an important role in your care, such as family members and carers, will also be involved.

From an occupational therapy perspective, support is all about optimising your function and ensuring you can participate in meaningful activities, Dietlind says. “In that end-to-end pathway of care with a person who is frail, we provide them with healthy, active ageing and supportive strategies to help them maintain independence,” she says.

To show what this can look like, Dietlind describes how she has worked with Beryl*, now in her mid-80s, over the past few years. Beryl’s original referral suggested she wasn’t safe to live on her own after a bout of flu. “Her goal was to stay in her home on acreage, look after her garden and grow her vegetables. Everything we did with her was related to those goals. She was involved in setting them and describing what was required to live where she does.”

Beryl’s care support team needed to consider her health conditions, which included diabetes, a heart condition, and arthritis. Beryl was also socially isolated, her nutritional status was poor and she was taking multiple medications, Dietlind says. With the involvement of Beryl’s support workers, including members of her family and community, they devised a plan for Beryl to stay at home safely.

A couple of years later, Beryl had a couple of falls, broke her hip, went to hospital and came home again, so the team reviewed her situation. “At that stage she was very frail and had difficulties getting in and out of bed and dressing herself, so she temporarily had homecare workers coming in to support her with getting dressed so she could get out in the garden. That was more important to her than spending all her energy getting dressed.”

Recently, Beryl had to give up driving, but her goal is still to stay at home. Dietlind is exploring ways Beryl can continue to access the community and attend activities she enjoys, like Country Women's Association meetings. “We’re looking at transport options for shopping and doctor’s appointments. We’ll do an assessment to see if she's able to use a scooter to get to her local shops and buy milk.”

Beryl is also struggling with fatigue, so they have looked at everything she does in 24 hours to find ways of simplifying activities and conserving her energy, along with deciding which tasks she is happy to delegate to other people.

Dietlind has also supported Beryl with creating her end-of-life plan, which her GP will help complete. “That's the sort of role and involvement I have with my community,” she says.

She adds that support should ideally be available rapidly and close to your home. Furthermore, the right support may prevent an unnecessary hospital admission, which new research shows is an important part of positive ageing, Dietlind says.

If you do need hospital care, post-discharge support is also very important, Dietlind says, as is reablement after an acute illness. “Sometimes it’s a confidence issue. We can provide extra support while a person is recovering and then step back so they can take over again.”

After a fall, for example, a physiotherapist can support people with a graded physical activity program to help them return to their pre-incident level. They will work with you to overcome barriers to physical activity, such as fear of pain, and help you develop good exercise habits.

(*names changed to protect patient confidentiality)

Choice and control about your care

Dietlind emphasises that a vital part of care is supporting you to actively participate in your daily activities, whether you live in the community or an aged care facility.

For example, say you have difficulty filling a pot with water to boil rice. Rather than a support worker doing everything for you, you may be able to get out the pot, put it on the sink and get a jug to fill it.

This not only gives you the satisfaction of being able to complete activities, it helps to maintain your function, Dietlind explains. “Research shows us that people age much better and are happier if they participate.”

Most importantly, “older people need to be properly valued and treated with compassion, dignity, and respect at all times,” Dietlind says. “Every person is unique and should have choice and control in their ageing journey.”


Support to stay at home

Benetas can support you to stay independent and continue doing what makes you, you; all from the familiar surrounds of your own home. We offer an extensive range of home care services and funding options to suit your individual circumstances.

Discover Homecare

Go deeper (6 minute read)

What services are available?

If you or someone you love has discovered they are frail or at risk of frailty – by using our Positive Ageing Tool, for example – numerous options are available to support you to live your best life into your advanced years. Changing habits, being active, and getting the right plan in place are crucial steps. Read More.

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Positive Ageing Tool

Start your Frailty Test

Start your Frailty Test