Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
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Coordination in Community health care Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Auckland
New Zealand data Age-group 2001 2011 Change 2001-11 N (000s) % N (000s) % N (000s) % 0-4 281 7 258 6 -23 -8 5-14 597 15 564 13 -33 -6 15-24 534 14 640 15 +106 +20 25-34 549 14 522 12 -27 -5 35-44 604 16 586 14 -18 -4 45-54 507 13 613 14 +106 +21 55-64 350 9 489 12 +139 +40 65-74 252 6 314 7 +56 +22 75+ 210 5 263 6 +53 +25 TOTAL 3,884 99 4,249 99 +365 +9 Statistics New Zealand, 2006
Females Males Indicator self- reported 50-64 65-74 75-84 85+ 65+ 50-64 65-74 75-84 85+ 65+ years years years years years years years years years years 0 29.4 17.2 12.4 18.7 15 32 17.6 11 14.9 1 to 3 63.6 63.7 61.6 63.2 63.8 61.9 70.0 70.0 73.5 70.3 4 + 7.0 19.1 26.0 18.1 20.6 6.0 12.4 19.0 14.8 457,000 65+ year olds, 80,000 to 100,000 65+ year olds with 4+ chronic conditions in NZ
What is ageing in place? “people should be able to continue living in their own place of residence in their later years” O.E.C.D. 1994
~~~AND WHAT IS HEALTHCARE DOING~~E
Compression of morbidity Hypothetical present morbidity 0 80 Scenario 1 - Extension 0 85 Scenario 2 - Compression 0 85
Impact of a healthier older population %65+ Moderate rising age ratio Stronger rising age ratio 30 moderate rising age ratio lifts the 65 year 25 age group by one year every five years 20 through to a cut off point of 70 and over 15 10 (2005, 66+, 2010, 67+ until age 70). The 5 stronger rising age ratio keeps lifting this 0 2001 2006 2011 2016 2021 2026 2031 2036 2041 2046 2051 cut-off point to 75, a point reached in 2050. A moderate age ratio lifts the 65 year age group by one year every five years through to a cut off point of 70 and over. Stronger rising age ratio keeps lifting this cut-off point to 75.
A changing world ...and for the next 10 years!
Six themes for community service development... Funding Coordination Improving capacity Community services Quality Integration with improvement primary care Maximising informal supports
• COSE (2000) - community-based needs assessment and service co-ordination service funded from Ministry, DHB and ACC funding pools. It aims to avoid duplication in service provision. • A key worker (COSE) is based in primary health care and is assigned to several general practice teams. The model allows the COSE to identify resources and opportunities within communities, both funded and non-funded. • This offers older people a greater choice of service support, enabling them to remain safely in the community as long as they wish to. Parsons et al, 2012, JAGS; Parsons et al, Age and Ageing, 2012
Relative risk reduction 33% 16% 43%
We focussed on home care Low funding (NZ: 17.7%; US: 25%; Mean: 30.4%, of total long term care, OECD, 2005) No regular assessments or reviews High staff turnover(39%) No / minimal health professional input No / minimal training for support workers No travel time or costs Ratio of ‘coordinator’ to clients 1:450
Key developments in NZ • Partnership between DHBs, Home Care providers and UoA – Coordination of clients with non-complex needs – Use of health professional ‘coordinators’ – Training: (Support Workers - national programme and shared DHB/Home Care coordinator) – Geographical clusters – Assessment and regular reviews – Use of goals to inform services
Nelly Bell, 86… Week ly indep grocery e s by Ap ndently u hopping ril 20 sing 03 taxi Make l by Ma unch for H rch 2 elen C 003 lark Groc er help y shoppin of SW g by Fe with b 200 3 Walki n in ind g to car a epen n 2003 dentl d getting y by J an Walki n metre g to dairy s) by ( Jan 2 450 003 Walki n indep g to letter ende ntly b box y Nov 2003 Wash in indep g and dre ende ntly b ssing y Jan 03 Walki n indep g to front ende d ntly b oor y Oct 02
Funding model remains an issue... • Most DHBs use fee per service – Providers have no incentive to discharge people – Difficulty in providing a responsive service • Several DHBs attempted a ‘gain share’ model with minimal success • Several utilised bulk funding, risky for providers as mix and demand change NEW METHOD REQUIRED
Case Mix • Development of DRGs and the Yale cost model – Focus on productivity • Some major criteria – Clinically meaningful – Homogeneity of resource consumption 25
interRAI • Older people with non-complex needs = CONTACT Assessment • Older people with complex needs = MDS- HC • Both can be used to develop casemix groups
We knew that our targeting was wrong
Five groups… 1. Housework only 2. Low needs: – lonely, socially isolated, require assistance to shop, not driving 3. Medium needs: – ADL deficit, unable to shower without assistance 4. High needs: – ADL deficit, requiring help dressing, carer stress, cognitive impairment 5. Residential care level in the community – Where total package exceeds cost of supporting someone in residential care
Descriptions of levels: Non-complex We have Complex clients, further assessment by Clinical Assessors using MDS-HC moved on... SCREENING Use of Supporting Allocations Tool (SAT) to screen non-complex and complex clients and provide indication of needs level (1, 2, 3 or complex) by Contact Centre / SPOE Face to face assessment by ACCESS coordinator using CONTACT ASSESSMENT I assessment and the Resource Allocation Funding Tool for Non Confirmatory stage Complex (RAFT-NC) clients LEVEL 1 LEVEL 2a LEVEL 2b LEVEL 3a LEVEL 3b CASE-MIX Housework only Low needs group Low needs group Moderate needs Moderate needs group (stable) (flexible) group group (stable) (flexible) ASSESSMENT II This client should AND GOAL not be delivered a TARGET tool, Sector standards assessment and allocation of Support Worker. FACILITATION ?service Usefromof Development of individualised support plan guided by RAFT-NC hours HBSS HBSS PACKAGE OF CARE Focus on Focus on Focus on recovery Focus on maximising maximising & community maximising independence and independence and integration, independence, supporting carers, supporting carers, allocation of an allocation of an allocation of an allocation of an average 1.5 hours average 2.0 hours average 3.0 hours average 4.0 hours OR LESS per OR LESS per OR LESS per OR LESS per week over three week over three week over three week over three months months months months REVIEWS Three monthly by Three monthly by Support Worker Three monthly by Support Worker Three monthly by (Level III trained), Coordinator, (Level III trained), Coordinator (face alternate face to alternate face to face-to-face using to face) using face / telephone face / telephone, RAFT-NC and RAFT-NC and using RAFT-NC using RAFT-NC TARGET (if TARGET tool and TARGET (if and TARGET tool indicated) indicated) REASSESSMENT Annual, by Coordinator or as indicated by RAFT-NC tool CARE MANAGEMENT HBSS coordinator
Case mix development
Case weight per week Average hrs Analysis 1.27 1 Housework Ignore 1.18 2a Shopping (stable) 1.00 1.64 2b Shopping (flexible) 1.39 Non-complex 3.64 3a Personal care (stable) 3.08 4.72 3b Personal care (flexible) 4.00 4 Disability Only 5.17 6.10 5 BSS/ Disability 5.42 6.39 6 CI/Disability 5.92 6.99 Complex 7 CI/BSS /Disability 6.40 7.56 Significant 8 Rehabilitation 5.43 6.41
To increase hospital capacity... • Supported Discharge Teams have been developed to: – Facilitate a timely and coordinated discharge home for older people who are medically stable and require ongoing support at home – Provide a flexible and rapid response to avoid admission and increase independence following an acute illness at home, – Maximise rehabilitation potential to reduce requirement for long term supports including delaying residential care. Growing evidence
Waikato DHB... • Launched START, Nov 2010 – Supported Discharge Team – Rapid Response Team – Two models, urban (discrete specialist services team) and rural (integrated community provider with specialist services overview) – Waikato wide roll out in 2011
Canterbury • Planned and phased introduction of supported discharge team in 2012. • Planning to commence July 2011
Targets • Reduced length of stay in hospital • Increased time spent at home over a year • Reduction in residential care placement • Reduction in the need for long term home care • Improvement in function
Agnes Foster
• One morning, Agnes’ 6 month old great grandchild visits and sneezes all over Agnes, • Within 2 days, she is in bed with a cold which quickly deteriorates into a pneumonia. Liz contacts the GP who starts on ABs but a day later, Liz visits and finds Agnes delirious and the GP advises visit to ED, upon which she is admitted to AMAU and 1 day later assessed by Jay (Liaison worker) • Given her past deterioration, CREST is considered and Jay informs Agnes’ GP, the CREST case manager and Agnes chooses Nurse Maude as the provider. • Agnes’ daughter collects her that afternoon and the team commences immediately.
Grocery shopping (& coffee) with Liz by x Commenced CREST discharge Attending church with friend by x HBSS x 2hrs Preparing breakfast and snacks by x week Walking to dairy (450 metres) by x One 2 hour visit Walking to car and getting in with help by x x3 week For pain to be 3/10 - getting in/out bed by x To be able to defrost and heat MoW by xxx Walking to letter box independently by xxx Withdraw Dressing independently at home by xxx weekend visits Washing independently at home by xxx Withdraw AM Dressing independently within 5 days visits CREST x3 a day x7 Drawing curtains independently by x Withdraw night Getting in / out of bed independently by x visits Hosp. discharge Washing independently within 3 days Walking to toilet independently day or night by 3 days Walking to ward doors within 2 days
START Evaluation • Successful HRC bid 2011 – RCT – Does START decrease hospital length of stay, time in hospital over a year, the number of ED visits, Aged Residential Care admissions and Home Care usage? – What are the patient and practitioner perceptions of the START service? – What does START cost from a health service perspective and from a patient perspective? – A total of 300 participants will provide 80% power to detect a 20 per cent reduction in length of hospital in- patient stay
A changing world What are we up to in NZ
Cluster development • Decentralisation • Re-orientation of services around Primary Care Clusters – Recognition that most healthcare is provided by the person’s GP
Development of clusters
Long term condition management Risk factors for Presence of long Unstable long disease term condition, term condition Increase in need development though stable for support Linking it together Population based programmes for Restorative Home Restorative Home Support (65+ or Support (65+ or Programmes Services or example: like age and like age and ·∙ Green interest) interest) prescription, Cluster aligned ·∙ Tai Chi ARC facility for respite Use of Co-creation / Self Management model (i.e. Flinders or goal facilitation model with older people) General Use of health / disability services General General Practitioner Practitioner Practitioner Practice Nurse Practice Nurse Medical specialist Health professional (Clinic Nurse) (Clinic Nurse) Providing District Nurse consultancy Other disciplines as appropriate (Mobile Nurse) Disease state (fitness with consumers nurses instructors etc) who are housebound District Nurse (Mobile Nurse) Other disciplines with consumers as appropriate who are (Kaiawhina etc) housebound Practice Nurse (Clinic Nurse) Other disciplines as appropriate (Kaiawhina etc) Care Management / General Practice Nurse District Nurse Practice Nurse District Nurse Practitioner / (Clinic Nurse) (Mobile Nurse) (Clinic Nurse) (Mobile Nurse) Navigation Practice Nurse for housebound for house- (Clinic Nurse) Non-complex Cluster bound Cluster care manager Complex care Complex care manager manager
Tele-care (ASSET) Multi centred randomised controlled trial Counties • Manukau DHB (respiratory disease) • Ngati Porou (multiple long term conditions) • Auckland DHB (Heart failure)
Technology Development of ‘Tele- hub’ • Joint initiative by ACCESS and UoA to develop an integrated multi-component device to address social isolation, reduce carer stress and provide remote monitoring to older people Life course
Conclusion • Rapid changes imminent – a reflection of changing demographics • Community care base quality at a level to springboard • DHBs recognising the potential of community services • Focus on ‘better, sooner, more convenient
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