Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago

Page created by Theresa Wood
 
CONTINUE READING
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
Coordination in
Community health care

            Matthew Parsons
 Clinical Chair in Gerontology, Waikato DHB,
            University of Auckland
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
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
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
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
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
HOSPITAL   PRIMARY CARE
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
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
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
Coordination in Community health care - Matthew Parsons Clinical Chair in Gerontology, Waikato DHB, University of Otago
...and consumer expectations
~~~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
You can also read