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
HOSPITAL PRIMARY CARE
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 consumer expectations
~~~AND
WHAT IS
HEALTHCARE
DOING~~ECompression of morbidity
Hypothetical present morbidity
0 80
Scenario 1 - Extension
0 85
Scenario 2 - Compression
0 85Impact 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, 2012Relative 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 servicesNelly 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
02Funding 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 REQUIREDCase Mix
• Development of DRGs and the Yale cost
model
– Focus on productivity
• Some major criteria
– Clinically meaningful
– Homogeneity of resource consumption
25interRAI • 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 wrongFive 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 careDescriptions 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 coordinatorCase 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
6.41To 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 evidenceWaikato 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 2011Canterbury • 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 daysSTART 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 stayA 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 GPDevelopment 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 managerTele-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 courseConclusion • 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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