Health of Older People Strategic Plan 2012-2017
Main cover photo - Courtesy of Ross Brown, Vision Media
Health of Older People Strategy 2012-2017
Contents Foreword 3 Executive Overview
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Goals and Objectives
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Summary of Standards and Recommendations
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A. Community health, prevention and information
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B. Person-centred care
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C. Integrated care and community services
9
D. Hospital care
10
E. Aged residential care
10
F.
Dementia and Mental Health in Older People 11
G. Stroke and TIA
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H. Falls and Bone Health
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I.
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Medications Management
Drivers for Change
13
Our ageing population
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Definition of “older people”
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Older people and healthcare costs
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Opportunities
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Underpinning Principles
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Services Covered by This Strategy
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Standards and Recommendations
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A. Community health, prevention and information Recommendations
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B. Person-centred care
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Culturally appropriate care
22
Tackling elder abuse
22
Advance care planning
23
Recommendations
23
C. Integrated Care and Community Services
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Integrated Care
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More flexible care in the community
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Needs assessment and service co-ordination
26
Recommendations
27
D. Hospital Care
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Intermediate Care
30
Allied Health
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Recommendations
31
E. Aged Residential Care
33
Recommendations
34
F.
Dementia and Mental Health in Older People 35
Promoting good mental health
35
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Early identification and treatment
35
Secure residential facilities
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Recommendations G. Stroke and Transient Ischaemic Attack (TIA) Preventing stroke Organised stroke services
37 37 38 38
Recommendations 38 H. Falls and Bone Health
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Preventing falls
39
Treating osteoporosis
40
Recommendations:
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I.
Medications Management
41
Medicines reconciliation
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Regular review of older people’s medicines
43
Recommendations
43
Delivery
44
Workforce
44
Recommendations
45
Implementation Plan and Next Steps
47
Supporting Information
48
Development of the Strategy
48
Background Documents
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Appendices 49
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Appendix 1: Terms and Abbreviations
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Appendix 2: Intermediate Care Service - Proposed Model
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Appendix 3: Measures of Success
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Appendix 4: Acknowledgements
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Foreword The New Zealand Health of Older People Strategy was published in 2002 and set out the Government’s policy for the future direction of health and support services for older people. It identified the need for significant change in the way services are provided and a framework for implementing those changes. Eight objectives were identified: 1. Older people, their families and whanau are able to make well-informed choices about options for healthy living, health care and/or disability support needs. 2. Policy and service planning will support quality health and disability support programmes integrated around the needs of older people. 3. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers. 4. The health and disability support needs of older Māori and their whanau will be met by appropriate, integrated health care and disability support services. 5. Population-based health initiatives and programmes will promote health and wellbeing in older age. 6. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. 7. Admission to general hospital services will be integrated with any community-based care and support that an older person requires. 8. Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and whanau carers for people who are disabled. Within these objectives, the Ministry of Health identified a number of key actions including:
• Strengthening the health workforce to meet the needs of an ageing population; • Integrated care between secondary services and community-based ones, including a single, comprehensive integrated assessment process; • Supporting older people to live in their own homes for as long as possible; • Better advance care planning, including palliative care when appropriate, for those in long term care; • The provision of a full range of culturally appropriate health and disability support services for older Māori. The Ministry of Health and District Health Boards are responsible for implementing this strategy. There is a growing recognition that population ageing is a significant factor in the Bay of Plenty. The district has one of the highest proportions of older people in New Zealand (Ministry of Health, 2007) and is projected to grow further. While the Bay of Plenty District Health Board (BOPDHB) has been a leader in developing innovative models of care and investing in services that support people to continue living in their own homes, the current fiscal climate has necessitated a re-think about how we can meet the demographic challenges of the future. The purpose of this document is to review current services for older people in line with the New Zealand strategy, current Government policy, international and New Zealand best practice, and identify and prioritise actions for local services to meet the challenges ahead. Given our ageing population, making savings or significant reductions in services for older people is unrealistic. However, implementation of this strategy will result in better management of the current and predicted rate of growth to levels that will be more sustainable in the future.
• Promoting positive attitudes towards older people; • Better information for older people and their carers; • A focus on health promotion and prevention, including physical activity, better nutrition, reduced social isolation, and falls prevention; • Early detection and better management of illness and chronic disease, including older people living in rural areas; • Processes to tackle elder abuse; • Provision of community-based rehabilitation, including a review of the need for Intermediate Care; • A review of specialist services for older people, including mental health services;
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Executive Overview It is preferable to keep older The Bay of Plenty’s population The number of people in the people independent and living is ageing, with the number of Bay of Plenty over 80 years is in their own homes for as long people aged over 80 predicted to as possible. This costs less and grow at a rate of approximately predicted to grow at a rate of is preferred by the vast majority 6% per annum. For New Zealand approximately 6% per annum. of service users. However, this as a whole, health expenditure Health expenditure requires a change in focus and consumed by older people is a different way of doing things. projected to increase from 40% in consumed by older people Increasing demand over time will 2002 to 63% in 2051. Most older is projected to increase from not be able to be met merely by people are well, independent 40% in 2002, to 63% in 2051. ramping up the existing systems and living in their own homes. of care. Systems need to change However, disease and chronic in order to respond to increased demand alongside a conditions are more common in old age. relative constriction of supply. The BOPDHB’s Board has identified that we need to This Strategy identifies nine standards that encompass live within our means, avoid duplication and consider the Government’s Health of Older People Strategy services “instead of” rather than “as well as”. However, (2002) as well as health problems that are particularly the current annual planning cycle is not fit for purpose significant for older people, namely: to address the impact and opportunities arising from an ageing population. Therefore, the purpose of this • Stroke; strategy is to provide an over-arching five year plan to • Falls and bone health; do this. • Dementia and mental health in older people; and • Medications management. Health of older people is a priority area for the Government and has been identified in the Minister’s In each of these areas, timely intervention by Letters of Expectations for the last two years. The evidence-based services reduces long-term needs and BOPDHB’s Board has also identified health of older healthcare costs, but these services are not uniformly people as a priority, and aims to be proactive in the available and access to them can be haphazard. management of services for the future given the predicted population increase and the associated high cost of care for this group. Minister of Health’s Letters of
Better care; better value
Expectations
The Minister of Health each year outlines his expectations for District Health Boards in his Letter of A great deal of evidence exists that better quality Expectations, which enables us to plan and prioritise health and disability care for older people can result activity for the coming year. In the 2012/13 year, the in improved health outcomes and reduced projected Minister’s expectations reinforce the Government’s costs in the future. Healthcare in older people is more commitment to a public health system that delivers complex than in the young. What are, in fact, medical “better, sooner, more convenient” problems are often labelled as care and improves health inevitable consequences of “old Systems need to change in outcomes for patients within age” that cannot be treated. This order to respond to increased constrained funding increases. attitude leads to unnecessary demand alongside a relative All DHBs are expected to work disability and costs, and the constriction of supply. co-operatively with the Ministry opportunity for diagnosis, of Health on implementing the treatment and rehabilitation is Government’s commitments. lost.
1 Stats NZ DHB Forecast Sep 2011. 2 Ministry of Health. Population Ageing and Health Expenditure: New Zealand 2002-2051.
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Particular expectations for older people include better engagement with primary / community care to develop integrated services for older people that support their continued safe, independent living at home, especially after hospital discharge, and an emphasis on developing organised stroke services and better dementia care.3
CARE – Compassion, Attitude, Responsiveness and Excellence
Our vision Healthy, thriving communities Kia Momoho Te Hāpori Ōranga Our mission Enabling communities to achieve good health, independence and access to quality services. Our values - CARE Compassion, attitude, responsiveness, excellence.
The Board reviewed the BOPDHB’s values and chose CARE as our values acronym – “Compassion, Attitude, Responsiveness and Excellence”. CARE reflects values of importance to the DHB. The Runanga has affirmed He Pou Oranga Tangata Whenua4 (HPO) and believes there is good alignment between the HPO principles and CARE.
This Strategy Each standard in this Strategy links to the eight objectives and actions in the Government’s national Health of Older People Strategy, the Minister’s priorities, and the Board’s values, and sets out relevant background information, the evidence-base where this exists, examples of good practice in the Bay of Plenty and elsewhere, and the case for change. A set of recommendations follows. This Strategy does not include an implementation plan and it is recommended that one is developed as part of our next steps to achieve the Strategy’s objectives (see Chapter 10 – Implementation plan and next steps). It is envisaged that, while this document will form a basis for the strategic direction for health of older people services, it will be reviewed annually to ensure its assumptions and recommendations remain valid and up to date.
3 By letters dated 26 January and 3 February 2012. 4 HPO represents the culmination of over two years of consultation, workshops, hui and development work between Te Runanga Hauora o Te Moana a Toi (the Māori Health Runanga), the BOPDHB, whanau, hapu, Iwi, the health sector and the wider community of the Bay of Plenty (Te Moana a Toi). HPO provides a conceptual framework for Toiora: optimum health and well-being, that is acceptable to the collective of Iwi within Te Moana a Toi.
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Goals and Objectives Goal The goal of this Strategy is to provide direction to the Bay of Plenty health and disability sector for the next five years by, in collaboration with our stakeholders, identifying areas where the DHB intends to focus its time, energy and resources. The content of this Strategy will also inform our Annual and Regional Plans.
Objectives The objectives of this Strategy are to provide quality health and disability services for our growing older population that:
Our goal is to provide direction to the Bay of Plenty health and disability sector for the next five years by, in collaboration with our stakeholders, identifying areas where the DHB intends to focus its time, energy and resources.
• Promote, improve, and support healthy, independent and dignified ageing; • Have an integrated approach across the continuum of care; • Reduce the demand on related high cost service expenditure to levels that can be sustained within current financial constraints; • Reduce duplication in the health system; • Are simple, streamlined and efficient.
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Summary of Standards and Recommendations Listed below is a summary of the standards and recommendations. The full version and associated commentary is covered in Chapter 8. A. Community health, prevention and information 1. Promote risk assessment for all people over the age of 75 years. 2. Promote proactive risk stratification for all those who have not received an InterRAI assessment. 3. Introduce targeted interventions for those at highest risk to avoid or reduce health deterioration and subsequent hospital admission and/or dependence on residential care. 4. Provide older people and their carers with clear and accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change. 5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB. 6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the World Health Organisation (WHO) Global Age-Friendly Cities Guidelines. Provide advice and expertise on population ageing through representation on the Population Ageing Technical Advisory Group, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required. 7. Actively contribute to the review of the SmartGrowth Strategy5 in the Western Bay of Plenty and make advice available to local government in the Eastern Bay of Plenty.
B. Person-centred care 1. Review any existing “blanket” upper age-limited BOPDHB policies that may be barriers to older people accessing appropriate services, particularly for Māori.
2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person-centred care. 3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse. 4. Enhance access to health services for older Māori through a knowledge exchange between Māori and mainstream providers to support mainstream responsiveness. Increase capacity and capability to meet the health and disability needs of older Māori and their whanau by promoting training targeted to the Aged Care and non-regulated health and disability workforce. 5. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co-operative Guidelines and training programme.
C. Integrated care and community services 1. Progress integrated models of care. Evaluate outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay Primary Health Alliance (EBPHA) Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team (SLAT) pilot on stratified assessment in primary care) to inform recommendations for further structural changes to primary care. 2. Develop specific Bay Navigator pathways that are relevant to older people e.g. falls prevention, osteoporosis, dementia, Transient Ischemic Attack (TIA), ie stroke. 3. Improve access to specialist advice by primary care. 4. Promote and support education for aged residential care and home and community support providers by primary care. 5. Implement a redesign of home and community support services in conjunction with the Midland Region DHBs as part of a regional project to a restorative model of care. Consider changes the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate.
5 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The programme is being led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with community groups and government agencies such as the NZ Transport Agency. The context for the Strategy is a sub-region facing long term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues and protection of the core values that make the sub-region such a desirable place to live, work and play. A review of the SmartGrowth Strategy commenced in 2011.
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6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge. 7. Consider implications arising from amending the current criteria for access to service assessed and co-ordinated by Support Net by removing the requirement for a disability lasting longer than six months. 8. Review needs assessment and service co-ordination (NASC) functions carried out by district nursing for short term support services. 9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with the national business case and implementation plan. 10. Review funding and contracts for provision of NASC services in light of recommendations above. 11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read-only access to InterRAI to home and community support providers. 12. Develop a seamless user-friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.
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6.
7.
8.
9.
workforce, provide essential specialist services to Whakatane and expand existing community work, education, “in-reach” services, advice and education to support primary and community care, service and pathway development and outpatient capacity. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver Comprehensive Geriatric Assessment in the future. Make better use of existing resources by developing different, cost effective, evidence-based models of care such as increased community rehabilitation or “Intermediate Care” Make funding provisions to increase the numbers of beds for specialist Geriatric Medicine services in line with national recommendations for the proportion of beds to the population of the Bay of Plenty and the planned redevelopment of Tauranga Hospital by 2017. Implement better communication between secondary and primary care on discharge from hospital, so that any Comprehensive Geriatric Assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.
D. Hospital care
E. Aged residential care
1. Specialist Services for Older People are developed in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health, 2004). 2. Expand the specialist geriatric workforce to recommended levels (including geriatricians, registrars and junior medical officers, nursing and allied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for Specialist Health Services for Older People to work within acute medical, surgical and orthopaedic services. 3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler for a number of recommendations in this Strategy. 4. Develop an acute geriatric ward in addition to the existing 39-bed (Health In Ageing) HIA unit, which would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a condition with significant mortality and morbidity). This is also an enabler to develop an organised stoke service (refer to Section G). 5. Through the provision of expanded geriatric
1. Plan and budget appropriately for the forecast growth in demand in aged residential care. 2. Manage demand on scarce high cost resources by developing new flexible, integrated and restorative models of care with Aged Residential Care (ARC) e.g. short term care, Intermediate Care, integrated community facilities. 3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D) 4. Fund and support roll out of the InterRAI Long Term Care Tool (refer to Section C) in ARC in accordance with the national business case. 5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service. 6. Streamline contracts and auditing processes to reduce compliance costs. 7. Consider ways in which Primary Care and Aged Residential Care can identify those nearing the end of their lives and offer/implement Advanced Care Planning.
F. Dementia and Mental Health in Older People 1. Promote recognition and assessment of mental health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia. 2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities. 3. Improve access to specialist advice and support for community providers. 4. Improve support to primary carers of people with dementia through education and training and a range of flexible respite, day and home based support options. 5. Introduce training requirements in service specifications for home based support services where staff work with people with dementia. 6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator. 7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the next five years and make appropriate budget provision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the Western Bay of Plenty and Eastern Bay of Plenty. 8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular reassessments of people to identify changes in levels of need. 9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care. 10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatric units and support existing providers to improve quality of care and environment.
G. Stroke and TIA 1. Complete the development of a TIA pathway through Bay Navigator. 2. Establish an organised stroke service – see Section D on the development of an acute geriatric ward. 3. Increase the number of specialist geriatric medicine workforce to provide appropriate treatment of TIAs and Stroke – see Section D.
4. Continue with on-going specific thrombolysis training for Emergency Department (ED) and general medical registrars/consultants in accordance with international best practice. 5. Develop a BOPDHB stroke guideline that sets out how the national New Zealand Clinical Guidelines for Stroke will be implemented locally.
H. Falls and Bone Health 1. Assess the impact of Accident Compensation Corporation’s withdrawal of funding for falls prevention programmes for older people. 2. Promote a population-based falls prevention strategy for older people, including the identification of those at risk of falls living in their own home or in care homes. 3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis. 4. Develop a specialist falls service for people with recurrent falls, “unexplained falls” or dizziness. Assess how this could work across the Bay of Plenty, working with GPs in more rural areas. 5. Implement a falls pathway through Bay Navigator that facilitates the evidence-based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care. 6. Implement an osteoporosis pathway through Bay Navigator that links with the falls pathway, facilitating the evidence-based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.
I. Medications Management 1. Adopt Health Quality and Safety Commission (HQSC) national medication safety programme for identification of high risk patient populations and provide Medicines Reconciliation for all patients identified as high risk of admission to hospital in the BOPDHB region. 2. Develop the role of Clinical Pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including (ARC). This will include medication reconciliation for complex patients on transfer of care or discharge. 3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers). 4. Participate in the development of medication management processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.
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Drivers for Change Our ageing population New Zealand is an ageing society. The Western Bay of Plenty’s warm sunny climate and pleasant coastal geography have provided an attractive retirement destination for many decades. The district experiences one of the highest proportions of older people in New Zealand and the annual growth rate is the highest in the Midland region. Our population of people aged over 65 is projected to grow by 84% in the 20 years between 2006 and 2026, the majority in the Western Bay of Plenty.6 However, the populations of rural or smaller towns in the Bay of Plenty, particularly the Eastern Bay of Plenty, while declining are also ageing. By contrast, the Eastern Bay of Plenty has a high Māori birth rate and a relatively high proportion of people aged less than 20 years. In 2011, the number of people in the BOP aged over 65 was approximately 37,500. Of particular importance is the estimated number of people aged over 80 that is predicted to grow at a rate of approximately 7% per annum, from less than 3,000 in 2006 to 35,000 in 2050 (see Figures 1 and 2).
BOPDHB Forecast Annualised Growth Rate:2006-2026 [SOURCE: Stats NZ DHB Forecast September 2011] 8% 7%
6.94%
6% 5% 4% 3% 2%
4.07% 3.23%
3.73%
3.45%
1% 0% 65-69
70-74
75-79
80-84
85+
Figure 1
BOPDHB Forecast Annualised Growth Rate:2006-2026 [SOURCE: Stats NZ DHB Forecast September 2011]
Most older people are well, independent and living in their own homes. However, as a group they have a much greater need for health and disability services than the young, so a significant proportion of health and social care resources are directed at their needs. Disease and chronic conditions are more common in old age. The (WHO) describes care for chronic conditions as being “the health care challenge of this century” with such conditions currently responsible for 60% of the global burden of disease.7 It recommends a new approach that integrates health and welfare services, connects families and communities, and the development of programmes that delay the onset of disability, ameliorate its trajectory and enhance older people’s capacity to take better care of themselves. Other factors driving the need for change include: • People with complex health needs are living longer; • The growing number of people living with dementia; • Increased utilisation of Māori as a result of more appropriate and culturally responsive services; • Changing family structures, with more people living alone with little or no family support, or carers who are themselves elderly. Society has changed - retirement is no longer seen as a preparation for decline. Older people are active participants in society and attitudes towards ageing are changing. However, for frail older people in particular, there are reports of poor, and in the worst cases, discriminatory, services. This is usually inadvertent, a result of failure to keep pace with advances in the capacity of professionals to make a difference. What are in fact medical problems are often labelled as inevitable consequences of “old age” that cannot be treated. Such attitudes are exemplified in specific areas such as the lack of access to specialist geriatric care, rehabilitation and stroke services.
4% 3.96%
3% 2% 1% 0%
0.60% Under 65s
Over 65s
Figure 2
6 Statistics New Zealand DHB Forecast: September 2011. 7 Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva World Health Organisation; 2002.
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Definition of “older people”
• Entering old age – people who have completed their career in paid employment and/or child rearing. This is a socially-constructed definition of old age, but generally means retirement age (over 65). These people are usually active and independent and many remain so. The goals of health and disability services are to promote and extend healthy, active life, and to “compress morbidity” (the period that may be spent in frailty and dependency before death). • Transitional phase – people who are in transition between healthy, active life and frailty. This transition often occurs around age 75-85 but can occur at any stage. The goals of health and disability services are to identify emerging problems ahead of crisis, and ensure effective responses that will prevent crises and reduce longterm dependency. • Frail older people – people who are vulnerable as a result of several interacting health problems and disability. Frailty is often, but not necessarily, experienced in late old age (over 85), so services for older people should be designed with their needs in mind. The goals of health and disability services are to anticipate and respond to problems, recognising the complex interaction of physical, mental and social care factors, which can compromise independence and quality of life.
Millions
$10 $5 $0 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Actual Actual Actual Actual Actual Forecast Budget
Figure 3
BOPDHB - Residential Care: Rest Home Expenditure $20 $18 $16 $14 $12 $10 $8 $6 $4 $2 $0 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Actual Actual Actual Actual Actual Forecast Budget
Figure 4 However, hospital level care has grown by 65% (cost and volume) over the same period (see Figure 5), reflecting the fact that people are either entering residential care at higher levels or have changing needs. The total cost of residential care in the Bay of Plenty was $44 million in the year ending June 2011.
Older people and healthcare costs
BOPDHB - Residential Care: Hospital Expenditure Millions
In New Zealand, expenditure on personal health and disability support for the over 85s is the highest for any age group with a yearly per capita expenditure of $13,640 for women and $12,144 for men (2006 figures). Our ageing population has obvious and serious implications for health services in the future.
$20 $15
Millions
Older people are not a uniform group and they have a wide range of needs. They may be broadly seen as three groups:
BOPDHB - Home Support Expenditure $25
$40 $35 $30 $25 $20 $15 $10 $5 $0
In 2011, there were approximately 5,900 people a year receiving long term support services funded by BOPDHB. Of these, approximately 1,500 people were in full time residential care at any one time. Of these, 770 are at rest home level, and 740 at hospital level. Rest home level care total expenditure (volume and cost) has grown by only 2.6% over the last five years reflecting our increased investment in home and community support services (see Figures 3 and 4).
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2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Actual Actual Actual Actual Actual Forecast Budget
Figure 5
The report Population Ageing and Health Expenditure: New Zealand 2002-2051, published by Public Health Intelligence, Ministry of Health, predicts that the share of total Government health expenditure consumed by older people is projected to increase from 40% in 2002 to 63% in 2051. Population ageing will drive increased health expenditure because per capita health expenditure is strongly related to age. In the BOPDHB, older people account for the largest increase in hospital admissions. In 2010 in Tauranga hospital, 63% of all acute and elective medical admissions were in people aged over 65. Of these the majority of patients were aged 75-84. In 2011, a team of specialists in Geriatric Medicine performed a snapshot audit of in-patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services.
Opportunities Due to medical advances we have gained an extra 20 years of life expectancy. There is a need to know more about advanced age as the oldest age group is the fastest growing and disability and dependence restricts quality of life and results in excess health and welfare spending. Life and Living in Advanced Age a Cohort Study in New Zealand (LILACS NZ), is a longitudinal cohort study enrolling those in the top survival group: aged 85+ for non-Māori and 80-90 years for Māori looking at the health and well-being of 1200 elderly people in the Bay of Plenty region. Early findings from the study are due out this year and can inform our Strategy further. Older people are a resource for their families, communities and economies in supportive and enabling living environments. The (WHO) regards active ageing as a lifelong process shaped by several factors that alone and acting together favour health, participation and security in older adult life. Active, civil and social engagement factors have been shown to be key influences on an older person’s health. Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible. A review of the SmartGrowth Strategy – 50 year growth strategy for the Western Bay of Plenty, has identified population ageing as a key factor shaping our region and the necessity for a collaborative multi-agency approach to planning. Local Government policies and plans are beginning to reflect an awareness of their
ability to influence positive ageing.
Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible. Advancements in technology, telecare and telemedicine are being used to complement models of care. In the Eastern Bay of Plenty, the Better Sooner More Convenient (BSMC) primary care business case is using telemedicine to assist with the management of older people with chronic health conditions in remote or rural areas. Learnings from the initial pilot can be used to inform our strategy further. Māori have the highest relative growth rate of all populations for people age over 65. Strategic direction for services for older people and other mainstream/ national directions are in line with many traditional Māori values. Kaupapa Māori providers have often developed services in relative isolation from the mainstream, using innovation and knowledge of their people. There are opportunities for Māori providers to share their knowledge for the development and responsiveness of mainstream services. There are numerous positive developments nationally, regionally and locally that impact on services for older people. The Ministry of Health is currently developing a new service specification for home and community support services that has a restorative focus, includes enhanced training requirements for support workers, includes compliance against Home and Community Sector Standards, and allows for a flexible purchasing model. The service specification is scheduled to be complete and ready for use by October 2012. A number of integration initiatives across and secondary and primary care services are taking place resulting from the Government’s Better Sooner More Convenient Primary Care policy, including the Eastern Bay of Plenty which has a focus on the management of people with complex chronic conditions. Promotion and support of the Whanau Ora approach to service delivery and integrated contracts provide opportunities for holistic, client and whanau centred service delivery.
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There is further work being developed nationally arising from the Grant Thornton Aged Residential Care Services Review 2010. We can learn from various developments and pilots to inform our work further. The BOPDHB has been a leader of many developments in services for older people, providing us with an excellent foundation on which to further develop the recommendations in this Strategy. Examples include the use of the InterRAI Tools for all assessments of older people for long term support services; the implementation of the Community Response Team focusing on admission avoidance; establishment of a model for flexible restorative home based support services; and Kaupapa Māori early intervention and support services including dedicated respite care.
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Underpinning Principles This strategy has been developed with the following principles in mind: 1. Treaty of Waitangi – recognition of the Treaty of Waitangi as the founding document of New Zealand and acknowledgement of Treaty principles, that Māori will have an equal role in developing and implementing health strategies for Māori.
The Bay of Plenty District Health Board’s vision for older people is: ‘healthy, independent and dignified ageing’.
2. Promoting health in older age – focus on a wellness model that takes into account all the factors affecting an older person’s health, including strengthening local authority and community liaison through promotion of “Age Friendly Communities”, “Positive Ageing” and “Whanau Ora” strategies. 3. Person-centred – older people are respected, treated with dignity, and all adult service development and reconfiguration is executed with the needs of older people in mind.
8. Collaboration and partnership – the knowledge and experience of older people, their families and whanau, and people working in services will be valued and utilised in all planning and implementation. 9. Evidence-based – initiatives and service redesign will be evidence-based and take in to account examples of innovation and good practice elsewhere. 10. Leadership – the opportunities and implications of population ageing require the highest levels of leadership in all service providers.
4. “Ageing in place” – the place that is the most appropriate for an older person to live is usually their own home. If required, access to high quality aged residential care is available and health service access for those residents is equitable. 5. Integration – services will be co-ordinated and work together so that older people receive the right service from the right provider, first time. 6. Preventative and restorative – a strong focus on preventing illness and injury occurring or getting worse through health promotion, early treatment and access to rehabilitation. 7. Best use of resources and living within our means – we are operating within a tighter financial framework and our rate of funding growth has significantly reduced. We consider the most efficient and innovative use of resources within a constrained fiscal environment, avoid duplication and consider services “instead of” rather than “as well as”.
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Services Covered by This Strategy Existing health of older people services for the BOPDHB generally refers to specialist health services for older people and long term disability support services for those aged over 65 (or those over 50 with age-related needs). These are:
Specialist health services • • • • • • •
Primary care DHB Allied Health District nursing Pharmacy Mental Health Services for Older People Palliative care Department of Health in Ageing (based at Tauranga Hospital)
Long-term disability support services • Needs Assessment and Service Co-ordination • Home based support services – generally includes home help and personal care • Limited short term support services following an admission to hospital • Day services • Kaumatua and Kuia Early Intervention Services • Respite care and carer support • Information and advocacy services such as Alzheimers Tauranga, Stroke Foundation, and Age Concern. • Accredited visiting services • Aged residential care
However, this Strategy is not restricted to current and existing service provision and it is recognised that the preferred model is one that supports health and wellbeing with a focus on prevention.
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Standards and Recommendations A. Community health, prevention and information National Strategy Population-based health initiatives and programmes will promote health and wellbeing in older age. Older people, their families and whanau are able to make well-informed choices about options for healthy living, health care and/or disability support needs.
A framework for promoting active ageing has been developed by the (WHO) known as the Global AgeFriendly Cities Guidelines. Strong evidence exists that by developing policies and promoting activity that promotes active ageing, reductions in functional decline in older people can be achieved and thereby reducing dependency on funded disability support services. Below is an extract from the guidelines:
“These determinants have to be understood from a life course perspective that recognises that older people are not a homogeneous group and that individual diversity increases with age. This is Older people will have timely access to expressed...[see Figure 7 below] which illustrates that primary and community health services that functional capacity (such as muscular strength and proactively improve and maintain their health cardiovascular output) increases in childhood, peaks and functioning. in early adulthood and eventually declines. The rate of decline is largely determined by factors related to There is a growing body of evidence to suggest that lifestyle, as well as external social, environmental and modification of risk factors for disease even in old economic factors. From an individual and societal age can have health benefits for the individual with perspective, it is important to remember that the speed increased or maintained levels of functional ability as of decline can be influenced well as disease prevention.8 and may be reversible at any “…an age-friendly city is not age through individual and Active ageing depends on just ‘elderly friendly’. Barrierpublic policy measures, such as a variety of influences or promoting an age-friendly living free buildings and streets determinants that surround environment. enhance the mobility and individuals, families and whanau. independence of people with They include material conditions Because active ageing is a disabilities, young as well as as well as social and health lifelong process an age-friendly factors (see Figure 6). old.” city is not just ‘elderly friendly’. Barrier-free buildings and streets enhance the mobility and independence of people with disabilities, young as well as old.
Figure 6 – Determinants of Active Ageing9
Secure neighbourhoods allow children, younger women and older people to venture outside in confidence to participate in physically active leisure and in social activities. Families experience less stress when their older members have the community support and health services they need. The whole community benefits from the participation of older people in volunteer or paid work. Finally, the local economy profits from the patronage of older adult consumers. The operative word in age-friendly social and physical urban settings is enablement.”
8 British Geriatric Society: Compendium of Guidelines. BGS, London, 1997. 9 World Health Organisation Global Age-Friendly Cities Guide
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Figure 7 – Kalache & Kickbusch Activities that promote healthy active life for older people include: • Wider multi-sector initiatives to promote “positive ageing”: health, well-being and independence in old age; • Optimising the opportunities for health, participation and security in order to enhance quality of life ; • Recognising the wide range of capabilities and resources among older people, and respecting their decisions and lifestyle choices; • Protecting those who are most vulnerable; • Promoting inclusion of older people and their contribution to all areas of community life ; • Access to mainstream health promotion and disease prevention programmes; • Health promotion activities of specific benefit to older people, tailored where necessary to reflect cultural diversity. The WHO Global Age-Friendly Cities recommends a programme of development that encompasses eight characteristics of age-friendly communities: transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support and health services, outdoor spaces and buildings. The BOPDHB and SmartGrowth have collaborated to establish the Population Ageing Technical Advisory Group (PATAG) which advises its two partners on the opportunities and issues related to population ageing. The BOPDHB, through PATAG, promotes the WHO Global Age-Friendly Cities programme and
development of policies, structures, environment, services and policies that reflect the determinants of active ageing. Older people benefit also from increasing physical activity, improved diet and nutrition, and immunisation programmes for influenza. They also benefit from specific strategies to prevent falls and their consequences and to prevent stroke.10 Many older people and their carers are poorly informed about their health problems, often assuming they are inevitable consequences of old age, an attitude sometimes reinforced by health professionals and carers. They may be unaware of what services are available to help them remain healthy and independent in their own homes. Adult children and whanau members are not necessarily well prepared to become carers of their parents later in life. For example, knowing what is important for older people to maintain function and independence, and being able to recognise a treatable medical condition. By learning to care for an older person, people also learn about how to care for themselves as they move into older age. Because unpaid carers, family and whanau make up the vast majority of carers for older people, investment in education for this group would have far reaching benefits. Health promotion for older people is not specifically funded through Public Health Units so solutions would need to be found locally. International research shows that poor health literacy is linked to poor health status and may also be a strong contributor to health inequalities. Māori aged 50-
10 National Institute for Health and Clinical Excellence (NICE). The assessment and prevention of falls in older people. Clinical Guideline 21, 2004 and Stroke Foundation/New Zealand Guidelines Group. New Zealand Clinical Guidelines for Stroke Management, 2010].
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65 years have significantly lower skills to obtain, process and understand basic health information in order to make informed and appropriate health decisions compared to non-Māori.11 Health literacy is broadly defined as someone’s ability to get and use basic health information needed to make good health decisions. It’s more than about the ability to read and write; it is about understanding a range of health messages, from mass media campaigns to what a doctor or nurse prescribes, and even correctly following instructions on medicine labels. It also includes health professionals giving clear and appropriate messages, and health services being user-friendly. The introduction of proactive care for those at highest risk is arguably the most significant change and has the potential to result in the greatest impact. Identification of those at highest risk should occur to ensure that resources are intensified for those at greatest risk. This is known as proportional universalism. A two pronged approach is recommended. • Proactive: Risk stratification for those at highest risk (various tools exist some of which are self administered); and • Reactive: use of InterRAI (which requires trained health care professionals to administer). It is acknowledged that risk assessment is not an intervention but an identification tool therefore intervention is required to manage risk. The provision of intermediate care referred to later in this Strategy to manage risk is an essential component to this model. In alignment with the Government’s policy of Better, Sooner, More Convenient healthcare, if the care required is not acute or highly specialised, then the care provision should be in primary care. There are a number of ways that enhanced intermediate care can be provided and various recommendations are made within the Strategy. However, the majority of intermediate care provision will need to come from realignment of existing resources and as appropriate a transfer of resources from secondary to primary where a greater impact at the same or reduced cost is anticipated. In essence, this Strategy recognises the imperative to
stratify and manage risk providing increasing intensity (such as intermediate care) for those at highest risk. This should ensure effective usage of scarce resource and aligns with the Strategy’s objectives.
Recommendations 1. Promote risk assessment for all people over the age of 75 years. 2. Promote proactive risk stratification for all those who have not received an InterRAI assessment. 3. Introduce targeted interventions for those at highest risk to avoid or reduce health deterioration and subsequent hospital admission and/or dependence on residential care. 4. Provide older people and their carers with clear and accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change. 5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB. 6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the WHO Global Age-Friendly Cities Guidelines, Provide advice and expertise on population ageing through representation on the PATAG, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required. 7. Actively contribute to the review of the SmartGrowth Strategy12 in the Western Bay of Plenty and make advice available to local government in the Eastern Bay of Plenty. 8. Promote physical activity, better nutrition (including increased calcium and vitamin D) and annual influenza vaccines for older people through public education and collaboration with Primary Care and Aged Residential Care. 9. Promote health literacy and education (both formal and informal) for older people and unpaid carers. Work with education providers and other agencies to develop targeted education and training programmes for families and unpaid carers.
11 Tatau Kura Tangata: Health of Older Māori Chart Book. 12 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The programme is being led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with community groups and government agencies such as the NZ Transport Agency. The context for the Strategy is a sub-region facing long term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues and protection of the core values that make the sub-region such a desirable place to live, work and play. A review of the SmartGrowth Strategy commenced in 2011.
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B. Person-centred care National Strategy Policy and service planning will support quality health and disability support programmes integrated around the needs of older people. The health and disability support needs of older Māori and their whanau will be met by appropriate, integrated health care and disability support services. Older people and their carers should receive person-centred care and services which respect them as individuals and are arranged around their needs. Person-centred care requires managers and professionals to: • Listen to older people; • Recognise individual differences and specific needs including cultural and religious differences; • Communicate in ways that meet the needs of all users and carers, including those with sensory impairment, physical or mental frailty, or those whose preferred language is not English; • Respect their dignity and privacy, meeting personal hygiene needs sensitively • In hospital, if patients choose to wear their own clothes, enable them to do so; • Support those with a long term illness or disability and their carers to develop expertise in their own care; • Enable older people to make informed choices, involving them in all decisions about their care; • Involve and support carers whenever possible; • Recognise the signs of possible elder abuse and take action if necessary. Denying access to services on the basis of age alone is not acceptable. Decisions about treatment and health care should be made on the basis of health needs and ability to benefit rather than a patient’s age alone.
traditional practices strengthens the spiritual and cultural dimensions of kaumatua contributing to overall well being. Māori comprise 14% of the total population and 2% of those over 80 years. However, they have the highest relative growth rate of all populations for people aged over 65. Of those Māori who reach age 75, many have multiple health problems but may not have readily available whanau to care for and support them due to migration of whanau members from rural to urban areas, often for employment. This leads to disparities in both longevity and disability levels for Māori. Demographic projections suggest that Māori people can expect to live longer than currently, potentially expanding the population of Māori living to advanced age and increasing the disparities in disability. Strategic direction for services for older people and other mainstream/national directions are in line with many traditional Māori values. Kaupapa Māori providers have often developed services in relative isolation from the mainstream, using the innovation and knowledge of their people. There are opportunities for Māori providers to share their knowledge for the development and increased responsiveness of mainstream services.
Tackling elder abuse Abuse of an older person is defined as any pattern of behaviour that causes physical, psychological or financial harm. It can be intentional or unintentional. Abuse or neglect occurs in a relationship of trust and anyone with a long-term disability is at increased risk. Institutional abuse occurs when an institution actively or passively allows, or accepts, any form of abuse or neglect to occur. This may arise from the action or inaction of an individual as an employee, or it may be embodied in organisational systems that fail to provide adequately for the safety and well being of individual patients or service users.
The BOPDHB has a clinical policy in place: “Older Person – Abuse We acknowledge that Māori Kaumatua are very important and Neglect Management and develop age-related conditions Reporting”, supported by an Elder in the leadership echelons of at an earlier age than average Abuse Co-ordinator. Any staff Māoridom and Iwi. and that there are disparities and member who suspects abuse inequalities in access to support or neglect of an older person, or and health services by Māori. to whom abuse/neglect is disclosed, has a mandatory responsibility (now a legal requirement) for reporting of Kaumatua are very important in the leadership that abuse. The policy outlines ten principles of adult echelons of Māoridom and Iwi. As such, programmes protection services to help guide decision making, that are culturally strong that can provide Māori models and outlines what action should be taken either in an within service delivery are an essential part of the emergency, or in a non-urgent situation. support system of kaumatua. Drawing strength from
Culturally appropriate care
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Advance care planning
Recommendations
Advance care planning (ACP) is a voluntary process of discussion and review to help individuals (who have the capacity to do so) who have been diagnosed with a terminal illness anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment and / or an advance decision to refuse a treatment in specific circumstances. These can be referred to by those responsible for their care or treatment (whether professional staff or family or carers) in the event that they lose their capacity to participate in decision making once their illness progresses. Primary care is encouraged to identify its patients nearing the end of life so that the wishes of the patient and their family are identified and systems put in place to allow appropriate care to happen when the time comes.
1. Review any existing “blanket” upper age-limited policies in BOPDHB that may be barriers to older people accessing appropriate services, particularly for Māori. 2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person-centred care. 3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse. 4. Enhance access to health services for older Māori through a knowledge exchange between Māori and mainstream providers to support mainstream responsiveness. Increase capacity and capability to meet the health and disability needs of older Māori and their whānau by promoting training targeted to the Aged Care and non-regulated health and disability workforce. 5. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co-operative Guidelines and training programme.
In New Zealand the Advance Care Planning Cooperative has developed a guideline for the New Zealand healthcare workforce in response to the increasing focus on the need for clear and accurate information and guidance regarding advance care planning. The intended audience encompasses providers, funders and planners in all areas of health care. Training tools which have been developed are intended for health professionals. Formal outcomes of advance care planning might include one or more of the following: • Advance statements to inform subsequent best interests decisions; • Advance directives which are legally binding if valid and applicable to the circumstances at the time; • Appointment of a Power of Attorney (“health and welfare” and/or “property and affairs”). Not everyone will wish to make such records. But for those who have the capacity and desire to participate, advanced care planning can be an integral part of the wider care planning process. The BOPDHB has endorsed the principles and approach developed by the Advance Care Planning Cooperative for use throughout the DHB where appropriate.
C. Integrated Care and Community Services National Strategy Policy and service planning will support quality health and disability support programmes integrated around the needs of older people. Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and whanau carer needs.
Funding and service delivery will promote timely access to quality integrated health and disability support It is recognised that primary, services for older people, family, whanau and carers. community focused, fully
integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients.
Integrated Care
The majority of medical care for older people is carried out in general practice. It is recognised that primary, community focused, fully integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients.13
13 Starfield, B, 2005, World Health Organisation, 2008. 14 Report to the Ministry of Health on Integrated Care Initiatives in selected New Zealand Health Networks – Baird, J & Smith, P: Nov. 2011
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While there is no single accepted definition of integrated care, most definitions include references to co-ordination, “complementarity”, seamlessness and continuity for the client.14 Disease and chronic conditions are more common in old age. As part of the Government’s plan for Better, Sooner, More Convenient (BSMC) Primary Health Care, the (BSMC) Eastern Bay of Plenty Business Case has, as one of its priorities, a focus on chronic disease management. A pilot being conducted by Te Whiringa Ora in the Eastern Bay of Plenty is developing a model of care that reflects connectivity and integration between primary and specialist services and case management for people with multiple chronic conditions who are rural or isolated and have had frequent admissions to hospital. Early results support the use of telemedicine for patient monitoring, encouraging self-management and using a holistic model of case management and support. The Midland Health Network Older Person’s Service Level Alliance Team (SLAT) is piloting a number of initiatives across the continuum of care for older people. In the Western Bay of Plenty, Bay Navigator is being developed as an online access point for clinical
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staff across primary and secondary care, enabling them to follow evidence-based clinical guidelines that deliver better outcomes for patients. For example, by following the new Bay Navigator TIA (transient ischaemic attack) Guideline, eight out of 10 strokes following a TIA can be prevented, with an approximate saving of $2.5 million per annum in the BOP alone. While the lessons and outcomes from these initiatives are still emerging, they are demonstrating a shift to a greater degree of primary care-based proactive management. The reason why there is a significant opportunity for improvements in efficiency is that the patients being targeted by integrated care account for significant costs. If collaborative, targeted and intensive care of older people and those with long term conditions can be implemented (with the consequential reduction of avoidable hospital admissions, lower spend on medicines and rest-home costs) then there will be significant benefits. Significant benefits can also be gained by improving the capacity and capability of general practice to be able to better identify, manage and support older people with long term conditions and avoid admissions to hospital. There is a range of ways that this can be achieved including:
• Population screening for targeted groups, such as people over the age of 75 for early detection and intervention; • Carrying out needs assessments for long term supports for older people; • Promoting screening and self-assessment; • Improving access to specialist advice via primary care. Primary care can also play a role in helping to support residential care and home and community providers through provision of training and education programmes, and developing better links with this sector. The Primary Nurse Liaison currently provides education available for staff of aged care providers to attend where appropriate. It is recommended that this is supported to continue.
More flexible care in the community In the last five years, in line with Government policy, the BOPDHB has been investing in strategies that improve older people’s ability to remain independent and living in their own homes. As a result, there has been an increase in the percentage of the eligible population over 65 that access home and community support services and a decrease in the percentage of the population in more expensive rest home level care. However, there is much still to be done. While considerable advances have been made in implementing a restorative model of care in home and community support services by the BOPDHB, the traditional model of care for older people is a disability support model. Currently the majority of home based support services (HBSS) in the Bay of Plenty, both long and short term, are delivered using a traditional model of service delivery, generally a task orientated approach and delivered in hours of support, with the minimum allocation being one hour. This time is allocated in a structured way (weekly, fortnightly etc) and is not flexible to meet individual or changing needs. Funding is uncapped, the growth in demand exceeds demographic growth and is not sustainable within current funding availability. A new approach is required. Illness, or exacerbations of chronic disease, often has functional consequences in older people, but they do not necessarily need to be admitted to hospital if they can be assessed in their own home, treated, and temporary additional support put in place. The most common reasons for avoidable admission to hospital are: • Falls and minor injuries/fractures; • Mild exacerbations of a chronic disease; • Minor infections;
• Gradual (and predictable) inability to cope at home – reaching a crisis point. Sometimes older people do need to be in hospital and they do have a right to a medical diagnosis. However, access to a General or Nurse Practitioner can be difficult, especially out of hours. The Ministry, in its Health of Older People Strategy, has committed to assessing options to reduce cost barriers for older people accessing primary health care. However, many older people are admitted to hospital unnecessarily because of the lack of alternatives. Currently HBSS contracts are not flexible enough to allow for intensive support periods when they are required without reassessment and sometimes lengthy delays. This often results in an unplanned admission to hospital via the Emergency Department. Rather than the traditional emphasis on household tasks and personal care, a more tailored response using a restorative approach and endorsing a wider variety of interventions/services that support a return to independence is both valued by service users and has benefits longer term across the health system. HBSS can also play a vital role in supporting people to remain living in their own homes rather than moving to an Aged Care facility, thus alleviating some of the shortfall in residential care/nursing home beds. National and regional work in line with this thinking includes the development of a new national service specification by the Ministry of Health that promotes a restorative approach across the board. Alongside this, Auckland University has developed a system to determine “case mix” which can be used to set eligibility and the service delivery approach. The case mix model is useful for tailoring the response to different client groups and early outcomes are that there are opportunities for improved efficiencies by providers. The temporary nature and urgent requirement to provide intensive services to some older people would appear to sit well within the restorative bulk funded model of care, but in reality it does not. Older people requiring additional support have the propensity to dominate service provision/resources from the providers – who understandably wish to reduce their care (and therefore their on-going costs) as soon as possible. This can lead to hospital admission/readmission, over utilisation of allied health services or admission to a residential care facility, compounding the problem and wasting resources. In reality intensive services are better “ring fenced” within a small and uniquely funded contract with clear expectations, auditable outcomes and provider accountability.
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The Midland DHBs15 propose to align their activity in this area to achieve efficiencies and streamline service delivery through a collaborative redesign project. This project includes a review the findings of a number of concurrent activities happening nationally including the Auckland Case Mix model, and a recent redesign project occurring in Capital and Coast DHB and changes recently implemented by the Accident Compensation Corporation in this area. The Midland project is in its early days, however the aligned regional approach is based on the following recommendations: • Services are delivered with a restorative approach across the board and are flexible and able to be delivered in smaller time slots; • Support workers are able to administer and supervise medications, deliver advanced personal care and supervise exercise programmes; • There is a focus on services that aim to prevent admissions to hospital and aged residential care; • There are incentives for providers to work proactively with people to restore function and independence and thereby reduce services over time where appropriate; • There is less provision of low need household management tasks except where necessary for health and hygiene reasons; • Increased training requirements for support workers; • Services are bulk funded within a capped budget based on a package of care approach. The national service specification developed by the Ministry of Health aligns with this approach. The redesign project has been included in the 2012/13 Regional Services Plan. Additional resource or a dedicated project manager may be required to ensure project deliverables are achieved within a time frame that meets individual DHB requirements.
Needs assessment and service co-ordination Eligibility for and access to all long term funded support services (both home based and in aged residential care) is through a needs assessment carried out by the DHB Needs Assessment and Service Co-ordination Agency, Support Net. Effective and standardised needs assessment and service co-ordination services are crucial for ensuring people have good information, equity of access to services and receive the right care at the right time. InterRAI is an internationally developed, standardised and validated needs assessment process that gives a
consistent objective measure of a person’s needs and enables information to be shared on patient assessment and care requirements. InterRAI is a comprehensive, multidimensional needs assessment which leads to provision of services that improve the health and well-being of older people and their carers. The implementation of InterRAI is being rolled out throughout the country. Assessors are required to be clinically trained when using the comprehensive tool. While some DHBs have only recently commenced using InterRAI this year, BOPDHB was an early adopter of InterRAI and the Home Care Tool and Contact Tools have been in use for approximately six years in the Bay of Plenty, giving us considerable experience in the use and potential of the tools. There are a number of developments which may impact on NASC services in the future including: 1. An InterRAI tool specifically designed for use in long term aged residential care (the InterRAI Long Term Care Tool) is currently being rolled out in aged residential care nationally as part of a national business case developed collaboratively between DHBs and the New Zealand Aged Care Association. InterRAI LTC Tool is designed to improve assessment and care planning, thereby improving quality in aged care. It can also be used by providers to determine changes in levels of care and consequent approvals for changes in funding levels, although this has yet to be approved by DHBs, given the potential financial impacts. 2. As the number of people requiring assessment increases and the focus shifts to supporting people with complex needs in the home, there is a need to consider the most effective way to carry out needs assessments. Auckland DHB Case Mix model reallocates needs assessment and allocation of service responsibilities to providers where people’s needs are considered to be noncomplex, while needs assessments for people with complex needs are carried out by the NASC. This enables resources to be used more effectively and incentivises providers to work proactively with people, to reduce reliance on funded services over time where appropriate. Quality requirements and monitoring can be included through the contractual terms of the agreement to reduce risk of inappropriate service reduction or gaming. 3. Assessments for short term support services following a discharge from hospital do not use InterRAI. Currently assessments are carried
15 The Midland DHBs comprise the BOPDHB, Lakes, Waikato, Taranaki and Tairawhiti.
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out by district nursing services in accordance with historical practice. However the Short Term Support Services Review for BOPDHB carried out in 2007 recommended that InterRAI be used for all assessments for older people, for both short term and long term care to improve equity of access to services and continuity of care, but this has not been able to be progressed. It is recommended that this process is reviewed alongside any reviews of NASC services generally arising from activity outlined above. 4. Not all assessments carried out in secondary services use InterRAI, leading to inconsistent access to long term residential care following discharge from hospital. There is now a national requirement for all assessments in secondary services to be using InterRAI by 30 June 2012. BOPDHB is currently implementing this. 5. The current NASC criteria (disability lasting six months or more) can create artificial barriers to coordinating and integrating services and inequities of access to services. Alongside moves towards seamless and integrated service provision, it is appropriate to review the eligibility criteria. Impacts on the contracting and funding model for NASC service will need consideration resulting from the activity outlined above. However, Support Net is well positioned to adapt to changes. For example, a number of assessments are currently carried out through a sub-contract process, including in kaupapa Māori services and primary care. Information technology and management is a key enabler to progressing person-centred integrated models of care. The potential of InterRAI has not been fully realised. For example, making the information available to service providers can streamline the way in which support services are accessed and delivered and reduce the need for multiple assessments. Work is currently under way with home and community providers to make InterRAI assessments available electronically.
3. Improve access to specialist advice via primary care 4. Promote and support education for aged residential care and home and community support providers by primary care. 5. Implement a redesign of HBSS in conjunction with the Midland Region DHBs as part of a regional project to a restorative model of care. Consider changes to the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate. 6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge. 7. Consider implications arising from amending the current criteria for access to service assessed and co-ordinated by Support Net by removing the requirement for a disability lasting longer than six months. 8. Review NASC functions carried out by district nursing for short term support services. 9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with national business case and implementation plan. 10. Review funding and contracts for provision of NASC Services in light of recommendations above. 11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read-only access to InterRAI to home and community support providers. 12. Develop a seamless user-friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.
Recommendations 1. Progress integrated models of care. Evaluate outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay PHA Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team (SLAT) pilot on stratified assessment in primary care) to inform recommendations for further structural changes to primary care. 2. Develop specific Bay Navigator pathways that are relevant to older people e.g. falls prevention, osteoporosis, dementia and TIA.
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D. Hospital Care National Strategy Policy and service planning will support quality health and disability support programmes integrated around the needs of older people. Admission to general hospital services will be integrated with any community-based care and support that an older person requires. Once in hospital, older people are at highest risk of acquired disability, cognitive decline or admission to residential care, either as a consequence of illness or as a consequence of treatment following hospital admission. Older people’s health needs are more complex, usually with co-existing medical, functional, psychological and social needs that are often misunderstood and require a different approach to care while in hospital and after discharge. Acute illness in older people often has functional consequences, and patients may require a period of rehabilitation to regain function and independence. Rehabilitation is a specific health intervention with a strong evidence base. This need not take place in hospital if a patient is medically stable, and in many regions it does not (e.g. the United Kingdom, Australia and parts of New Zealand). However, the BOP lacks community-based alternatives to hospital in-patient rehabilitation after an acute illness. Comprehensive geriatric assessment (CGA) is the assessment of a patient by a specialist team that is led by a doctor trained in Geriatric Medicine, followed by interventions and goal setting agreed with the patient and carers. It is a form of specialist organised geriatric care. It covers the following areas: • Medical diagnoses; • Review of medicines and concordance with drug therapy; • Social circumstances; • Assessment of cognitive function and mood; • Functional ability (ie ability to perform activities of daily living); • Environment; • Economic circumstances. CGA should inform discharge planning and the InterRAI needs assessment process (see Section C).
Meta-analysis of randomised controlled trials shows that patients who undergo CGA after emergency admission to hospital are more likely to be discharged to their own home, less likely to need residential care, less likely to experience deterioration and more likely to have better cognition compared with those who receive general medical care.16 Outcomes are most improved when hospital care is delivered in specialist geriatric wards rather than by mobile teams. In studies, “comprehensive assessment” that does not include a doctor trained in Geriatric Medicine does not have the same positive outcomes. The reasons for this are that older people tend to be medically complex. The Royal College of Physicians of London and British Geriatric Society stated in 2001: “At the core of Geriatric Medicine as a specialty is the recognition that older people with serious medical problems do not present in a textbook fashion, but with falls, confusion, immobility, incontinence, yet are perceived as a failure to cope or in need of social care. This misconception that an older person’s health needs are social leads to a prosthetic approach, replacing those tasks they cannot do themselves rather than making a medical diagnosis. Thus the opportunity for treatment and rehabilitation is lost, a major criticism of some current services for older people. Old age medicine is complex and a failure to attempt to assess people’s problems as medical are unacceptable.” Comprehensive Geriatric Assessment can be delivered in a range of acute hospital settings: • In the ED: For example, NHS Lanarkshire demonstrated a reduction in admissions by 6% for older people through an “Acute Care of the Elderly” (ACE) team based in the Emergency Department.17 • In surgical wards: The sub-specialty of Orthogeriatrics involves a specialist geriatrician sharing care with orthopaedic consultants. This means older people admitted with fractures receive a multi-factorial falls assessment and treatment for osteoporosis when they otherwise would not. “Proactive Care of Older People undergoing Surgery (POPS) and “Systematic Care of Older People in Elective Surgery (SCOPES) are other programmes developed in the UK that demonstrate reduced complication rates, reduced length of stay and better functional outcomes on discharge for older people undergoing surgery.18
16 Ellis G, Whitehead MA, Robinson D et al. Comprehensive Geriatric Assessment for older adults admitted to hospital: met-analysis of randomised controlled trials. BMJ 2011; 343: d6553]. 17 Dr Graham Ellis, Consultant Geriatrician, NHS Lanarkshire, UK. 18 British Geriatric Society www.bgs.org.uk POPS special interest group and SCOPES:
[email protected]].
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• In dedicated Acute Stroke Units: Specialist stroke unit care means that patients are more likely to be independent and living at home following a stroke.19 Stroke unit care means complications are identified and treated earlier, and combined with early supported discharge (eg via Intermediate Care), this results in reduced length of stay.20 • In acute geriatric wards: Acute geriatric unit care significantly reduces length of stay, hospital costs, leads to improved function on discharge and increases the likelihood of returning home, compared to usual hospital care.21
DHBs with a framework for progressively developing specialist health services for older people that provide an expert service, build on initiatives in other parts of the health system (such as primary care), disseminate knowledge and develop collaborative partnerships that deliver integrated services to vulnerable older people, their whanau and carers. Access to Comprehensive Geriatric Assessment by community home based support providers can improve quality, effectiveness and timeliness of service provision and reduce unnecessary errors, duplication and admissions to hospital.
Demand on hospital services will continue to grow with an ageing population, particularly for specialist services for older people. The Government’s Guidelines for Specialist services for Older People were developed in 2004. The Guidelines provide
The majority of medical admissions to secondary services are for people aged over 65 (63% in BOP in 2010). However, the vast majority of older people admitted to hospital in the BOP do not receive specialist care. There is a Health in Ageing (HIA)
19 Stroke Unit Trialists Collaboration. Organised in-patient (stroke unit) care for stroke. Cochrane Database Syst Review 2007, issue 4. CD000197. 20 Fjaertoft H, Rohweder G and Indredavik B. Stroke unit care combined with early supported discharge improves 5 year outcome. Stroke 2011; 42: 1707-11. 21 Baztan J, Suarez-Garcia FM, Lopez-Arrieta J et al. Efficiency of acute geriatric units: a meta-analysis of controlled studies. Rev Esp Geriatr Gerontol 2011; 46 (4): 186-92].
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service in Tauranga Hospital (but not in Whakatane). This consists of a 39-bed rehabilitation focussed unit, with limited “in-reach” services. The current number of specialists in geriatric medicine is below what is nationally recommended for our population to deliver a basic service. In 2011, the number of geriatricians was increased to three, however a recent independent review by Dr Fred Hirst indicated a minimum of five full time equivalent (FTE) geriatricians is required to deliver proper specialist services and provide input to Whakatane, with one FTE being a community geriatrician. The current specialists in Geriatric Medicine have recommended a way forward to expand numbers to a recommended minimum level of six within existing FTE for physicians. This would allow the conversion of an existing general medical ward to an acute geriatric ward in addition to the existing 39-bed HIA unit, a plan this Strategy supports. The acute geriatric ward would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency, specialist care for older people with delirium (a condition with significant mortality and morbidity), and potentially enable co-location of stroke patients in an organised stroke service (refer to section G). An expanded geriatric service and workforce would also allow essential specialist services to be provided to Whakatane, and expand existing community work, education, “in-reach” services, increased specialist advice to primary care, service and pathway development and outpatient capacity. In the redevelopment of Tauranga and Whakatane hospitals, provision has been made for an increased number of beds for HIA in line with national benchmarks for the proportion of bed numbers to the population aged over 65. However, increases have been deferred until 2017 and will require significant funding. In the meantime, without the ability to fund any increased capacity, our focus will be on improving the care of acute admissions for older people, managing patients better to reduce length of stay, and developing new models of care that are better suited to older people as well as being more cost effective, such as proper acute geriatric unit care and community-based rehabilitation or “Intermediate Care”.
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Intermediate Care In 2011, a team of specialists in geriatric medicine performed a snapshot audit of in-patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services. Intermediate Care offers a co-ordinated service that links acute hospital care, community health services and social care to make more effective use of hospital capacity by providing Comprehensive Geriatric Assessment and rehabilitation in alternative settings. Evaluation of Intermediate Care services elsewhere has demonstrated reduced length of stay in hospital and higher patient satisfaction. Outcomes are as least as good as traditional acute hospital care. “Intermediate Care” describes services that meet all the following criteria: • Targeted at people who would otherwise have had an unnecessary, prolonged hospital stay, or inappropriate admission to acute inpatient care, or long term residential care; • Provided on the basis of a comprehensive geriatric assessment (that includes a geriatrician) resulting in a structured care plan that involves active rehabilitation and opportunity for recovery; • Has a planned outcome of maximising independence and typically enabling patients to resume living at home; • Is time limited, typically no longer than 6 weeks, and often as little as 1-2 weeks; • Involves multi-disciplinary working, with a single assessment framework, single professional records and shared protocols.
Intermediate Care is geared towards both admission avoidance, and early discharge; and encompasses rehabilitation at home, as well as in a community Intermediate Care facility (see diagram in Supporting Information section). Examples of Intermediate Care services Our focus will be on in New Zealand include the Community Rehabilitation, improving the care of acute Enablement and Support Team admissions for older people, (CREST) service in Canterbury managing patients better to and the Supported Transfer and reduce length of stay, and Rehabilitation Teams (START) developing new models of service in the Waikato. These care that are better suited to services feature community older people. based rehabilitative supported discharge service (either in the person’s home or in a residential facility), a rapid response service, and a
multidisciplinary team (general practice, community service providers and older person health specialist services).
to allied health professionals is addressed as an essential part of the implementation plan.
Elements of these services currently exist in the BOP that can be incorporated as part of any future Intermediate Care service. The Western Bay of Plenty has two “transitional care” beds in an aged residential care facility targeted towards older people who have been admitted to hospital following a fracture and are not yet ready for rehabilitation, and a Community Response Team (CRT) that focuses on admission avoidance. Community Primary Options (CPO) funding for general practice provides for the ability for GPs to admit a patient to residential care for a few days to avoid an admission to hospital or after a discharge. However, if patients require more support that can be provided at home or through CPO funding, there are limited options for GPs or the CRT to refer or admit patients to more appropriate cheaper care in the community such as an Intermediate Care facility or increased temporary support in the home.
1. Specialist services for older people are developed in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health, 2004). 2. Expand the specialist geriatric workforce to recommended levels (including geriatricians, registrars and junior doctors, nursing and allied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for specialist health services for older people to work within acute medical, surgical and orthopaedic services. 3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler to implement a number of recommendations in this Strategy. 4. Develop an acute geriatric ward in addition to the existing 39-bed HIA unit, which would incorporate a comprehensive geriatric assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a condition with significant mortality and morbidity). This is also an enabler to develop an organised stoke service (refer to section G). 5. Through the provision of an expanded geriatric workforce, provide essential specialist services to Whakatane and expand existing community work, education, “in-reach” services, advice and education to support primary and community care, service and pathway development and outpatient capacity. 6. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver a comprehensive geriatric assessment in the future. 7. Make better use of existing resources by developing different, cost effective, evidence-based models of care such as increased community rehabilitation or “Intermediate Care”. 8. Make funding provisions to increase the numbers of beds for specialist geriatric medicine services in line with national recommendations for the proportion of beds to the population of the BOP and the planned redevelopment of Tauranga Hospital by 2017. 9. Implement better communication between secondary and primary care on discharge from hospital, so that any comprehensive geriatric assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.
The introduction of an Intermediate Care service would reduce length of stay for older people across all hospital specialties. It would allow the HIA in-patient service to focus on older patients with more complex medical and rehabilitation needs (e.g. acute stroke) and also mitigate the projected increased need for HIA beds in the future.
Allied Health With a focus on a comprehensive geriatric assessment, rehabilitation and restoration of function and independence are key elements to the success of a number of the services for older people recommended in this Strategy. Examples include the Intermediate Care Service, acute geriatric ward, organised stroke service and the redesign of home based support services including assessment and treatment by allied health professionals (particularly physiotherapy and occupational therapy). Currently there is limited access to both hospital and community allied health across the BOP, but particularly in the Western Bay of Plenty. There are no foreseeable plans to address this shortage. In developing this Strategy, consistent messages were received from hospital and community based services and older people themselves about the importance of access to allied health professionals as a fundamental enabler to many of the recommendations in the Strategy. Many people described difficulties with accessing sufficient (even basic) allied health treatment and advice due to insufficient staffing levels. It is strongly recommended that options to address increased access
Recommendations
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E. Aged Residential Care National Strategy Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. (ARC) is a scarce, high cost resource. People are entering residential care at an older age and with higher support needs. The number of people requiring residential care, particularly at hospital and dementia levels of care is predicted to grow. Currently, there are insufficient “Stage 3” secure dementia care and psychogeriatric beds available in the BOP which can lead to hospital stays lasting several months for some patients. A comprehensive review of the future needs for residential care carried out by Grant Thornton in 2010 sets out the predicted increase in bed numbers over the next 20 years.22 ARC is a demand driven service purchased by DHBs for people over 65 who have health and disability related needs and are assessed as needing ARC. BOPDHB purchases capacity in ARC facilities throughout the BOP. ARC providers are private organisations following legislative and contract changes made in 2006, DHBs no longer have the ability to control the number of beds purchased in ARC providers facilities. Availability of beds is market driven and there is no guarantee of any level of occupancy by the DHB and providers accept this level of commercial risk. Access to residential care is through the Needs Assessment and Service Coordination (NASC) process. Only those people who have been assessed as eligible and needing full time residential care will be able to access a funded bed. The assessment process used is InterRAI (refer to Section C). Thresholds for entry to access are reviewed and all other options for community care are explored before the BOPDHB agrees to grant access to an ARC bed. Contracts for services and the price paid for ARC beds are negotiated and set nationally through DHBs and the providers’ representative body, the majority of whom belong to the New Zealand Aged Care Association. All DHBs sign up to this process, which then prohibits the development of local funding models or options. Price increases negotiated for ARC through this process in the last few years have exceeded the level of cost pressure funding generally received by DHBs through the funding envelope. Funding for ARC is a mixture of DHB funding (for
fully subsidised residents who meet eligibility criteria through a financial means test), private payments, and client contributions through their national superannuation. People who do not qualify for a DHB subsidy (they have assets higher than the required threshold) are required to pay for the cost of their care, but this is no more than the maximum contribution each week. The maximum contribution is the same for all residents, regardless of the level of care they are assessed as requiring. It is an amount set by legislation each year and is equal to the weekly cost of rest home level care (the lowest level of care). The difference between the maximum contribution and the cost of higher levels of care if required, eg hospital level care, is topped up by the DHB. Approximately 5.2% of people aged over 65 in the Bay of Plenty live in an ARC facility. This compares to a range of approximately 5-7% nationally. The proportion has been declining overall, but particularly at rest home level, as the BOPDHB has invested more in home support services that enable “ageing in place”. However, the proportion of people in higher levels of ARC has been increasing due to higher acuity and complexity of care. A range of factors influence the proportion of people who access ARC including availability of community services eg medication supervision, respite care, day programmes and home support; where people live, what family or whanau support they have, and the health and wellbeing of a primary carer. The utilisation rate by Māori of residential care is low in comparison to non-Māori, largely due to culture and whanau structures encouraging and enabling support and care to be provided at home. However, this is changing as family structures change and younger Māori are moving away from home, often in search of employment. In the Western Bay of Plenty many older people do not have family nearby and many live on their own. The average age of people accessing ARC is currently 84 years 11 months. This has implications for growth in demand for ARC as the growth rate for people over age 85 is increasing at the rate of approximately 6% per annum. Hospital level care has steadily grown at the rate of between 5% and 9% each year for the last 5 years. This level of growth will continue with the influence of population ageing and higher levels of disability. This has inevitable cost implications for the DHB because of the funding mechanism set out above and the DHB needs to plan and budget for this appropriately.
22 Grant Thornton. Aged Residential Care Service Review. Sep 2010. wwwgrantthornton.co.nz.
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To ensure we will have sufficient ARC capacity in the community, commercial commitment and an element of risk by private organisations based on forecast modelling and demand projections is required. Investment in new buildings requires time and money and therefore a long lead in time to develop new capacity. The funding and focus of ARC is currently on long-term care and support. To better manage future demand and maximise this high cost specialised resource, much more focus could be directed to preventative and rehabilitative care, with development of shortterm service options. Currently, services are standalone with little community services integration. The ARC contract does not allow for flexibility. There are few incentives for restorative care (i.e. reversal of functional loss). Yet there is considerable expertise in ARC, and investment in facilities in central community locations that could be better utilised. More flexible services could provide: • Residential care (medium and high needs care); • Intermediate care beds (temporary care-home based rehabilitation – (refer to Section D); • Palliative care; • Day, night and weekend care; • A community electronic monitoring base (for falls prevention, medication management, diabetes etc); • Co-ordination of aged care education and access to available services; • A base for primary care and community allied health providers (aligned with the integrated family health centre model); • Social meeting points for older people and their families. The current ARC access and funding regulations make it difficult to re-enter community based care due to income/asset testing (assets, usually the family home, often have been sold when entering ARC to pay for the cost of care). In the current environment where funding follows eligible residents, there is little opportunity to manage the growing demand for ARC. Furthermore, the cost component of providing accommodation and catering services in ARC is high and alternative models could be considered. For example, accommodation and catering could be provided by specialist private sector providers with the health care component provided by health care providers.
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Recommendations 1. Plan and budget appropriately for the forecast growth in demand in aged residential care. 2. Manage demand on scarce high cost resources by developing new flexible, integrated and restorative models of care with ARC e.g. short term care, Intermediate Care, integrated community facilities. 3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D) 4. Fund and support roll-out of the InterRAI Long Term Care Tool (refer to Section C) in ARC in accordance with the national business case. 5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service. 6. Streamline contracts and auditing processes to reduce compliance costs. 7. Consider ways in which Primary Care and Aged Residential Care can identify those nearing the end of their lives and offer/implement Advanced Care Planning.
F. Dementia and Mental Health in Older People National Strategy Population-based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers. The number of older people with dementia is rising rapidly. Nationally, dementia affects 40,746 people. By 2050 it is estimated there will be 146,699 people living with dementia. The prevalence of Alzheimer’s Dementia (AD) strongly correlates with age (see the table below). Of all the patients under mental health services for older people in the BOP, approximately 80% have dementia and 20% have other mental health disorders.
Prevalence of Alzheimer’s Dementia (AD), 2006: Age
65-69 75-79 85-89 90-95
Prevalence (%) 1.1%
4.7%
15.2%
26%
AD represents 60-70% of all dementia in New Zealand (this figure does not include “mild cognitive impairment” or early dementia which carries a significant risk of progressing to AD). Mental health problems among older people exact a large social and economic toll on patients, their families and carers, as well as the statutory agencies. Under-detection of mental illness in older people is widespread due to the nature of symptoms and the fact that many older people live alone. Depression in people aged 65+ is especially under diagnosed, and this is particularly true of residents in care homes. Mental health problems may be perceived by older people and their families, as well as by professionals, as an inevitable consequence of “old age” and not as health problems which can respond to treatment.
Promoting good mental health Promoting mental health is as important in older people as in younger people. Interventions at a population level to promote good mental health include educational activities, and creative and social pursuits. Specific additional interventions which promote good mental health in older people include tackling social
isolation and providing bereavement support. Older people in residential care and nursing homes and those receiving day care should be able to participate in a range of stimulating group or one-to-one activities. These can include reminiscence, art therapy, newsbased discussions, aromatherapy, games and quizzes, adult education and drama. Older people should be offered a choice of activities matched to their needs and preferences. An appropriate environment can also aid orientation and help to avoid visual and sensory confusion. Continued engagement for older people in valued roles in the community, including flexible options for older people to continue working should they choose, also promotes good mental health (see the wider determinants of health in Section A).
Early identification and treatment Most people with mental health problems will be diagnosed and cared for in primary care with the support of social services, but specialist mental health services should be available to develop care pathways with primary care and be consulted when needed. A range of specialist services should be available, from diagnosing and treating more complex problems, to providing community and in-patient services for those with a clinical need. The emphasis should be on promoting the independence of older people with mental health problems and supporting them and their carers in the community whenever possible. The BOPDHB has a specialist mental health service for older people. However, services that focus on early identification of dementia, support and preventative interventions are very limited. Early identification of people with dementia enables support to be put in place earlier to prevent further loss of function and to support primary carers to take a break. Flexible options in the community for supporting people with dementia are required to reduce carer strain and delay entry to residential care for as long as possible. There few services in the BOP that focus on people in the early stages of dementia. A report to the Disability Issues Directorate of the Ministry of Health recommends “Memory Assessment Centres” for quality improvement in the diagnosis of dementia. International research has shown services that focus on the early stages of cognitive impairment can significantly improve health and social care outcomes, delay admission to residential care, improve well-being of full time carers, prevent unnecessary admission to hospital and reduce health care costs in the long term.
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A memory pilot undertaken by mental health services for older people (MHSOP) in the BOP in 2011 demonstrated a significant demand for early intervention services for people with dementia. Currently in the BOP, specialist assessment for dementia is spread across three services including MHSOP, HIA and neurology. While all services have contact in various ways, there is no co-ordinated or targeted service delivery, and there is little coordination or integration with primary care. A coordinated approach, with greater integration with primary care is recommended. A business case is currently under development for the establishment of a coordinated dementia service, incorporating an early intervention service.
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The acuity of older people who present to specialist mental health services is increasing. When there is a shortage of suitable options in the community to enable a safe and well supported discharge, this impacts negatively on average length of stay in hospital.
Secure residential facilities
To further manage the growth in demand for psychogeriatric level care, careful management of access to this high cost scarce resource is required to ensure those most in need have access to this level of care when required. The assessment process and access criteria differs across different DHBs and impacts on capacity. This is a national issue and there is a need for a standardised assessment process and access criteria. Locally, bed availability can be actively managed by ensuring people in psychogeriatric facilities are appropriately assessed and re-assessed regularly for changes in their care needs.
Specialist residential facilities (secure dementia facilities and psychogeriatric level care) throughout the BOP operate at close to 100% occupancy, making placement in the community difficult and increasing length of stay in hospital. There is a need to expand psychogeriatric level capacity in the community, particularly in the geographical areas at either end of the BOP, namely the west of Western Bay of Plenty and the Eastern Bay of Plenty.
New models of care and knowledge about the importance of the environment of secure dementia units are being developed locally and internationally. Quality facilities and care in line with best practice has been shown to reduce admission to hospital, improve resident outcomes, reduce the need for psychotropic medication and give confidence to family members when residential care is required. Residential providers
need support to be the best they can and develop innovative facilities and models of care for people with dementia as well as access to specialist assessment and advice when required. A set of best practice guidelines is recommended to support provider care and development.
Recommendations 1. Promote recognition and assessment of mental health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia. 2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities. 3. Improve access to specialist advice and support for community providers. 4. Improve support to primary carers of people with dementia through education and training and a range of flexible respite, day and home based support options. 5. Introduce training requirements in service specifications for home based support services where staff work with people with dementia. 6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator. 7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the next five years and make appropriate budget provision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the Western Bay of Plenty and Eastern Bay of Plenty. 8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular reassessments of people to identify changes in levels of need. 9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care. 10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatric units and support existing providers to improve quality of care and environment.
G. Stroke and Transient Ischaemic Attack (TIA) National Strategy Population-based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers The Ministry of Health and New Zealand Stroke Foundation published the national Guidelines for Stroke Management Implementation Plan in 2011. A national acute stroke audit commissioned by the Ministry in 2009 found that: • New Zealanders currently do not have sufficient access to organised acute stroke services. • Only eight out of 21 DHBs at the time provided stroke services that are consistent with international best practice, and only 39% of patients in the audit received care in a stroke unit. The Implementation Plan is clear that all DHBs should provide an “organised stroke service”, and all people admitted to hospital with a stroke should expect to be managed in a stroke unit by a team of health professionals with expertise in stroke and rehabilitation. DHBs are also expected to develop organised stroke services as signalled in the DHB annual planning guidelines for 2012/13 and to develop regional stroke services within existing resources. Key objectives for large (population greater than 200,000) DHBs are: • They should provide an acute TIA service; • They should provide an acute thrombolysis service or a pathway to access one; • Inter-disciplinary teams should utilise current stroke protocols for stroke management; • They should provide organised stroke care in a designated geographical area under the care of a designated stroke physician; • They should provide rehabilitation in a dedicated area (i.e. a stroke rehabilitation unit) under the coordinated care of a team experienced in stroke rehabilitation including a designated stroke physician; • They should implement ongoing education for staff, patients and families/caregivers;
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Preventing stroke The Ministry of Health has recently produced best practice guidelines on better prevention of cardiovascular diseases – including a toolkit for DHBs. The risk factors for cardiovascular (heart) disease and stroke are the same. Heart disease occurs because of disease in the arteries supplying the heart; stroke occurs because of disease in the arteries supplying the brain. Stroke is the third leading cause of death in New Zealand after heart disease and all cancers combined. It is also a major cause of neurological disability. There is a large volume of evidence to show that early detection and management of risk factors for stroke can prevent stroke from happening. It is only in recent years that the risk of stroke after a transient ischaemic attack (TIA) has been appreciated. A TIA is defined as stroke symptoms and signs that resolve completely within 24 hours. TIAs are sometimes referred to as “mini-strokes” but there is nothing minor about a TIA. A person’s risk of a disabling stroke after a TIA can be as high as 12% in the next seven days and 80% of all strokes following a TIA can be prevented. There are at least 540 TIAs each year in the Bay of Plenty DHB. By treating TIA as an emergency, and following the evidence-based New Zealand TIA guidelines, we could prevent around 52 disabling strokes and save over $2.5 million each year in stroke-related care. Stroke is a health gain priority area for Māori. Māori develop risk factors for stroke earlier. Prevalence, morbidity, and mortality from stroke are all higher in Māori than in people of European origin. Healthcare providers must recognise the cultural values and beliefs that influence the effectiveness of services for Māori people with TIA and stroke. Māori may be less likely to present to hospital with symptoms of a TIA or stroke, particularly in more rural areas. A TIA pathway is currently being developed through Bay Navigator to promote best practice but disparity in services between the Western and Eastern Bay of Plenty is evident (and being addressed).
Organised stroke services
few days are managed by general physicians with the advice of the stroke physician and nurse who then follow patients up in clinic. For patients with a major disability following stroke, randomised controlled trial evidence shows that outcomes are significantly improved if care is provided on a geographically defined stroke unit run by a specialist team of nurses, therapists and stroke physician(s). The best outcomes are found in units that are co-located with the stroke rehabilitation unit. Specialist stroke unit care means that patients are more likely to be independent and living at home following a stroke.23 There is no such unit in the BOP. Recent Ministerial emphasis on the importance of stroke units supports the development of an acute stroke unit. It is recognised that this will need to be achieved within current funding resources. However, in line with the rest of this Strategy, provision of community-based rehabilitation (eg Intermediate Care), would free up beds currently being used in hospital for slow-stream rehabilitation so that an acute stroke unit could be created in the most appropriate area (refer to recommendations in Section D). An organised stroke service is also dependent on an appropriate workforce, as outlined in Section D.
Recommendations 1. Complete the development of a TIA pathway through Bay Navigator . 2. Establish an organised stroke service - Refer also to Section D on the development of an acute geriatric ward. 3. Increase the number of specialist geriatric medicine workforce to provide appropriate treatment of TIAs and Stroke - refer to Section D. 4. Continue with on-going specific thrombolysis training for ED and general medical Registrars/ Consultants in accordance with international best practice. 5. Develop a BOPDHB Stroke Guideline that sets out how the national NZ Clinical Guidelines for Stroke will be implemented locally.
In Tauranga Hospital at the moment, patients with high risk TIAs are admitted to hospital and seen by a specialist stroke physician and nurse. All outpatient referrals from the ED or GPs are seen in a TIA clinic within one week. Many patients with “low-disability strokes” who only require admission to hospital for a
23 Stroke Unit Trialists Collaboration. Organised in-patient (stroke unit) care for stroke. Cochrane Database Syst Review 2007, issue 4. CD000197.
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H. Falls and Bone Health National Strategy Population-based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers. Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged over 75. It is estimated that one-third of communitydwelling over 65s fall each year, usually in their own home with no obvious hazard. There is good evidence that interventions to prevent falls reduce an older person’s risk of falling in the future. The national Health of Older People Strategy specifically highlights falls as an area for action. One in three women and one in twelve men over 50 are affected by osteoporosis, which increases the risk of fracture following a fall. Osteoporosis is called the silent epidemic because of its symptomless development and the lack of public awareness. Osteoporosis is not just an “old people’s disease”. Young people with low bone density can get osteoporosis too. • More than 3,000 New Zealanders break a hip each year. This figure is expected to rise to 4,800 in ten years time, as our population ages. • About a quarter of people who fracture a hip die within a year from related complications. One third never return home, and those that do lose their mobility and independence. • More women are hospitalised with a hip fracture due to osteoporosis than through breast cancer. The prevalence of osteoporosis is predicted to increase by 30% from 2007 to 2020 due to population ageing.24 The total health cost of osteoporosis through fractures in New Zealand in 2007 was more than $1.15 billion or $3 million per day. Problems with both falls and osteoporosis can be detected early and treated successfully, preventing injuries, fractures and disability.
What is little understood by the public, and many health professionals, is that falls in older people are not accidents, but are the result of medical problems, many of which are treatable. In one study of older people presenting to the ED with a fall, patients had an average of five risk factors for falls – the most common being disorders of gait and balance, inappropriate medications, problems with blood pressure, visual impairment and cardiovascular disorders. Falls in a later life are also a common symptom of previously unidentified health problems which need to be managed. A fall can precipitate admission to long-term care. After an osteoporotic fracture, 50% of people can no longer live independently. Hip fractures are the most common serious injury related to falls in older people, costing on average of $24,000 per person for acute treatment and rehabilitation, resulting in an annual cost to New Zealand of around $18 million per year.25 Of this, around half is for acute hospital care and half for long term disability services or aged residential care.
Preventing falls Previously, the Accident Compensation Corporation (ACC) was the lead agency for funding falls prevention programmes for people aged over 65. However, in 2010 ACC discontinued funding for falls prevention programmes for older people, but retained promotion of Vitamin D use in older people to prevent falls. There is currently no falls prevention strategy or service in the BOPDHB. There are three levels of approach to falls prevention: A population-based strategy • Including the promotion of exercise and activities that promote muscle strength and balance (eg Tai Chi classes). • An increased intake of calcium and vitamin D in the diet for older people. • Ensuring that pavements are kept clear and in good repair, and there is adequate street lighting . • Making property safer – many falls in older people are related to “home hazards”. Preventing falls in individuals • Better identification of those at risk of falling – ie those with gait and balance disorders (eg an old stroke or Parkinson’s Disease); visually impaired; taking four or more medications; those with home hazards. • Referring older people who have fallen to a health professional for a “falls assessment” and interventions as necessary.
24 Osteoporosis NZ Independent Research Report 2007 25 Osteoporosis New Zealand Inc. “The Burden of Osteoporosis in New Zealand 2007 to 2020”.
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• Implementing measures in aged residential care and hospitals to prevent falls in older people. Specialist falls service • Older people with recurrent falls, “unexplained falls” or dizziness benefit from a specialist multifactorial falls assessment that involves a specialist geriatrician and therapy team. Interventions for falls usually include: • Diagnosis and treatment of underlying medical problems such as eye diseases/visual impairment, diseases causing abnormal gait and balance, correction of postural hypotension or cardiac rhythm abnormalities, discontinuing inappropriate medication, treating bladder problems etc; • Rehabilitation, including physiotherapy to improve confidence in mobility, and occupational therapy to identify home and environmental hazards; • Equipment to improve the safety of an older person at home; • Social care support if required. Individually tailored exercise programmes administered by a qualified professional can reduce the incidence of subsequent falls in older people or as part of a multiple intervention approach in those at risk. Falls prevention programmes for individuals should contain more than one intervention and focus on the individual’s particular risk factors.26 The redesign of HBSS recommended in Section C supports this approach.
Treating osteoporosis Any person who has had a fragility fracture (ie a fracture that occurred when falling from standing height or less) should be flagged for an osteoporosis assessment. Risk factors for osteoporosis include: • Previous fragility fracture; • Prolonged corticosteroid therapy; • Premature menopause or history of amenorrhoea (not treated to reduce risk of osteoporosis); • The presence of eg liver or thyroid disease, malabsorption, alcoholism, rheumatoid arthritis; • A family history of osteoporosis (including maternal hip fracture); • Low body mass; • Smoking.
Osteoporosis may also be identified through: • DXA (Dual Energy X-ray Absorptiometer) bone mineral scan; • Radiographic evidence of vertebral fracture and/or loss of height associated with vertebral fracture. In women aged over 75, a DXA scan is not required to diagnose osteoporosis, if there is a history of previous fragility fracture and other metabolic bone diseases are excluded by an x-ray of the fracture and blood tests.27 There is no routine assessment and treatment for falls and osteoporosis in older people who attend ED each year in the BOPDHB with fragility fractures. The opportunity for health promotion and prevention, potentially saving millions of dollars in hip fracture care alone, is lost. The HIA department in Tauranga Hospital currently provides an orthogeriatric service for older people with fractured hips. However, the problem of falls and bone health needs to be tackled far earlier in order to make a difference.
Recommendations: 1. Assess the impact of Accident Compensation Corporation’s withdrawal of funding for falls prevention programmes for older people. 2. Promote a population-based falls prevention strategy for older people, including the identification of those at risk of falls living in their own home or in care homes. 3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis. 4. Develop a specialist falls service for people with recurrent falls, “unexplained falls” or dizziness. Assess how this could work across the BOP, working with GPs in more rural areas. 5. Implement a Falls Pathway through Bay Navigator that facilitates the evidence-based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care. 6. Implement an Osteoporosis Pathway through Bay Navigator that links with the Falls Pathway, facilitating the evidence-based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.
26 National Institute for Health and Clinical Excellence (NICE). The assessment and prevention of falls in older people. Clinical Guideline 21, 2004. 27 Royal College of Physicians and Bone and Tooth Society of Great Britain. Osteoporosis: clinical guidelines for prevention and treatment. RCP, London, 2000 / and Osteoporosis New Zealand www.bones.org.nz.
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I. Medications Management National Strategy Population-based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Older people are high users of medications, particularly those in Aged Residential Care. Two-thirds of people over the age of 60 are taking regular medication, and over half of those with repeat prescriptions are taking more than four drugs. Medications are a valuable therapeutic tool but they can cause significant problems, particularly if they are not reviewed regularly: 1. Many health problems in older people are a direct result of unrecognised side effects of their medication. Up to 30% of admissions to hospital in older people may be associated with problems related to medication.28 2. As many as 50% of older people may not be taking their medicines as intended. Campaigns for people to return unwanted medicines to pharmacies confirm that large amounts of medicines are never taken. “Inequivalence” in quantities on repeat prescriptions mean that patients have to order different items at different times, and may unintentionally receive the same medicine on separate prescriptions. The wastage that results from this has been estimated to account for 6-10% of total prescribing costs. 3. Following discharge from hospital, changes to medication are frequently made both intentionally and unintentionally. Communication between Secondary and Primary Care is often poor. For example, the HIA stroke follow-up clinic regularly sees patients who are taking dangerous combinations of powerful blood-thinning drugs which were accidentally prescribed on discharge from hospital, a recurring theme that has recently been flagged as a clinical risk.
4. Elderly people have a higher prevalence of polypharmacy, which is associated with more adverse drug events. The risk of an adverse drug event has been estimated at 13% for two drugs, 58% for five drugs and 82% for seven or more.29 As we get older, our bodies change and handle medications differently – older people are more sensitive to side effects of medications due to age-related physiological changes. As well as causing side-effects, many medicines are no longer required as we age and can be successfully withdrawn. Two large studies have shown that approximately 21% of medicines used in older people may be inappropriate.30 31 Other issues for older people and medicines are that their carers’ potential contribution and needs are often not recognised or addressed. Formal carers (eg home care) are discouraged from assisting older people to take their medicine, even though this could be of benefit. Family members, who could be more involved in treatment decisions and practicalities, including administration and the recognition of possible sideeffects, are often under-utilised. The redesign of HBSS outlined in Section C supports the increased ability for support workers to supervise medication adherence. DHBs, PHARMAC and the pharmacy sector agents are planning significant changes in 2012/13 to the way medicines are dispensed and managed in the community. These changes seek to improve the safety, quality and effectiveness of pharmaceutical dispensing and encourage the development of a patient-centred service model that utilises the skills and competencies of community pharmacists. Pharmacists will have the flexibility to provide medicines education and adherence support for certain patient groups including people who are “frail, infirm or unable to manage their medicines”. This includes the ability to tailor the way they dispense medicines according to individual patient need and should benefit older people through the use of compliance packaging to improve medication adherence.
28 Hanlon JT, Schmader KE, Kornkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45:945-948. 29 Fulton MM, Allen ER. Polypharmacy in the elderly: A Literature Review. J Amer Acad Nurse Pract. 2005;17(4):123-131. 30 Zahn C, Sangl J, Bierman AS, et al. Potentially inappropriate medicine use in the community-dwelling elderly. JAMA 2001;286(22):2823-9. 31 Curtis LH, Ostbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Int Med 2004;164(15):1621-5.
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Medicines reconciliation
Recommendations
A high proportion of medication errors occur when patients are admitted to and discharged from hospital. Issues with medication errors on admission and discharge can be addressed using “medicines reconciliation”. Medicines reconciliation by pharmacists ensures that patients receive all intended medications and no unintended medications following transitions in care and significantly reduces medication errors. In the BOPDHB, there is no formal provision of medicines reconciliation in hospital. There is a pharmacist discharge support service for high-risk patients that includes medicines reconciliation on discharge, but there is no assessment process to identify high-risk patients and consequently many are not identified.
1. Adopt HQSC (Health Quality and Safety Commission) national medication safety programme for identification of high risk patient populations and provide Medicines Reconciliation for all patients identified as high risk on admission to hospital in BOPDHB. 2. Develop the role of a clinical pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including aged residential care. This will include medication reconciliation for complex patients on transfer of care or discharge. 3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers). 4. Participate in the development of medication management processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.
Regular review of older people’s medicines Medication reviews ensure that patients are obtaining the maximum benefit from their medicines. This results in better disease management, fewer exacerbations of chronic conditions, reduced need for acute interventions such as GP visits and hospital admissions, improved medication adherence and fewer medication errors. Studies in general practices and aged residential care in the United Kingdom have shown that every £1 spent on employing pharmacists to review patients’ medication resulted in a £2 cost saving. Currently, medication reviews in primary care are funded through a primary health organisation (PHO) contract which does not cover medication review in aged residential care. Studies have shown that people in residential care are more likely to be on a greater number of medications than a similar aged population living in the community. Compared with residential aged care facilities around the world, New Zealand facilities have a 42% higher drug use.32
32 Grant Thornton, Aged Residential Care Services Review 2010.
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Delivery Delivering the recommendations of this Strategy will depend on a review of our existing workforce, a successful implementation plan, and the highest support at Board level. We recommend that a separate implementation plan is developed following approval of this Strategy and re-presented to key stakeholders. Funding provision, contracts and purchasing methods will need to be reviewed across most portfolios including health of older people, primary care, chronic conditions, secondary services, mental health and pharmacy to enable the recommendations to be achieved.
Workforce The impacts of an ageing population will place significant stresses on workforce demands. Strategies for increasing and diversifying the workforce are not well developed or focused. The workforce itself is ageing. The average age of nurses in the BOPDHB is now 52 and the average support worker is 50. Pay rates for unskilled labour are at minimum wage level or marginally above as rates for home based
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support services have not been able to keep up with increases in cost of living. The skill level required by support workers is increasing to keep up with increasing complexity of older people’s support needs. The industry is not an attractive option for younger people. Working in aged care is generally low skilled, untrained and low-paid, and not highly valued by younger people. Unpaid caregivers are also undervalued. It is recognised throughout the care industry that in New Zealand we pay people less to look after our vulnerable kaumatua and kuia, and our mothers and fathers, than we pay other low-skilled workers (eg those who stack supermarket shelves). If we are to attract the right people to meet the demands that an ageing population will have on the workforce, considerable work needs to be done to change this culture. Considerable investment and multi-agency collaboration is required to attract and train the workforce of the future, particularly tailored to younger Māori school leavers. Recent research published by the Department of Labour in 2009: Workforce 2020 – The Future Demand for Paid Caregivers in a Rapidly Ageing Society outlined the actual and projected number of paid caregivers needed for New Zealanders aged 65 years
and above from 2006-2036. It estimated that in 2006 there were around 54,700 people over the age of 65 requiring care in New Zealand, and approximately 17,900 paid caregivers. The report projects that by 2036 there will be approximately 147,700 people over the age of 65 requiring care, and there will be a requirement for 48,200 paid care workers.
Workforce planning for an ageing population is also the subject of specific strategic work both nationally and locally. Health Workforce New Zealand has developed forecasts of what the future health workforce in New Zealand will look like in 11 specialties including aged care. Some clear themes have emerged from the forecasts. They recommend:
The report notes the projections are based on current models of care. It further notes that the average age of paid care workers is currently 50 years old. The research makes a number of recommendations to address projected workforce shortages. The recommendations in this document align with the recommendations in the research.
• Making better use of the existing health workforce, from untrained workers to highly specialist, by developing new roles and extending existing roles to make best use of the skills of all members of the health care team. • A focus on prevention, rehabilitation and self care to underpin a shift of resources from hospital to community. • Better use of the potential of information technology, including telemedicine. • Development of regional clinical networks to make the best of resources and ensure provision of services to all communities.
In the year to December 2011, the unemployment rate for Māori flat-lined at 13.4% in comparison to the general unemployment rate of 6.3%. The latest update from Statistics New Zealand’s Household Labour Force Survey shows the jobless rate of 15 to 19 year old group in the Eastern Bay of Plenty’s Rangatahi Iwi is at 24.2%. Some whanau and mokopuna are capable of finding employment or going in search of educational opportunities outside of Eastern Bay of Plenty. However, the whanau who remain, many of whom are unemployed, and young Rangitahi who have left school with little or no educational achievement will be the main caregivers or whanau support for what will become vulnerable kaumatua. There is a need for any Health of Older People Strategy to allow inter-sectorial approaches, including Whanau ora, integrated service provision and extended whanau members to be employed to provide care. The Organisation for Economic Co-operation and Development (OECD) has examined the potential contribution to efficient use of the health workforce and recommends skill mix changes and the development of new roles, including enhancing skills among particular groups of staff as ways to address future workforce demands. Allied health professionals play a significant role in rehabilitation, treatment and long term support for the health and wellbeing of older people and can help alleviate projected medical and other specialist workforce shortages. However, access to community allied health therapists is limited, particularly in the Western Bay of Plenty and there are no major structural changes planned to increase the numbers or level of service. This will require a rethink about how these issues can be addressed within existing resources.
Recommendations 1. Support the implementation of the recommendations from Health Workforce New Zealand Aged Care Workforce Service Review. 2. Promote a transformational “cascade of knowledge” to mitigate the shortage of specialists and the sparse workforce for the most efficient and best clinical effect. Focus on the clinical presentations and treatment of older people, management of dementia and delirium, restorative and rehabilitation approaches. 3. Review current level of education and advice by specialist services and develop a work plan to increase education by and access to specialists in older people’s health to other sub-specialties, community agencies, Primary Care and aged residential care. 4. Support the development of changed roles eg rehabilitation assistant, advanced specialty nursing, clinical advisers, care navigators (people with a sophisticated understanding of the services available and threaded links for referrals). 5. Increase the current level of service provision for community allied health to recommended levels. 6. Recognise the value of the unpaid/volunteer workforce, family and whanau by providing specific training and development opportunities for these groups. 7. Maximise opportunities through the BOP Clinical School to support the above. 8. Develop policies to increase workforce participation and retention of older workers within BOPDHB.
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9. Review contractual requirements for staff training in provider contracts and introduce where necessary minimum standards and levels of attainment against nationally relevant unit standards. 10. Collaborate with and make submissions to other government agencies such as the Department of Labour to influence long term planning approaches to encourage participation in the workforce by older workers. 11. Provide incentives for community providers to include volunteers and primary carers in training programmes.
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Implementation Plan and Next Steps A detailed implementation plan will be developed following a prioritisation process for the recommendations. It is envisaged that a number of work streams will be necessary to implement the recommendations in a staged process. Prioritisation of recommendations and resulting work streams will take into account Government and Board priorities, annual and regional planning commitments and funding availability and priorities. A prioritisation process will be developed and recommended by the Executive Council of the DHB and approved by the Board. The Strategy Steering Group has now been disbanded following development of the Strategy. It is recommended that an implementation committee be formed to prioritise the recommendations and resulting work streams (in accordance with the prioritisation process) and oversee implementation. Membership of the implementation committee will be agreed by the DHB Executive Council. Details of shifts in current funding, investments required and where appropriate, expected savings, costs avoided or reductions in forecast growth will outlined with each work stream. Approvals for contracts, funding and service reconfiguration will be subject to the current BOPDHB approval process through the Funding Management Committee.
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Supporting Information Development of the Strategy The development of this Strategy has included: • Review of overarching Government strategies and priorities for health of older people. • Review of international trends and priorities in health services for older people. • Review of previous local strategic work and service reviews carried out for BOPDHB and a stocktake of progress. • Review of work being carried out by other DHBs and throughout the Midland Region and consideration of what can be applied to the BOP setting. • Future demand analysis and implications from the population projections for the BOP and what we know about demand on current service provision. • Collection of base line data by the BOPDHB Planning and Funding team to measure our success and track performance. • Discussion and consultation over a period of time with BOPDHB staff, clinicians, Planning and Funding Portfolio Managers in the BOPDHB and around the country but particularly in the Midland Region, and local stakeholders groups including the Population Ageing Technical Advisory Group, about the current model of care, identified gaps and identifying solutions for the future. • Formation of a Steering Group to provide direction and develop the Strategy. The Steering Group has broad representation from the sector and includes local specialists in geriatric medicine, providers of aged care and community services, Māori Health services, needs assessment and service co-ordination, and DHB Planning and Funding. Members are also represented on or have links with broader groups including the Population Ageing Technical Advisory Group, Positive Ageing Tauranga, Age Concern, Alzheimers Tauranga, Western Bay of Plenty PHO and Eastern Bay of Plenty Alliance Leadership Team, Disability Services and various community non Government organisations (NGOs). • Forums with Midland Region Health of Older People Portfolio Managers on potential regional activity and areas of alignment. • Formation of a draft strategy document to inform further discussions and stakeholder consultation.
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• Consultation and input from key stakeholder groups including older people themselves and NGO providers that advocate for older people, Primary Care, all providers of community based aged care services, Cluster Leaders in Tauranga and Whakatane Hospitals.
Background Documents The following documents have been considered in the development of this Strategy: The New Zealand Health Strategy The New Zealand Disability Strategy The New Zealand Health of Older People Strategy Health of Older People Strategy, 2001 Positive Ageing Strategy The Carers’ Strategy Guidelines for Specialist Health Services for Older People Mental Health and Addiction Services for Older People Dementia Services Guideline Diabetes and CVD Guidelines Better Sooner More Convenient Health Policy Health Needs Analysis for the Bay of Plenty Māori Health Plans for BOPDHB BOPDHB Programme of Care for Older People, 2003 Redesign of Specialist Services for Older People, 2005 Short Term Support Services Review for BOPDHB, 2007 PATAG Strategic Recommendations for Health, 2010 BOPDHB Annual Plan 2011/12 and 2012/13 Midland Regional Clinical Services Plan 2011/12 and Regional Plan 2012/13 Ministers Letter of Expectations for DHB for 2011/12 and for 2012/13 Midland Health Network Older Person’s Service Level Alliance Team Recommendations National Service Framework for Older People, NHS (UK), 2000 New Zealand Clinical Guidelines for Stroke: Implementation Plan, 2011
Appendices Appendix 1: Terms and Abbreviations Appendix 2: Intermediate Care Service Proposed Model
Appendix 3: Measures of Success Appendix 4: Acknowledgements
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Appendix 1: Terms and Abbreviations Abbreviation
Definition
ARC
Aged Residential Care
BOPDHB
Bay of Plenty District Health Board
HBSS
Home Based Support Services, generally home help and personal care.
HIA
Health in Ageing, the secondary specialist geriatric service in Tauranga Hospital.
HQSC
Health Quality and Safety Commission
NASC
Needs assessment and service co-ordination. Access to funded long term support services requires a needs assessment be carried out by a DHB approved needs assessor. In the Bay of Plenty, the DHB NASC service is Support Net.
MHSOP
Mental Health Services for Older People, the secondary specialist mental health service for older people in Tauranga and Whakatane hospitals.
SHSOP Specialist Health Services for Older People. This is the combined services of HIA and MHSOP.
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STSS
Short Term Support Services, generally home help and personal care provided for people after an admission to hospital.
TIA
Transient Ischaemic Attack
WHO
World Health Organisation
Appendix 2: Intermediate Care Service - Proposed Model
Key: CRT = Community Response Team AHP = Allied Health Professionals
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Appendix 3: Measures of Success The following table outlines indicators or measures of improved performance that we can expect to see as implementation of the recommendations progresses. These measures have been selected based on availability of current data (either through our own data base or reported to us by providers through Performance Monitoring Returns). The implementation plan may identify gaps in current data collection which may require changes to our current data collection systems, service specifications or provider contracts. The implementation plan will provide detail on targets for performance improvement associated with each work stream. Where indicated, some measures are expected to be monitored and reported on in the DHB Annual Plan 2012/13.
Standards Measure of Success A. Community Health Prevention and Information
2012/13 Annual plan measure
Older people, their carers, family and whanau are informed about their choices. Government agencies and local government develop policies that are age-friendly and responsive and reflect opportunities and impacts of population ageing.
B. Person Centred Care
Increase percentage of people in age residential care facilities are prescribed Vitamin D.
√
Increased percentage of the population of people age over 65 receive influenza vaccine.
√
Increased proportion of the population who identify as Māori are accessing services. Increased awareness and identification of elder abuse Increase in number of people diagnosed with a terminal illness have an Advance Care Plan
C. Integrated Care and Community Services Bay Navigator pathways that are relevant to older people are developed.
Reduction in the rate of growth of acute or unplanned admissions to hospital for people over the age of 65
√
Reduction in the rate of growth of readmissions to hospital for people over the age of 75
√
The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced. The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced. There is an increase in utilization rates for respite care and carer support
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√
Standards Measure of Success D. Hospital Care
Annual plan measure
An increase in the proportion of patients over 65 admitted acutely to hospital return to live independently in their own homes The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced. The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced.
√
Reduced average length of stay in hospital for all patients over 65.
E. Aged Residential Care
Increased access by primary and community providers to specialist geriatric advice and education. The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced. The average length of stay in residential care is reduced. √ An increase in the number of residents in long term residential care who have a comprehensive clinical assessment and care plan developed using InterRAI Long Term Care Tool. Reduced unplanned admissions to hospital from residents in aged residential care An increase in the number of providers certified with the Ministry of Health who are certified for a three year period or more. A reduction in the number of formal complaints received by the DHB
F. Dementia
Reduced average length of stay for patients in MHSOP Reduction in the number of acute admissions to MHSOP √ A pathway for dementia care is developed through Bay Navigator. The rate of expected growth in the proportion of the population with dementia admitted to long term residential care is reduced.
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Standards Measure of Success G. Mental Health on Older People
Reduced average length of stay for patients in MHSOP Reduction in the number of acute admissions to MHSOP
H. Stroke and TIA
A pathway for TIA is developed through Bay Navigator Increase in percentage of patients presenting with a TIA that are treated within recommended time frames as set out in the NZ Stroke Guidelines. Reduction in the percentage of people with a TIA who develop a disabling stroke. An increase in the percentage of people who have a stroke who return to live independently and in their own homes.
I. Falls and Bone Health
Reduction in the number of people over 65 who present to the Emergency Department with a fracture following a fall. Decrease in prevalence of osteoporosis
J. Medications Management
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To be developed.
Annual plan measure
Appendix 4: Acknowledgements There were a range of people, including members of the community, hospital clinicians and business leaders, service providers and primary care providers who have all provided valuable input, advice and expertise in the development of this Strategy. BOPDHB thanks you all for your contributions. In particular we acknowledge the following people: Bronwen Foxx, CEO Disability Resource Centre, Whakatane, Member CPHAC/DSAC Dorothy Stewart, Community Member, Age Concern, Elder Forum Trevor Deane, Regional Manager, Access Tony Lawson, Nurse Practitioner, Health in Ageing Dr Elizabeth Spellacy, Clinical Director, Health in Ageing Dr Nicola Cooper, Senior Medical Officer, Health in Ageing Rosemarie Webb, Regional Team Leader over 65 Team, Support Net Sharon Linwood, Clinical Co-ordinator, Mental Health Services for Older People Sandra Fielding, Nurse Leader, Medical Cluster, BOPDHB Joop Wieringa, Manager, Hodgson House, ARC Provider, Secretary BOP branch NZACA Judi Harpur, Manager Ngati Kahu Hauora Enid Ratahi-Pryor, CEO Ngati Awa Social and Health Services, Eastern BOP Alison Wieringa, Service Manager, Enliven, Presbyterian Support Northern Philippa Jones, Primary Nurse Liaison, Western BOP PHO and Planning and Funding BOPDHB. Kiri Peita, Senior Portfolio Manager, Māori Health Planning and Funding, BOPDHB Sarah Davey, Portfolio Manager, Health of Older People, Planning and Funding, BOPDHB
Kia Momoho Te Hāpori Ōranga – Healthy, Thriving Communities 55
18 July 2012
