Integrated Health Models The Calvary Experience

Transcription

1 Calvary Health Care Sydney Integrated Health Models The Calvary Experience Karen Edwards CEO / DON

2

3 Calvary Health Care Sydney 56 Rehabilitation beds reconditioning and orthopaedic 39 Palliative Care beds Community Palliative Care team >300 clients registered & active Community Rehabilitation & Aged Care Team >650 clients registered & active Aged Care Assessment Team Transitional Aged Care 41 bed equivalents Dementia & Brain Injury respite service recently commenced ON Multidisciplinary community based rehabilitation & aged care Driver assessment Equipment loan pool Day-only rehabilitation & hydrotherapy 30 per day x 12 weeks Parkinson s day-only rehabilitation Outpatient Clinics Palliative Care / Rehabilitation / Dementia Screening & assessment / MND / Pain

4 BACKGROUND deaths in Australia in % increase in deaths from 2006 Increase in population=increase in aged people Over 65y =79% of all deaths Over 80y = 51% of all deaths Ageing population = more people requiring residential aged care, many dying in RACFs

5 BACKGROUND Currently, almost 33% of people admitted to RACFs as high care, will die within 6 months 61% will die within one year By 2020, 50% of all deaths are expected to occur in RACFs Previous collaboration between the Calvary & St George Palliative Care Teams and the St George Division of General Practice and RACF staff to improve care at the end of life 63 RACFs in St George District & Sutherland Shire

6 CHALLENGES Difficulties discussing death & dying Prognostication Recognising patients who are dying Lack of awareness of palliative care Lack of palliative care resources-workforce Specialist vs. generalist palliative care Lack of education and access to consistent clinical support for RACF staff about palliative care approach & end of life care

7 THE SOLUTION The Palliative Care Aged Care Programme (PACP) Calvary Health Care Sydney St George District and Sutherland Shire

8 Why was funding needed for a PACP? To improve care for palliative care patients & families on RACFs Anxiety, stress & decreased QOL due to hospitalisation Difficulties adjusting to a RACF for first time Frustrations related to inequity of access to specialist palliative care & optimal end of life care Increased distress for palliative care patients & families without access to expert psychosocial support in the transition from hospital to RACF Palliative care is MULTIDIMENSIONAL

9 Why was funding needed for a PACP? To reduce demand on the healthcare system Health services experiencing increased demand on: ED, acute & subacute services Ambulance service resources Patients presenting to ED with conditions that could be managed in RACF with appropriate support Extended hospital and Palliative Care Unit admissions for patients awaiting transfers to RACFs No formalised, standardised process for transfers to RACFs from acute/sub-acute facilities to support patients and families

10 EVIDENCE RACF residents who become acutely unwell & are admitted to acute setting often receive futile & distressing treatment U.K. Study reported RACF residents significantly less likely to survive the admission than elderly living in community Need for careful advance care planning (Ahearn et al. BMJ,5/11) A study (2005) looking at the effectiveness of the implementation of an End of Life Pathway undertaken at St George Hospital found that 30% of all expected deaths seen by the Consultative Palliative Care Service at St George were from Residential Aged Care Facilities.

11 Palliative Aged Care Program To improve outcomes for aged care residents who require a palliative approach and end-oflife care by: Building capacity in RACFs in the St George District and Sutherland Shire Providing a designated consultative clinical service to RACFs, with Programme CNS Specialist & Consultant Working with palliative and aged care advance practice nurses from acute, subacute and aged care to develop and present palliative care workshops to RACF staff Building on existing existing capabilities in aged and palliative care sector

12 Palliative Aged Care Program To support residential aged care facilities Minimal ability to meet a patient s & family s psychosocial needs during transition to RACF and at end of life Limited knowledge, experience & confidence in palliative care, and managing EOL symptoms Lack of knowledge & related increased stress, about the appropriateness of transfers from RACFs to hospital Support the implementation of End-of-life Care Pathways developed at CHCS, StGH & TSH in RACFs

13 FUNDING HOW WAS IT INVESTED? $500K to fund 3.8 FTE in Community Palliative Care Team (CPCT) + a car Service provided 5 days by Palliative Care Staff Specialist, 1.2 FTE Social workers & 1.6 FTE Specialist Nurses 24 hour, 7 day phone consultation available to advise on interventions to optimise patient care & avoid crisis admissions to acute facilities

14 CPCT Role and Composition Multidisciplinary team: staff specialist, nursing (CNS and CNC), social work, physiotherapy, occupational therapy, pastoral care Role is to provide specialist palliative care support to people with complex needs (e.g. pain, dsypnoea, delirium) related to a life limiting illness and their families CNS s case-manage palliative care clients living at home AND provide consultative support to people living in residential aged care facilities

15

16 Key principles Social worker facilitates transition from acute/sub acute settings to RACF to address psychosocial needs of patients & families Build capacity of RACFs to provide optimal palliative care to patients by education, training, clinical consultation and support Bridge the gap between RACF & tertiary Palliative Care services Medical specialist availability for clinical support & guidance to both RACFs and GPs, including after hours Enhance liaison with GPs in RACFs and Medicare Local

17 Palliative Aged Care Program COAG funded Aim: to build capacity in RACF sector in a palliative approach and end of life care Social Worker: transitional support to residents and their families, newly admitted to a RACF with a palliative diagnosis CNS: clinical consultations and clinical support, education -> in-services, one on one, information resources

18 Clinical consultations - Commonly asked to see residents with symptoms and range of conditions Pain Agitation Dyspnoea Significant wounds Advanced dementia Cancer Heart, respiratory or renal failure Neurological disorders Very frail and old and coming to the end of life Or a combination of two or more of the above

19 Workshops and in-services 12 workshops held RACF staff members have attended (managers, coordinators, RNs, ENs, AINs, pastoral care workers) 93% rated workshops as supportive / very supportive Further workshops are planned : Complex disease still not well-understood within RACFs In-service education on palliative care delivered at around 50 facilities annually include self care, pain assessment and management, care of the dying person, palliative approach to care, advanced care planning

20 One on one clinical support Clinical consultations are undertaken with a collaborative approach Aim to support the capacity of the primary care nurses Providing support and reassurance in difficult palliative care situations supports and empowers primary care nurses and other staff

21 Social work transition support Weekly or fortnightly visits during first 12 weeks in RACF Regular phone contact with family carers & RACF staff Bereavement follow-up & referral Honest preparation for life in RACF Continuity of psychosocial care Advocacy, Advance Care Planning Anticipatory grief counselling and Grief & loss counselling Dignity & reminiscence therapy Case conferencing & education for families & staff

22 CHCS has achieved a LOS reduction of 2 days from baseline & a corresponding increase in the number of inpatient episodes. This provides an annual efficiency of $1,122,452 or 1,562 bed days (based on 90% occupancy, $300k annual bed cost).

23 Reduced demand on acute health care system 2012 snapshot over 4 months: 87% (65) of patients died in their home RACF - with CPCT support Improved confidence of Palliative Care staff in transferring patients to RACFs: 70% increase in transfers from PCU to RACFs Improved patient flow to PCU from acute settings Improved access to specialist palliative inpatient beds when indicated for transfer

24 Statistics Increased CPCT activity in RACFs: 40% increase in referrals to CPCT from RACFs > 400% increase in CPCT OOS in RACFs 150+ patients & families supported by SW in >40 RACFs and CPCT nursing Pre-PACP (Jan-Dec 2010) 174 phone calls, 251 visits, 47 recorded referrals During PACP (Jan-Dec 2011) 574 phone calls, 403 visits, 81 recorded referrals

25 4 month snapshot 2012: 8 patients died in RACF before being seen by CPCT nurse 1 died in acute hospital after being seen in RACF by CPCT nurse 1 died in hospital before being seen by CPCT nurse ONLY 2% OF PATIENTS WERE TRANSFERRED TO AN ACUTE FACILITY

26 CHCS has demonstrated an increase in average monthly non-admitted referrals during the COAG funding period, primarily observed in the 2012/13 FY.

27 Feedback Thank you so much for the palliative education... I had returning staff full of enthusiasm ready to share all they had learned. We have named the staff who attended, our palliative champions, and given them the role to guide others into best practice in delivering care to our dying residents Their quest for knowledge and understanding is being supported and has already proven beneficial to our residents. We have included them in the ongoing formal assessment of our palliative residents, which I think will prove very valuable to our residents. So a great big thanks to you for empowering the attending staff.

28 Start typing THANKYOU