Aged Health, Chronic Care Rehabilitation and General Medicine (ACC&R) Position Paper

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1 ` Aged Health Care, Rehabilitation, General Medicine, Chronic and Ambulatory Care and General Practice Clinical Stream Aged Health, Chronic Care Rehabilitation and General Medicine (ACC&R) Position Paper P a g e

2 Contents Foreword by Clinical Director... 3 Our Organisation... 7 Our Community... 9 Our Patients Carers and Consumers Our Services Our Staff Our Research and Education Our Priorities References Appendixes List of Abbreviations/Acronyms P a g e

3 Foreword by Clinical Director This document is one of two papers generated by the Aged Health, Rehabilitation, General Medicine, Chronic and Ambulatory Care, Endocrinology, Andrology and General Practice Liaison Clinical Stream of Sydney Local Health District. The second paper, overseen in its preparation by the Deputy Clinical Director, concentrates on the Endocrinology components of the Stream. The Aged Health, Chronic Care, Rehabilitation (ACC&R), and General Medicine components of the Clinical Stream provides care for those health care consumers who are more likely to have multiple acute and chronic co-morbidities and who are most likely to have frequent interactions with the healthcare and wider human services systems. Our patients and clients include the aged, disabled and those with chronic care conditions. Our services include a complex range of acute and subacute inpatient services, community services, outpatient and ambulatory care services. These services are provided across all sites in the District. The Stream s complexity is increased by a wide range of funding bodies and groups requiring activity and financial acquittals, and the imperative of working with partners across a broad spectrum of agencies. The General Medicine service at Canterbury Hospital manages large numbers of acute medical patients of all ages, in the setting of a District Hospital with a small medical bed base relative to its ED activity. Similar patients presenting to the EDs of RPAH or Concord Hospitals would be admitted under sub-speciality medical units or to the acute geriatric medicine service. Of the current SLHD population, 64,731 people (11.8%) are aged over sixty-five years. Literature shows that over 70% of total demand in growth for health services is expected to be for people aged over 75 years of age and 45% of growth will be for sub-acute care 1. The following are the health issues which commonly arise in older people using healthcare: Low levels of physical activity and inadequate nutritional intake; High rates of osteoporosis and arthritis, knee and hip replacements and hip fractures - with associated risks of, and from, falls; High blood pressure and high cholesterol - present in over half of people; High rates of respiratory illness; High rates of chronic health conditions - including multiple conditions with associated polypharmacy; Problems with vision, hearing, oral health and continence; End of life care - palliative care and advanced care planning; Mental illness, particularly depression linked to social isolation and high rates of suicide; High rates of dementia; Inability to perform activities of daily living e.g. bathing, dressing, meal preparation. High levels of reliance on both informal carers and formal community support services, with consequent stress on the former, and difficulties of meeting demand by the latter. Specific issues for residents of Aged Care facilities Chronic diseases, by definition, have complex causality, multiple risk factors, are prolonged and result in functional impairment or disability. Most chronic diseases persist in an individual throughout their lifetime. The prevalence of chronic disease increases with age. The Stream provides a range of programs and services addressing these conditions. 1 NSW Department of Health 2005d 3 P a g e

4 It is estimated that there are well over 100,000 people with disabilities living in Sydney Local Health District, with almost half of those having a cognitive disability of some form. The greater majority of these are elderly people as age is the main risk for dementia. Equity is a core service consideration. The SLHD is highly culturally diverse, with 43% of the community speaking a language other than English at home and 7% not speaking English well or at all. The District also has over 4,875 people who identify as Aboriginal, with the largest numbers being resident in Sydney LGA (Redfern-Waterloo) and Marrickville. The Stream has extensive networks and partnerships with community organisations, the Medicare Local, other LHDs and Residential Aged Care Facilities. SLHD has 77 Residential Aged Care Facilities (RACFs), with 4,576 beds. The Aged Health Service has a strong responsibility to ensure that residents living in aged care facilities receive the appropriate healthcare in the most appropriate setting. The range of issues and the potential scope of the work required are complex, and cannot be explored in detail within the constraints of this document. Over the next five years, the key strategic priorities outlined in this Position Paper are to: Physically upgrade the Aged Care and Rehabilitation ward facilities at Concord (ramp wards) and Balmain, and review the acute bed allocation to Geriatric Medicine at RPAH. There needs to be capacity within inpatient environments to manage older patients who manifest behavioural disturbances as part of their illnesses, and to enable the provision of a model of care that facilitates the restoration of functional abilities that may have been lost as a consequence of acute illness. With the opening of the RPA North West precinct, an appropriate site needs to be allocated and refurbished for the re-establishment of the RPA Day Hospital and Aged Care and Rehabilitation outpatient services. Establish and expand Ambulatory Care Services / HITH across all sites in SLHD. Of importance is ensuring a dedicated, accessible site for each of these services, ideally within a non-inpatient precinct. Across the District we need to ensure a networked arrangement, agreed model and common set of operational policies for Hospital in the Home services. A District Plan for Ambulatory Care will be developed. Re-establish and staff the Aged Care and Rehabilitation Service (14-16 beds) at Canterbury Hospital, following the relocation of 14 Palliative Care beds from Canterbury to Concord Hospital. Ensure the provision of sub-specialty support from other SLHD facility services for the Canterbury Hospital general medical and surgical beds as well as the aged care services. Review the role of Balmain Hospital to ensure the optimal future mix of rehabilitation and acute care is provided, especially in view of the need to expand rehabilitation beds across the District. Support the optimal ongoing provision of community aged care with the implementation of the National Aged Care Reforms. Of central importance is maintaining and strengthening the service provision priorities in the light of changed funding arrangements. 4 P a g e

5 Form partnership with various NGOs for the benefit of mutual clients. This will become a high priority issue as the effects of the National Aged care reforms become clear. Increase our aged care and rehabilitation service and bed capacity, both acute and subacute, commensurate with our expanding elderly populations and the needs of younger disabled people. This includes improving Inreach to acute care rehabilitation capacities at RPAH. The enhancement of inpatient capacity needs to occur simultaneously with the exploration and implementation of models of community and ambulatory care appropriate for the directorate s target patient /client population. Ensure that our key target populations, including people with dementia, people with chronic conditions, people with disabilities, older people, people needing rehabilitation, and people that have avoidable hospital DRG s, have appropriate and available services commensurate with their needs. These services need to develop a restorative and preventative focus. Further, we will need to ensure that the needs and issues of people from Aboriginal and Torres Strait Islander, CALD and LGBTI communities are equitably provided for, and, as required, specifically targeted, within the Stream. Review and reform the Sydney LHD Chronic Care Programs, to increase access, efficiency, consistency of service provision, and measurable outcomes of these services. Upgrade emergency services related to the care of the elderly. This includes the RPAH Aged Service Emergency Team (ASET) and the MAU at all sites. Work with the Inner West Sydney Medicare Local to ensure a strong continuum of care for our target populations. Finalise and implement the Sydney Inner West Dementia Action Plan, in collaboration with other stakeholders. In conjunction with SMHSOP review the implications for service delivery in relation to provision of Dementia Behaviour Management Advisory Services ( DBMAS) in view of the change in funding of those services from NSW Health to HammondCare from July Ensure appropriate organisational, structural and administrative support for ongoing and future service developments. This especially relates to the further roll-out of the electronic medical record, including for the Chronic Care Programs, and the forthcoming introduction of activity based funding, in particular sub-acute ABF (AN-SNAP). Provide targeted support to the Residential Aged Care Facilities in SLHD, in association with the Sydney Inner West Medicare Local, to ensure the provision of appropriate healthcare in the most appropriate setting. For example, the provision of oral health services at RACFs is an important initiative. Work across sectors and services to systematise the end of life pathways to ensure clear communication and support for patients, their families and carers. Work within the health service and hospitals to ensure that providers across all streams and services understand the special requirements of aged and disabled consumers. The further development of collaborative models of care such as the 5 P a g e

6 Orthogeriatric Model, to the LHD s acute hospitals, has the capacity to improve service delivery. Explore the development of health pathways across primary and secondary health providers in developing sustainable, clear, concise and localised pathways from a whole-of-system perspective. Explore the formation of inpatient clinical pathways for rehabilitation services. Review Stroke Services across the Sydney LHD, including the need for cross clinical stream partnerships. Develop plans for Aged Health Care and Rehabilitation, Chronic Care and Ambulatory Care over the next 1-2 years. Explore the capacity of TeleHealth services to deliver outreach services to regional and remote, and residential care communities. We will strive to ensure that we have in place all the components necessary for a capable, efficient, highly accessible client focused service with leading models of care that promote the highest possible service standards throughout our District. Dr John Cullen Clinical Director Aged Care, Rehabilitation, General Medicine, Chronic Care, Ambulatory Care, Endocrinology, Andrology, and General Practice Liaison 6 P a g e

7 Our Organisation The Sydney Local Health District provides Aged Health, Chronic Care and Rehabilitation Services (ACC&R) through a network of services, across multiple service delivery settings and with multiple sources of funding (including some time-limited contracts). Integral to an integrated model of service provision, across sites and agencies, is the effective roll-out of the emr. The Clinical Stream, which includes Aged Health Care, Rehabilitation, General Medicine, Chronic and Ambulatory Care, Endocrinology and General Practice, is managed by the Clinical Director, the Deputy Clinical Director, the Clinical Manager, the Operational Manager and the Business Manager. The service works with the SLHD Executive and Facility Executives to oversee the provision of integrated aged health, chronic care and rehabilitation services across the LHD. The ACC&R Clinical Stream is a matrix of services offering care across the continuum. The organisational chart for the stream is below. Figure 1 ACC&R Organisational Chart Aged Care, Ambulatory, Disability, Andrology, Chronic care, General medicine, Endocrinology, Rehabilitation Clinical Stream Director Deputy Clinical Director Operational Manager Clinical Manager Service Manager * Community Team * Compacks * Community Visitors Scheme * Comm. Transitional Aged Care Program Aged Chronic Care Triage Sydney & SWS LHDs AC&R Day Therapy/Clinics RPAH QE11 CRGH Bld 12/16 Endocrinology Andrology Sydney Inner West Medicare Local Business Manager Performance & Data Administration Service Manager * Aged Care Assess Team * SMHSOP/ DBMAS * Referral & Information Centre * Take a Break * Therapy Team (incl. DARTYP, Continence Nurses, Stepping On, CONFAB) Aged care Services in Emergency Team (ASET) RPAH CRGH TCH Chronic Care Program CRGH TCH RPAH/Bal Aged Care & Rehab Inpatient NUMs Ambulatory Care November 2012 Service Manager * Centre-based day care (4) * Dementia Support Service * Dementia Advisory Service * Employed Carers Program * Sydney Adult Home Ventilation Program (AHVP) * Sydney HACC Liaison Aged Care & Rehab. Inpatient Services RPAH 8W1 Acute Aged Care 30 RPAH MAU Balmain JB Rehabilitation 26 Balmain Lever Acute/sub-acute AC26 Balmain Wakefield Acute/sub-acute AC26 CRGH Wd 10 Sub-acute AC 28 CRGH Wd 11 Acute AC 24 CRGH Wd 14 Rehabilitation 15 CRGH Wd 15 Acute AC 24 CRGH Wd 17 Delirium 12 CRGH MAU 14 TCH Banksia GM/AC (incl. MAU) 30 TCH Boronia GM/AC 30 TCH Telopea Subacute AC 8 Sydney NUM ACR Community RPAH/Ba. CNC3 Continence CRGH/TCH CNC2 Continence CRGH CNC3 Gerontology RPAH/Ba. CNC3 Rehab/Amputee Sydney CNC3 Dementia Sydney CNC DARTYP RPAH CNC Diabetes Centre RPAH NP Diabetes RPAH NP Diabetes RPAH CNC Endocrine/Metabolism RPAH CNC Endocrine/Metabolism CRGH NP Diabetes CRGH CNC Endocrinology CRGH CNC Andrology 7 P a g e

8 The Aged Health, Chronic Care and Rehabilitation Service is comprised of inpatient wards, outpatient services, ambulatory care and community based services. These services are provided across multiple sites, with various reporting structures. Our main partners are our clients/carers, General Practitioners, Residential Aged Care Facilities (RACF), other community service providers outside of Health, EDs, multiple other LHD services, in particular Orthopaedics, Allied Health, Neurology and Mental Health. Services directly managed include the following: Inpatient acute and subacute geriatric medicine Inpatient rehabilitation including amputee management Inpatient consultative services in Geriatric Medicine and Rehabilitation Medicine General Medicine at Canterbury Hospital Geriatric and Rehabilitation Outpatient services Severe Chronic Disease Management Specialist Mental Health Services for Older People (SMHSOP) including BASIS/DBMAS via Service Agreement with Mental Health TeleHealth and rural outreach geriatric consultation Domiciliary and RACF consultation services A range of community-based ambulatory care services. 8 P a g e

9 Our Community The SLHD comprises the eight local government areas of Ashfield, Burwood, Canterbury, City of Sydney (part), Canada Bay, Leichhardt, Marrickville and Strathfield. The District currently has a population of 582,100 (2011 erp). By 2021, the local SLHD population is expected to reach 642,000 and almost reach 670, 000 five years after that. Significant planned urban developments include the new Green Square Development in Zetland and Beaconsfield in the City of Sydney, urban consolidation along the Parramatta Road corridor and new developments in Rhodes, Breakfast Point, the former Carlton United Brewery site, Redfern/Waterloo and the former Harold Park site at Glebe. During , the population of Sydney LHD has grown by 16.7%, with some LGAs having growth in excess of 50%. Over the last five year intercensural period, the District population has increased by over 50,000 people. The growth in the aged and the old old population of SLHD is especially important for health care delivery over the forthcoming decade, with an increase of 29.2% and 28% in the age group and the 85+ age group respectively predicted by Of particular interest is the significant increase projected in the population of the City of Sydney, projected to exceed Canterbury LGA by This population growth, together with its ageing is placing significant pressure on aged care services across SLHD. The growth, since 2001, is shown in Table 1. Table 5 and Figure 2 shows the projected population increases to Table 1: Current Estimated Residential Population, SLHD by LGA and SLA, 30 June 2012 Change LGA % % no. Ashfield 43, , Burwood 34, , Canada Bay 79, , Canterbury 144, , Leichhardt 55, , Marrickville 81, , Strathfield 37, , Sydney South (SLA) 60, , Sydney West (SLA) 44, , TOTAL 582, ,397 Source: The Picture of Health. A SLHD Health Profile P a g e

10 Table 2: Projected population SLHD LGA Ashfield 41,520 43,464 45,663 46,787 4, ,607 49,671 Burwood 32,395 34,243 37,443 42,315 47,019 51,923 57,009 Canada Bay 68,725 79,664 87,497 90,149 91,736 93,513 95,419 Canterbury 135, , , , , , ,538 Leichhardt 51,554 52,855 54,093 55,410 56,366 57,456 58,637 Marrickville 75,546 79,225 82,241 84,275 85,769 87,472 89,315 Strathfield 33,231 36,322 39,136 42,022 44,708 47,721 50,847 Sydney City (part) 93, , , , , , ,315 TOTAL 531, , , , , , ,751 Source: The Picture of Health. SLHD Health Profile 2012 Table 3: Projected population SLHD Source: The Picture of Health. SLHD Health Profile P a g e

11 Table 4: Projected population SLHD by selected age groups Age-Related Projections TOTAL 2011 (est) 2 96, , ,614 39,294 8, , , , ,529 43,324 10, , , , ,131 50,762 11, ,009 % Change % 5.5% 14.2% 29.2% 28.0% 11.0% Source: Department of Planning 2009 Of the current SLHD population, 64,731 people (11.8%) are aged over sixty-five years. Over 8,500 of these people are aged over eighty-five years, the highest users of the health system. 54% of the over 65 year s population is female, 46% male. At the 2011 census, there were 4,875 people who identified as either Aboriginal or Torres Strait Islander living in SLHD. 941 persons aged over 50 years identify themselves as indigenous Australians i.e. 19% of the total SLHD indigenous population. See below Tables 5-9. Table 5: SLHD Population aged 65+ by Gender and Age Grouping Table 6: Population Aged 65+ by LGA in SLHD, 2011 Population Aged Over 65 years by LGA/SLA in SLHD, 2011 Census Ashfield Burwood Canada Canterbury Leichhardt Marrickville Strathfield Sydney Total Bay * years 2,534 2,142 5,314 9,605 3,106 4,317 2,106 4,468 33, years 2,177 1,734 3,679 6,681 1,646 2,767 1,447 2,383 22, years 1, ,504 2, ,625 TOTAL 65+ POP TOTAL POP. 5,945 4,688 10,497 18,513 5,382 7,987 4,226 7,493 64,731 41,213 32,424 75, ,454 52,196 76,500 35,187 97, ,629 2 Note: These numbers are estimates derived by the Department of Planning. Thus, they differ from actual populations counted at the 2011 census. 11 P a g e

12 Table 7: Population Aged 65+ by LGA in SLHD, 2011 as a Percentage of Population Ashfield Burwood Canada Bay Canterbury Leichhardt Marrickville Strathfield Sydney years 6.1% 6.6% 7.0% 7.0% 6.0% 5.6% 6.0% 4.6% years 5.3% 5.3% 4.9% 4.9% 3.2% 3.6% 4.1% 2.4% 85+ years 3.0% 2.5% 2.0% 1.6% 1.2% 1.2% 1.9% 0.7% 65+ as % of total pop. 14.4% 14.5% 13.9% 13.5% 10.3% 10.4% 12.0% 7.7% Table 8: Population Aged 65+ by LGA in SLHD Table 9: SLDH Indigenous Population by Age The Sydney (South and West Statistical Local Areas) and Marrickville LGAs have the 12 P a g e

13 highest number of Aboriginal residents (1,714 and 1,111 respectively). 16% of the SLHD indigenous population is aged over 50 years (Table 9). Across Sydney LHD, 43% of residents reported at the 2011 census that they speak a language other than English at home. The proportion and numbers of people speaking another language ranged from 64% (87,793 people) in Canterbury LGA to 15% (7,892 people) in Leichhardt LGA. Across the LHD, 7% of the population described themselves as not speaking English well, or not at all. The main languages spoken were Mandarin (28,712 people), Arabic (26,665 people), Greek (24,654 people) and Cantonese (22,881 people). Literature shows that elderly people from non-english-speaking backgrounds lose their English language with ageing. In 2010/11 there were 2,384 hospitalisations resulting from falls recorded for people in the 65+ age group in SLHD, a rate of 3,338.7 per 100,000 (compared to 3,129.2 per 100,000 for NSW). 3 Falls rates were significantly higher than the state in the LGAs of Ashfield, Canada Bay, Leichhardt, Marrickville and City of Sydney, with rates in Leichhardt LGA being more than 40% higher than the State average (see Table 10). Table 10: NSW / SLHD Fall related injury overnight stay hospitalisations by sex, persons aged 65 years Sydney LHD NSW. Sex Number per - year Rate per 100,000 population LL 95% CI UL 95% CI Number per year Rate per 100,000 population LL 95% CI UL 95% CI Males , , , , , , ,732.0 Females 1, , , , , , , , Persons 2, , , , , , , , Source: NSW Admitted Patient Data Collection and ABS population estimates (SAPHaRI). Centre for Epidemiology and Evidence, NSW Ministry of Health The population of people living with dementia in the Inner West area of Sydney (all LGAs except City of Sydney LGA) is expected to increase from 5,453 people in 2012 to 6,653 in 2018, according to Access Economics prevalence calculations. The AIHW estimates that the numbers of people with dementia will increase by almost 30% by Based on the rates found across Australia, the ABS Survey of Disability and Carers 2009 indicates that in 2011, an estimated 106,960 people with disabilities live in Sydney Local Health District. Of these, an estimated 48,000 people would have a cognitive disability. 4 Further, approximately 36,135 SLHD residents have a severe disability needing assistance in core activities of living such as self-care, mobility and communication because of a disability, long term health condition or old age. This represents approximately 6% of people living in Sydney Local Health District. Residents with disabilities include approximately 1,270 children aged 0-4 years. 3 Health Statistics NSW 4 Disability was defined as any limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts everyday activities. Examples range from hearing loss, which requires the use of a hearing aid, to difficulty dressing due to arthritis, to advanced dementia requiring constant help and supervision. 13 P a g e

14 Overall it is expected that just fewer than one in five people or approximately 18.5% of the population have a disability. A further 21% are expected to have a long term health condition. 88% of people aged over 90 are expected to have a disability. About 5.8% people are expected to have a severe disability needing assistance in the core activities of self-care, mobility or communication. At the 2011 census, 44,960 people identified themselves as providing unpaid care or assistance to people with a disability, chronic long term health problem, or old age. These include carers of people with dementia and mental health conditions. This equates to 8.2% of the population. The proportion of people identifying as carers ranged from 6.3% in the SLHD part of Sydney LGA to 9.2% in Burwood LGA. In SLHD, people over 80 years accounted for an increase of 2,000 separations or 19,000 bed days over the past 5 years, effectively an additional 58 additional beds. Health Roundtable data has confirmed that people over 80 years comprise 3% of the population but make up 11% of hospital admissions, 22% of ED admissions, 19% of acute bed days and 22% of complex bed days 5. Tables 11 and 12 show the usage of hospitals by age groups in SLHD hospitals. Table 11: Over 65+ By Age Grouping Usage of SLHD Hospitals Over 65+ age Group Acute and Sub-acute Usage of SLHD Hospitals in Balmain Canterbury Concord RPA IRO SLHD TOTAL Seps Beddays Seps Beddays Seps Beddays Seps Beddays Seps Beddays Seps Beddays 65 to 69 years to 74 years to 79 years to 84 years to 89 years to 94 years years Grand Total Table 12: SLDH Bedday Usage of 65+ in SLHD Hospitals 5 NSW Department of Health 2005e. 14 P a g e

15 The following tables show trends in bedday use for older people to June These show peak periods of activity in the winter months. The tables show a pattern of stability in bedday use (although there are more presentations) in activity over this period. Tables 13-15: Bedday Usage for 65+ Patients Canterbury Hospital Bed Day Usage for Patients 65+ years July June Bed Days JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN P a g e

16 Concord Hospital Bed Day Usage for Total Patients 65+ years July June bed days JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN RPAH Bed Day Usage for Total Patients 65+ years July June bed days JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN P a g e

17 Our Patients Carers and Consumers ACC&R Clinical Stream provides services to five main target groups: 1. Aged Care Patients/Clients 2. Rehabilitation Care Patients/Clients 3. Chronic Care Patients/Clients 4. Carers 5. General Medical Patients at Canterbury Hospital 1. The Aged Care Patient/Client The term aged care client refers to people who will most benefit from access to multidisciplinary aged care assessment and management. The definition of the aged care client is therefore not based on chronological age, or on particular Australian National Diagnosis Related Groups (AN-DRGs), but based on need. They have high levels of need due to problems with their physical, mental or functional ability, or with the provision of their care, accommodation and support. It should be noted that these needs may not be reflected, and accurately recompensed, within the current Activity Based Funding (ABF) model, or captured by current MOH service planning models. Aged Care clients managed with the geriatric model of care have fewer acute care hospital admissions, spend less total time in acute care hospitals and have a lower mortality rate as a result 6. In addition, greater improvements in functional status have been demonstrated, with fewer initial discharges to residential aged care facilities (RACFs) and less time spent in RACFs. Studies evaluating the cost-effectiveness of this model of inpatient services demonstrate either cost neutrality, or long-term cost-benefit, compared with inpatient hospital care in generic wards. Literature shows that frail older people readily become deconditioned in hospital, are at higher risk of complications and iatrogenic events from hospitalisations, with increased falls, pressure areas and other debilitating conditions, due to their multiple medical problems and frailty which can lead to prolonged hospital stay, institutionalisation and death. This increased vulnerability to adverse outcomes is a hallmark of frailty. SLHD falls data by age band is below. With appropriate enablement care, the hospital experience for the older person can improve health outcomes. There is good evidence that multi-disciplinary care lead by Geriatricians with expertise in medical care of the older person decreases the risk of adverse events and the resulting poor outcomes. In addition this expertise can prevent inappropriate care. This expertise can in some instances prevent futile and distressing treatment for older people at the end of their lives. In other instances it may important to advocate strongly for potentially beneficial interventions which have been denied to an older person on the basis of chronological age alone 6 Stuck et.al, P a g e

18 Table 16: SLHD Patient Falls by Age Band October 2012 vs. last 12 month average. There are 3 specific aged needs groups: People with Dementia People with Delirium People at Risk of Falls 1.2 People with Dementia Age is the strongest risk factor for the development of Alzheimer s disease, the most common form of dementia. There is currently no cure for the disease, although drugs are now available which have been shown to slow its progression. Dementia has a profound effect on clients/patients and their carers quality of life. Early and accurate diagnosis and assessment is critical to the successful care and management of people with dementia and the development of care plans to support their carers. A correct medical diagnosis to clarify the dementia syndrome is essential as some dementias are reversible, people often have co-morbid psychiatric conditions, medical illnesses may be masked by their dementia, and medical treatment may be affected by subtle physiological and pathological disturbances. People with dementia are extensive users of the health system and this will clearly increase. Within a year of an outpatient assessment, Callahan et al (1995) 7 reported that patients with moderate to severe cognitive impairment were more likely than those with no impairment to be hospitalised, to visit the emergency department or to die. People with dementia are more prone to develop delirium when they have an acute medical or surgical condition. The rates of morbidity, mortality and length of hospital stays are much greater in this population compared to those without dementia, with length of stay 4 times longer. 8 This longer length of stay may be able to be reduced via rapid recognition and management of delirium, involvement of carers in management plans and the development of more supportive hospital environments, both in terms of the physical environment and the availability of consultative services and educated clinical staff. A specific target group requiring more specialised services are those who experience behavioural and psychological symptoms associated with dementia (BPSD). SMHSOP currently includes the Dementia Behaviour Management Advisory Service (DBMAS) and 7 Callahan, Hendrie & Tierne, Nichol, Lonergan & Mould, P a g e

19 Behavioural Assessment and Intervention Service (BASIS) for those older people with complex, severe and persistent behaviour disturbance associated with dementia and/or mental illness (BPSD) either living at home or in residential aged care facilities. Service delivery to this group will require review in view of the change in funding of DBMAS services from NSW Health to HammondCare from July 2013 noting that BASIS positions will remain with SMHSOP. 1.3 People with Delirium Delirium is a common life threatening neuropsychiatric syndrome. It is an acute, reversible organic brain disorder characterised by reduced ability to maintain attention to external stimuli and disorganised thinking as manifested by rambling, irrelevant or incoherent speech. The Australian Society of Geriatric Medicine (2005) reports the prevalence rates of delirium on admission are 10% - 24% and that delirium develops in up to 56% of older people in hospital (climbing to 61% post operatively). People with delirium have worse outcomes overall resulting from largely preventable incidents such as falls. Appropriate building design and layout can contribute to prevention and management of delirium. Integral to good care of patients with delirium is appropriate preventative models of inpatient care. Patients with delirium require rapid assessment followed by the development of management plans that involve minimising the risk of adverse events during the acute phase and supporting carers in maintaining their caring role post discharge. 1.4 People with Fall Related Injuries or at risk of Fall Related Injuries Older people (over 75 years) are known to have a higher incidence of fall related injury than the remainder of the population. Fall related injuries have a significant impact on the quality of life of older people and are a significant cost to the NSW Health system in terms of inpatient and residential aged care beds, medical and allied health staff, and pharmaceuticals (NSW Health, 2005b). Using demographic change only, based on 2008 admission rates the number and cost of fall injury hospitalisations among older people is expected to increase almost three-fold by With current trends of falls-related hospitalisation this increase could be as much as ten-fold by Either method indicates a significant impost on existing resources available for this group of people. In , 2,384 people aged over 65, living in SLHD were hospitalized for fall-related injuries. The rate in SLHD is higher than the state rate. In 2001, 208 beds were required in the previous SSWAHS to manage fall related injuries. Assuming no effect from prevention efforts, this demand is projected to increase by 38% to 288 beds (or an additional 80 beds) in 2016 (assuming an occupancy rate of 85%). Closely linked with the issue of falls is the need to provide orthogeriatric support involving geriatricians and orthopaedic surgeons across acute, sub-acute and community settings. Rehabilitation specialists are also essential to the delivery of holistic care for patients with fall related injuries. Falls services need to be linked to fracture prevention and bone health service. 9 Watson, Li & Mitchell, P a g e

20 2. The Rehabilitation Client The Australasian Faculty of Rehabilitation Medicine (2005) describes a client of rehabilitation medicine as a person with a loss of function or ability due to injury or disease who can reach the highest possible level of independence (physically, psychologically, socially and economically) through a combined and coordinated use of medical, nursing and allied health professional skills. Rehabilitation clients have suffered significant loss of function due to accident, illness or injury, including those with chronic pain, who have identifiable and reasonably achievable goals. Rehabilitation services are provided to people of all ages, however ACC&R focus on the needs of adults (16+ years) requiring rehabilitation services. Some ACC&R teams also service children and younger adults with disability and high level needs, who may require case management, respite or socialization. As with the aged care client, the rehabilitation client can be categorised into various special needs or sub-groups. 2.1 People who have had a Stroke Stroke is the leading cause of chronic disability in adults in Australia 10. Almost all patients require rehabilitation services after an acute episode of care for stroke (Pollack & Disler, 2002). For at least a year after the stroke occurs, people will, to varying degrees, require assistance with activities of daily living, with mobility and with managing communication impairment. An analysis of hospitalisations due to stroke and transient ischemic attack (TIA) in SLHD over recent years has shown a slight increase in the number of hospitalisations with 80% of residents hospitalised for stroke or TIA in 2010/11 being aged over 65 years (Table 8). Table 17: Stroke and TIA separations and beddays in SLHD by age / / / / /11 Seps Beddays Seps Beddays Seps Beddays Seps Beddays Seps Beddays Stroke TIA TOTAL TOTAL SLHD Rehabilitation of these patients should commence in the acute setting, with continued multidisciplinary rehabilitation provided in either a sub-acute, community or home based setting depending on individual circumstances. See Appendix 4 for other special needs groups including: People with Non-Traumatic Brain Injuries People with a Traumatic Brain Injury People with a Spinal Cord Injury People with Severe Burns People with an Intellectual or Developmental Disability People who had undergone an amputation 10 Pollack & Disler, P a g e

21 3. Chronic Disease Management (CDM) Clients The aim of the SLHD CDM program is to identify, enroll and support patients with chronic diseases to better manage their own care within the community, improve their quality of life, positive psycho-social wellbeing and engagement with their community, thus reducing the demand on SLHD inpatient facilities. The program brings various care provider teams together such as General Practitioners, specialist medical expertise, acute hospital and community health services to provide patient focused and team-based coordinated care. Chronic diseases include: Coronary Artery Disease Coronary Heart Failure Diabetes COPD-Chronic Obstructive Pulmonary Disease Hypertension. For people with Aboriginal and/or Torres Strait Islander background the following chronic diseases are relevant: Asthma Cardiac Failure COPD-Chronic Obstructive Pulmonary Disease Diabetes and Renal Failure. 4. Carers The ABS defines a carer as a person of any age who provides any informal assistance, in terms of help or supervision, to persons with disabilities or long-term conditions, or persons who are elderly (i.e. aged 60 years or over). The assistance has to be ongoing, or likely to be ongoing, for at least six months. Carers play a fundamental role in the health and support system for older people, people with a disability and people with a chronic illness. Early discharge and long term independence is often related to the availability and capability of a carer and as such carers must be considered as an integral part of health care services for older people. Carers of all ACC&R target groups are supported in their caring role. Carers experience challenges in managing the health of the person they care for as well as problems with their own personal health (physical and mental). Only 24% of carers are satisfied with their caring role, half report sleep interruption as a result of their caring role and a small proportion of carers identify themselves as having a stress related illness as a result of their caring role, whilst a similar proportion consider themselves angry or resentful about their role General Medical Patients at Canterbury Hospital At Canterbury Hospital there are: 52 General Medical beds MAU beds 26 bed ward comprising 14 Palliative Care beds (managed by the Cancer Clinical Stream), 6 Aged Rehabilitation and 6 low acuity General Medical beds. The patients in these services are within the ACC&R Stream. 11 Australian Bureau of Statistics, Caring in the Community, Australia, P a g e

22 Our Services Within the Aged Health, General Medicine, Chronic Care, and Rehabilitation Services Clinical Stream there are: 1. Core Core Aged Health, Chronic Care and Rehabilitation Services 2. Supra-regional Services 3. Partnership/Associated Services. 1. Core Aged Health, Chronic Care and Rehabilitation Services Core Aged Health, Chronic Care and Rehabilitation Services are those that are provided to targeted clients which need to be available consistently and equitably across SLHD. Core services are available along the continuum of care, commencing with a centralised intake/referral service, and are categorised as being either inpatient services or community/ambulatory/non-inpatient services. Some of these services (generally in the community) are externally funded whilst others are funded by the Local Health District. The future governance and funding arrangements for the majority of community services are unclear at this stage due to the National Aged Care Reforms planned to take effect from It is likely that open procurement processes will occur for the ongoing service delivery responsibilities of these services at both a State and Commonwealth level. A review of the ongoing role of SLHD in the service delivery of these services will need to occur in Many initiatives are now being implemented to streamline services and improve effectiveness and efficiency, including outreach and TeleHealth models of care, and these will assist in increasing capacity. However, there will be insufficient capacity to respond to the anticipated demand without genuine ACC&R service expansion. The models of care and the translation of research in ACC&R are integral to quality care provision eg. in rehabilitation care, stand-alone facilities are appropriate, but beds are also needed within the acute hospital system for higher acuity patients. There is also considerable evidence about the importance of having access to the right care in the right place. Figure 2 outlines the core components of the Aged Health, Chronic Care and Rehabilitation Service. 22 P a g e

23 Figure 2: Core Aged Health, Chronic Care and Rehabilitation Services Aged Health, Chronic Care & Rehabilitation Services Emergency / Inpatient Services Acute Emergency Department Inpatient Aged-care Services in Emergency Team Acute Aged Care Units Inpatient Geriatric Consultation Sub-Acute Inpatient Sub-Acute Aged Care / Geriatric Rehabilitation Units Rehabilitation Units Community/Residential Care Services Intake (RIC /ACCT) Outpatient Geriatric and Rehabilitation Clinics Day Hospitals and Outpatient Therapy Geriatric Consultation Home Based Therapy (incl. Stepping On) Ortho-geriatric Model of Care Inpatient Rehabilitation Consultation Medical Assessment Unit (MAU) Dementia & Gerontology Clinical Nurse Consultants Aged Care Assessment Team Ambulatory Care Ambulatory Care (including Hospital in the Home) Aged Care Assessment Team (ACAT) ComPacks Transition Aged Care Program (TACP) Community Care / Case Management Centre Based Day Care Dementia Advisory Service Dementia Advisory Service Respite and Support Services Chronic Care Program Chronic Care Program Continence Nursing Disability Assessment & Rehabilitation for Young People (DARTYP) Specialist Mental Health Services for Older People (SMHSOP) 23 P a g e

24 Table 18: Aged Health Care and Rehabilitation Service Availability Inpatient Geriatrics Outpatient Geriatrics Inpatient Rehab Outpatient Rehab General Medicine MAU Chronic Care Program ACC&R Community Services RPAH * x CRGH x Balmain x x x Canterbury * x * Consultation service only Within SLHD, inpatient ACC&R services are provided at Royal Prince Alfred (RPAH), Balmain, Concord Repatriation General (CRGH) & Canterbury Hospitals. Ambulatory and home based services are provided across the District. The complexity of the service system requires excellent communication and cooperation to/from the Clinical Stream, facilities and across all providers. The following table outlines the current beds across the District Table 19: SLHD Aged Health Care and Rehabilitation Beds by Facility RPA Concord Canterbury Balmain Medical Assessment Unit Acute Aged Care Sub-acute Aged Included in above Care Delirium Ward Acute Rehabilitation General Medicine Table 20 outlines the role delineation levels in 2011 agreed with the Ministry of Health and the projected levels for Table 20: Role Delineation Current and Future Service Balmain Current Balmain Future RPA/ IRO Current RPA/ IRO Future CRGH Current CRGH Future TCH Current Geriatrics Palliative Care Rehabilitation TCH Future ACC&R Services and Strategic issues/priorities in SLHD This section overviews the current services and strategic issues and priorities for the next 5 years. The section is divided into: Aged Health Care and Rehabilitation inpatient services across the District General Medicine at Canterbury Hospital Aged Health, Chronic Care and Rehabilitation Community Care Chronic Disease Management Ambulatory Care Hospital in the Home 24 P a g e

25 Aged Health Care and Rehabilitation Inpatient Services across the District Concord Hospital The 48 bed acute aged care unit aims to identify and treat the multidimensional problems of the aged care client through coordinated medical, psychosocial and rehabilitative care tailored to the patient s specific needs. The integrated model is geriatrician-led, multidisciplinary and care is delivered in multiple settings and across the continuum. The 28 bed subacute aged care/geriatric rehabilitation unit provides post-acute and restorative care for geriatric patients. These patients are frailer, have multiple comorbidities and are therefore less medically stable than those who receive rehabilitation in a general unit. Geriatricians also provide consultative services for many older inpatients admitted by other services. A 12 bed acute aged care delirium unit is provided at CRGH (Ward 17), co-located with the broader CRGH Aged Care Service. Patients are older and require management of severe behavioural disturbance, in conjunction with their acute medical care. This ward is managed by Aged Care with significant Aged Care Psychiatry input, and is the only unit in SLHD. Orthogeriatrics at Concord involves an agreement between the Orthopaedics Department and the Aged Care Service for shared care of selected patients. Concord also has an Aged care Service in Emergency Team (ASET) which comprehensively assesses and develops plans for older people who present at the Emergency Department. A 14 bed Medical Assessment Unit (MAU) is managed by the ACC&R stream. Inpatient services are supported by ambulatory and outpatient services co-located in the ACC&R precinct. Services consist of: o Outpatient Geriatrician clinics supported by multidisciplinary teams o Day Hospital services providing a mix of medical, nursing and allied health interventions to assist older people to improve functional outcomes reduce the need for hospitalization and achieve earlier discharge from hospital. o Ambulatory Falls Clinic o Outreach Geriatrician service provision to RACF Rural TeleHealth services to Northern NSW LHD, Western NSW LHD and Far Western NSW LHD, with planning to extend to other LHDs emedication Management trial site Strategic Issues and Priorities for Concord Aged Health Care and Rehabilitation Upgrade the aged care and rehabilitation physical inpatient facilities at Concord. The ramp wards are considered less than optimal and should be upgraded as part of a whole of Concord Master plan. Expand Ambulatory Care Service and ideally develop an Ambulatory Care Precinct as part of the broader Concord Master Plan. Ensure an agreed model and operational policy for the service is consistent across the District. Ensure adequate aged health care and rehabilitation inpatient and outpatient capacity is available, consistent with the planning parameters and community need. 25 P a g e

26 Royal Prince Alfred Hospital (RPAH) The Aged Health Care Service at RPAH provides a comprehensive service for the elderly involving both community and hospital based services including: Thirty designated acute geriatric beds Three RPAH geriatric medicine teams Fifteen designated Medical Assessment Unit beds A geriatric medicine consultation service to other specialities ASET team comprising CNC and an Advanced Trainee in Geriatric Medicine An orthogeriatric shared care service with consultant and registrar involvement Community based Advanced Trainee in Geriatric Medicine Geriatric ambulatory care service (HITH) offering multidisciplinary services including general clinics plus falls clinics. Strategic Issues and Priorities for RPAH Physically upgrade the existing ward facilities, with capacity to both manage older patients who manifest behavioural disturbances, and promote a restorative model of care. Review the acute bed allocation to Geriatric Medicine at RPAH. With the opening of the Northwest Sector, re-establish and fit-out an appropriate area for the RPAH Day Hospital and ACC&R outpatient services in a suitably accessible location. Increase the outpatient service operating from the Day Hospital. Outpatient services are currently provided three days per week. There is potential to increase to five days Expand the ASET program at RPAH to provide after hours and weekend cover. Consider the development of psychogeriatric inpatient service at RPAH as a component of the long term development of the North West Precinct The longer term option of consolidating acute aged care at RPAH could be considered in view of the District s needs for additional rehabilitation capacity. Ensure adequate aged care and rehabilitation inpatient and outpatient capacity is available, consistent with the planning parameters and community need. Balmain Hospital Balmain Hospital is a dedicated Aged Health Care and Rehabilitation Hospital. Balmain Hospital plays an important role in the provision of aged care services and rehabilitation and receives the majority of its inpatients from Royal Prince Alfred Hospital. The geriatric and rehabilitation services provided at Balmain include: 52 acute/sub-acute aged care beds and 26 rehabilitation beds The two Geriatric Wards which provide assessment and treatment of medical conditions in the elderly and are supported by Social Workers, Dieticians, Physiotherapists, Occupational Therapists and Speech Pathologists. The Rehabilitation Ward provides goal orientated therapy to address functional deficits. Rehabilitation specialists assess patients to determine the required therapies to regain as much function as possible. Balmain Hospital also operates a 14 bed Australian Government funded Transitional Care Unit which is a slow stream, goal oriented residential service providing short-term (up to 12 weeks) support for older people to complete the restorative process at the conclusion of an inpatient stay. Patients are transferred into the Unit from Hospitals across the Local Health District when they are medically stable, and have approval from ACAT. Most patients will benefit from the extended inpatient management and be able to return to their home. Outpatient clinics provide treatment and advice in diabetes, nutrition, podiatry, continence, homeopathy, medical acupuncture and general medicine. 26 P a g e

27 A pulmonary rehabilitation outpatient service for chronic disease called Inner West Inspirations. The Centre for STRONG Medicine integrates the use of exercise as a medicine into mainstream geriatric medical care. It is the first centre of its kind in Australia. It conducts clinical care, education of other health professionals and internationally recognized research into depression, hip fracture and diabetes Geriatricians rotate between RPAH and Balmain Hospitals. The enhancement of 0.5fte geriatrician at Balmain Hospital will allow for the commencement of a TeleHealth service and the capacity to undertake outpatient clinics for clients from Aboriginal and Torres Strait Islander backgrounds in collaboration with the Redfern Aboriginal Medical Service. Strategic Issues and Priorities for Balmain Hospital Review the longer term acute role of Balmain in view of the need for increased rehabilitation bed capacity across the District. Upgrade the physical facilities at Balmain including wireless upgrade. Increase intern numbers to enable better after hours coverage at Balmain Hospital. Ensure adequate aged health care and rehabilitation inpatient and outpatient capacity is available, consistent with the planning parameters and community need. Canterbury Hospital Canterbury Hospital currently has the 20 bed Palliative Care Service for the District. This will relocate to Concord in At that time, the plan is for part of this ward to become an aged care and rehabilitation service for the Canterbury community. Currently there are limited rehabilitation services provided to the subacute palliative care ward. The Service currently provides ambulatory care, domiciliary home visits, and residential aged care facility visits. There are 8 designated Medical Assessment Unit (MAU) beds. An ASET Team is available at the Canterbury Emergency Department to comprehensively review and develop a plan for elderly people who present. Geriatrician input has been provided into case conferencing for community teams, and into RACFs. Strategic Issues and Priorities for Canterbury Hospital Open the acute/subacute aged care ward with the relocation of the palliative care ward to Concord Hospital. Review the operational policy for the 6 remaining palliative care beds. Establish an Ortho-geriatric (shared care) model for older orthopaedic patients. Expand the community role with dedicated staffing for residential aged care service, chronic care service, and hospital avoidance/substitution services. Ensure adequate aged health care and rehabilitation inpatient and outpatient capacity is available, consistent with the planning parameters and community need. General Medicine Services at Canterbury Hospital At Canterbury Hospital there are: 52 General Medical beds MAU beds 26 bed ward comprising 14 Palliative Care beds (managed by the Cancer Clinical Stream), 6 Aged/Rehabilitation and 6 low acuity General Medical beds. 27 P a g e

28 A substantial component of Canterbury Hospital services General Medical, as well as the Medical Assessment Unit, and these services are within the ACC&R Clinical Stream. These services are supported by other facilities with specialty services at RPAH and Concord Hospitals. The following table shows the bedday usage for General Medicine at the Canterbury Hospital over the past 5 years. This figure does not include Palliative Care. The patient needs are substantial and would be managed by subspecialty services at other SLHD facilities. Table 21: Canterbury Hospital General Medical Beddays Canterbury Hospital General Medical Beddays by SRG / / / / /11 24 Respiratory Medicine 27 Non Subspecialty Medicine 11 Cardiology 15 Gastroenterology 84 Rehabilitation 21 Neurology 22 Renal Medicine 14 Endocrinology 19 Oncology 18 Immunology and Infections 25 Rheumatology 17 Haematology 26 Pain Management The following table shows the top 12 DRGs by separations within the General Medical group for Canterbury Hospital. Table 22: Top 12 DRGs by Separations in General Medicine Top 12 DRGs by Separations for Canterbury Hospital F74Z Chest Pain G67B Oesophagitis and Gastroenteritis W/O Cat/Sev CC E69B Bronchitis and Asthma W/O CC G70B Other Digestive System Diagnoses W/O Catastrophic or Severe CC L63B Kidney and Urinary Tract Infections W/O Catastrophic or Severe CC J64B Cellulitis W/O Catastrophic or Severe CC E65B Chronic Obstructive Airways Disease W/O Catastrophic CC E62C Respiratory Infections/Inflammations W/O CC F62B Heart Failure and Shock W/O Catastrophic CC F76B Arrhythmia, Cardiac Arrest and Conduction Disorders W/O Cat or Sev CC E62B Respiratory Infections/Inflammations W Severe or Moderate CC E62A Respiratory Infections/Inflammations W Catastrophic CC Strategic Issues and Priorities for General Medicine Services at Canterbury Hospital Continue to ensure the support and back-up of major SLHD sub-specialty services for the service provision at Canterbury Hospital. Important areas include: stroke, cardiology, endocrinology and infectious diseases, in particular. 28 P a g e

29 Aged Health, Chronic Care and Rehabilitation Community Services The stream has multiple funding sources, diverse funding timeframes and complex data and activity acquittals. There is a risk with external funding of losing access to services and of only medium term viability. These community services are described below: Referral and Information Centre (RIC) All ACC&R services are accessed via a central intake service. Referral to this service can be accessed via on-line, postal, faxed or telephone referral. Aged and Chronic Care Triage Service (ACCT) ACCT is a single point of contact telephone service providing clinical advice and support to Residential Aged Care Facility staff, GPs and carers. The service is staffed by experienced Registered Nurses between the hours of hrs. The aim of the service is to provide care to clients in the most appropriate care setting with the aim of avoiding unnecessary transfer of clients to acute facility emergency departments. The service is also available to clients enrolled in the SLHD Connecting Care Program for health advice and health coaching. The service offers a partnership between RACFs, GPs, Chronic Care and hospitals within SLHD by linking medical specialists and Clinical Nurse Consultants (CNCs) of acute facilities with GPs, community teams (ACAT, Community Nursing/Palliative Care) and RACF staff. ACCT has the capacity to facilitate and coordinate transfers to the most appropriate health services, such as appropriate emergency department if required. Sydney Inner West Aged Care Assessment Team (ACAT) ACAT is funded to undertake assessments of people to facilitate entry into residential or residential level care i.e. community packaged care. ACAT s provide multidisciplinary assessment of the aged care client; recommendation of appropriate levels of support; and provide a consultative service to hospital, specialist and primary care practitioners. The Sydney Inner West ACAT covers all of SLHD. Community Care Team The Community Care Team aims to assist frail older people, and people with disabilities and their carers, with complex needs. They provide case management to negotiate and access community care services. They cover all of SLHD. ComPacks ComPacks is a service which aims to promote safe hospital discharge by ensuring that short term, low level support is available to clients immediately on discharge from an inpatient setting. This service is available for up to 6 weeks. SLHD ACC&R is the provider of ComPacks services for the residents of SLHD. Transitional Aged Care Program (TACP) The Transitional Aged Care Program provides time limited post-acute support and low-level therapy to clients who would otherwise be at risk of entry to residential care. Access to the program requires an ACAT assessment, which identifies that the person would be eligible for residential level care, has the capacity to optimize their functional capacity and/or requires time to determine their appropriate long term care requirements. There are 76 community based TACP packages available across the SLHD, with 14 residential TACP beds at Balmain Hospital. Dementia/Delirium/Aged Care Clinical Nurse Consultants (CNC s) Dementia/Delirium and Aged Care CNC s provide expert advice, support and education to staff and patients regarding, issues relating to the aged care client, such as dementia, delirium and falls. The role of the Dementia/Delirium CNC is to work with other clinicians to better manage people with dementia and/or delirium and to reduce complications through education and modeling care. The SLHD Dementia/Delirium CNC is based at Canterbury 29 P a g e

30 Hospital and the Aged Care CNC is based at Concord Hospital. Dementia Support Services (DSS) Dementia Support Service provides in-home respite for people with dementia and their carers as an alternative to centre based day care. It covers the SLHD area except the City of Sydney local government area. Dementia Advisory Service This service provides group and community health promotion; education and support; service development initiatives with a range of providers; dementia planning and the coordination of services available to people with dementia and their carers. This service covers the SLHD area except the City of Sydney local government area. Specialist Mental Health Services for Older People A Service Agreement currently exists between ACC&R and Mental Health for the delivery of community based Specialist Mental Health Services for Older People within SLHD. The Service Agreement provides for operational responsibility for SMHSOP by ACC&R with both services sharing a combined intake process via the Referral and Information Centre (RIC). Clinical governance for SMHSOP including strategic policy direction, service review and development and leadership in relation to clinical practice improvement is provided by Mental Health through the SMHSOP Clinical Director and SMHSOP Coordinator. SMHSOP staff are located at 3 sites (Camperdown, Canterbury and Concord) and provide specialist mental health assessment, care planning and case management services for older people who develop or are at high risk of developing a mental health disorder at the age of 65 years and over or who have had a lifelong or recurring mental illness, and now experience age-related problems causing significant functional disability. SMHSOP also provides assessment, intervention and referral for older people with severe and complex behavioural and psychological symptoms associated with dementia and/or mental illness through the Dementia Behaviour Management Advisory Service (DBMAS) and Behavioural Assessment and Intervention Service. (BASIS) The Service Agreement is in place until June 2013 and will require review in light of changing environments within both ACC&R and Mental Health which will have implications for the interface between SMHSOP and ACC&R. Continence CNCs SLHD has two Continence CNCs. One Continence CNC is based at Balmain Hospital and covers clients living in the City of Sydney, Leichardt and Marrickville LGA s. Clients must be Home and Community Care eligible for service. The CNC provides expert assessment and advice to clients and/or carers in their homes to assist them to manage their bladder and bowel dysfunction. The Concord Hospital based Continence CNC covers the Ashfield, Canada Bay, Burwood and Strathfield LGAs plus provides outreach and educational assistance to staff and residents of Residential Aged Care Facilities across the LHD. The CNC provides expert assessment and advice to clients and/or carers in their homes and RACF s to assist them to manage their bladder and bowel dysfunction. (Canterbury LGA is covered by a Registered Nurse position.) Day Hospitals Day Hospital services provide a mix of medical, nursing and allied health interventions to assist older people to improve functional outcomes, reduce the need for hospitalization and achieve earlier discharge from hospital. Service recipients may be under the management of either a geriatrician, rehabilitation specialist or both. Day Hospital and/or outpatient services are provided at RPAH and Concord Hospitals. 30 P a g e

31 Home Based Therapy (HBT) Home Based Therapy services complement day hospital and outpatient therapy services. They are particularly provided to clients who are able to be treated in the community setting and those who are unable to access outpatient type services. HBT can prevent deterioration and institutionalization or improve function and potentially prevent readmission to hospital. There is a specific falls intervention program within HBT. The team consists of Occupational Therapy, Physiotherapy and Dietetics. This team provides service across the District. Centre Based Day Care (CBDC) Centre Based Day Care provides socialization and monitoring opportunities for frail older people and respite for carers. SLHD operates 4 centres including: Karinya dementia specific based at Canterbury Kalparrin dementia specific based at Concord Kindilan frail aged and multicultural groups based at Concord Carter-Evans dementia specific, frail aged and multicultural groups based at Newtown. Disability Assessment and Rehabilitation Team for Young People (DARTYP) The Disability Assessment & Rehabilitation Team for Young People is a multidisciplinary team (nursing, allied health and rehabilitation specialists). The team provides a rehabilitation service for people with intellectual disabilities, multiple and/or complex disabilities. The service is provided to people with complex neurological and multiple lifelong disabilities aged years and intellectual disability 16 years and over. This service is only funded until June SLHD Amputee Services The Amputee Rehabilitation Consultative service is provided to patients at Concord and RPAH and occasionally Canterbury Hospital. There is also a Rehab/Amputee CNC providing services primarily to RPAH and Balmain with occasional services to Concord and TCH. Inpatient amputee rehabilitation is carried out in both Ward 14 at Concord and John Beasley Ward at Balmain. There is a weekly clinic at RPAH and a monthly clinic at Concord. Physiotherapy services are provided at both Concord and RPAH. The Appliance and Limb Centre at Redfern provides the tender service for manufacture of interim prostheses. Definitive prostheses are provided by a range of external manufacturers. There is expected to be a very large increase in the number of patients with type 2 Diabetes Mellitus in the next few decades due to increased rates of overweight and obesity. This is likely to increase the number of partial foot amputations and maintain the number of major limb amputations in patients with multiple co-morbidities. Services will need to be maintained. Service improvements and LOS could be improved by the addition of an in-reach program to facilitate earlier discharge of patients who can be sent home before being fitted with a prosthesis. Amputee and Rehabilitation Clinical Nurse Consultant (CNC) The Amputee Rehabilitation Clinical Nurse Consultant provides expert consultation for Rehabilitation across the SLHD. The CNC facilitates the ongoing coordination of care of complex rehabilitation patients between RPAH and Balmain Hospital. The CNC facilitates the ongoing coordination of care of patients who have had an amputation within the SLHD. Community Visitors Scheme (CVS) This service matches culturally and linguistically diverse appropriate volunteer visitors to 31 P a g e

32 residents of residential aged care facilities who are at risk of isolation from the general community and to provide friendship and companionship. This service is based at RPAH and covers the Sydney Metropolitan area. Strategic Issues and Priorities for Community Services Understand the implications of the National Aged Care Reforms, and position SLHD as a competitive service provider in any procurement processes for these services in the future. Ensure adequate community capacity as the population ages. Form partnerships with various NGOs for the benefit of mutual clients, as the effects of the National Aged Care Reforms become clear. Explore and implement models of community and ambulatory care appropriate for the directorate s target populations. 2. Supra-regional Services These are specialised services catering for a small number of people with specific health needs. This includes Burns Rehabilitation and Non-Traumatic Spinal Cord Injury. Given the scope of these services is beyond SLHD, planning needs to be undertaken in conjunction with a state-wide planning process, in which SLHD is an active participant. It is anticipated that demand for these services will continue to increase with population growth. 3. Partnership/Associated Services A number of services are operated cooperatively between ACC&R and other clinical services, or other LHDs. These partnership/associated services include other clinical streams of SLHD such as Mental Health Services, Community Health and Allied Health Services, as well as external partners such as other LHDs, Inner West Sydney Medicare Local, General Practitioners, Housing NSW, Residential Aged Care Facilities and community care providers. Telehealth enables partnerships with rural and remote communities, and potentially improved access to specialist services for people in RACFs. Strategic Issues and Priorities for Partnerships/Associated Services Further develop collaborative models of care across directorates to improve service delivery. Finalise and implement the Sydney Inner West Dementia Action Plan in collaboration with all stakeholders Provide targeted support to the Residential Aged Care Facilities in SLHD, in collaboration with Sydney Inner West Medicare Local. Form partnerships with NGOs as the effects of the National Aged Care Reforms become clear. Chronic Disease Management Program in SLHD People with a chronic disease are projected to account for up to 80% of the health care burden by 2020, with these people likely to have several co-morbidities (NSW Health 2005a). Chronic Disease Management programs have been functioning in SLHD for many years. In 2010 NSW Health commenced the Connecting Care in the Community Program to assist in further development of an integrated aged, acute and complex model of care established across both acute and community sectors. The program targets 5 specific disease types: Heart Failure Coronary Artery Disease Chronic Obstructive Pulmonary Disease 32 P a g e

33 Diabetes Hypertension Chronic Care programs for people from an Aboriginal or Torres Strait Islander background are also interested in Asthma and Renal Failure. In SLHD the Chronic Disease Management Program comprises of teams working in: NSW Chronic Disease Management Program - Connecting Care in the Community (IWSML) Cardiac Chronic Care (RPAH, Concord, Canterbury) Cardiac Rehab (RPAH, Concord, Canterbury) Respiratory Chronic Care (RPAH, Concord, Canterbury) Pulmonary Rehabilitation (RPAH, Concord, Canterbury, Balmain) Diabetes including High Risk Foot Clinic (RPAH, Concord, Canterbury) Aboriginal Chronic Care IWSML coordinators Aged and Chronic Care Triage (Concord based Telehealth) including the 48 hour follow-up role. Patients eligible for the program must have a diagnosis of one of the specified disease types, be over 15 years of age and have had 3 admissions to hospital over the last 12 months or be at risk of admission to hospital. Patients eligible for enrolment in the program can be identified by using a CERNER algorithm or can be referred by the GP, the inpatient team, Justice Health, or by self-referral. Patients on the program receive health coaching and/or case management services with the aim of: Reducing the progression and complications of chronic disease Improving the quality of life of people with chronic diseases Supporting their carers and families Reducing unplanned and avoidable admissions to hospitals Improving the health system s capacity to respond to the needs of people with complex needs. The provision of rehabilitation services for people with chronic disease may result in greater health and psychosocial outcomes for the individual, reduced hospitalizations and length of stay, and reduced morbidity and mortality. 12 The roll-out of the electronic medical record is integral to the Model of Care. 12 NSW Health 2005c 33 P a g e

34 Figure 3: Proposed Chronic Disease Management Model of Care Strategic issues and Priorities for Chronic Care Review and reform the Sydney LHD Chronic Care Programs, to increase access, efficiency, consistency of service provision, and measurable outcomes of these services. Review the existing initiatives of the Chronic Care for Aboriginal People Program for Aboriginal patients who may benefit from the Program and integrate Aboriginal Chronic Care positions (including the 48 hour follow up role). Develop systems within SLHD to implement and adhere to activity target key performance indicators, including improved co-ordination and outcomes focus. Explore referral pathways for Aboriginal patients of the Aboriginal Medical Services for enrolment in the Program. Develop and maintain a Service Directory for providers who cover clients living in the SLHD LGAs to assist discharge planning and primary care referral processes. Facilitate the early roll out of the emr across the district. Ambulatory Care Hospital in the Home (HiTH) HITH is a model of care endorsed by SLHD and the NSW Ministry of Health. There is a demonstrated clinical need for this model of care at acute care facilities within the District. This will enable hospital substitution and improve access to acute beds for those with the most clinical need. It is anticipated that HITH services will be operating across the District within the next 5 years. Existing HITH arrangements are described below. Hospital in the Home Service at Balmain Hospital Opened in May 2009, the Balmain service has focused on clinic- based care for cellulitis, community acquired pneumonia, anticoagulation for DVT/PE/AF, pyelonephritis, rehydration post vomiting during pregnancy, tonsillitis and gastroenteritis and management of complex wounds. The capacity of the HITH Service at Balmain is inclusive of the General Practice Casualty s capacity including 2 recliner chairs and 6 beds. The hours of operation are 8am to 10 pm seven days a week. Referrals are direct from local GPs and from RPAH Emergency Department. Balmain HITH currently provides weekend care for those RPAH HITH patients who choose clinic based rather than home care. Currently the average number of patients seen per day is 10 patients per day. Bed 34 P a g e

35 25 type care categories are in the process of being developed in the emr. Power chart emr is used for patient daily documentation by the Balmain HITH service. Table 23: Balmain Hospital Ambulatory Care New Referrals Table 24: Balmain Hospital Ambulatory Care New Referrals Royal Prince Alfred Hospital in the Home Service This HITH was opened in June 2012 and operates from Ward 6E3 with 4 recliner chairs and 3 beds in two separate bays. Care is provided by a medical officer and two nurses with operational oversight by the Medical Assessment Nursing Unit Manager. The hours of operation are 8am to 4.30 pm Monday to Friday. Priority is given to Emergency Department patients and promoting timely ward discharges from RPAH. The current eligibility criteria include cellulitis, pneumonia and exacerbation of COAD, new DVT/PE requiring anticoagulation, pyelonephritis and complex wound care. There is currently no capability to use Power chart for daily documentation, only final discharge summary. The service liaises with SLHD Community Health Nursing Service and Balmain HITH service to ensure provision of 7 day service for patients. Referrals are made to allied health and other clinical services on a patient needs basis. 35 P a g e

36 Table 24: RPA Hospital Ambulatory Care New Referrals 3 months of data SLHD Community Health Nursing (CHN) SLHD Community Health Nursing accepts referrals for patients referred from all SLHD facilities for HITH services. They are able to deliver twice daily antibiotics in the client s home. As a result of the development of District HITH services, skill sets of CHN s have been augmented; these include cannulation and use of anticoagulation testing equipment. Concord HITH Planning has commenced via the Clinical Stream to have a Home IV Antibiotics service at Concord Hospital. Canterbury HITH There is no current structure or resources for medical governance of a HITH service. Consultations with interested parties have commenced. Best practice model of care In order to provide 24 hour nursing and medical care for HITH patients, a mixed model of care is provided between Balmain, RPAH and Community Health Nursing. This model of care will be considered for the proposed Concord and Canterbury Hospital HITH service. Paediatric and neonatal HITH will need to be explored in terms of medical governance, nursing skills and availability and community health nursing capacity and skill levels. In order for streamlined and safe patient care the utilisation of the existing emr will need to occur. This will provide readily available patient care information to health providers in all care settings Patient direct access to HITH services will be an aim in order to reduce pressure on stretched Emergency Departments in SLHD. Ongoing close liaison with Emergency Departments will be required to assist with the National Emergency Access Targets and to maximise hospital substitution strategies. Increased liaison with specialists to reduce lengths of stay of patients. While staff skill in intravenous infusions, transfusions, taps, catheterisation etc. is the current need this may change in the future depending on future technology and future pharmacy. The newer MABs are becoming available as self-administrable injections reducing the need for long infusions. Oral anticoagulants if made widespread in usage will reduce the need for injectables and INR monitoring. Education and training for staff in these areas will be required. 36 P a g e

37 Strategic issues and Priorities for Ambulatory Care Develop a District Plan for Ambulatory Care Explore and implement models of ambulatory care appropriate to SLHD. Establish and expand Ambulatory Care Services / HITH across all sites in SLHD. Ensure a dedicated, accessible site for each of these services, ideally within a noninpatient precinct. Across the District ensure a networked arrangement, agreed model and common set of operational policies for Hospital in the Home services. TeleHeath TeleHealth is an effective and efficient mode of service delivery to those who for reasons of illness, mobility or distance are unable to access appropriate assessment and/or care planning. Concord Geriatric Medicine currently provides services to Northern NSW LHD, Western NSW LHD and Far Western NSW LHD, with planning to extend to other LHDs. Opportunities to share education sessions using TeleHealth equipment between staff from SLHD and rural LHDs also exist. Strategic issues and Priorities for Telehealth models of care Explore the capacity of TeleHealth services to deliver outreach services to regional and remote, and residential care communities. Ensure hardware and connectivity infrastructure is of maximum quality to enhance sessions. Identify shared educational opportunities, and promote amongst rural LHDs. 37 P a g e

38 Our Staff The ACC&R workforce comprises a range of specialist and generalist medical, nursing, allied health and technical/support staff. Recruitment to the workforce is often difficult although retention rates are high, with good levels of job satisfaction reported. Other significant workforce issues, posing a barrier to effective management and service delivery, include high workloads in inpatient settings for staff of all disciplines, the ageing of the workforce, the need for succession planning within younger generations, and access to ongoing training and educational opportunities. For some medical groups, the limited opportunity for private practice is a barrier. Attempts have been made to set ACC&R staffing benchmarks. The Greater Metropolitan Transition Taskforce (GMTT) recommended the establishment of four inpatient geriatrician positions (providing support to acute and sub-acute units, clinics and consultative services) per 25,000 people aged over 65. This number does not include the Geriatricians providing a community based service, General Medicine component, Orthogeriatric or Stroke liaison services, or fulfilling a primarily academic role. To implement the recommended service delivery model consistently as population growth occurs, enhancements to the medical, nursing and allied health workforce will be required. Further detailed planning of staffing numbers will need to occur as the services develop. The Australasian Faculty of Rehabilitation Medicine (2005) has established staffing standards for inpatient rehabilitation teams. These standards could be used as a guide to staffing rehabilitation services. Adequate levels of both managerial and administrative support are required to ensure the optimal delivery of ACC&R services. This will ensure clinical staff can focus on clinical activities, while the legislative requirements of numerous multiple funding sources, with a range of performance measures and accountabilities, can be met. Table 24 and 25provide an overview of the staffing numbers. Table 24: ACC&R FTE Staff ACC&R Community Staff (incl Balmain Trust) Balmain Hospital Canterbury Hospital Royal Prince Alfred Hospital Repatriation General Hospital Concord Table 25: ACC & R Staffing as at November Note: This staffing number does not include vacancies or staff on leave. 38 P a g e

39 Our Research and Education Opportunities for research and education are unique in SLHD with strong teaching relationships with the University of Sydney. With the growth in the ageing population as described earlier, there will be a need for more staff with skills and expertise in research and education within the sector. Aged Care Research Research into ageing and the health and wellbeing of ageing people is undertaken by many practitioners in the Stream. The ANZAC Research Institute, a major independent biomedical research institute on the grounds of the Concord Hospital has a major focus on ageing and translational research. Other medical research institutes in SLHD also focus at times on ageing issues. The Centre for Research and Education on Ageing (CERA) CERA is a joint Centre of the University of Sydney s Department of Medicine and CRGH, also based in the CRGH Aged Care and Rehabilitation Precinct. CERA is strongly affiliated with the ANZAC Research Institute. CERA s functions include: epidemiological, clinical, biological and health service research on ageing; coordinating a structured education program for the University of Sydney Faculty of Medicine, and providing educational input into courses for health workers and community organisations supporting postgraduate research. CERA undertakes work in a range of disciplines, using funding from a variety of sources including SLHD, University of Sydney, National Health & Medical Research Council (NHMRC) grants, project tenders from government departments, and the Ageing and Alzheimer s Foundation, a Foundation of the University of Sydney. Many of the CERA staff hold conjoint appointments within SLHD. CERA is now the largest and most successful academic geriatric medical organisation in Australia. It has expanded in the last 5 years to include 4 professors and some 40 affiliated staff and researchers. It has achieved over $6 million in competitive Australian Research Council (ARC) and NHMRC funds. To accommodate plans to expand the epidemiology and clinical research undertaken at CERA a Clinical and epidemiology centre has been established. This centre will provide research space for the personnel involved in these studies. Currently the largest epidemiology study is the Concord Hospital Ageing Male Project (CHAMP) funded primarily by a $2 million NHMRC grant. This aims to study prospectively, some 3,000 older men in the Concord region, and will continue for at least 10 years. This substantial project is expected to establish CRGH s reputation internationally and increase the connections with local residents by their involvement in the project as subjects. Current and future hypotheses will be tested around dietary impacts, oral health and cardiac disease. In addition, the $2.5 million ARC NHMRC Ageing Research Network, places CRGH at the centre of ageing within Australia. This project involves leading national research in ageing and is centred within Concord Hospital. The CERA laboratory research within the Biogerontology Laboratories of the ANZAC Research Institute continues to be highly successful in terms of grants and publications, with a steady increase in post graduate students. 39 P a g e

40 As a result of this activity, CRGH has been successful in attracting specialist medical registrars and junior medical staff to Concord Hospital, with many continuing on to research Masters and PhD qualifications (with approximately 12 medical practitioners completing or enrolled in PhD and Master s program since 2001). Future research plans include; National and international collaboration with basic science researchers with interests in biogerontology and fundamental ageing research Expanding epidemiological research Clinical trials in a number of settings including acute hospital, community and residential care. Such growth has enormous benefits for the LHD in terms of national and international reputation and attraction of high quality medical staff, as well as providing a milieu that supports and develops nursing and allied health professionals. Given the rate of growth of CERA and the ageing of the population, it is likely that the spatial requirements of the unit will at least double in the next 10 years. Rehabilitation Research Rehabilitation services in SLHD have an active interest in research around a range of themes including; multidisciplinary teams and their effect on patient care patient outcomes particularly in relation to stroke, cancer and amputee rehabilitation the availability of day hospital rehabilitation comparisons of different models of rehabilitation care and factors effecting length of stay and functional outcomes. services are also collaborating on international research, on the development and validation of International Classification of Functioning, Disability and Health core sets for stroke, brain injury and cancer. a clinical research program conducted in the Rehabilitation Medicine Department at CRGH over a four year period has concentrated on Health Service Research with a focus on the capacity of the health system to meet the health service needs of people with disabilities in particular adults with Intellectual Disability and young people with complex and multiple disabilities. The Centre for Strong Medicine Four major research studies have been conducted at the Centre: two in hip fracture (SHIP- Sarcopenia and Hip Fracture Study and HIPFIT- Hip Fracture Intervention Trial, both funded by the NHMRC) as well as studies of depression, power training and diabetes (the GREAT2DO Study- Graded Resistance Exercise for Anabolism in Type 2 Diabetes for Older Adults- funded by Diabetes Australia and The University of Sydney). This ongoing research is original and has the potential to change clinical practice on an international level. 40 P a g e

41 Our Priorities Priorities for the Aged Health, Chronic Care & Rehabilitation Clinical Stream for the next five years can be summarized into five major themes: Strategic Issues Models of Care Support Structures and Resources Partnerships Priority Groups Strategic Issues Physically upgrade the aged health care and rehabilitation ward facilities at Concord (ramp wards) and Balmain, and review the acute bed allocation to Geriatric Medicine at RPAH. With the opening of the RPAH North West precinct, an appropriate site needs to be allocated and refurbished for the re-establishment of the RPAH Day Hospital, and provision of ACC&R outpatient services. Establish and expand Ambulatory Care Services / HITH across all sites in SLHD. Of importance is ensuring a dedicated, accessible site for each of these services, ideally within a non-inpatient precinct. A networked arrangement, agreed model and common set of operational policies for Hospital in the Home services is needed. A District Plan for Ambulatory Care will be developed. Re-establish and staff the Aged Care and Rehabilitation service (14-16 beds) at Canterbury Hospital, following the relocation of 14 Palliative Care beds from Canterbury to Concord Hospital. The provision of sub-specialty support and support from other SLHD facility services is vital in ensuring quality care at the Canterbury general medical and surgical beds as well as the aged health care services. Review the role of Balmain Hospital to ensure the optimal future mix of subacute and acute care is provided, especially in view of the need to expand rehabilitation beds across the District. Support the optimal ongoing provision of community aged care with the implementation of the National Aged Care Reforms. Of central importance is maintaining and strengthening the service provision priorities in the light of changed funding arrangements. Increase aged health care and rehabilitation service and bed capacity, both acute and subacute, commensurate with expanding elderly populations. This includes improving inreach to acute care rehabilitation capacities at RPAH. Ensure that key target populations, including people with dementia, people with chronic conditions, people with disabilities, people needing rehabilitation and the elderly have appropriate and available services commensurate with their needs. Further, ensure that the needs and issues of Aboriginal and Torres Strait Islander communities, culturally and linguistically diverse communities, and lesbian, bi-sexual, gay, transsexual and intersex communities are equitably provided for, and, as required, specifically targeted, within the Stream. Upgrade emergency services related to the care of the elderly including enhancement of the Aged care Service in Emergency Team (ASET) at Canterbury, Concord and RPAH. Assist in meeting the 4 hour rule of NEAT through ongoing development of the MAU model at Canterbury, Concord and RPAH. 41 P a g e

42 Work with the Inner West Sydney Medicare Local to ensure a strong continuum of care for our target populations. Ensure appropriate organisational, structural and administrative support for ongoing and future service developments. This especially relates to the further roll-out of the electronic medical record and the forthcoming introduction of activity based funding (AN-SNAP). Provide targeted support to the Residential Aged Care Facilities in SLHD to ensure the provision of appropriate healthcare in the most appropriate setting. For example, the provision of oral health services at RACFs is an important initiative. Work within the health service and hospitals to ensure that providers across all streams and services understand the special requirements of aged and disabled consumers. The development of collaborative models of care between aged health care and medical/ surgical teams, such as the ortho-geriatric model of care, has the capacity to improve service delivery. Consolidate the provision of sub-speciality medical support, from the LHDs tertiary hospitals, for the general medical services at Canterbury Hospital. Explore the development of health pathways across primary and secondary health providers in developing sustainable, clear, concise and localised pathways from a whole-of-system perspective. Explore the formation of inpatient clinical pathways for rehabilitation services. Review Stroke Services within Sydney LHD, across all clinical streams, including need to identify cross stream partnerships ie. neurosciences, allied health. Develop plans for Aged Care and Rehabilitation, Chronic Care and Ambulatory Care over the next 1-2 years. Model of Care Priorities The existing ACC&R model of care is proven, effective and maximizes outcomes for patients, clients and families. To manage future demand methods to increase efficiency must be introduced, along with newly identified alternatives to traditional care models. Areas needing attention include: Review access to rehabilitation across the District. A range of rehabilitation beds is required to continue to provide for the wide range of rehabilitation clients requiring inpatient treatment. Whilst there is the option of having some beds located in standalone facilities there should also be beds located within the acute hospital system for higher acuity patients. Less than 50% of the rehabilitation needs of the SLHD 65+ age group are currently met within the district. Expansion of collaborative care with other medical services, such as the orthogeriatric model of care. This should be negotiated at all SLHD hospitals. Provide targeted support to the Residential Aged Care Facilities in SLHD to ensure the provision of appropriate healthcare in the most appropriate setting. For example, the provision of oral health services at RACFs is an important initiative. Provision of care in, and alternatives to, Emergency Department presentations. 42 P a g e

43 The ongoing role of SLHD in community service provision after implementation of National Health Reforms, and the need for continued funding for community services. Expand Ambulatory Care and Hospital in the Home models. Review and reform the SLHD Chronic Care Programs to increase access and efficiency, while integrating Chronic Care across Clinical Streams. Work across sectors and services to systematise the end of life pathways to ensure clear communication and support for patients, their families and carers. Support Structures and Resource Priorities Inpatient Accommodation current arrangements for ACC&R at most sites is inadequate and, in some cases, inappropriate, affecting patient outcomes. Enhancements, including purpose-designed/built areas, are required, including delirium observations bays. Human Resources/workforce specific recruitment and retention strategies for ACC&R are required, along with additional professional staff in medical, nursing, allied health and administrative positions. Technology and support maximizing use of available technology for both patients/clients and staff is required, with associated support from IMTD. This includes TeleHealth models of care, and the continued expansion of emr including for Chronic Disease and to support subacute ABF data management. Partnership Priorities Develop a robust community consultation framework to ensure the collaboration with partner organisations and groups and identify service areas which could benefit from a partnered arrangement. Work with the non-government sector to ensure the most efficient and effective service structures and service models are developed. Ongoing negotiation and cooperation with the following is required, and will form the basis of service level agreements over the next five years: o o o o o o o o o Inner West Sydney Medicare Local General Practitioners Residential Aged Care Facilities Aboriginal Medical Service SLHD Clinical Streams including Mental Health, Community Health, Bone and Joint, Neurosciences, Allied Health Public and private community care providers/ngos Inner West Dementia Network Rural and remote services Housing NSW. Finalise and implement the Sydney Inner West Dementia Action Plan. Priority Groups Strategies to ensure equity of access and service provision to people from all special needs groups must be identified and implemented, including: Aboriginal & Torres Strait Islander communities 43 P a g e

44 Culturally & Linguistically Diverse communities Lesbian Gay Bisexual Transgender InterSex communities (identified as a new special needs group under the Aged Care Act in 2011) People living with dementia, and their carers People without carers Rural and remote communities. 44 P a g e

45 References Agency for Clinical Innovation 2012; CHOPs Study Agency for Clinical innovation; Orthogeriatric Model of Care; Clinical Practice Guide data/assets/pdf_file/0013/153400/aci_orthogeriatric s_clinical_practice_guide.pdf#zoom=100 AIHW, Dementia in Australia, Alzheimer s Australia 2005; Dementia Estimates and Projections. Australian Stats & Territories. Access Economics t.pdf Alzheimer s Australia 2009; Keeping Dementia in Front of Mind Access Economics AE_FullKeepDem FrontMind.pdf Alzheimer s Australia 2011; Dementia across Australia Deloitte Access Economics Aust.pdf Alzheimer s Australia Position Paper ; Dementia, Lesbians and Gay Men y.pdf Arkles R, Jackson Pulver LR, Robertson H, Draper B, Chalkley S & Broe GA Ageing, cognition and dementia in Australian Aboriginal and Torres Strait Islander peoples: a life cycle approach, a literature review. Sydney: University of New South Wales. Australian Bureau of Statistics, Caring in the Community, Australia, 2009 Australian Government National Aged Care Reforms; Living Longer Living Better Australian Institute of Health and Welfare Residential aged care in Australia : a statistical overview. Aged Care statistics series no.33.cat.noage66. Canberra: AIHW. Accessed 4/11/11 Callahan, Hendrie & Tierne, 1995; Documentation and evaluation of cognitive impairment in elderly primary care patients; Ann Intern Med Mar 15;122(6): P a g e

46 DoHA 2006; National Framework for Action on Dementia E717/$File/nfad.pdf DoHA 2012; National Lesbian, Gay, Transgender, Intersex Aged Care Strategy Health Statistics NSW Journal of Safety Research; Projections of hospitalised fall-related injury in NSW, Australia: Impacts on the hospital and aged care sectors; 42(6), Dec 2011, pp Nichol, Lonergan & Mould, The use of hospitals by older people: a casemix analysis. Occasional Papers: New Series no. 11. Canberra: Commonwealth Dept. Health & Ageing. NSW Health Policy (GL2011_004) Dementia Services Framework NSW Department of Health (2003/b) Selected Speciality and Statewide Service Plan No.4: Sever Burn Service Plan. NSW Department of Health (2005a) NSW Chronic Care Program: Strengthening General Practitioner involvement in Chronic Care NSW Department of Health (2005d) Presentation by Robyn Kruk re: Aged Care Program and Strategic Approach, February NSW Department of Health (2005e) Presentation by Tony O Connell, NSW Branch Australian Society of Geriatric Medicine, Leura Pollack & Disler, 2002; Rehabilitation of Patients after Stroke; Med J Aust 2002; 177 (8): https://www.mja.com.au/journal/2002/177/8/2-rehabilitation-patients-afterstroke Productivity Commission 2008, Trends in Aged Care Services: some implications, Commission Research Paper, Canberra. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ.1993; Comprehensive geriatric assessment: a meta-analysis of controlled trials; Lancet Oct 23; 342 (8878): P a g e

47 Appendix1 SLHD Activity and Patient Flows The following table (Table 26) shows the acute and sub-acute activity by Service Category across SLHD hospitals. Rehabilitation was the core sub-acute service category. These data reflect the activity at service units, rather than the reasons for hospitalization. For example, the palliative care statistics reflect those in palliative care units, rather than the numbers receiving palliative care. Table 26: SLHD Hospital Usage by 65+ year old people by Service Category SLHD Hospital Usage by 65+ year old people by Service Category by Hospital, Acute and Sub-Acute, Balmain Canterbury Concord RPA/IRO Seps Beddays Seps Beddays Seps Beddays Seps Beddays Acute Care Geriatric Evaluation/Management O o 2 11 Maintenance care Palliative Care ( in a unit) Psychogeriatric Care Rehabilitation Care Grand Total Table 27 shows the outflow of SLHD residents aged 65+ for these same service categories. This indicates that, in particular for rehabilitation, there are considerable outflows to the private sector for services and to SESLHD. Table 27: SLHD Outflows by Service Category for 65+ year olds SLHD Residents Aged 65+ Outflows by Service Category and Beddays, Grand Total SLHD Other Private SESLHD SWSLHD St. Vincent's Network Private Day Proced NSLHD SWLHD Other Acute Care Geriatric Eval./ Management Maintenance care Palliative Care Unit Psychogeriatric Unit Care Rehabilitation Unit Care Grand Total P a g e

48 Tables show the inflows for the acute and sub-acute service categories for each of the hospitals. Balmain, consistent with its local district support role, has less than 10% of its beddays occupied by elderly people who do not live in the SLHD. Concord, consistent with its tertiary role, treats 36% of people across the acute and sub-acute spectrum who are not residents of SLHD, mainly from NSLHD, WSLHD and SWSLHD. Table 28: Concord Inflows by Service Category for 65+ year olds Concord Inflows 2010/ y.o. by Service Category for Acute and Sub-acute Beddays Service Category Grand Total % from SLHD % from NSLHD S% from WSLHD % from SWSLHD % from SESLHD % from Other (999) % from NBMLHD Acute Maintenance care Palliative Care Psychogeriatric Rehabilitation Grand Total % from Other Table 29: Balmain Inflows by Service Category for 65+ year olds Balmain Inflows 2010/ y.o. by Service Category for Acute and Sub-acute Beddays Service Category Grand Total % from SLHD % from SESLHD % from NSLHD % from SWLHD % from SWSLHD % from WNSW % from Other(9 99) % from Other NSW % from Other States Acute Geriatric Evaluation/Manage/nt Palliative Care Rehabilitation Grand Total Canterbury Hospital similarly has relatively small inflows, while RPA, provides 44% of its care to elderly people from outside of the District. Major inflows to RPA come from Western NSW, SESLHD and SWSLHD. Table 30: Canterbury Inflows by Service Category for 65+ year olds Canterbury Inflows 2010/ y.o. by Service Category for Acute and Sub-acute Beddays Grand Total Sydney South Eastern Sydney South Western Sydney Other(999 ) Western Sydney Hunter New England Other Acute Geriatric Eval./Management Maintenance care Palliative Rehabilitation Grand Total P a g e

49 Table 31: RPA/IRO Inflows by Service Category for 65+ year olds RPA/IRO Inflows 2010/ y.o. by Service Category for Acute and Sub-acute Beddays Grand West Other Total SLJD NSW SESLHD SWSLHD NSLHD SWLHD ISLHD (999) HNELHD Other Acute Geriatric Eval/ Management Maintenance Care Palliative Care Psychogeriatric Rehabilitation Care Grand Total Table 32: Inflows to SLHD Hospital for People Aged 65+ by Acute and Sub-Acute Beddays Table 32: Inflows to SLHD Hospital for People Aged 65+by Acute and Sub-Acute Beddays Grand % from SLHD % from % from % from % from % from % from Total NSLHD WSLHD SWSLHD SESLHD WestNSW Other Total No Grand Total Rehabilitation Orthopaedics Respiratory Medicine Non Subspecialty Medicine Cardiology Gastroenterology Neurology Non Subspecialty Surgery Vascular Surgery Interventional Cardiology Tracheostomy Neurosurgery Urology Colorectal Surgery Oncology Haematology Cardiothoracic Surgery Upper GIT Surgery Palliative Care Renal Medicine Plastic and Reconstructive Diagnostic GI Endoscopy Ophthalmology Rheumatology P a g e

50 87 Maintenance Gynaecology Unallocated ENT & Head and Neck Endocrinology Pain Management Immunology and Infections Psychiatry - Acute Psychogeriatric Care Extensive Burns Drug and Alcohol Dermatology Breast Surgery Transplantation Dentistry Table 33: SLHD Resident Outflows for People Aged 65+by Acute and Non-Acute Beddays Table 33: SLHD Resident Outflows for People Aged 65+by Acute and Non-Acute Beddays SLHD Resident Outflows Grand Total % to SLHD % to Oth Private % to SESLHD % to SWSLHD % to St Vin c % to Private Proc % to Other Grand Total Rehabilitation Orthopaedics Respiratory Medicine Non Subspecialty Medi Cardiology Gastroenterology Neurology Non Subspecialty Surg Vascular Surgery Neurosurgery Urology Interventio. Cardiology Palliative Care Ophthalmology Colorectal Surgery Tracheostomy Oncology Diagnostic GI Endoscopy P a g e

51 Table 33: SLHD Resident Outflows for People Aged 65+by Acute and Non-Acute Beddays SLHD Resident Outflows Grand Total % to SLHD % to Oth Private % to SESLHD % to SWSLHD % to St Vin c % to Private Proc % to Other Grand Total Upper GIT Surgery Cardiothoracic Surgery Renal Medicine Haematology Plastic and Reconstructive Surgery Maintenance Rheumatology Gynaecology Endocrinology ENT & Head and Neck Unallocated Psychiatry - Acute Pain Management Psychogeriatric Care Immunology and Infections Dermatology Breast Surgery Drug and Alcohol Extensive Burns Dentistry Transplantation The following tables, Table 34 and 35, show the top 25 DRGs for people aged over 65 years in the SLHD by separations and beddays. Those aged 65 years+ are most frequently hospitalised in SLHD hospitals (beddays) for DRGs related to Rehabilitation, Respiratory and Dementia across the acute and sub-acute spectrum. The most frequent reason for separations was Lens Procedures, followed by rehabilitation, chest pain. Table 34: Top 25 DRGs for over 65 years old patients in SLHD Hospitals 2010/11 by Acute and nonacute beddays. Table 21: Top 25 DRGs for Over 65 years old patients in SLHD Hospitals by Table 34: Top 25 DRGs for Over 65 years old patients in SLHD Hospitals by Acute and Non-Acute Beddays Z60A Rehabilitation W Catastrophic CC Z60B Rehabilitation W/O Catastrophic CC E62A Respiratory Infections/Inflammations W Catastrophic CC P a g e

52 A06B Trach W Vent >95 hours W/O Cat CC or Trach/Vent >95 hours W Cat CC 5217 B63Z Dementia and Other Chronic Disturbances of Cerebral Function 3753 F62A Heart Failure and Shock W Catastrophic CC 3748 F62B Heart Failure and Shock W/O Catastrophic CC 3532 E65B Chronic Obstructive Airways Disease W/O Catastrophic CC 3051 I08A Other Hip and Femur Procedures W Catastrophic CC 2914 B70A Stroke and Other Cerebrovascular Disorders W Catastrophic CC 2815 L63A Kidney and Urinary Tract Infections W Catastrophic or Severe CC 2753 G02A Major Small and Large Bowel Procedures W Catastrophic CC 2664 I04B Knee Replacement W/O Catastrophic or Severe CC 2340 E62B Respiratory Infections/Inflammations W Severe or Moderate CC 2321 A06A Tracheostomy W Ventilation >95 hours W Catastrophic CC 2317 E65A Chronic Obstructive Airways Disease W Catastrophic CC 2088 I03B Hip Replacement W/O Catastrophic CC 2005 I68A Non-surgical Spinal Disorders W CC 1886 I08B Other Hip and Femur Procedures W/O Catastrophic CC 1859 Z64A Other Factors Influencing Health Status 1852 F08A Major Reconstruct Vascular Procedures W/O CPB Pump W Catastrophic CC 1842 G70A Other Digestive System Diagnoses W Catastrophic or Severe CC 1810 I03A Hip Replacement W Catastrophic CC 1705 G01A Rectal Resection W Catastrophic CC 1659 B02A Cranial Procedures W Catastrophic CC 1468 X60A Injuries W Catastrophic or Severe CC 1460 Table35: Top 25 DRGs for over 65 years old patients in SLHD Hospitals 2010/11 by Acute and nonacute separations. Table 35: Top 25 DRGs for Over 65 years old patients in SLHD Hospitals by Acute and Non-Acute Separations C16Z Lens Procedures 1110 Z60B Rehabilitation W/O Catastrophic CC 808 Z60A Rehabilitation W Catastrophic CC 710 F74Z Chest Pain 684 F62B Heart Failure and Shock W/O Catastrophic CC 628 E65B Chronic Obstructive Airways Disease W/O Catastrophic CC 597 E62A Respiratory Infections/Inflammations W Catastrophic CC 573 Z40Z Endoscopy W Diagnoses of Other Contacts W Health Services, 527 Sameday G70B Other Digestive System Diagnoses W/O Catastrophic or Severe 464 CC Q61B Red Blood Cell Disorders W/O Catastrophic or Severe CC 448 F76B Arrhythmia, Cardiac Arrest and Conduction Disorders W/O Cat or 445 Sev CC L41Z Cystourethroscopy, Sameday 387 I04B Knee Replacement W/O Catastrophic or Severe CC 382 E62B Respiratory Infections/Inflammations W Severe or Moderate CC 370 L63B Kidney and Urinary Tract Infections W/O Catastrophic or Severe 364 CC G48C Colonoscopy, Sameday 320 F62A Heart Failure and Shock W Catastrophic CC P a g e

53 L63A Kidney and Urinary Tract Infections W Catastrophic or Severe CC 316 G46C Complex Gastroscopy, Sameday 299 F42B Circulatory Disorders W/O AMI W Invasive Cardiac Inves Proc 293 W/O Cat or Sev CC I03B Hip Replacement W/O Catastrophic CC 278 B63Z Dementia and Other Chronic Disturbances of Cerebral Function 276 F73B Syncope and Collapse W/O Catastrophic or Severe CC 271 X60B Injuries W/O Catastrophic or Severe CC 271 L67B Other Kidney and Urinary Tract Diagnoses W/O Catastrophic or Severe CC P a g e

54 54 P a g e

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