crest (community rehabilitation enablement & support team)
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CREST (Community Rehabilitation Enablement & Support Team) . CREST. Community, Rehabilitation, Enablement, Support Team. Dr Anne Roche Paulina Baird April 2013. How it started. Demographics. 13.5% of the Canterbury population is over 65 Estimated to rise to 20% in 2020 - PowerPoint PPT PresentationTRANSCRIPT
CREST (Community Rehabilitation
Enablement & Support Team)
CREST
Dr Anne RochePaulina Baird
April 2013
Community, Rehabilitation, Enablement, Support Team
How it started
• 13.5% of the Canterbury population is over 65
• Estimated to rise to 20% in 2020• Number of 85+ will double• 85+ year olds utilise 3x health care
resources of other age groups
Demographics
Pressure on aged care and hospital beds• Prior to the earthquake plans were in place to plan and
implement a support discharge programme in Canterbury.• The earthquake resulted in a loss of 106 medical beds and
635 ARC beds • We needed to progress the supported discharge initiative
rapidly to reduce facility constraints
What is CREST?• CREST is a community based rehabilitative supported discharge
and admission avoidance service for older people.• It works with an interdisciplinary team
– a liaison team (covering both hospital and primary care)– a case manager (physiotherapist, OT, RN) that establish
rehabilitation plans– a coordinator (community provider RN) who supervise
teams of well-trained Key Support Workers.• CREST provides clients with up to 4 visits a day, 7 days a week
Why CREST?• Hospital is not the best location to rehabilitate and
care for older people• 25-50% older people lose some function in hospital,
and 66% have not regained function 3 months later• CREST improves client function and independence and
increases the time the client spends at home• Designed to reduce:
– length of stay in hospital– residential care placement– need for long-term home care
Eligibility Criteria• Age > 65 years • Medically stable – ready for discharge from hospital• At risk of readmission, or entering ARC• Potential for partial or complete recovery with suitable home
rehabilitation within six weeks.• The client is able to stand and transfer with one person (with or
without the help of a resident carer).• The client consents to being treated at home by the team and aware of
the objectives set by the IDT • The client has had a recent acute illness or injury or is at a borderline
level of function with an associated reduction in ADL and/or EADL
Making disability worse worse• Physical inactivity and disuse aggravate
medical conditions such as diabetes, heart disease and causes deconditioning
• Hospitalisation induces inactivity and dependence, “ wrapping older people in cotton wool”. Risk of adverse events 10 x higher > 65y
• Preclinical disability can be recognised and averted with health promoting interventions, e.g. activity, nutrition
• Ageing, Health Risks and Cumulative Disability NEJM 1998.338:1035-41
Transition to home to home
• Discontinuity in clinical responsibility• Uncertainty about changes to medication, what
medications already at home, whether prescription will be filled etc
• Uncertainty about physical environment, resilience of family, perceived risk
• Little consideration of what is important for the person
Referral Process
for CREST
CREST Client Pathway & Supporting Documentation
Documentation & SupportClient Pathway
CREST Liaison identifies appropriate
CREST Client
Completes Liaison Assessments &
determines complexity
CREST Administrator completes admin
procedures
Client transferred to
CREST
Client managed as per CREST requirements
· CREST Liaison Process Map· Chapter 3 CREST Handbook· CCMS User Guide
· CREST Liaison Assessment Form· RAT
· CREST Administration Process Map
Case Manager OPHSS
(Complex)
Coordinator Comm Provider (Non- Complex)
· Complex CREST Client Management Process Map
· Non-Complex CREST Client Management Process Map
· EuroQol· Nottingham EADL· Goal Ladder (CCMS)· Chapter 5 - 7 CREST Handbook
· Chapter 8 CREST Handbook· Completion of CREST Non-Complex Client
Process Map (CREST Coordinator)· Completion of CREST Complex Client Process
Map (CREST Case Manager)
Client transferred from CREST
Client Pathway
CREST is growing…
SMARTS pecificM easurable (meaningful to pt)A ttainableR ealisticT ime orientedGoal Ladder- client identifies “distal goal”- where they want to be, proximal goals are the steps required, how they get there.
Goals
Grocery shopping (& coffee) with Liz by x
Walking to car and getting in with help by x
Walking to dairy (450 metres) by x
Walking to letter box independently by xxx
Walking to ward doors within 2 days
Dressing independently within 5 days
Walking to toilet independently day or night by 3 days
Washing independently at home by xxx
Dressing independently at home by xxx
To be able to defrost and heat MoW by xxx
For pain to be 3/10 - getting in/out bed by x
Getting in / out of bed independently by x
Drawing curtains independently by x
Preparing breakfast and snacks by x
Attending church with friend by x
Hosp. discharge
CREST discharge
Withdraw night visits
Withdraw AM visits
Withdraw weekend visits
CREST x3 a day x7
One 2 hour visit x3 week
Commenced HBSS x 2hrs week
Week 3 Long term goal:To walk to fish and chip shop once a week to buy meal
Week 2 To have a robust plan to manage COPD and CHF symptoms -weekly weigh -Respiratory OR education, domicilary O2 -prompt breathing exercises
Week 2 To walk to his letter box each day, increasing distance by 1 power pole each time
Goal ladder continuedWeek 1 To take medication each day at the correct
timesKSW to check daily for 3 days, then observe
Week 1 To eat 3 meals a dayKSW to check he has eaten each time they visit
Week 1 To wash and dress independently each day
Patient examples
• Mr CG age 93,lives with wife.– Admitted May 2 with abdominal pain due to
constipation– Previous admission April 20 with NSTEMI and
exacerbation heart failure. Urinary retention- D/C with IDC and plan for trail of void at home (DN)
– Presented to ED May 1 with abdo pain
• Mr GC– Constipation resolved, recatheterised with flip flow
valve, LRTI and UTI treated– Apprehensive about discharge– CREST- CM present when he got home, helped to
settle, distal goal- get out into garden, twice daily KSW- showering, walks, Physio- chair raiser, frame, exercise programme.
– Became independent w shower, D/C 30/5
Primary Care CREST
• Gradual extension into Primary Care since Dec 2011• Initial pilot, 4 General Practices, Referral to OPH
Clinical Nurse Specialist who screened potential candidates
• Patients need to be well enough for GP management at home, but would benefit from increased support, with rehabilitation focus to enhance recovery.
• OPH triage team redirected some referrals for respite care etc to CREST
Primary Care CREST
• October 2012: 8 referrals from General Practice, 13 internal referrals from Older Persons Health Community Teams- triage, Clinical Assessors, patients seen on visits by Geriatrician and/ or Community Gerontology Nurses
• Steady increase in numbers
• March 2013: 18 referrals from GP, 19 referrals internal referrals
Primary Care CREST- patient example Care CREST
• 75 yr old woman, referred for respite care• Morbid obesity, exacerbation of back pain, had
pushed personal alarm 3 times in 10 days• Supportive daughter away on holiday• Bipolar Affective Disorder, currently depressed• Had been incontinent in bed, unable to get up to the
toilet because of back pain. Sleeping in Lazy Boy chair
• Seen by CREST Liaison, increased supports at home, practical assistance to get mattress and bedding cleaned
Patient example continued
• Seen by Physiotherapist and Occupational therapist• Goals identified• Care plan around encouraging independence in
shower, frequent supervised walks, sleeping in bed• Referred to Medication Management Service ,
Dietitian and Psychiatric Services for the Elderly• Back pain resolved, able to return to baseline
package of care at home, more confident about ability to stay at home in medium term
CREST (tip) of an iceberg
• Intervention and close observation at home can unmask previously unidentified problems
• Cognitive impairment• Anxiety, made worse by social isolation• Shortness of breath, made worse by anxiety.
• Co-ordinators inform Primary Care Team. CREST can assist in appropriate response/ referrals/ discussion with family etc.
Quality and Improvement• Group structure
o Operational Group to discuss day to day issueso Data collection, monitoring through Quality Groupo Sign off from Steering group
• Case Managers / Providerso Monthly educational training sessions and peer reviews
• On-going improvemento Continual Process improvement Process – what's working wello Tool development – how do we do it bettero Training and development – do we have the right skill mix
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-130
5
10
15
20
25
30
35
CREST Clients Average Length of Stay
Admissions to ARC• During the 2011/12 Year
• During the 2012 Year
2011/12 28 days 90 daysCrest Discharges Entering ARC 3% 7%General 65+ Discharges Entering ARC 11% 13%Difference -8% -6%
2012 28 days 90 daysCrest Discharges Entering ARC 2% 5%General 65+ Discharges Entering ARC 11% 13%Difference -9% -8%
Client Survey• Approximately 1500 surveys were sent out in January 2013• 80% surveys returned• 90% clients satisfied or very satisfied with the overall CREST
service• 84% believed they set obtainable goals• 73% of clients received between 1 – 6 hours of care per week
while on CREST • 78% of clients believe that CREST works well with other health
services in the home• 76.5% of clients believed they were able to do what they wanted
with the assistance of their support worker