Angliss Box Hill Healesville & Maroondah Peter James Wantirna Yarra Ranges Yarra Valley Turning Spectrum Hospital Hospital District Hospital Hospital Centre Health Health Community Health Point

Acute Aged Care in the Community -

Improving Client Experience and

Providing ED Diversion

A/Professor Mary O’Reilly

Executive Clinical Director

Ambulatory and Community Services

Eastern Health

Eastern Health

EH Ambulatory and Community

Services program

• Focus• Client centred care in the community

• In partnership with clients, families and community

partners

• Strategy• Diversion

• Bed substitution

• Secondary prevention

ACS

Service type Average Daily Client Contacts

PAC 90.92 ACAS assessments 33.8 TCP 92 Rehabilitation Services and Specialist clinics 296.34 ECASA 13.47 Yarra Valley Community Health 83.21 HARP 97.43 Eastern@Home 98.99 District Nursing 24.4 Residential Inreach Program 22.35 TOTAL 852.91

ACS Client Age

Residential In-Reach (RIR)

• What is In-Reach?

• What do we do?

• Novel models of care

Residential In-Reach (RIR) Services

• Role:

– Provide hospital type care to reduce avoidable

presentations to hospital from aged care

facilities

• How:

– Provide urgent assessment and care at facility

– Up-skill facility staff

– Support primary care providers

– Facilitate Advanced Care discussions

– Improve hospital staff’s understanding of aged

care facilities for discharge planning

RIR – what we are not

• GP service

• Locum service

• Substitute for routine facility care

• Post acute discharge service

• Community geriatrician substitute

Advantages of RIR• Resident-centred care

• In their own familiar environment - “home”

• Less delirium, less falls, less hospital aquired

infections

• Optimises use of health care resources• Ambulance avoidance

- increased access, less ramping

• ED avoidance

• Minimise acute health facility admission

Eastern Health’s RIR Service

• Team– Lead: Consultant Geriatrician

– Medical: • Consultant Geriatricians

• Accredited Aged Care registrar

– Aged Care Clinical nurse consultants

– Clerical support

• Program– Telephone support

– Client visits

– Tele-health

• Availability– 7 days a week

• Medical 0800 – 1630

• Senior nursing phone support 1630-2100

• Hospital in the Home 24/7

RIR: What do we do?• Urgent assessment & management of acutely unwell clients

• Sepsis, cellulitis, pneumonia, delirium, gastroenteritis

• Exacerbation of heart failure or chronic lung disease

• Undifferentiated acutely ‘unwell’ client

• Acute symptom control– e.g. cancer related pain

• Falls requiring acute medical review (+/- Xray)

• Acute palliative care

• Acute behavioural change

• Complex urinary catheter management

• PEG complications– (not routine changes)

ED and Hospital DIVERSION

RIR: Advanced care planning

As part of our care:

• Discuss with GP and seek permission to attend for family meeting

• Facilitate Advanced Care discussions

• Create and document a facility-based medical management plan

Supporting RACF

• Telephone advice

• Provide or direct to resources

– Written, electronic

– Training providers

• Expedite appointments to avoid admission

• Up-skill RACF nursing team

Eastern Health RIR Partnerships

• Emergency Departments

• Hospital Pharmacy

• Hospital In The Home (Eastern@Home)

– Direct referral system to HITH

• Inpatient Units for consultation/telemedicine:

– Plastics, Dermatology, Vascular

– Infectious Diseases Unit

• Inpatient Units for direct admission

• Infection Prevention and Control Unit

– For advice

• Palliative Care Unit

– For advice

Eastern Health RIR External Partnerships

Resident and families GPs, locum GPs

RACF Ambulance Victoria

HARP Eastern Palliative care

Community nursing

Wound care

Catheter management

Primary Health Networks

(Formerly Medicare Local)

Community pharmacy

External Specialists Other Acute Health Services

Eastern Health RIR

EH presentations from RACF-

Before and after Inreach

Data 2009 - 2011

Reduced ED presentation (2278 2051)

Median ED LOS reduced by 24 minutes

Reduced admission rates from 70% 45% (23%)

Repeat ED attendances reduced from 27% 15% (12%)

End of life palliative care plans increased from 8% 21% (13%)

Ref: Street M et al, Aust Journal on Ageing, 2014 (available online)

Inreach & Hospital in the Home:Patient centred care & hospital diversion

• HITH in RACF

– Management of

• Urosepsis

• Pneumonia

• Cellulitis

– Negative pressure wound dressings

– Chemotherapy

– Acute palliative care

New models of care:

Outbreak management in RACF– Gastroenteritis

– Flu/Respiratory illness

Partnerships with:

Eastern Health Infectious Diseases & Infection Prevention and Control Unit

RACF

General Practitioners

Gastro outbreak in RACFSunday afternoon

• Call from 120 bed RACF

• ‘Gastro’ outbreak for 1 week

• 26/40 residents in one section affected

• Unwell residents, unable to get GP or locums over the weekend

• Requesting In-Reach for 11 - 21 patients or

– Will call the ambulances……

– For transfer to Eastern Health Emergency Department(s)

GEM@HomeGeriatric Medical Evaluation

• Model– Bed substitution

– Recognises client preference to remain in their own home for care

• Client target group– >65 years of age, directly from the community

– Complex, age related issues

– Requiring geriatrician and multidisciplinary team evaluation &

management to reduce likelihood of a hospital admission

GEM@Home

• Multidisciplinary team– Geriatrician, Nursing and Allied Health

– 8 -10 active patients per week

• Length of stay– average 25-33 days

• Main referral source– General Practitioners

– Aged Care Assessment Service

GEM@Home

• Main referral reason– Specialised aged care assessment, evaluation and short term

care coordination by multidisciplinary team.

– Generally related to daily living issues

• e.g. cognitive decline impacting on ability to independently complete

activities of daily living

• Community Linkages– Strong engagement with community providers in order to

facilitate appropriate matching and linking clients into longer

term services

GEM@Home

ACAS Rapid Outreach Response

(ROR)

ROR offers an intensive mobile outreach service to

older people living in the community who are

experiencing an exacerbation of a chronic health

condition, or deterioration of complex social

situation that would normally lead to an

inappropriate hospital presentation or admission.

ACAS Rapid Outreach Response

(ROR)

• Multi-disciplinary rapid assessment response

• Aged Care Assessment Services (ACAS) will complete a

comprehensive assessment

ACAS Rapid Outreach Response

(ROR)

• Determine client eligibility to access Commonwealth

funded aged care services

• Home Care Packages

• Residential Aged Care (permanent or respite).

• Improved care planning and collaboration with primary

care providers.

• Short-term care coordination (up to 12 weeks) and

provision of services to frail, older clients living in the

community.

ROR

Eastern Health HARP

Hospital Admission Risk Program

• Established 2006

• Complex case management

• Preventable, chronic disease, frequent presenters

• Referral

• From community, ED or inpatient services, AV

• Reduce frequent hospital presentation

• Streamed and tiered model

• Outreach model

Rapid response clinics

• Daily Specialist clinics

• HARP medical review

ACS Navigation

• ACS intake team

• Single point of contact

What do our clients think?

Angliss Box Hill Healesville & Maroondah Peter James Wantirna Yarra Ranges Yarra Valley Turning Spectrum Hospital Hospital District Hospital Hospital Centre Health Health Community Health Point

Acknowledgements

Eastern Health ACS team & our clients

nurse practitioners & nurses, physiotherapists, social workers,

occupational therapists, dieticians, podiatrists, counsellors,

clinical psychologists, neuropsychologists, speech pathologists,

specialist medicine physicians & general practitioners & senior

medical trainees, community development workers, welfare workers,

allied health assistants, Aboriginal Health workers, educators,

administrative support