Emus

1
Emus Cupcakesthinking aloud about community
based health care in Australia

• Professor Craig Veitch
• Chair in Community Based Health Care
• Director, Community Based Health Care Research
  Unit

2
Outline

• Community Based Health Care Research Unit
  (CBHCRU)
• Overview of Australian CBR literature
• Key issues
• Potential research opportunities
• Emus cupcakes

3
CBHCRU

• Collaborative arrangement between FHS, FNM,
  RRCS (5 yrs initially)
• Unit located at RRCS
• Chair/Director appointed Dec 2007
• Research background in
• rural health
• primary health care
• health services research evaluation
• community health services development
• health care behaviour
• Knowledge of rehabilitation .??

4
CBHCRU goals

• develop research program to address the
  effectiveness of community based health care for
  people with major traumatic injuries and
  long-term conditions with complex care needs
• foster collaborative interdisciplinary networks
  of researchers
• research leader and mentor to Royal Rehab staff
  students
• understand the role and influence of primary
  health care in maintaining well-being in
  community-dwelling individuals with traumatic
  injuries and long-term conditions with complex
  care needs
• evaluate new community based service initiatives

5
Emus Cupcakes ?

• Emus
• Big
• Mean (known for kicking down dunny doors)
• Not easily controlled
• Dangerous in quantities of 1 and more
• Impact immediate obvious
• Cupcakes
• Small
• Sweet
• Do not move on their own account
• Harmless in small medium quantities
• Impact gradual subtle (also immediate
  pleasurable, but short-term)

6
Literature search

• Purpose to get a feel for CBR research in
  Australia
• Why CBR not CBHC?
• Community based health care 16,005 articles in
  20 yrs
• Community based rehabilitation 3,913 articles
• Why Australia?
• CBHC 679 articles in 20 yrs
• CBR 173 articles
• Its where we live!
• Medline (PubMed Entrez)
• Keywords community based rehabilitation
  Australia
• Time limit 1988-2007

7
Results

• N 173 articles
• 69 selected on title/abstract relevance
• brain injury stroke, ABI, TBI
• spinal Injury
• disability
• cancer, palliative care
• cardiac
• COPD
• musculoskeletal injury/orthopaedic/arthritis
• chronic venous leg ulcers
• Exclusions drugs, alcohol, paroled prisoners,
  mental health (non-BI)

8
Designs subjects

• Designs
• RCT (8)
• longitudinal comparative retro/prospective (15)
  
• repeated measures (8)
• cross-sectional (14)
• qualitative (8)
• review/opinion (6)
• evaluation (10)

• Subjects (unit of analysis)
• Patients/clients
• Carers/supporters
• Allied health professionals
• Nurses
• Rehab funding agencies
• Rehab services/units
• ICUs
• Peer support groups

9
Methods

• chart review
• clinical measures/benchmarks
• questionnaire survey
• semi/structured interview
• action research
• case studies
• secondary data analysis
• non/systematic literature review
• historical review

10
Measures

• ICF
• TOM
• QoL
• FIM
• ADL / IADL
• QALY
• MMSE
• Physical functioning
• Pain intensity
• Re-admission
• Cost-efficiency
• Goals/setting

• Health care utilisation
• Measures of Processes of Care (MPOC-20/SP)
• Needs lists
• Godin Leisure Time Exercise Questionnaire
• Stroke Impact Scale
• Discharge destination
• Re-integration to community living
• Functional assessment of cancer therapy
• Self-reported health history

11
General observations 1

• Numbers of studies increasing over time
• 1988-92 2
• 1992-97 8
• 1998-02 18
• 2003-07 41
• Tend to be
• Focused on one clinical discipline
• Few multi-disciplinary studies
• Differing interpretations of community-based
• Hospital in the home Rehabilitation in the home
• Hospital-based care to community-based clients
• Hospital practices procedures in community
  settings
• Community-based health services practitioners
• Family-centred practice

12
General observations 2

• Differing interpretations of rehabilitation
• What is done to clients
• What is done with clients
• What clients go through after injury/ailment
• Biomedical process of recovery
• Part of a continuum from injury to living with a
  disability/deficit
• Living with a disability issues
• Function
• Continual/appropriate care support
• Ageing
• Mx of co-morbidities
• GP/PHC professional CBR knowledge/experience/use
• Re-admission/emergencies

13
General observations 3

• Measures generally
• Developed validated in institutional settings
• Functionally focused
• Cost
• Mix of clinically-focused (procedural) and
  academic
• Clinical generally use measures developed for
  institutional biomedical settings
• Academic commonly lack theoretical or model
  basis
• Mixed levels of evidence
• 11 RCTs
• Few demonstrate program development or strategic
  vision
• Few authors/groups with multiple publications

14
Dilemmas (for the aspiring CBHC researcher)

• Are institutionally relevant measures appropriate
  in the community setting?
• Success at keeping people out of hospital
  (unplanned admissions)
• Community engagement
• Impact on community based activities function
• Is clinical function always what clients want?
• Community-dwelling stroke survivors function is
  not the whole story with quality of life The
  development of needs-related effective long-term
  service delivery models is required.

15
Research opportunities

• CBR/CBHC fertile fields of opportunity
• Calls for more well-designed clinical trials to
  increase the evidence base, particularly for
  guideline development.
• Plan a research program (any program)
• Interdisciplinary teams
• Effectiveness of current practices
• Change management institutional to
  community mindset practices
• Barriers to change
• Client carer-centred issues
• Measures for CBHC
• Community role/s in CBHC
• Workforce issues

16
CBR Model

• CBR is a strategy within general community
  development, for rehabilitation, equalization of
  opportunities and social inclusion of all
  children and adults with disabilities CBR is
  implemented through the combined efforts of
  people with disabilities themselves, their
  families and communities, and the appropriate
  health, education, vocational and social
  services.
• ILO, UNESCO, UNICEF, WHO, 2002

17
The CBR Model in Australia (report from 2003
forum)

• Forum recognised
• considerable strengths in CBR model.
• yet to make a significant impact on Oz service
  system.
• suitable to remote, rural and Indigenous
  communities.
• need for greater community involvement in
  disability services,
• need to develop appropriate training frameworks,
• need to redirect resources to community models.
• if CBR model is to be implemented effectively,
  substantial consumer community involvement will
  be instrumental in future steps.
• Kuipers P, Allen O, 2004

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Who does this?

• monitor signs symptoms and reinforce patients'
  self-management identify trends and appropriate
  action
• organise, liaise, and consult with other health
  professionals to deal with changes in clinical
  status
• clarify and reinforce patients' self-care
  strategies
• assist patients in their desire to avoid
  institutionalized care
• identify patients' psychosocial issues dealing
  with social isolation
• provide support journey with patients their
  patients' families
• help patients their families deal with death
  and dying.

19
Answer

• A major proportion of the activities of
  home-based heart failure nurse specialists are
  related to facilitating communication between
  health professionals and providing information
  and support to patients and patients' families.
• Davidson P, Paull G, Rees D, Daly J, Cockburn J,
  2005

20
What role for the CBHCRU

• Build relationships
• Understand professionals issues potential
  research Qs
• Identify research stream/s
• Recruit staff attract RHD students with
  experience/interest in focus area/s
• Look for Cupcakes (small, achievable projects)
• Take on the Emus (CBHC Inational CBR lit)