A DHB Perspectve on Aged Care

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A DHB Perspectve on Aged Care

• Dwayne Crombie
• HCPNZ Conference
• September 12th, 2006

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Key Issues

• Funding Environment
• Living within Budget
• DHB Funding Variation and Mix
• Snapshot of Services Waitemata DHB
• WDHB Approach to the HOP Strategy
• Workforce issues
• Quality issues

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Funding Environment

• DHBs are funded typically in one of three ways
• Inflation (FFT 2.93 in 06/07)
• Demographic Growth, average 1 (0 2.2)
• New Government policy initiatives, e.g. PHO
  funding
• Movement towards Population Based Funding Target

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Living Within Budget

• Major Financial Risks with Residential Care
  sector
• Legislative
• Annual contract negotiations
• TLA pricing
• A23 provision
• Inter-district flows
• Population growth and aging impact
• Typically 75 population increasing by 6 p.a.
  and 85 population by 8-9 p.a.
• Co payment options

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Contract Negotiations
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Aged Care Population by DHB
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Aged Care Population by DHB

• Percentage of Population aged over 75 yrs
• Average 5.8
• High
• South Canterbury 9.1
• Wairarapa 8.1
• BOP 7.5
• Low
• Capital and Coast 4.8
• Auckland 4.7
• Counties Manukau 3.9
• Age is incorporated in the Population Funding
  Formula

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DHB Spend by Size of Aged Population
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Cost Variation Among DHBs
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Cost Variation Among DHBs

• Cost per capita (for people 75yrs) varies
  between DHBs
• Average cost per capita 3,315
• High
• West Coast 4,844
• Hutt 4,163
• Southland 4,122
• Low
• Counties Manukau 2,715
• BOP 2,615
• Waitemata 2,547

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Per Capita Spend vs Agedness
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DHB Mix Variation

• Home Care Spend As a Percentage of Aged Care
• Northland 32
• South Cant. 27 top six average
• Southland 26 total spend per capita
• Waikato 25 3,611
• West Coast 25
• Hawkes Bay 23
• Average 19 Average 3,315
• Canterbury 16
• Wairarapa 15 bottom six average
• Hutt 14 total spend per capita
• Taranaki 14 3,604
• Capital Coast 13
• Auckland 13

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Snapshot of Waitemata DHB- Current Service
Utilisation

• PHOs
• Six PHOs serve the Waitemata area
• 51,406 people are enrolled in PHOs which 96 of
  the 53,480 people aged over 65 years
• Total DHB population of 505,000
• Emergency Department
• 16,632 visits to Emergency Care Centre (ED) of
  people aged over 65 years which represented 30
  of the older population group (and 27 of total
  ECC visits)
• Of all visits, 70 were admitted, 1 went to rest
  home or private hospital and 28 to home

N 53,480 gt 65 yrs
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Hospital Inpatient Care

• 10867 acute medical and 3624 acute surgical
  admissions (which together are around 27 of
  older group population)
• Average LOS 5.3 (compared to 3 for lt65)
• Disposition
• 79 to home
• 10 to rehabilitation ward ( correlated with
  age)
• 4 to rest home or private hospital
• 3 died
• 346 other community admissions to rehab. ward as
  well as the 1473 from hospital acute wards
• 65 discharged to home
• 15 to rest homes
• 9 to private hospitals
• 8 back to other inpatient wards
• 2 died

N 53,480 gt 65 yrs
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Hospital Outpatient Care

• 24,438 medical outpatients
• 20,621 surgical outpatients
• 2,915 older adults outpatients
• 2,422 acute therapy outpatients
• Each older person had an average of 3.2 medical
  and surgical appointments per year (i.e. 14,080
  different patients or 26 of older population)

N 53,480 gt 65 yrs
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DHB Home Health and Community Services for Older
Adults
N 53,480 gt 65 yrs
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NASC Clients
N 53,480 gt 65 yrs
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NASC Home Based Care

• 70 of clients are home based
• 4534 home help
• 2094 personal care
• 896 carer support
• 83 respite care
• 24 dementia day care
• 249 meals on wheels

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NASC Residential Care

• 2296 clients receiving support package
• 1930 subsidised clients in residential care (or
  3.6 of population aged 65 yrs)
• 976 in rest homes
• 769 in private hospitals
• 129 in dementia care
• 56 in psycho-geriatric care

N 53,480 gt 65 yrs
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Residential Care Acute Interface

• Waitemata analysed all admissions from
  residential care providers during 2005
• On an annualised basis there were 1672 admissions
  occupying 14,000 bed days or an average of 38
  acute hospital beds daily
• Average stay was 8.4 days compared to 5 days for
  the remainder of older people

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Presenting Admissions

• Top Seven DRGs
• Fractured femur/hip with catastrophic CC
• Respiratory infection with catastrophic CC
• Lymphoma
• CORD with catastrophic CC
• Dementia
• Respiratory infection with severe CC
• Stroke with catastrophic CC

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Variation By Facility

• Annual admissions as a percentage of facility
  beds
• Hospital Average 74 (n 23)
• T 242 B 30
• S 180 W 20
• L 160 S 20
• Rest Home I/II Average 54 (n 50)
• Rest Home III Average 54 (n 8)
• K 158 F 12
• T 138 H 12
• H 120 P 10

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Health of Older Peoples StrategyA Population
Approach
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Framework for Responding

• Complex adaptive systems
• Relationships
• Distributed control
• Emergent, non-linear and history dependent
• Preventative approach
• Reducing the number of critical events, catching
  problems early and preventing deterioration in
  functional ability
• Integrated approach
• Continuity and multi-disciplinary approach
• Well developed needs assessment and care pathways
• Care co-ordination for those with complex needs
  and care
• Care partnership with older person and their
  carers

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Preventative Approach
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The Way Forward

• Helping people to stay out of hospital
• Acute care in the community, primary options
• Integrating home based support services within
  the continuum of care and a restorative approach
• More intensive and integrated residential care
• Quality coordinator working with residential
  providers
• Increasing clinical support to residential care
  such as specialist care, gerontology nursing and
  wound care
• Team based primary care in residential settings
• Joint staff training with specialist services
• Shared care pathways for common conditions
• Increased short term respite
• Access to specialist equipment

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The Way Forward

• Reducing deterioration in functional ability
• Chronic disease management
• Cadriovascular risk screening and diabetes care
• Screening for at risk older people
• Trialling in ECC and in primary care
• Care co-ordination
• Trialling with primary care and new information
  systems
• Medication management and QUM approach
• High risk patients identified in rehabilitation
  wards
• Improving timely access to specialist services
• Improving link between NASC, ATR and acute wards
• Care pathway for dementia and delerium

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Workforce Issues

• Second level nurse
• impact of HPCAA on ability to practice in acute
  settings
• scope of practice issues by regulatory body
• lack of production by tertiary training
  institutions because of uncertainty
• big priority for both DHB and NGO settings
• Non regulated workforce
• high turnover
• lack of nationally consistent training programmes
• no clear pathway for career advancement
• many other options because of low unemployment
• Differential pay conditions with DHBs

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Quality Issues

• Health sector standards used as a proxy for
  quality
• Huge variability in care provided against known
  best practice
• Elder abuse attracting media attention
• Inability to connect up information about
  population care and access and to measure
  progress on outcomes easily
• Lack of incentives to do the right system thing
• Significant improvement is likely to come from
  systems improvement i.e. redesigning care
  pathways, handovers of care, use of guidelines
  and protocols in key areas, consumer input and
  joined up clinical information systems

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