Transition Care Program SA Experience

1
Transition Care Program SA Experience

• Dawn J Kroemer
• Senior Manager
• Transition Health Services ACH Group
• Dept General Practice and Primary Care FUSA
  2006

2
What started this in SA

• Bad Press regarding access to aged care and acute
  sector beds..always a good catalyst !!!
• OFTA DOH proposal with sector to access unfunded
  aged care space
• Model across sector resi / community
• Partnership acute / aged sector
• Small pilot 2000 empty long stayers 149
• ATA Begun

3
Strategy

• Pool funding State / Aust Govt
• Unfunded capacity
• Bring together acute and aged sectors
• ownership of issue and solution
• Timely.. ICRS pilots ATA HRSS
• Flexible range rehab support

4
Issues for Acute / Aged Interface

• Capacity of aged sector to participate in
  widespread initiative for sector change
• Inadequate systems and access to appropriate
  timely responsive Aged Care Services.
• Need for prompt response to Discharge Planning
  options.

5
Issues for Aged Care Sector

• Decision made to enter permanent residential care
  made during crisis event.
• Fixed funding system, incentives.
• Clients may and do improve following admission.
• Cohort of clients inappropriately in residential
  care.
• Impacts financially, emotionally, service level.

6
Incentives for aged sector

• Uitilising unfunded capacity
• Building capacity future
• Responsive services
• Participate planning for aged services
• More appropriate admissions to long term care
• Cutting edge

7
Providers ATA - Agreement

• Capacity beds / packages
• Agree triage function
• Willing individual assessment
• Willing innovative flexible services / options
• Ability rehab, restoration of function focus
• Participate evolving program / outside current
  boundaries
• Collaborate other ACP / hospitals / networks
• Understand funding principles
• Accredited / approved aged care provider / ACSA.

8
ATA - Aged Care Participants

• Gleneagles Aged Care
• Helping Hand Inc
• Italian Benevolent Foundation (IBF)
• Masonic Homes SA
• Murray Mallee Aged Care
• Resthaven Inc
• Southern Cross Care
• Tregenza Avenue Aged Care Service
• Wesley Mission

• ACH Group
• Anglicare SA
• Alwyndor Aged Care
• Adelaide Hills CHS
• Bethsalem Care
• Boandik Lodge Aged Care
• CHAPs
• Barossa Village
• ECH
• Eldercare Inc
• Fullarton Lutheran Homes
• Life Care

ATA
9
ICRS Results

• Referrals end Sept 1285 (av 38/mth)
• Admitted to HRSS 794 (64)
• 48 to Residential HRSS
• 52 to Community HRSS
• 50-63 clients at any time.

10
Client Profile

• Gender 65 females64 live alone
• Median Age Males 81, females 83
• Nearly 40 gt 84yrs age
• 58 live alone
• 76 widowed, never married or separated.
• Over 80 have either no or one service prior to
  admission to hosp (equip, gardening)
• 80 in hospital gt 16-20days

11
Outputs
12
Funding

• Paid on RCS model - plus intensity
• 11 clients required extra funding,
• Physio, transport, client contribution,
• Resi Av cost per bed day 102.57 / day
• Comm Av cost per bed day 55.48 / day

13
Client Contribution

• Fee waivering more likely in community programs
• In only 5 cases the ATA has funded the client
  contribution where extreme hardship has been
  demonstrated. Providers were unable to recoup
  fees as agreed from 4 clients..
• Where there has been partial fee contribution by
  clients it ranges between 16 83.
• 50 providers waived fees for some clients in
  their programs.
• Over 72 of clients paid 100 of the client
  contribution. In residential this was the daily
  care fee at the time. (around 24 - 26/day)
  indexed over the time of the pilot and in
  community the weekly fee ( 30-35 )
• No providers stated that services where not
  delivered on the basis of fee issues

14
Services

• Most physiotherapy / OT assessment, therapy
• Case management (1-5hrs per week)
• Personal Care, Domestic Assistance Lifestyle
  Allied Health Services provided by Aged Care
  organisation
• Brokered cost higher

15
Long Stay ATA gt 90 days

• 122 (19 ) clients received services gt 90
  days.
• Av Hosp LOS for this group is 41 days (nearly
  double whole cohort)
• 47 ( 38 ) had a residential rehab option,
  Resi - AV LOS is 118 days (91-264)
• Community - Av LOS is 107 days (90-222)
• 82 of all these clients remained in their own
  homes.
• - 31 CACP
• - 19 to CO
• - 23 to existing services
• - 8 to family or no services
• - 13 to HLC/LLC.

ATA
16
City Views July 2003

• Partnership ACH Group 5 other providers bed
  licences
• RGH Dept Rehab Aged Care Allied Health
• SA Dept of Health
• RCT
• 36 beds empty floor Julia Farr Blg
• - SAHS referring hospitals
• Staffed Aged / Acute Care Rehab
• Outcomes for p/tants
• - improvement in function
• - happier with d/c outcome in transition
• - 9 d/c home more about CAP transitions
• Model for transition between sectors reflected
  current environment in SA - collaboration

17
How did we do it ..?

• Advisory Group
• hospital and provider and govt depts.
• working groups
• Steering group
• m/ment of project
• Project management focus
• Providers letter of agreement

18
still how did we do it .

• Triage model
• single point entry referrals ATA ,
• - Single person for acute and providers
• - referrals all fed back to program support
  officer
• - providers assess in hospital 2 reasons
• Training sessions differences
• - RCS in community
• - Careplanning for client outcomes focus
• - measurement ie Barthels
• - now goals focus, documentation,
  measurement, ongoing

19
More how..?

• Aged Care Liaison role
• manage culture between sectors
• targeted problem solving
• expert aged experience in acute sector
• Information and Specification Booklet
• Small Workgroups
• to problem solve issues
• collaborative agreed processes to take back
  to Advisory to implement
• timely response
• Data Base / feedback

20
National Evaluation

• Conducted over ICRS across Aust
• Outcomes similar in terms of d/c outcomes
• Collaboration seen as positive
• pilot has made a significant contribution to the
  care of people who would otherwise have been
  admitted to permanent residential aged care.
• Triage model good

21
What now.

• Refunded Transition Care Program TCP
• Both programs provided a way forward TCP
• 176 places allocated to SA
• - 50 place metro / rural regional
• - 40 beds at City Views Transition Service
• ATA Partners involved / ongoing relationship with
  RGH and acute sector.

22
Differences

• Mainstream guidelines agreed by funders.
• State approved provider. (SA)
• No leave entitlements on program.
• Existing recipients of other programs OK.
• Time Limited (? gt84 days -126 days)
• ACAT TCP extensions.
• Care plan goal, sign off.
• Quality framework.
• Service delivery focus restoration of function.
• Discharge outcomes

23
Guidelines

• Restorative Process
• Quality Care Planning requirements
• - goals focus, client sign off, measurement
• Define types of services

24
Recipient Agreement

• Based Service Agreement from C/W and State
• Informed consent impact on acute sector
• Seeking Consumer Input goals and signoff
• Time limited. Extension requires ACAT for this.

25
Careplanning

• Client centred - Goals approach
• Articulated and documented
• Measured and include other assessment
  instruments.
• Developmental
• Systems development assistance to do this.

26
Reports

• Quarterly govt stats / funding
• Monthly activity stats
• Stats re Goals / Outcomes etc
• KPIs related to outcomes and activity

27
Statistics to date Sept 06

• Total referrals received 796
• - ATA TCP 468
• - CV TCP 328
• Total admissions 599
• - ATA TCP 309 (67)
• - CV TCP 290 (88)
• D/C home Outcomes
• - ATA TCP 65 (same up 2)
• - CV TCP 19 (up from 9- last ¼ 36)

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TCP City Views Model

• Medical, allied health and aged care staff
• admission medical nursing and allied health
  assessment / summaries,
• family meetings,
• case conferencing - weekly
• discharge planning meeting / summaries
• Issues in Transition Care
• expectations,
• comparison acute care,
• placement,
• future care planning,
• discharge information from acute sector,
• GPModel - viability

29
Challenges

• Impact ever changing staff in sectors
• Expectations of TCP to meet all needs
• Capacity for innovation now mainstreamed
• Funding model in community
• Short term nature of contracts
• Innovative up against fixed system models
• Roles / responsibilities in good d/c planning
• Engaging the GPs

30
General Practitioners

• ATA engaging GPs, may not be primary GP
• - 92 GPs not informed client referred to TCP by
  referring hosp.
• - may receive d/c letter but who did it go to
  ..?
• - TCP provider contacts GP
• - little success with EPC items targets for
  06/07
• - poly-pharmacy huge issue
• - engaging for careplan difficult
• - strong commitment to ensure GP part of process

31
More GPs City Views

• CV GP on site - 2 sessions /wk
• Aim to manage outstanding issues and assist
  ongoing GP management after TCP
• - sub acute environment
• - significant polypharmacy issues
• - assisted by Geriatrician,c/c however needs to
  meet community practice
• - Innovations admissions coordinator,
• - use of medical director inc IT support
• - careplan d/c careaplan
• - on site pharmacist 0.5 (RGH - AH)
• -
• Issues same as other sites but stand alone for
  GP
• Work in progress !!