Residential Outreach and Support Service ROSS

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Residential Outreach and Support Service (ROSS)

• Ms. Jenny Chapman
• Team Leader ROSS
• Peninsula Health

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Managing Emergency Demand

• Acute care of the elderly in Residential Care a
  complex but worthwhile endeavour
• What is ROSS?
• What have we found?
• What impact has ROSS had?
• Moving forward

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Residential Outreach Support Service

• Why ROSS?
• Significant number of admissions from the
  residential care sector
• Preventable
• Better outcomes for Residents and Families/carers
• Opportunity to assist in managing Emergency
  Demand
• New model of interdisciplinary outreach to
  Residential Care proposed

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Residential Outreach Support Service

• Policy Context
• Shift from hospital to ambulatory and home-based
  care
• Consumer focus and participation
• Coordinated care across the health care continuum
• Collaboration with all health and primary care
  providers

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Residential Outreach Support Service
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Residential Outreach Support Service

• So what did we know?
• 100 presentations to ED from RCFs per month
• 33 from NH/67 Hostels
• 32 were d/c directly from ED
• 62 were admitted
• The average length of stay in acute 4 6 days
• The average No. of hours in ED 4 6 hours
• Source Audit of Acute Medical Records, August
  2003
• .

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Residential Outreach Support Service

• Complexity of Residential Care Context
• Untrained staff in RCFs/lack of RNs
• Knowledge deficits within RCFs
• Compensation for low staffresident ratios
• Commonwealth/State funding tensions
• GP cover in RCFs across the region

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Residential Outreach Support Service

• How did we respond?
• ROSS Team established November 2003
• Funded under HARP
• Staffing
• Social Worker (Team Leader) 1 EFT
• Clinical Nurse Consultant 1EFT
• OT (Psych experience) .5 EFT/psychiatric RN
• Emergency Medicine Consultant .3 EFT

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Residential Outreach Support Service

• Dual Aims
• Better Outcomes for residents of Residential Care
  Facilities (RCFs)
• Management of Emergency Demand
• Underlying assumptions
• ED transfer is not always in the best interests
  of elderly and chronically unwell residents of
  both hostels and nursing homes.
• With support the RCFs can continue to provide the
  care their residents need.

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Residential Outreach Support Service

• Stakeholders

APATS/ACAS
Families
Acute
Resident
Sub-Acute
HITH
RCF staff
ED
GPs
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Residential Outreach Support Service

• Strategic Partnerships
• APATS
• ACAS
• Acute Sub-Acute Sectors
• Palliative care
• HITH
• GP Division

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Residential Outreach Support Service

• Generic Model of Assessment
• Proactive Interdisciplinary team
• Up-skilling of ROSS staff to perform generic
  intake and triage role which includes acute
  medical referrals.
• Use of specialist skills both internal and
  external to the team.
• Use of interdisciplinary case management

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Residential Outreach Support Service

• Key ROSS Intervention Strategies
• Comprehensive Generic assessment and care
  planning.
• Acute medical and Nursing outreach
• Education
• Brokering services
• Therapeutic equipment e.g. for hydration etc.
• Advance care Planning
• Agreed Transfer agreements
• Partnerships with GPs
• Effective links with acute and community services.

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Residential Outreach Support Service

• Major clinical focus
• Acute Medical Problems
• Behaviour Management Strategies
• Advance Care Planning
• Opportunity to push traditional boundaries by
  providing support and education to RC staff and
  GPs already providing care

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Residential Outreach Support Service

• So what have ROSS achieved?
• 123 referrals
• 100 referrals responded to within 24 48 hours
• 39 of total ROSS referrals prevented admission
• 14 of total ROSS referrals prevented
  re-admission post acute presentation

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Residential Outreach Support Service
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Residential Outreach Support Service
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Residential Outreach Support Service

• Acute Medical Intervention
• Acute medical outreach comprises 20 all ROSS
  referrals
• Outcomes include
• prevented admission
• Coordinated admission
• Fast-tracked assessment in ED
• Good communication with GPs
• HITH admission

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Residential Outreach Support Service

• Acute Medical Outreach
• Required clear boundaries articulated to the GP
  community
• Limited medical resources - 0.3 Senior Emergency
  Medicine Specialist/HITH Consultant
• Limited Geriatrician consultation and support
  available
• Good links with ED and HITH
• Positive relationships with the GP community

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Residential Outreach Support Service

• Behavioural Management
• Key platform of original submission
• Vexed issue as further research has indicated
  that, on average, behavioural disturbance
  comprises just 2 - 5 of all presentations to ED
  from the RCF sector
• Difficulty in recruiting and retaining specialist
  staff

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Residential Outreach Support Service

• Advanced Care Planning
• End of Life Care Planning and Advanced Directives
• An emerging field in the US, Canada and now
  Australia
• Dedicated projects exist in Australia, but
  limited sharing of resources and information
• Implementation of ACP strategies and
  documentation in RCFs complex
• ACP crucial to long term success of ROSS and a
  major priority for the next 12 months

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Residential Outreach Support Service

• What impact have ROSS had?
• Prevented admissions
• Improved transition between RCFs and Health
  Sector
• Improved relationship and mutual understanding
  with residential sector
• Fruitful Partnerships
• Falls Service, Continence Service, Div of
  GPs/Aged Care Panel, Complex Care Program,
  Palliative care, HITH

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Residential Outreach Support Service

• How do we know?
• Satisfaction Survey January 2005
• Random sample of RCFs
• Results
• 88 had referred to ROSS
• 77 stated ROSS were very responsive
• 72 rated assistance provided as excellent

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Residential Outreach Support Service

• Feedback from GPs
• GPs appreciate the consultative role of ROSS MO
• Consultation with ROSS MO assists in reinforcing
  GP wish not to transfer resident to ED a good
  sounding board
• GPs welcome Advance Care Planning initiative in
  Residential Care

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Residential Outreach Support Service

• Challenges encountered
• Recruitment and retention of staff
• Need for more robust structure
• Branding promotion
• Acute model vs community outreach
• Medical resources/tension between acute medical
  outreach and GP care.
• Staffing profile in RCFs
• Enormity of task implementing Advance Care
  Planning into Residential Care

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Residential Outreach Support Service

• Future Directions
• Continued promotion
• Clearer expectations and service boundaries
• Increased medical resources.
• Better knowledge of issues and active research.
• Ensure Client/Family/Carer feedback
• Options for more robust structure.
• Advanced Care Planning Pilot and collaboration
  with Professor of Palliative Care Nursing, Monash
  University

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Residential Outreach Support Service

• Conclusion
• Residential Outreach model an effective model to
  respond to emergency demand
• Need to continue to strengthen partnerships with
  RCF sector and service providers