Home' Australian Ageing Agenda : AAA Spt-Oct 2015 Contents tool scored before and after
every transitional care episode,
the Modified Barthel Index. This
measures chair/bed transfers,
ambulation, stair climbing, toilet
transfers, bowel control, bladder
control, bathing, dressing,
personal hygiene and feeding.
There has been less focus on
activities required for independent
living -- otherwise known as
instrumental activities of daily
living, such as being able to obtain
transport, being able to prepare
meals -- even though problems with these activities are associated with
greater risk of residential aged care admission. Mental health and social
functioning could also arguably be targeted as lower social support is
associated with increased risk of readmission to hospital, and nursing
home admission. Further, good medical management may be essential
in avoiding hospital readmission however transition care services have
struggled with communication and support with discharging hospitals.
Greater focus on coordination with general practitioners, medication
review and education in chronic disease self-management may
enhance achievement of program aims.
IS THERE EVIDENCE THE CURRENT
TRANSITIONAL CARE PROGRAM IS
There is some evidence that transitional care works, but there is room for
improvement. Australian Institute of Health and Welfare data from 2005/06
to 2012/13 showed that 21 per cent of recipients entered residential aged
care directly from transition care, and 17 per cent returned to hospital.
Three quarters of care recipients improved on their Modified Barthel Index
scores. The national evaluation of the transition care program in 2008
reported that transition care recipients had fewer readmissions to hospital
and were less likely to move into permanent residential aged care
compared to similar groups of frail older people discharged from hospital.
However, Professor Len Gray and colleagues suggested in 2012 that
there is a lack of convincing evidence of efficacy for the transition care
program from a patient outcome and cost reduction perspective because
the program has not been compared with a robust comparison group.
WHO SHOULD RECEIVE RESTORATIVE CARE?
Current transitional care is offered to hospitalised patients at discharge.
It seems counter-productive to wait for a medical crisis before attempting
to improve function. Studies of programs targeting older people with
functional difficulties because of chronic health conditions or old age
have demonstrated improved physical and/or daily function and to be
cost-effective. Trials have been conducted by Professor Gill Lewin from
SilverChain in Western Australia, Professors Matthew and John Parsons
in Auckland, New Zealand and Professor Laura Gitlin from Baltimore,
US. Common elements of their programs, which range from three to six
months, are goal setting by participants and program elements delivered
depending on need -- for example, education, assistive technology,
exercise, chronic disease self-management, social reconnection -- by
multidisciplinary teams including allied health professionals.
Will the new program target older people at highest risk of re-
hospitalisation or residential aged care entry? Or older people with
greatest capacity to benefit from the available resources (for example,
highly motivated individuals)?
Dementia is a major risk factor for entry to a residential aged care
facility. However, most restorative care trials and transitional care
programs have excluded people with dementia, possibly because of
perceptions that they cannot improve. Research has demonstrated that
is possible to improve function of people with dementia -- how can this
knowledge be translated into restorative care?
WHO WILL DELIVER RESTORATIVE CARE?
The Department of Social Services has indicated that aged care
providers will be offering the new restorative care program. This is a
change from the current transitional care program which is co-funded
and managed by state and territory governments. Services are delivered
by health departments and some are brokered to other organisations.
Better outcomes in the transitional
care program are associated with
higher nursing and allied health
Aged care has not traditionally
provided restoration or
rehabilitation and has limited
expertise in allied health, patient
motivation including goal setting,
and educating patients in chronic
disease management, as well
as working collaboratively with
hospital clinicians, specialists and
general practitioners. It is likely
that the shifts in culture of care that have been observed as required
to deliver successful consumer directed care will also be necessary to
deliver successful restorative care. It will also be interesting to observe
how providers manage tensions between doing what an older person
wants, in alignment with consumer directed care, and what is needed to
improve function even though it may be difficult for that person. Health
education and motivational approaches may help with this.
WILL RESTORATIVE CARE BE DELIVERED IN
RESIDENTIAL CARE OR THE COMMUNITY?
In the current transitional care program about two thirds of care days are
being delivered in the community and one third in a live-in facility -- both
aged care and health facilities. Recipients receiving transitional care in
live-in facilities were more likely to enter residential care than those receiving
care in the community, this may be partly because more functionally
disabled clients are accepted by live-in services. It is not clear how many
live-in beds on one site are needed to deliver effective restorative care. I am
not aware of any studies of live-in restorative care programs where older
people are expected to be discharged to the community, like in live-in drug
or mental health rehabilitation programs. Given that physical environment
affects how an older person functions, ensuring that the person can
function in the environment they will live in when discharged is essential
-- for instance, availability of a walk-in shower may help them shower
independently whereas they would need help if they only had a bathtub.
HOW WILL SYSTEM DRIVERS IMPACT
Currently the distribution of acute hospital, rehabilitation and aged
care services are uneven geographically. Transition care services have
adapted to fill their local needs -- providing rehabilitation in areas where
those services are lacking, and acting as a temporary aged care service
where aged care places are limited. In geographical regions where
there are proportionately low levels of health and aged care beds there
may be system pressures on restorative care services to accept clients
who may not benefit clinically from the service.
HOW WILL THE PAYMENTS BE SET?
A system's payment and regulatory incentives have great impact in
determining the type of care that is delivered. Services will expend
resources improving outcomes on which data is being collected for
monitoring or accreditation.
The current basic daily subsidy for transitional care places is $190.86,
higher than for a Level 4 home care package ($132.01) and slightly
higher than for an aged care resident with high activity of daily living and
complex health care needs ($108.92 plus $66.82).Payment systems
can also reward achievement of outcomes. Will the payment be set per
patient (like current transitional care), be awarded based on ACAT-
determined level of need (like home care packages), be paid based on
the service provider's rated level of need (like the aged care funding
instrument) or based on casemix (like in hospitals and in rehabilitation)?
Given the program title 'restorative care' -- we await clarity on what
the purposes of the program will be. Hopefully the purpose will be
reflected in the eligibility criteria and monitoring systems, and payment
levels and payment models will also incentivise high-quality care. n
Dr Lee-Fay Low is an Associate Professor in Ageing and Health
in the Faculty of Health Sciences, University of Sydney. She is
keen to work with providers on developing or evaluating new
models of restorative care, and can be contacted on
"Research has demonstrated
that is possible to improve
function of people with
dementia -- how can this
knowledge be translated
into restorative care?"
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