CAPAC and the Healthy at Home program Richard Woods Healthy at Home Program Manager AAG-Spinning the Web Integrating Services to Provide Person-Centred Care September 2014

Healthy at Home background SAFTE (Sub Acute Fast Track Elderly) CARE Pilot – 2006 Followed by: Healthy at Home 2007 Retrospective study undertaken by POW geriatrician - Dr Tully Rosenthal 80% of elderly people in ED could have avoided presentation if deterioration noticed sooner SAFTE care teams across four sites with a different team / model Central intake Ongoing funding Name change Same client group Same model in Newcastle

Newcastle model SAFTE pilot / Healthy at Home embedded into the CAPAC Service in Newcastle

The Multidisciplinary Team Program Manager Geriatrician Registrar/CMO Nurses Occupational Therapists Physiotherapists Dietician Social Worker The CAPAC team consists of medical, nursing and allied health staff with admin and allied health assistant support. Each program has a clinical manager. Staff specialist geriatrician joined the team a couple of years ago (after being an advanced trainee here) and the rotational medical registrar position is chnaging to that of a CMO Physio, OT, dietitian and social worker

ComPacks Services brokered by Community Options Unit - Personal Care - Domestic - Transport - In home respite

Referral Criteria Aged over 65 or 45 years and over for Aboriginal and Torres Strait Islanders Living in Newcastle or Lake Macquarie local government area At risk of hospitalisation Referrals processed through Referral and Information Centre (RIC)

Assessment Intake assessment Initial nursing assessment – within 48 hours Routine pathology (EUC, FBC, LFT, CMP, TFT, anaemia screening, Vitamin D, urinalysis +/- MC&S) Vital signs Timed Up and Go test (TUG) MMSE, CDT, GDS, KPS, CAMI (if indicated)

Case conference All clients discussed at multidisciplinary planning meeting within the first week Referrals generated internally and externally - OT, PT, SW, dietician, geriatrician - ComPacks - ACAT - Medical/Surgical specialties More focused investigations planned

Demographics 2006-2014 Age criteria is for 65 years and older (except for indigenous Australians – 45 years) Vast majority are between 80 and 90 (more over 90 than younger than 70)

Demographics 2006-2014 1305 Greater number of females

Reasons for referral Falls, decreased mobility General deterioration Deteriorating cognition Problems managing medications Weight loss Pain Carer issues (under stress, hospitalised, deceased)

The challenges Getting appropriate referrals Fluctuations in referral numbers 350-450 annually Quality of information from referrers No exclusion criteria Complexity Acute illness Guardianship issues Mental health issues

More challenges Access and engagement with GPs Accepting clients making ‘bad decisions’ Balancing hospital avoidance with client safety in the community Access to appropriate service providers / packages Co-ordinating investigations in the community Short time frame

Hospital transfers 75-80% remain at home The need for transfer to hospital is generally recognised early

The advantages of the Healthy at Home model Multidisciplinary team Longer period of assessment Takes assessment and intervention to the home Rapid response time Provides in home perspective Supports other community health services, GP’s and geriatricians

Contact Healthy at Home Richard Woods Ph. 40164688 richard.woods@hnehealth.nsw.gov.au