Reforming community services Professor Matthew Parsons Clinical chair (gerontology), Waikato DHB / University of Auckland

Age-group Change N (000s)% % % TOTAL3,884994,

ImplicationsImplications ?

Key features of Home Care Low funding (NZ: 17.7%; US: 25%; Mean: 30.4%, of total long term care, OECD, 2005) No regular assessments or reviews High staff turnover (49%) No / minimal health professional input No / minimal training for support workers No travel time or costs Ratio of ‘coordinator’ to clients 1:450

We had to try something NEW

Restorative Home Support Care management Use of health professional ‘coordinators’ Training (Health professionals=post- graduate; support workers=national training programme) Assessment and regular reviews Use of goals to inform services Functional rehabilitation

Weekly grocery shopping independently using taxi by April 2003 Make lunch for Helen Clark by March 2003 Grocery shopping with help of SW by Feb 2003 Walking to car and getting in independently by Jan 2003 Walking to dairy (450 metres) by Jan 2003 Walking to letter box independently by Nov 2003 Washing and dressing independently by Jan 03 Walking to front door independently by Oct 02

Significant investment in evaluation 1.King, A.I., Parsons, M., Robinson, E., & Jörgensen, D. (2011). Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health Soc Care Community, /j x. 2.King, A.I., Parsons, M., & Robinson, E. (2012). A restorative home care intervention in New Zealand: perceptions of paid caregivers. Health Soc Care Community, 20 (1), p70-79, /j x. 3.Parsons, M., Senior, H., Kerse, N., Chen, M.H., Jacobs, S., Vanderhoorn, S., & Anderson, C. (2011). Should care managers for older adults be located in primary care? A randomized controlled trial. J Am Geriatr Soc, 60 (1), p86-92, /j x. 4.Parsons M, Senior HEJ, Kerse N, Chen M-h, Jacobs S, Vanderhoorn S, et al. The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand. Age and Ageing August 22, Parsons J, & Parsons, M. Evaluation of the impact of implementation of a focused goal facilitation tool for older people receiving homecare. Health & Social Care in the Community. in press. 6.Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of homecare services for older people: does it make a difference? Age and Ageing. 2012;41(1):24-9.

To increase hospital capacity... Supported Discharge Teams have been developed to: –Facilitate a timely and coordinated discharge home for older people who are medically stable and require ongoing support at home –Provide a flexible and rapid response to avoid admission and increase independence following an acute illness at home, –Maximise rehabilitation potential to reduce requirement for long term supports including delaying residential care. Growing evidence

Supported Discharge Teams in NZ Waikato DHB launched START (Supported Transfer & Accelerated Rehabilitation Team), Nov 2010 –Supported Discharge Team –Rapid Response Team Canterbury DHB to introduce supported discharge team in 2013

C.R.E.S.T.C.R.E.S.T. Community, Rehabilitation and Enablement Support Team implemented in 3 weeks, launched 3 weeks after earthquake.

We are evaluating START Randomised controlled trial, A total of 180 participants will provide 80 per cent power to detect a 20 per cent reduction in length of hospital in-patient stay

Length of in-patient stay, admission prior to randomisation Why? Immediate responsive service Intensive input, up to 4 visits per day Active pull system (liaison) N=93, error bars=1SD

All in-patient activity N=93, error bars=1SD

Our funding was all wrong

“fee per service” Disincentive to discharge clients Creates unfavourable work conditions for support workers Inability to meet client needs Inflexible responses Duplication of assessments

We have been looking for alternatives Casemix, a form of bulk funding, –Used in hospitals –Linked to DRGs –Patients in each group have similar conditions –Similar inputs and same price But...it hasn’t worked in the community

Forget diagnosis, what about needs? interRAI introduced, 2006 to current –Contact assessment for non-complex –Home Care for complex Cluster analysis of assessment data –5 non-complex casemix groups –5 lead complex case groups (33 in total)

ConclusionConclusion We are getting there Now for national implementation Ongoing development of clinical pathways Quality frameworks and benchmarking