1. 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

2. 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

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

4. 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

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

6. 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)

7. 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)

8. 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

9. Demographics
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)

10. Demographics
1305
Greater number of females

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

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

13. 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

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

15. 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

16. Contact Healthy at Home
Richard Woods Ph