1. CREST (Community Rehabilitation Enablement & Support Team) CREST Dr Anne Roche Paulina Baird April 2013 Community, Rehabilitation, Enablement, Support Team

2. How it started 13.5% of the Canterbury population is over 65 Estimated to rise to 20% in 2020 Number of 85+ will double 85+ year olds utilise 3x health care resources of other age groups Demographics

3. Pressure on aged care and hospital beds Prior to the earthquake plans were in place to plan and implement a support discharge programme in Canterbury. The earthquake resulted in a loss of 106 medical beds and 635 ARC beds We needed to progress the supported discharge initiative rapidly to reduce facility constraints

4. What is CREST? CREST is a community based rehabilitative supported discharge and admission avoidance service for older people. It works with an interdisciplinary team –a liaison team (covering both hospital and primary care) –a case manager (physiotherapist, OT, RN) that establish rehabilitation plans –a coordinator (community provider RN) who supervise teams of well-trained Key Support Workers. CREST provides clients with up to 4 visits a day, 7 days a week

5. Why CREST? Hospital is not the best location to rehabilitate and care for older people 25-50% older people lose some function in hospital, and 66% have not regained function 3 months later CREST improves client function and independence and increases the time the client spends at home Designed to reduce: –length of stay in hospital –residential care placement –need for long-term home care

6. Eligibility Criteria Age > 65 years Medically stable – ready for discharge from hospital At risk of readmission, or entering ARC Potential for partial or complete recovery with suitable home rehabilitation within six weeks. The client is able to stand and transfer with one person (with or without the help of a resident carer). The client consents to being treated at home by the team and aware of the objectives set by the IDT The client has had a recent acute illness or injury or is at a borderline level of function with an associated reduction in ADL and/or EADL

7. Making disability worse worse Physical inactivity and disuse aggravate medical conditions such as diabetes, heart disease and causes deconditioning Hospitalisation induces inactivity and dependence, “ wrapping older people in cotton wool”. Risk of adverse events 10 x higher > 65y Preclinical disability can be recognised and averted with health promoting interventions, e.g. activity, nutrition Ageing, Health Risks and Cumulative Disability NEJM 1998.338:1035- 41

8. Transition to home to home Discontinuity in clinical responsibility Uncertainty about changes to medication, what medications already at home, whether prescription will be filled etc Uncertainty about physical environment, resilience of family, perceived risk Little consideration of what is important for the person

9. Referral Process for CREST

10. Client Pathway

11. CREST is growing… SMART S pecific M easurable (meaningful to pt) A ttainable R ealistic T ime oriented Goal Ladder- client identifies “distal goal”- where they want to be, proximal goals are the steps required, how they get there. Goals

12. Grocery shopping (& coffee) with Liz by x Walking to car and getting in with help by x Walking to dairy (450 metres) by x Walking to letter box independently by xxx Walking to ward doors within 2 days Dressing independently within 5 days Walking to toilet independently day or night by 3 days Washing independently at home by xxx Dressing independently at home by xxx To be able to defrost and heat MoW by xxx For pain to be 3/10 - getting in/out bed by x Getting in / out of bed independently by x Drawing curtains independently by x Preparing breakfast and snacks by x Attending church with friend by x Hosp. discharge CREST discharge Withdraw night visits Withdraw AM visits Withdraw weekend visits CREST x3 a day x7 One 2 hour visit x3 week Commenced HBSS x 2hrs week

13. Week 3Long term goal: To walk to fish and chip shop once a week to buy meal Week 2To have a robust plan to manage COPD and CHF symptoms -weekly weigh -Respiratory OR education, domicilary O2 -prompt breathing exercises Week 2To walk to his letter box each day, increasing distance by 1 power pole each time

14. Goal ladder continued Week 1To take medication each day at the correct times KSW to check daily for 3 days, then observe Week 1To eat 3 meals a day KSW to check he has eaten each time they visit Week 1To wash and dress independently each day

15. Patient examples Mr CG age 93,lives with wife. –Admitted May 2 with abdominal pain due to constipation –Previous admission April 20 with NSTEMI and exacerbation heart failure. Urinary retention- D/C with IDC and plan for trail of void at home (DN) –Presented to ED May 1 with abdo pain

16. Mr GC –Constipation resolved, recatheterised with flip flow valve, LRTI and UTI treated –Apprehensive about discharge –CREST- CM present when he got home, helped to settle, distal goal- get out into garden, twice daily KSW- showering, walks, Physio- chair raiser, frame, exercise programme. –Became independent w shower, D/C 30/5

17. Primary Care CREST Gradual extension into Primary Care since Dec 2011 Initial pilot, 4 General Practices, Referral to OPH Clinical Nurse Specialist who screened potential candidates Patients need to be well enough for GP management at home, but would benefit from increased support, with rehabilitation focus to enhance recovery. OPH triage team redirected some referrals for respite care etc to CREST

18. Primary Care CREST October 2012: 8 referrals from General Practice, 13 internal referrals from Older Persons Health Community Teams- triage, Clinical Assessors, patients seen on visits by Geriatrician and/ or Community Gerontology Nurses Steady increase in numbers March 2013: 18 referrals from GP, 19 referrals internal referrals

19. Primary Care CREST- patient example Care CREST 75 yr old woman, referred for respite care Morbid obesity, exacerbation of back pain, had pushed personal alarm 3 times in 10 days Supportive daughter away on holiday Bipolar Affective Disorder, currently depressed Had been incontinent in bed, unable to get up to the toilet because of back pain. Sleeping in Lazy Boy chair Seen by CREST Liaison, increased supports at home, practical assistance to get mattress and bedding cleaned

20. Patient example continued Seen by Physiotherapist and Occupational therapist Goals identified Care plan around encouraging independence in shower, frequent supervised walks, sleeping in bed Referred to Medication Management Service, Dietitian and Psychiatric Services for the Elderly Back pain resolved, able to return to baseline package of care at home, more confident about ability to stay at home in medium term

21. CREST (tip) of an iceberg Intervention and close observation at home can unmask previously unidentified problems Cognitive impairment Anxiety, made worse by social isolation Shortness of breath, made worse by anxiety. Co-ordinators inform Primary Care Team. CREST can assist in appropriate response/ referrals/ discussion with family etc.

22. Quality and Improvement Group structure o Operational Group to discuss day to day issues o Data collection, monitoring through Quality Group o Sign off from Steering group Case Managers / Providers o Monthly educational training sessions and peer reviews On-going improvement o Continual Process improvement Process – what's working well o Tool development – how do we do it better o Training and development – do we have the right skill mix

28. Admissions to ARC During the 2011/12 Year During the 2012 Year 2011/1228 days90 days Crest Discharges Entering ARC3%7% General 65+ Discharges Entering ARC11%13% Difference-8%-6% 201228 days90 days Crest Discharges Entering ARC2%5% General 65+ Discharges Entering ARC11%13% Difference-9%-8%

29. Client Survey Approximately 1500 surveys were sent out in January 2013 80% surveys returned 90% clients satisfied or very satisfied with the overall CREST service 84% believed they set obtainable goals 73% of clients received between 1 – 6 hours of care per week while on CREST 78% of clients believe that CREST works well with other health services in the home 76.5% of clients believed they were able to do what they wanted with the assistance of their support worker