Well Elderly Project

Consumer Feedback

A random selection of clients, aged 65 years and over, were selected from the DMC database. Of these, 32% met the criteria for frail elderly. There was a 75% response rate from this survey. All indicated either a very satisfied or satisfied response to the question relating to satisfaction with the service they currently receive.

The other responses, which were of particular concern to this project’s development, are listed below.

These concerns were addressed in the project development.

Feedback from Maori

Two hui were planned in consultation with Te Ha o Te Oranga and Kuia to gain input from Maori for the project. It was decided to hold a Hui at Oturei Marae and at Tinopai in the Community Hall. Valuable feedback for the project development was gained from both hui. In particular the importance of cultural safety, respecting individual differences and the difficulty many Maori have had with the health system and health workers in the past were noted. Stories were shared.

At Tinopai, problems relating to the lack of information, services and assistance available were identified as a concern that would require addressing by the project.

The manager of Te Ha o Te Oranga and the Project Co Ordinator addressed the need for a planned approach for the consultation between Te Ha o Te Oranga and other service providers. There is now a great deal of good will between the service providers for this plan and it is an integral part of the Well Elderly project.

The Process

The working party reconvened with the arrival of the Project Co Ordinator, and time frames set for meetings.

The initial step taken was to access information regarding the strategies for improving health outcomes for the elderly. While there is an emerging literature base on the well elderly, the only known intervention to improve the health outcomes for the frail elderly living at home is the implementation of an interdisciplinary coordinated team. The successful components of the team are not known but may relate more in the way it’s packaged together and organised than any single factor.

An initial developmental map was prepared which took into consideration the components required for a coordinated multidisciplinary approach (Table One). The map also included the components of a coordinated approach, case management, disease management, service integration and care management. There was a great deal of willingness between the provider groups to work together and develop this project.

Professor Craig Anderson at the University of Auckland Medical school, based at the Geriatric Unit North Shore Hospital, assisted in the formulation of the multi - disciplinary team map and put a frame work together from which the team could focus and work from.

Frail Elderly Project Development Map

The key elements for a multi-disciplinary team are:

CASE MIX Age Sex Ethnicity Team support Carer support Multiple Medication Risk of falls Mental IQ ADL Co-morbidity Family support

PROCESS Multidisciplinary meetings Case reviews Communication Hand held notes Case Management Care co -ordination Service Integration Disease Management EDUCATION ®  staff ®  family ®  patient KEY HEALTH MEASURES ®  social situation ®  ADL scores ®  Mental status score ®  Care pathways

OUTCOMES Death Hospital admission Decrease in medication errors and falls leading to hospitalisation Retrospective reviews Repeating ADL measures Service use Quality of life e.g. EuroQual quality of life measure Visits to the GP Consumer satisfaction Staff Satisfaction

Table One

The following narrative describes part of the process, reasons for decisions made and content of the project. The details of the project are part of the implementation document.

Case Management

The project team opted for a group management approach to case management through the Community Assessment and Rehabilitation Team known as CART This team consists of the community service providers involved in the care of the elderly population. It comprises of Social Workers, Community Nurses, Occupational Therapists, a Physiotherapist, Te Ha o Te Oranga, a Practice Nurse, a General Medical Practitioner, a Pharmacist and a Geriatrician. from the Northland CHE who attends once a fortnight.

One of the strengths of this project, perceived initially, was the history of the CART team, who had met regularly over six years. This team provided the framework for a multi disciplinary case management arrangement which was to foster both service integration and care management. This history subsequently proved to be a barrier as the resistance to changing the old methods, amongst some providers, become apparent.

To better meet the needs of this project the terms of reference for CART have been rewritten and a Co Ordinator appointed, with delegated responsibilities for ensuring these terms of reference are met. This position eventually was given to a Co Ordinator who held a leadership position with one of the major health providers. This ensured the success of the project was not derailed by the resistance of some providers, who were eventually managed into positive behaviour.

Disease Management

Initially, the working party had considered the management of congestive heart failure as a disease focus. However, the initial sortie into this found that heart failure, as the primary cause of admissions to hospital, elicited only small numbers. The available data was confused by the lack of secondary disease and incidents captured for analysis but common occurrences in the elderly associated with heart failure. A wider scope was then applied and consideration given to factors which may lead to ill health or hospitalisation and, if detected early, hospitalisation averted.

There were three components considered for disease management in this project, health checks for the elderly, polypharmacy/multi medication and falls.

Polypharmacology and Multiple Medication

As the population ages, so does their use of healthcare resources - including drug therapy. In the Kaipara Care area, it is difficult to ascertain the proportion of the elderly population who receive multiple medications and admissions to hospital as a result of medication mismanagement.

Elderly, particularly those in the very old group, use a disproportionately high percentage of drug therapy. There is general agreement amongst commentators (McElnay, J.C. et al, 1998 ) that when large numbers of drugs are used in the elderly, coupled with changed pharmodynamics, the patients are particularly susceptible to adverse drug reactions. These reactions can lead to more hospital admissions and a greater use of health care resources.

Polypharmacy, according to (Lee R.D. MD, 1998 ), can be defined as the administration and use of pharmacological agents for which there is no indication. Lee claims Polypharmacy is frequently iatrogenic. The number of drugs appears to be less important than the clinicians ability to relate the use of each drug to the patients medical, social and economic circumstances. Lee developed a SAIL protocol for prescribing multiple medications. Although at this stage it has not been tested in clinical practice, when used in practice in a particular case study, it demonstrated how effective it can be in managing Polypharmacy.

(Crammer Joyce. A ) argues that polypharmacology is less of a problem in the elderly as are the problems related to multiple medication. These problems occur not because the elderly are less compliant than younger patients when it comes to taking medication, but because the elderly often have a large number of medications combined with a high incidence of deficits in physical dexterity, cognitive skills and memory. It is also worth recalling the results of the consumer feedback where 46% of the respondents had changes to their medication regimes in the last year.

Therefore, the way in which prescriptions are filled and delivered by the Pharmacists, gives the Pharmacist an important role as a CART team member. The physical and cognitive changes associated with advanced aging suggested a systematic and planned approach to undertaking health checks in the elderly. Adherence to medication regimes and ability to manage the activities of daily living became part of the project package.

Falls in the Elderly

Falls are reported to be one of the most important reasons for elderly people admitted to hospital. Falls are also associated with apprehension about falling and a source of distress to those living in the community. (Tinetti et al, 1998)

In the Kaipara District, there were 11 admissions to Whangarei Hospital as a result of a fractured femur and 10 as a result of some other fracture in the over 65 years of age group during the July 1997/98 period.  We do not know the numbers who fell and were not admitted to hospital but were recipients of health care services. Nor do we have any information to indicate the number of people who had falls in their homes and did not receive any attention.

Falls may be an indication of a worsening medical condition, non-adherence to medication regimes or from postural instability. Best Practice Guidelines suggest the ongoing specific assessment of the elderly at risk of falling, (Oliver, D et al, 1997) coupled with the approach to strengthening and balancing interventions, (Simpson J M et al 1998) may give the best outcomes for the elderly at risk of falling. It is of significance to note the respondents to the consumer questionnaire reported 42% of them had fallen in the last year, 27% of them after a medication change.

The disease management component of this project, then, is not on a specific disease process, but rather focuses on the incidents which can lead to poor health outcomes and hospitalisation for the elderly. The health checks for elderly include as a special focus, adherence to medication regimes, falls and abilities with the activity of daily living. Each client will be case managed by the CART. The management of polypharmocology will be the responsibility of the Doctors at DMC and the Pharmacists will participate.

Service Integration

The service integration strategies have depended on the definition of the elderly for the project. Initially there was some debate on the age criterion being at 75 years plus but there was some concern that Maori would not benefit from the service and some non Maori, who required the service, would not qualify.

The development of a database was a significant milestone for this project. It demonstrated the willingness of service providers to share information. Considerable work has been done on this database. It is updated weekly and information is used for the ongoing planning and management of the project. Substantial work has been done on obtaining the ethnicity data and now every person on the project completes an ethnicity profile.

Criteria for Referral

Persons living alone or with another person who meets the criteria below.

Persons 65 years and older or for Maori 55 years or older.

Persons who are:

The total client numbers involved are not yet fully established. There will be a planned approach taken in monitoring activities initially to ensure resources are not overly stretched. The client selection will be drawn from the newly constructed database and the professional knowledge held by the team, whose individual clients are currently most at risk.

CART is responsible for the admissions, discharge planning, monitoring and follow up activities.  These responsibilities are given in detail in the implementation section of this document.

Care Coordination

This aspect of the project is concerned with the systems in place for referrals, information exchange and quality management activities. The CART is the pivot for care co-ordination.

Well Elderly Nurse Management Team

A Well Elderly Nurse Management team has been developed to manage the coordination aspects of the project outside the clinical activities CART is involved in. The management group sets the targets and monitors the demand on providers.They keep an overall view on the contracs held, which have provider components that may have an impact on the project.

Performance Outcome