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CAPAC and the Healthy at Home program Richard Woods Healthy at Home Program Manager 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 – Healthy at Home background - SAFTE (Sub Acute Fast Track Elderly) CARE Pilot – 2006 Followed by: - Healthy at Home 2007

Newcastle model Newcastle model

The Multidisciplinary Team • • Program Manager Geriatrician Registrar/CMO Nurses Occupational Therapists Physiotherapists Dietician The Multidisciplinary Team • • Program Manager Geriatrician Registrar/CMO Nurses Occupational Therapists Physiotherapists Dietician Social Worker

Com. Packs • Services brokered by Community Options Unit - Personal Care - Domestic Com. Packs • 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 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 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 Case conference • All clients discussed at multidisciplinary planning meeting within the first week • Referrals generated internally and externally - OT, PT, SW, dietician, geriatrician - Com. Packs - ACAT - Medical/Surgical specialties • More focused investigations planned

Demographics 2006 -2014 Demographics 2006 -2014

Demographics 2006 -2014 1305 Demographics 2006 -2014 1305

Reasons for referral • • Falls, decreased mobility General deterioration Deteriorating cognition Problems managing 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 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’ 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 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 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 Contact Healthy at Home • Richard Woods Ph. 40164688 richard. woods@hnehealth. nsw. gov. au