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Caring for the acutely ill older person in hospitals in the Greater ...

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Caring for the acutely ill older person in hospitals in the Greater ...

Care of the acutely ill older person

in Greater Metropolitan Hospitals

December 2003

    …“But there is one area he admits he would

    like to leave a legacy in

    "If there is one thing I want to change, it‟s how we treat and deal with our aged people. I want to see aged care done better. People need different kind of care and it should be available. There are many different options, working with the private sector, the non-government sector perhaps”.

    “It‟s a national issue, funding aged care, but I want to see what can be done. Older people have earned and deserve better care”.

    Morris Iemma

    NSW Minister for Health

    as quoted in the Sydney Morning Herald,

    P 13 April 21, 2003

    News Review Profile: Morris Iemma

    "Out of the Shadows" by Paola Totaro

    Greater Metropolitan Transition Taskforce

    An advisory body to the NSW Minister for Health

    PO Box 6314 North Ryde, NSW 2113

    Tel: 9887 5728 Fax 9887 5646

    E-Mail: gmtt@doh.health.nsw.gov.au

    http://health.nsw.gov.au/policy/gap/gmt2/

     Table of Contents

    Table of Contents

    Section 1 Executive Summary ...................................................................... 1

    Section 2 - Background .................................................................................... 5

    Section 3 - The Model ....................................................................................... 8

    Section 4 Factors underlying the Medical, Nursing and Allied Health Workforce proposals ...................................................................................... 12

    Section 5 - Acute Aged Care Services - existing and proposed in the Greater Metropolitan Region ......................................................................... 13

    Section 6 Factors underlying the Medical Workforce proposal ................ 14

    Medical Workforce proposed timeframe ....................................................... 16

    Medical solutions to recruitment and retention problems in Acute Aged Care ................................................................................................................. 18

    Section 7 Factors underlying the Nursing Workforce proposal ................ 19

    Nursing Workforce proposed timeframe ....................................................... 22

    Nursing solutions to recruitment and retention problems in Acute Aged Care ................................................................................................................. 23

    Section 8 Factors underlying the Allied Health Workforce proposal ....... 26

    Allied Health Workforce proposed timeframe .............................................. 30

    Allied Health solutions to recruitment and retention problems in Acute Aged Care ....................................................................................................... 31

    Section 9 - Proposal for Program Manager ................................................... 35

    Section 10 Summary costing for Acute Aged Care Workforce proposal.. 37

    Appendix A - Medical Workforce Numbers and Population over-65 year olds by Area Health Service (as at November 2003) ........................................... 38

    Appendix B - Geriatric Interventions: The evidence base for comprehensive Acute Aged Care services ................................................... 39

    Appendix C - Group Membership ................................................................... 46

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    Section 1 Executive Summary

    The purpose of this paper is to seek approval for the progressive introduction of the „Model‟ and its concomitant staffing needs for „The

    Care of the Acutely Ill Older Person in Greater Metropolitan Hospitals‟.

    The proposal is to introduce this generally-endorsed and evidence-based

    ‘model of care’ over a period of 8 years. The paramount issue determining

    the rate of implementation of the model is the recruitment, training and

    retention of an appropriate workforce and the costs incurred.

    Initial funding is sought in the first year to address the most critical

    shortages of staff in order to improve equity of access and outcomes in

    the areas with the greatest need.

    Actions to follow approval and implementation of the Model will be: ; To formalise the Executive, its role and membership.

    ; To advertise and appoint more consumer representatives to the

    committee and its working groups.

    ; To establish a continuous review process including monitoring of

    progress to workforce goals and outcome based Key Performance

    Indicators.

    ; To establish an efficiency and outcomes monitoring and development

    group.

    Actions for these Working Groups and the Executive over the next year will include:

    ; Research into outcome statistics, arising from variations of the Model

    within the Greater Metropolitan region, interstate and overseas. ; Research into data and statistics to allow for modification of priorities

    in the introduction of the Model to ensure equity of access and

    outcomes whilst minimising expenditure.

    ; Review of population demographics, including factors such as

    socioeconomic status, cross boundary flow of patients and statistics

    relating to the „old-old‟ in each Area Health Service, to better enable

    equity of access and outcomes.

    ; Conduct a major review after one year, of the plan and its priorities. ; Research into the use and role of volunteers and paid „carers‟ in the

    acute setting.

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    ; Review the priorities in properly linking the Acute Aged Care service

    to all other elements of the continuum of care as laid down in the

    Model and in conjunction with the Department of Health framework

    for Aged Care in the community.

    This paper is concerned with acute hospital care

    ; It is acknowledged that good health care does not operate in a vacuum

    and a continuum of care exists, including the care provided in

    hospital as well as that provided in the community. This continuity of

    care is essential to the wellbeing of the older adult.

    ; The focus of this project is to improve acute inpatient services to the

    older person, by addressing workforce and training issues for existing

    and prospective staff.

    ; It is necessary for Acute Aged Care services to meet the needs of the

    acute patient. In addition, in order to be easily accessible for family

    and carers, Acute Aged Care services need to be available at every

    Principal Referral and Metropolitan (formerly District) Hospital. ; Many hospitals and/or services may currently have a sub-acute ward

    and/or rehabilitation unit for the aged care patient. These facilities

    may or may not be co-located at the acute hospital. This paper does

    not address the existing or proposed organisation or staffing needs of

    these sub-acute services. This paper is strictly concerned with the

    acute elements of the service.

    The Workforce issues are core

    ; The critical issue facing this Aged Care Project and the NSW

    Department of Health, in order to implement the agreed model, is the

    acute workforce problems of recruitment and training. It is stressed

    that no extra hospital beds are being requested for this project. The

    provision of an adequate workforce is seen as fundamental to

    providing high quality and effective services.

    ; There is a dearth of qualified and enthusiastic professionals wanting to

    work in Acute Aged Care. A core principle of the Model is a

    comprehensively staffed, dedicated multidisciplinary team. ; The negative impact of workforce shortages in all health professions

    will inevitably lead to overwork and burnout of existing staff, system

    dysfunction and most importantly, less optimal outcomes for patients.

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    ; It is recognised that some Area Health Services and specific hospitals

    may have an overlap of existing staff duties and responsibilities

    between acute, sub-acute and community services. The proposed

    staffing numbers in this paper refer to the Nursing and Allied Health

    staffing for the Acute Aged Care unit only. The proposed numbers of

    Medical staff are for the unit, whilst recognising that those Medical

    staff will have a consultancy role to other inpatient units, for Acute

    Aged Care patients.

    ; The staffing numbers identified in the Model of Care are considered to

    be the minimum to achieve optimum patient outcomes. Some Area

    Health Services and specific hospitals may already exceed these

    minimum levels. It is not recommended that staffing (or bed base) be

    reduced at any location. The priority will be to bring each Area Health

    Service, up to the minimum standard.

    ; Provision of appropriate equipment is seen to be essential to support

    the recruitment and retention of staff, in particular, Nursing and

    Allied Health. A full equipment proposal (including costing) will be

    developed at a later stage by the Allied Health and Nursing

    Subgroups and submitted through the Interim Executive Committee.

    Addressing Workforce issues

    ; The existence of a complete and skilled multidisciplinary workforce is

    seen as fundamental to the provision of a high quality service, for the

    sick elderly patient in hospital.

    ; The GMTT survey of Greater Metropolitan Geriatric Services was

    commissioned by the Working Group and conducted by Helen Felton

    in December 2002.

    ; The findings of that survey indicated a shortage in the health

    workforce for aged patients, across all areas of the Greater

    Metropolitan region, and significant variation in how services were

    provided for this population. There were significant inequities with

    regard to clinician staffing and training opportunities. ( See Appendix

    A)

    ; The Table on page 14 lists the current Acute Aged Care services as

    well as projections of required staffing ratios to 2009, based on the

    Model which has been endorsed by the Working Group on the Care of

    Older People in NSW Health Care System and the Clinical Council, in

    relation to the current and estimated population.

    ; Acknowledging that workforce issues are complex and not easily

    resolved, the Acute Aged Care Working Group has devised both short

    term and long term solutions.

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    ; The Medical workgroup has taken a creative approach to their short

    term workforce problem. Current unfilled positions can be re-designed

    to allow for Career Medical Officers (CMOs) and General Practitioners

    (GPs) to fill these positions while the other long-term strategies are

    employed. The benefits include training the CMOs and GPs in Acute

    Aged Care skills and reducing the workload of the Geriatricians and

    Advanced Trainees in Geriatrics and thereby providing increased

    opportunities for training and cross-fertilisation of specialties. ; The Nursing workgroup has devised a plan to address workforce

    issues which will provide quality services to Acute Aged Care patients

    and improve the career structure available within Acute Aged Care

    nursing. Strategies include increasing training and educational

    support for existing staff via Clinical Nurse Educator (CNE) positions

    as well as the development of new positions for Enrolled Nurses (EN),

    Trainee Enrolled Nurses (TEN) and Assistants in Nursing (AIN).

    These positions will improve the workforce-to-patient ratio and

    provide opportunities for the cultivation and promotion of potential

    Registered Nurses in Acute Aged Care.

    ; The Allied Health workgroup developed a recommendation and

    consensus statement, outlining Allied Health staffing required for an

    Acute Aged Care unit. This would ensure that older patients in

    hospitals receive equitable and holistic care, targeted to the

    individual‟s needs. An essential element of this Allied Health model is

    the provision of a career structure and ongoing provision of training

    for Allied Health staff.

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    Section 2 - Background

    The number of Acute Aged Care patients will increase

    ; The Australian population is getting older. In 2000, over- 65 year olds

    represented 12.3% of the population; by 2011 they will represent 114.3%. Age alone is the greatest risk factor for physical dependency,

    multiple co-morbidities, need for community service support,

    admission to hospital or admission to residential care.

    ; The population at highest risk for acute hospital admissions and with

    the highest complex and chronic care needs, are the oldest-old or those

    85 years and above. This age group will increase progressively over

    the period 2001 - 2011 and beyond. By 2001 it will increase by 50%

    (from 260,000 to 389,000 people), by 2021 it will increase by 100% (to

    0.5M people) and by 2051 it will increase 400% (1.3M people). This,

    2while the total Australian population grows by only 30%. See table

    3below.

    ; Over the same period average life expectancy in countries such as

    Australia, will increase from 80 years to 95 years (UN prediction) and

    4will break the 100year barrier in women.

     1 Australian Bureau of Statistics < http://www.abs.gov.au/Ausstats/abs> Accessed 1/9/2003 2 Ibid. 3 Report of the NSW Chief Health Officer, August 2002 < http://internal.health.nsw.gov.au/public-

    health/chorep/toc/choindex.htm> Accessed 3/12/2003 4 Jim Oeppen; James W Vaupel ”Broken Limits to Life Expectancy” Science May 10, 2002; 296; 5570; Wilson

    Applied Science & Technology Abstracts Plus Text pg.1029

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    ; Importantly, on today‟s figures, around 80% of this over-85 age group

    are disabled in self-care abilities, with 70% having a gait disorder (10%

    Parkinson‟s disease) and 70% having cognitive impairment (30% with

    5. Despite these patients disabilities, the majority of actual dementia)

    are living at home.

    ; This increase in numbers has resulted in and will increasingly result in,

    higher utilisation by this population of health care services. Over- 65 6year olds already account for 33% of hospital separations, with the

    sickest and most dependant group being admitted to hospital. ; Many of these admissions are not for single issues. The elderly patient

    entering hospital is more likely to have concomitant complex and

    interrelated medical, functional and psychosocial issues.

    ; This paper is not intended to address care of a patient with a single

    health problem or disease, in an otherwise well nourished and well,

    but aging body. It is about ensuring equity of access and outcome for

    the elderly patient with multiple system medical, functional and

    psychosocial problems, on presentation to the health system for acute

    care.

    ; A well developed and coordinated plan is required to ensure effective

    use of staffing and resources and to ensure that the elderly hospital

    patient of the future obtains the most equitable and efficient service

    and effective outcomes, possible.

    The GMTT Working Group is representative and inclusive

    ; The Care of the Acutely Ill Older Person in Metropolitan Hospitals Project

    has a committee infrastructure including an Interim Executive and

    Medical, Nursing and Allied health working groups.

    ; There is clinician membership from a wide hospital and professional

    representation. Over 70 Geriatric Medical, Nursing and Allied Health

    professionals contributed to this submission. (See Appendix C) ; The group has co-opted the expertise of other groups including the

    Heads of Divisions of Medicine in Principal Referral Hospitals and

    General Practitioner representation to ensure a broad discussion and

    development of relevant and achievable strategies.

    ; The Project has incorporated the invaluable assistance of consumer

    representatives, which is seen as essential by members to gain a wider

    perspective of the issues.

     5 Waite LM, Broe GA, Creasey H, Grayson DA, Cullen JS, O'Toole BI, Edelbrock D, Dobson M.

    Neurodegenerative and other chronic disorders among people aged 75 years and over in the community. Med J

    Aust 1997; 167(8): 429-32 6 2001-2002 Hospital Separations, Flow Reversal, Department of Health

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    ; The Acute Aged Care Full Group has met fifteen times, not including

    the meetings of the working parties and other interested groups. There

    is a strong commitment and clear focus on the part of the members. ; The focus of the clinical working groups (Medical, Nursing and Allied

    Health) was specifically to develop strategies and solutions for their

    workforce issues of recruitment, retention and training. ; A Marketing group is being established to develop practical and

    effective solutions for staff recruitment and retention by highlighting

    the benefits and positive professional challenges of working in Acute

    Aged Care. The main tasks of the Marketing group will be to

    recommend strategies to improve the image and desirability of Acute

    Aged Care.

    The Model is evidence-based and endorsed

    ; The Model underpinning this Acute Aged Care Project has been

    endorsed by the Working Group on the Care of Older People in NSW

    Health Care System and the Clinical Council.

    ; The essential components of this holistic model include a Geriatrician-

    led adequately staffed multidisciplinary team, including Nursing and

    Allied Health personnel. (See Section 3)

    ; It incorporates the principles of Comprehensive Geriatric

    Assessment” (CGA), and “Geriatric Evaluation and Management

    (GEM). These principles aim to identify and treat the

    multidimensional problems of at-risk frail older people and to plan

    and provide coordinated medical, psychosocial and rehabilitative care

    tailored to the patient‟s specific needs, from the acute setting to the

    community.

    ; Frail elderly patients managed with the GEM inpatient care model

    have been shown to have fewer acute care hospital admissions, spend

    less total time in acute care hospitals and have a lower mortality rate

    as a result. In addition, greater improvements in functional status

    have been demonstrated as well as fewer initial discharges to nursing

    homes and less time spent in nursing homes. (See Appendix B) ; Studies evaluating the cost-effectiveness of this Model of inpatient

    services demonstrate either cost neutrality or long-term cost-benefit

    compared with usual inpatient hospital care.

    ; The NSW Department of Health, through the Area Health Services,

    has introduced ASET teams in Emergency Departments as the first

    step towards introducing the Model.

    ; The success of the Model demonstrated by better patient outcomes

    depends heavily on adequate staffing levels with an appropriately

    skilled health professional workforce. Implementation of the model

    has also been shown to improve the morale of staff.

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