EngAGE – Improving Outcomes for Older People in Hawkes Bay, New Zealand

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Introduction: engAGE community teams & ORBIT team support frail older people to remain independent in Hawkes Bay. Practice Change: engAGE community teams: locality-based multidisciplinary teams meeting weekly at general practices, include professionals from primary care, hospital Older Person’s Services and community agencies. Comprehensive interprofessional assessment in the older person’s home, creative solutions developed to maximise independence. engAGE Intermediate Care Beds (ICB’s): MDT input in partnership with primary care for up to 6 weeks in an aged residential care facility for people not well enough to be home but not requiring hospital care. Orbit team: interprofessional allied heath team based in ED/AAU delivering comprehensive assessment and discharge support planning, linking with community MDT’s. Aim: Maximise ability of older people to live independently and age in place. Maintain and restore good health and function. Be person-centred and engage older people in decision making. Lead integration and coordinated care across the continuum of care. Targeted Population and Stakeholders: Community-dwelling people over 65 years or ‘like in age and need’ ie. 55 years and over Maori and Pacifica, in Hawkes Bay NZ. Primary Care, community services involved in the care of older people, the Hawkes Bay District Health Board Older Peoples’ Health Service. Timeline: Cross sector Steering Group and Working Group 2011. Pilot MDT with ICB services in a single locality 2012, second MDT 2014. Four further MDTs November 2015. ICB services April 2016. Highlights: 20% reduction in ED attendances in the 6 months following engAGE compared to the six months prior. ED presentations for people over 85 have decreased by 2.6% from 2015-16, against population growth of 3.3%. Sustainability: Growth will be needed to meet increasing demands of population aging. Transferability: Highly transferable to other locations and populations. Conclusions: engAGE has improved health outcomes for older people in Hawkes Bay.