Aged Care Assessment Teams Research Articles

Facing uncertainty - Pilot testing of a palliative prognostic index training with hospital aged care assessment teams

BackgroundPrognostic avoidance can delay discussions about older hospital patients’ life expectancy. This pilot study examined the effects of a prognostic training program on hospital clinicians’ knowledge and confidence in identifying older patients at risk of dying. MethodsFifty-seven clinicians from aged care assessment teams at two Australian hospitals were introduced to the Palliative Prognostic Index, a 5-item checklist indicating prognoses between 3 and 6 weeks. Mixed-methods training evaluation included pre-post-training surveys and semi-structured interviews, conducted three months post-training. ResultsClinicians used a combination of experience, knowledge, and intuition as strategies to generate prognoses. Allied health staff relied on intuition more often than medical and nursing staff. Prognostic tools were rarely used. Pre-post-training comparisons showed significant improvements in clinicians’ knowledge and confidence in identifying signs of dying, particularly amongst allied health. Follow-up interviews highlighted advantages and challenges of using prognostic tools. Recommendations are made for addressing these.

The ostrich approach – Prognostic avoidance, strategies and barriers to assessing older hospital patients’ risk of dying

BackgroundPredicting older patients’ life expectancy is an important yet challenging task. Hospital aged care assessment teams advise treating teams on older patients’ type and place of care, directly affecting quality of care. Yet, little is known about their experiences with prognostication. MethodsTwenty semi-structured interviews were conducted with seven geriatricians/ registrars, ten nurses and three allied health staff from aged care assessment teams across two hospitals in Melbourne, Australia. Data were analysed thematically. ResultsTo generate prognoses, clinicians used analytical thinking, intuition, assessments from others, and pattern matching. Prognostic tools were an underutilised resource. Barriers to recognition of dying included: diffusion of responsibility regarding whose role it is to identify patients at end-of-life; lack of feedback about whether a prognosis was correct; system pressures to pursue active treatment and vacate beds; avoidance of end-of-life discussions; lack of confidence, knowledge and training in prognostication and pandemic-related challenges.

How can dementia diagnosis and care for Aboriginal and Torres Strait Islander people be improved? Perspectives of healthcare providers providing care in Aboriginal community controlled health services

BackgroundAboriginal and/or Torres Strait Islander people experience dementia at a rate three to five times higher than the general Australian population. Aboriginal Community Controlled Health Services (ACCHSs) have a critical role to play in recognising symptoms of cognitive impairment, facilitating timely diagnosis of dementia, and managing the impacts of dementia. Little is known about the barriers and enablers to Aboriginal people receiving a timely dementia diagnosis and appropriate care once diagnosed.This study aims to explore, from the perspective of healthcare providers in the ACCHS sector across urban, regional and remote communities, the barriers and enablers to the provision of dementia diagnosis and care.MethodsA qualitative study involving semi-structured interviews with staff members working in the ACCHS sector. Aboriginal Health Workers, General Practitioners, nurses, practice or program managers, and Chief Executive Officers were eligible to participate. Consenting ACCHS staff completed a telephone interview administered by a trained interviewer. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis.ResultsSixteen staff from 10 ACCHSs participated. Most participants perceived their communities had a limited understanding of dementia. Symptoms of dementia were usually noticed by the GP or another healthcare worker at the ACCHS who had an ongoing relationship with the person. Most participants reported that their service had established referral pathways with either hospital-based geriatricians, geriatricians located with aged care assessment teams, or specialists who visited communities periodically. Key enablers to high quality dementia care included the use of routine health assessments as a mechanism for diagnosis; relationships within communities to support diagnosis and care; community and family relationships; comprehensive and holistic care models; and the use of tailored visual resources to support care. Key barriers to high quality care included: denial and stigma; dementia being perceived as a low priority health condition; limited community awareness and understanding of dementia; lack of staff education and training about dementia; and numerous gaps in service delivery.Conclusions Substantially increased investments in supporting best-practice diagnosis and management of dementia in Aboriginal communities are required. ACCHSs have key strengths that should be drawn upon in developing solutions to identified barriers to care.

Diagnosis of dementia in Australia: a narrative review of services and models of care.

Objective There is an impetus for the timely diagnosis of dementia to enable optimal management of patients, carers and government resources. This is of growing importance in the setting of a rising prevalence of dementia in an aging population. The Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referral to comprehensive memory services for dementia diagnosis, but in practice many patients may be diagnosed in other settings. The aim of the present study was to obtain evidence of the roles, effectiveness, limitations and accessibility of current settings and services available for dementia diagnosis in Australia. Methods A literature review was performed by searching Ovid MEDLINE using the terms 'dementia' AND 'diagnosis OR detection'. In addition, articles from pertinent sources, such as Australian government reports and relevant websites (e.g. Dementia Australia) were included in the review. Results Literature was found for dementia diagnosis across general practice, hospitals, memory clinics, specialists, community, care institutions and new models. General practitioners are patients' preferred health professionals when dealing with dementia, but gaps in symptom recognition and initiation of cognitive testing lead to underdiagnosis. Hospitals are opportunistic places for dementia screening, but time constraints and acute medical issues hinder efficient dementia diagnosis. Memory clinics offer access to multidisciplinary skills, demonstrate earlier dementia diagnosis and potential cost-effectiveness, but are disadvantaged by organisational complexities. Specialists have increased confidence in diagnosing dementia than generalists, but drawbacks include long wait lists. Aged care assessment teams (ACAT) are a potential service for dementia diagnosis in the community. A multidisciplinary model for dementia diagnosis in care institutions is potentially beneficial, but is time and cost intensive. New models with technology allow dementia diagnosis in rural regions. Conclusion Memory clinics are most effective for formal dementia diagnosis, but healthcare professionals in other settings play vital roles in recognising patients with dementia and initiating investigations and referrals to appropriate services. What is known about this topic? Delays in dementia diagnosis are common, and it is unclear where majority of patients receive a diagnosis of dementia in Australia. While the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referrals to services such as memory clinics for comprehensive assessment and diagnosis of dementia, such services may have limited capacity and may not be readily accessible to all. What does this paper add? This paper presents an overview of the various settings and services available for dementia diagnosis in Australia including evidence of the roles, accessibility, effectiveness and limitations of each setting. What are the implications for practitioners? This concerns a disease that is highly prevalent and escalating, and highlights the roles for practitioners in various settings including general practices, acute hospitals, specialist clinics, community and nursing homes. In particular, it discusses the potential roles, advantages and challenges of dementia diagnosis in each setting.

The Community Assessment of Risk Instrument: Investigation of Inter-Rater Reliability of an Instrument Measuring Risk of Adverse Outcomes.

Frailty is increasingly common in community dwelling older adults and increases their risk of adverse outcomes. Risk assessment is implicit in the Aged Care Assessment Teams process, but few studies have considered the factors that influence the assessor's decision making or explored the factors that may contribute to their interpretation of risk. to examine the inter-rater reliability of the Community Assessment of Risk Instrument (CARI), which is a new risk assessment instrument. A cohort study was used. A sample of 50 community dwelling older adults underwent comprehensive geriatric assessment by two raters: a geriatrician and a registered nurse. Procedure and measurements: Each participant was scored for risk by the two raters using the CARI. This instrument ranks risk of three adverse outcomes, namely i) institutionalisation, ii) hospitalisation and iii) death within the next year from a score of 1, which is minimal risk to 5, which is extreme risk. Inter-rater reliability was assessed with Gamma, Spearman correlation and Kappa statistics. Internal consistency was assessed with Cronbach's alpha. There were 30 female (mean age 82.23 years) and 20 male (mean age 81.75 years) participants. Items within domains showed good-excellent agreement. The gamma statistic was >0.77 on 6/7 Mental State items, 14/15 items in the Activities of Daily Living domain. In the Medical domain, 6/9 items had Gamma scores >0.80. The global domain scores correlated well, 0.88, 0.72 and 0.87. Caregiver network scores were 0.71, 0.73 and 0.51 for the three domains. Inter-rater reliability scores for global risk scales were 0.86 (institutionalisation) and 0.78 (death). The gamma statistic for hospitalisation was 0.29, indicative of lower inter-rater reliability. Cronbach's alpha was 0.86 and 0.83 for the Activities of Daily Living domain, 0.51 and 0.42 for the Mental state domain and 0.23 and 0.10 for the Medical state domain. Overall, the instrument shows good inter-rater reliability. Poor correlations on some items relate to poor communication of clinical data and variable interpretation based on professional background. Lack of internal consistency in the medical condition domain confirms the discrete nature of these variables.

Pharmacist-Led Medication Review to Identify Medication-Related Problems in Older People Referred to an Aged Care Assessment Team

Aged Care Assessment Teams (ACATs) in Australia assess the care needs of frail older people. Despite being at high risk of medication-related problems (MRPs), ACAT patients do not routinely receive a comprehensive medication review. The aims of the study were to compare three methods for facilitating a pharmacist-led comprehensive medication review for people referred to an ACAT, and compare MRPs identified via ACAT usual care with those identified via pharmacist-led medication reviews. A prospective, randomized, comparative study involving 80 community-dwelling patients (median age 84 years) referred to an ACAT in Melbourne, Australia, was conducted. Following ACAT assessment (usual care), a clinical pharmacist reviewed all participating patients' ACAT files to identify potential MRPs not identified by the ACAT (medication review method 1). Patients were then randomized into two groups. Group A received information about the Australian government-funded, general practitioner (GP)-initiated Home Medicines Review (HMR) programme, and a letter was sent to their GP recommending an HMR (GPHMR; medication review method 2). Group B patients were referred directly to a clinical pharmacist associated with the ACAT for an ACAT-initiated pharmacist home medicines review (APHMR; medication review method 3); the pharmacist arranged a home visit, obtained a thorough medication history and conducted a comprehensive medication review. The main outcome measures were the proportion of patients who received a pharmacist home visit within 28 days; the number of MRPs identified by ACAT usual care, pharmacist review of ACAT files, and APHMR, and their clinical risk (assessed by a geriatrician-pharmacist panel); and patients', GPs' and ACAT clinicians' opinions about pharmacist medication review. Three hundred patients were referred to the ACAT, and 80 were recruited into the study. Thirty-six of 40 APHMR patients (90.0%) received a pharmacist home visit within 28 days, compared with 7/40 GPHMR patients (17.5%).[p < 0.001]. Twenty-one MRPs were identified via ACAT usual care. Pharmacist review of ACAT files identified a further 164 potential MRPs (median 2.0 per patient; inter-quartile range [IQR] 1.0-3.0); however, in patients who received an APHMR, 35/82 potential MRPs (42.7%) turned out not to be actual problems, most commonly because of discrepancies between the patient's ACAT medication list and the medications currently being used by the patient (median 3.0 discrepancies per patient; IQR 2.0-5.5). APHMR identified a further 79 MRPs (median 2.0; IQR 1.0-3.0). One hundred and twenty-two MRPs were included in APHMR reports sent to patients' GPs. Of these, 94 (77.0%) were assessed as being associated with a moderate, high or extreme risk of an adverse event. Sixty-four APHMR recommendations (52.5%) led to changes to patients' medication regimens or medication management. Thirty-six of 39 GPs (92.3%) who provided feedback reported that pharmacist medication reviews were useful. Patients (or their carers) also reported that pharmacist home visits were useful: median rating 4.25 out of 5 (IQR 4.0-5.0). Seven of 11 ACAT clinicians (77.8%) agreed that pharmacist-led medication review should be a standard component of ACAT assessments. ACAT assessments without pharmacist involvement detected fewer MRPs than any of the evaluated pharmacist-led medication review methods. APHMR was more effective than pharmacist review of routinely collected ACAT data, and more reliable and timely than referral to the patients' GP for a GPHMR.

Does assessment make a difference for people with dementia? The effectiveness of the Aged Care Assessment Teams in Australia.

The needs of individuals with dementia and other psychiatric problems of old age have received increased attention in Australia over the last decade. This paper reports on the role of Aged Care Assessment Teams (ACATs) in managing these clients, and the extent to which they are differentiated from other clients in the assessment process and outcomes recommended. Data on some 26,500 clients seen by ACATs in Victoria in the second half of 1999 are analysed to show (1) the relationship between a diagnosis of dementia and reporting of disability in orientation, (2) characteristics of clients with and without a diagnosis of dementia and (3) outcomes for groups of clients defined on the basis of a diagnosis of dementia and disability in orientation.

The delegate's dilemma: ACATre-assessment in hostels

The provision for 'ageing in place' in the Aged Care Act of 1997 has provided an opportunity for hostel facilities to broaden their scope of care for older people. Aged Care Assessment Teams (ACATs) are required to provide assessments to give approval for high or low level entry to these facilities, and to provide approval for reclassification from low to high care. However, guidelines for ACAT assessments are contradictory with respect to the Resident Classification Scale (RCS) which provides the facility funding formula, thus creating gatekeeping compared with advocacy difficulties for the ACAT. If the facility can support a claim of high care need for a resident via the RCS but the ACAT (using different and less in-depth criteria) does not agree with that claim, then the care of that resident might be compromised due to inadequate funding. Recommendations made to solve this dilemma include conferring the right of the hostel staff to reclassify residents when necessary, with the responsibility for confirmation of that classification to remain with the trained validation officers from the Commonwealth Department of Health and Family Services, not the ACAT.

At the interface of health and community care: developing linkages between aged care services in a rural context.

This paper explores issues concerning the development of linkages across the interface between acute and community aged care services in a small regional Australian city. It addresses a participatory action research project that took place over a 2 year period involving an Aged Care Assessment Team (ACAT). Aged Care Assessment Teams are multidisciplinary teams whose members mediate between hospitals and the aged care system in the community and have a key role in developing networks and linkages between various service providers in the field. In an age of economic rationalist-inspired reform agendas in health and community care, rural infrastructures have been compromised to such a degree that the role of rural ACAT in developing linkages between sectors has never been more important. This paper takes up this issue and addresses the project findings, which highlight a field characterised by ineffective linkages within and between the various sectors, a lack of understanding of the operation of the rural aged care system among nurses working in regional hospitals, and the efficacy of ACAT working collaboratively with nurses to create new and more effective linkages in aged care.

Health care costs of people referred to an aged care assessment team: the effect of cognitive impairment.

The aim of this study was to determine the effect cognitive impairment has on direct and indirect costs to elderly people, their carers and the community over one year, by following prospectively a cohort of elderly people referred to an aged care assessment team. The 78 subjects were drawn from a random sample of people referred to the NorthWest Hospital team, and validated tools were used to assess their cognitive state. Outcome measures included total costs of community services, residential care, hospital bed use, carer burden and psychological morbidity. A comparison of outcome measures was made between those with cognitive impairment and those without. Use of community services and hospital beds was high overall. Those with cognitive impairment were substantially greater users of residential care, accounting for the higher expenditure in this group. Psychological morbidity and burden remain high in carers of those with cognitive impairment despite a high rate of institutionalisation in this group. The total costs for those referred to aged care assessment teams with cognitive impairment are double those seen for those with normal cognition.

Elder abuse: prevalence, intervention and outcomes in patients referred to four Aged Care Assessment Teams.

To establish the prevalence and patterns of elder abuse, and outcomes of intervention, among patients of four Australian Aged Care Assessment Teams. Descriptive study, with victims identified retrospectively from medical records for the first three months, and prospectively form the remaining nine months, of 1994. Four area-based Aged Care Assessment Teams in three States. Referred patients over 65 years of age who lived in private homes and who met a predetermined definition of elder abuse. Prevalence of abuse, types of abuse and the effect of interventions. The overall prevalence of elder abuse in the study population was 1.2% (95% CI, 0.4%-2.0%). The rate identified retrospectively was double that identified prospectively. Psychological abuse was the most common form of abuse detected. Patterns of abuse were identified and related to psychopathology of the abuser (30%), dependency of the older person and carer stress (25%), domestic violence (19%), carer abuse (18%) and financial dependency (8%). Interventions and outcomes varied according to the pattern of abuse. Our findings on the factors causing elder abuse are consistent with those identified in previous Australian studies. The prevalence of elder abuse detected in this study was lower than that in other Australian and overseas studies. A more uniform approach to detection is necessary, which may be aided by improved identification and management techniques, and appropriate training of health professionals in aged care services in case definition, interventions and management.

Dementia and Driving: a Survey of Clinical Practice in Aged Care Assessment Teams

Current clinical practice in Aged Care Assessment Teams (ACATs) in NSW and ACT regarding assessment of fitness to drive in clients with a diagnosis of dementia was examined. Of 42 ACATs with a geriatrician on staff, 38 (90.5%) responded to a telephone survey. Results showed that assessment of driver fitness is largely a medically based procedure, with functional on‐road assessment of driver competence occurring in 42.1% of ACATs. Use of the Mini Mental Status Examination in determining the severity of dementia and impact on driving was common (94.7%), although such predictive ability has not been demonstrated. Few ACATs (36.8%) systematically review drivers despite likely disease progression. 73.7% of ACATs reported experience of clients continuing to drive against advice. Approaches to assessment in city and rural ACATs are compared.

Tipping the Balance Between Community and Hostel

Achieving a balance between the provision of community and residential care for older people is a prime task for the aged care system. This paper identifies some of the factors which appear to influence the care plan recommendations made by Aged Care Assessment Teams in Victoria, for those older people at the margin between community living and hostel care. The paper is based on data from two sources: a survey of Victorian Aged Care Assessment Team clients which provided information on a range of health status measures for around 2,000 older people, and a regular collection of socio‐demographic and care plan information provided by the same teams. Multivariate regression techniques were used to identify the factors associated with each care plan. The reason for which an older person seeks an assessment is the most powerful predictor for the alternatives of community living or hostel care, suggesting the presence of a complex of social and systemic factors. Health related factors such as presence of dementia and hospitalisation at time of assessment, together with age, are shown to be less important, but consistent, predictors of whether an older person is recommended for a hostel waiting list or to remain in the community with additional services

Ethnicity and aged care assessment teams in Queensland

To examine how functional, medical and psychosocial factors influence the differences in use of community and residential services by Australian-born and ethnic aged persons, all persons (n = 31,737) assessed by aged care assessment teams in Queensland in 1992 and 1993 were surveyed. Subjects were classified as Australian-born, overseas-born in countries where English is the primary language, or overseas-born in countries where English is not the primary language. Factors compared included use of services and residential care both prior to assessment and following assessment, and functional, medical and psychosocial factors. The group with non-English-speaking background were more likely to be both younger and underreferred compared to their proportion in the community. They were more likely to be referred for, and more likely to be recommended for, nursing home placement than the English-speaking groups. They were more commonly referred for assessment because of mental deficit problems, carer stress and/or social isolation, more likely to be diagnosed with dementia and diabetes, and less likely to be diagnosed with respiratory disease and vision disorders. That clients of non-English-speaking background are more likely to be recommended for nursing home placement is probably largely because of more advanced disease at the time of referral and therefore more functional dependence. Aged care assessment teams should increase ethnic communities' awareness of their services, particularly of the benefits of earlier referral.

Prevalence of dementia among patients referred to an aged care assessment team and associated stress in their carers

The objective of this study was to determine the prevalence of dementia among patients referred to an aged care assessment team and to compare levels of burden and psychological morbidity between carers of cognitively normal persons and carers of people with dementia, in this population. Validated cognitive tests were administered to participants drawn from a random sample of all persons referred to the North West Hospital Aged Care Assessment Team, and diagnoses of dementia were made according to ICD‐10 criteria. Available carers were assessed for psychological morbidity and burden with the General Health Questionnaire and the Zarit Family Burden Interview. Of 100 patients selected, 78 were assessed, of whom 34 (44 per cent) were cognitively normal and 34 (44 per cent) fulfilled ICD‐10 criteria for dementia. A further 8 (10 per cent) had cognitive impairment not meeting the criteria for dementia. There was a high level of psychological morbidity and burden among the carers of both the cognitively normal patients and the dementia sufferers, which was largely accounted for by the patients' physical disability. This has implications for the adequate provision of health care and services to both patients and carers of this population. Adequate education of members of aged care assessment teams in the identification of dementia and their ability to refer to appropriate dementia‐specific services and provide counselling for carers requires future planning. (Aust J Public Health 1995; 19: 275–80)

A Specialised Advisory Service for Older People and Those Caring for Them

An Information Office for older persons and their carers was established at Bundoora Extended Care Centre in 1990. The Office accepts enquiries by telephone or in person, both by appointment and on an ‘off‐the‐street’ basis. To determine the effectiveness of the project, a study of 798 consecutive enquiries made between October 1990 and March 1991 was conducted. People making enquiries participated in an interview at the time of their initial enquiry and a follow‐up telephone interview 3–4 weeks later. This second interview ascertained the relevance and usefulness of the information provided to the user. The study identified two major groups of enquirers‐professional health workers (40%) and children of elderly people (28%). The main areas of enquiry related to residential care (23%), Aged Care Assessment Teams (20%) and information on specific diseases or disabilities, e.g. Alzheimer's disease (10%).

Aged Care Assessment Teams in Australia: a General Practice Perspective

To explore the interaction between general practitioners (GPs) and Aged Care Assessment Teams (ACATs) from the GP's perspective, structured telephone interviews were held with the GPs of 77 people consecutively admitted to nursing homes in the Hunter region of New South Wales. Overall, GPs expressed satisfaction with the assessment process. However, on 37 (48%) occasions, GPs claimed not to have been asked for information prior to assessment, on 36 (47%) occasions no feedback was received, and on 58 (75%) occasions, GPs claimed they were not informed of their patient's admission to a nursing home. Some solutions to these perceived deficiencies were offered by the GPs interviewed. These indicate practical ways in which cooperation between GPs and ACATs can be enhanced.

A clinical specialist in psychiatric-mental health nursing in rural South Australia

A holistic view of aging states that humans are seen to be endeavoring toward wholeness from birth until death within an ever changing world. Nurses are part of that wholeness, evolving with patients throughout their lives. The Commonwealth of Australia has designed the concept of aged care assessment teams (ACATs) to address the specific and unique needs of its aging communities. The article provides an example of the role of a clinical specialist in psychiatric-mental health nursing who provides a holistic approach to the assessment process as nurse consultant to two ACATs in rural South Australia.

The influence of clinical problems, age and social support on outcomes for elderly persons referred to regional aged care assessment teams

Aged Care Assessment Teams (ACATs) have been established throughout Australia during the past seven years. Early studies of their effect have concentrated on their impact on the rate of institutionalisation of disabled elderly, the clinical characteristics of referred cases and the relationship between disability and recommended care plan. The aim of this study was to explore the relationship between age, clinical features and social characteristics of ACAT subjects with outcomes at 12 months after assessment. The examination of an arbitrary sample of persons referred to ACATs over a year by one generalist geriatrician with follow-up of all cases by the three ACATs associated with the study was carried out. All analyses were performed on raw data presented as categorical variables in the form of contingency tables. The sample included 324 subjects who suffered from 2030 clinical problems with a mean of 6.5 per person aged 75 or over and 5.5 for those under 75. Cardiovascular and neurological disease were the commonest source of problems. Study of accommodation outcome at 12 months, for those subjects who survived this period revealed that, in the older group, over 60% of subjects with neurological disease were resident in nursing homes while the majority of all other groups remained in the community, as did two-thirds of those aged under 75. Admission to a nursing home was independent of social support for older subjects with neurological disease, but it played a significant role in those with cardiopulmonary or musculoskeletal disease. The study demonstrates that for one-year survivors there is an increased likelihood of admission to a nursing home of people aged 75 or over with neurological disease, while those under 75 were more likely to remain at home. The association was independent of whether spouse, family or friends were living with the subject.

General practice and dementia

To find out what difficulties general practitioners (GPs) experience with diagnosing and managing dementia. Postal questionnaire to a random stratified sample of one in seven active Australian GPs (2182 of 14,932). 1473 GPs (67.5%) responded to the questionnaire. The results indicated reasonable knowledge about diagnostic features of dementia and good insight into common issues facing family carers. Even so, GPs had difficulties with diagnosis and management of dementia and wanted assessment protocols and educational programs. A minority of GPs regularly screened elderly patients for cognitive impairment but the majority relied on passive means of diagnosing dementia. Although generally positive about Aged Care Assessment Teams (ACATs) and Aged Care Community Services (ACCS), GPs expressed some concerns about these services. Recommendations arising from the survey were: development of an assessment protocol and a screening instrument, regular cognitive check-ups for patients over 75 years, educational programs, improved coordination with Aged Care Assessment Teams and Community Services, inventories and registers of local community services and residential facilities, and appropriate Medicare rebates.