Home Care Packages Research Articles

The regional effect of the consumer directed care model for older people in Australia

Evaluation of Consumer Directed Care (CDC), an internationally recognized means to promote autonomy and choices in the delivery of health in community aged care, is growing, but little is known about the spatial implications of such policy. With differences in the utilisation of home care services across locations, the introduction of a national CDC program may affect different regions to different extents. This paper explores the regional effect of the CDC introduction on older Australians' mental health. We analyse data on 1780 individuals aged 65 years and over, from 11 waves (2007–2017) of the Household, Income and Labour Dynamics in Australia (HILDA) Survey. We find that older adults’ mental health is worse after the introduction of the CDC in 2013. Moreover, older adults, who lived in the areas with higher utilisation of Home Care Packages, experienced worse mental stress than the same individuals who lived in the areas with lower utilisation of home care services. This pattern may reflect regional differences in Government funding, community aged care waiting time and provider service fees. Therefore, it is important for health policies that aim to promote choices to older consumers, such as CDC, to consider regional differences in its implementation, to minimise unwarranted variations in the population health and well-being.

Has consumer-directed care improved the quality of life of older Australians? An exploratory empirical assessment.

To assess the impact of a Consumer Directed Care (CDC) model of service delivery on the quality of life of older people receiving home care packages. Quality of life was assessed using validated instruments. The relationship between quality of life and length of time exposed to CDC was examined using descriptive statistical and multivariate regression analyses. Consenting older adults (n=150) in receipt of home care packages participated. Quality of life and capability scores were higher for older people in receipt of a CDC model of service delivery for <12months compared to those receiving the model of care for longer, although this difference was not statistically significant. However, older people with more recent exposure to CDC indicated a stronger capability to do things that made them feel valued. Extended longitudinal follow-up is needed to facilitate a detailed examination of the relationship between the evolution of CDC and its longer-term influences on quality of life.

Can a Home Care Package deliver a meaningful life? Challenges for rural home care delivery

Objective: To explore the capacity and responsiveness of the Home Care Package (HCP) Program to deliver the promise of a meaningful life for rural residents.Methods: In-depth interviews utilising appreciative enquiry in two local government areas in rural/outer regional Tasmania (MM2-6). Participants: Rural staff and residents who were either receiving, seeking or delivering support through the HCP Program.Results: Interviews revealed that positive impacts of being assisted to stay at home resulted when staff were able to provide support that was appropriate to need, and enabled the continuation of rural community engagement, individual autonomy and control. When the HCP did not provide these, or even hindered them, there were negative consequences, and feelings of confusion, mistrust, and disappointment for staff and residents. The rural context creates specific challenges for the HCP Program in its current form, related to service availability and choice, staff recruitment, training and availability, and client/provider needs mismatch.Conclusions: Older rural people are variously impacted upon by the HCP Program. Factors of rurality, including workforce issues, hamper the Program’s potential to positively contribute to a meaningful life. As demand grows, changes are needed. There is a need to examine the Program design for urban-centrisms, and gain a greater awareness of older rural people’s needs and rural service challenges.

Frailty screening among older adults receiving home care packages: a study of feasibility and prevalence.

Home care packages (HCPs) aim to support older people to remain in their homes for as long as possible. Early detection and management of frailty in community-dwelling older people may prevent or delay transfer to residential aged care. This suggests that it is important to establish mechanisms for identifying frailty among older adults. This study examined the feasibility of obtaining self-reported level of frailty from a sample of older adults receiving HCPs from an Australian aged care provider. The prevalence of frailty and sociodemographic and clinical correlates were assessed. Customers aged ≥65 years receiving an HCP from an aged care and disability service provider in New South Wales (n=158; 53.5% consent rate) completed a survey during their scheduled visit. The mean (±s.d.) total score on the Edmonton Frail Scale was 7.3±2.4 (range 1-13). The prevalence of frailty was 45% (5% 'severe frailty', 14% 'moderate frailty', 26% 'mild frailty'). Clients who had fallen in the past year had, on average, a 1.0-point higher frailty score (95% confidence interval 0.16-1.90) than those who had not. Given the high proportion of adults in our sample who were identified as frail, regular standardised assessments of frailty may assist community aged care providers to provide early intervention to reduce the risk of falls within this group of clients.

General practitioner conduct of clinical services representing comprehensive geriatric assessment is associated with lower risk of mortality in older Australians receiving home care packages.

The purpose of this paper is to investigate the utilisation of general practice Medicare Benefit Schedule (MBS) services aligned to Comprehensive Geriatric Assessment (CGA) within 6months of an aged care eligibility assessment and its effects on mortality and transition to permanent residential aged care (PRAC). Retrospective cohort study from the Historical Cohort of the Registry of Senior Australians. Community. In total, 69,171 Individuals (aged 75+) receiving home care packages (HCPs) between 2011 and 2015. Mortality and transition to PRAC. The claims for a management plan with team care arrangement (TCA) within 3months of the health assessment (i.e. CGA) was present in 5% and associated with 14% lower mortality (adjusted hazard ratio [aHR], 95%CI = 0.86, 0.80-0.93) compared to no claims, lower than that seen with partial CGA which was either health assessment claims only 7.0% (aHR, 95%CI = 0.93, 0.89-0.97) or management plan coupled with TCA claims only 9.0% (aHR, 95%CI = 0.91, 0.89-0.97). This pattern was seen in those frailer but not in those where the frailty index score was <0.21. Claims for management plans coupled with TCAs alone were associated with a 10% lower transition to PRAC (asHR, 95%CI = 0.90, 0.85-0.96) in those with FI score < 0.21 while this estimate was not significant in individuals with FI score≥ 0.21. It appears the conduct of a combination of interventions considered to be components of the CGA by GPs was associated with a lower risk of mortality that no claims or partial conduct of CGA.

Mortality in the first year of aged care services in Australia

To examine the one-year mortality of Australians entering aged care services compared with the general population. A population-based analysis evaluating one-year mortality among people who received first ever aged care services in 2013 compared with the general population was conducted. In 2013, 3.3 million Australians were≥65years and 34919 (1%) entered permanent residential care, 23288 (0.7%) respite care, 20265 (0.6%) commenced home care packages, and 15387 (0.5%) transition care. Individuals receiving aged care services had higher mortality than the general population, with those entering permanent residential care (age and sex direct standardised mortality rate ratio=10.1, 95% CI: 9.8-10.5) having the greatest difference, followed by people accessing respite (7.2, 95% CI: 6.9-7.6), transition (4.6, 95% CI: 4.4-4.9) and home care (4.1, 95% CI: 3.9-4.4). Significant variation by sex and age was observed. Our study has identified significant variations in mortality rates that highlight which cohorts entering aged care are the most vulnerable.

Decision-making in home care package spending.

ObjectiveTo understand the motivations and drivers of spending decisions made by home care package recipients, in the context of high levels of unspent funds.MethodsQualitative study using 30 semi‐structured interviews with 38 home care package clients and/or client representatives in rural and urban Victoria conducted between December 2018 and March 2019. Interview transcripts were analysed to determine themes.ResultsSpending decisions were influenced by assessment and entry experiences, knowledge and understanding of package funds, availability and acceptability of services, and attitudes to spending.ConclusionClients need confidence in their individual funds and their use in order to maximise the potential benefits. Clear, consistent communication at all stages, and additional supports to build consumer capability, will enable clients to better understand packages and their application. This in turn will optimise the capacity of home care package recipients to maximise their health and well‐being.

Utilisation of general practice health assessments around an aged care assessment is associated with lower mortality risk in older Australians.

(i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP. retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted. 75,172 individuals aged ≥75years who received HCP between 2011 and 2015. for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC. of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8-8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3-37.0%) had management plans, 33.0% (95% CI: 32.7-33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2-5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92-0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02-1.08) compared to those who did not have these services. the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Consumer expectations of self-managing aged home care packages in Australia.

This study investigated the expectations of older people who chose to participate in a self-management trial of home aged care packages conducted by COTA Australia. Empowerment theory is used to interpret the findings. All Australian home aged care support packages are delivered using a consumer directed care (CDC) model, and most are managed by an aged care provider. The COTA Australia trial gave older people the opportunity to self-manage their package and have more control over spending and less constraints on its use. This study examined three questions: (a) what motivated the older person, or an informal carer acting on their behalf, to participate in the self-managing trial; (b) what outcomes they expected (c) and what was their attitude towards risk. The trial was conducted over 9months in 2018-2019. Seven registered home aged care providers from six Australian states and territories recruited 103 consumers to the trial, with having an informal carer act on their behalf. Online questionnaires with consumers (n=103) and informal carers (n=66), and 18 semi-structured interviews showed that older consumers and their informal carers had high expectations that self-management would result in: increased choice and control and more flexible use of funds; lower administration fees and more money to spend on services and supports; improved relations with service providers and the opportunity to select support staff. Participants wanted clear information and guidelines and support from their provider. While wanting to have more control and be empowered, few respondents noted concerns about possible risks. This finding raises questions about consumers' awareness of risks that are documented in the literature, and it challenges providers to balance risk management with facilitating independence and autonomy.

Fortunate and fearful: emotions evoked by home-care policies for older people in Ireland

This article examines the emotions of fear and feeling fortunate experienced by key actors in home-care services in Ireland. We take a relational approach to emotions; that is to say, an understanding that emotions are produced in social interactions and play an essential part in how people engage with, and respond to, long-term care policies. The study involved focus groups and in-depth interviews with 104 participants. Our findings show that the most vulnerable participants – service users and care workers on precarious contracts – feel fortunate or fearful about outcomes that had, or would have, a direct impact on them: respectively, having a good carer and obtaining job satisfaction, or losing a home-care package and not having enough work. Professionals were more likely to speak about luck and fear, not in relation to what could happen to them directly but in relation to the fate of service users and care workers. The unregulated home-care services in Ireland have influenced actors to construe their own and others’ participation in the system as increasingly individualised, where desired outcomes depend on one’s good luck or strong personal relationships. For the system to work properly trust needs to be present not only at the micro level of individual relationships but also at a system level. This could lead to a decline in emotions that centre on feeling fortunate and fearful, and an increase in expressions of trust and a sense of control by both care providers and care recipients.

Consumer experiences of home care packages.

The study aimed to explore consumers' experiences of receiving a home care package (HCP). Community engagement was used to recruit older people approved for a HCP. Data were collected through face-to-face interviews, and data analysis identified themes. Effective consumer-directed care depends on access to reliable information. Participants who reported satisfactory experiences had: (a) providers that charged reasonable fees; (b) case managers who delivered person-centred care; (c) support workers who were consistently assigned to them; (d) a family member for support and advocacy; and (5) ongoing community engagement. Consumer experience requires tighter regulation of providers and policy attention to fees and minimal standards of staff training. The policy of full cost recovery restricts consumers' access to local government services.

The effect of home care package allocation reforms on service uptake, use and cessation at a large Australian aged care provider.

To utilise routinely collected data to examine changes in the client profile of a large aged care provider before and after commencement of the 2017 policy reforms, whereby home care packages were allocated to individuals rather than providers. Interrupted time series analysis was used to measure changes in service uptake and cessation. Chi-square and t tests were used to compare client profiles in the 12months before and after policy changes. A total of 4132 people used home care services with the provider between March 2016 and March 2018. Fewer people commenced services post-reforms, and they were more likely to be younger and have a partner. There was no change in the number choosing to terminate services post-reforms. Vulnerable older Australians may experience greater difficulty accessing services under the new system, suggesting greater scrutiny of the reforms in achieving policy objectives is required. Analyses of routinely collected data sets can support this evaluation process.

A Qualitative Study on How Social Workers From Regional and Metropolitan Queensland, Australia Perceive the Impact of the National Prioritisation System on Hospital Discharge Planning: A Study Protocol

In 2012, the Australian Commonwealth Government introduced a series of reforms for the aged care sector including the implementation of the National Prioritisation System for a flexible, accessible and demand-driven approach to home care services for older people. Nevertheless, an increasing number of older people continue to wait for months to be assigned home care packages on the national prioritisation queue, a component of the National Prioritisation System. There is limited evidence on the impact of the national prioritisation queue on discharge planning practices of social workers in supporting older people returning home from hospital admission. The aim of the research described in this paper is to explore the perceptions of social workers from rural and urban health services areas on how the introduction of the national prioritisation queue has influenced discharge planning of older people who are still waiting assignment of home care packages. This study protocol establishes the need for this qualitative study and provides an overview of the theoretical framework underpinning the research; discusses and describes the methods for sampling/recruitment and data collection, the approach to be utilised for qualitative analysis and the planned dissemination strategy. Understanding how social workers respond to the perceived challenges to discharge planning posed by the national prioritisation queue and the implications arising from the research have the potential to inform the development of best practice approaches and further enhance social work response to identified issues.

71 Challenges of Delayed Discharges – A Rehabilitation Hospital’s Perspective

Abstract Background Delayed discharge is a system level problem. It is prevalent internationally, expensive and associated with detrimental outcomes for both patients and health care staff. The aim of this study was to examine reasons for delayed discharges and investigate the relationship between it and clinical complications in a rehabilitation unit. Methods A retrospective study design of patients on delayed discharge list, from December 2017 to August 2018. Data collected from review of medical charts and electronic patient records (BlueSpier). Results 62 patients were identified as delayed discharges, representing 33.3% of the total 186 discharges from the ward, over a 9-month period. Data was obtained for 27 patients. Mean age was 82 years (66-96 years) with an equal male: female ratio. Mean bed days lost was 37 days (4-274 days). 63% of discharges were delayed due to home care packages (HCP), including 44.4% (n=12) awaiting approval of new HCP and the remaining 18.5% (n=5) awaiting an increase in hours. 25.5% (n=7) of delayed patients were awaiting suitable nursing home placements. Other reasons for delayed discharges included awaiting equipment for home (n=5), home adaptations (n=3) and ward of court proceedings (n=1). Morbidities and clinical complications were common among delayed patients. 26% (n=7) became more dependent in mobility at discharge and 51.9% (n=14) experienced clinical complications. These complications include infections (n=9), falls (n=3), acute delirium (n=2), exacerbation of heart failure (n=1), low mood (n=1), acute coronary syndrome (n=1) and pressure sore (n=1). Conclusion 1 in 3 discharges from our rehabilitation ward were delayed. These delays led to functional decline in our patients and exposed them to avoidable adverse outcomes by unnecessary prolonging hospitalisation. Resources need to be directed towards prompt delivery of community services to facilitate a safe and timely hospital discharge.

307 A Survey of Nutritional Status of Older Patients Attending Medicine for Older Person Clinics

Abstract Background Nutritional assessment is an important but frequently overlooked aspect of comprehensive geriatric assessment. Malnutrition is common and associated with clinical complications. Our study aimed to assess older patients’ perceptions of their nutritional status and to investigate clinical factors affecting it. Methods All patients attending our clinics over a 2 week period were invited to complete a self-administered questionnaire. Further clinical information including diagnosis and weight collected by review of medical notes. Results A total of 43 patients completed the questionnaire; median age 82.5 years (67-102). Of these, 69.8%(n=30) were female and 27.9% (n=12) lived alone. Majority reported good appetite (83.7%, n=36) and eating 3 meals a day (79.1%,n=34). 25.6%(n=11) prepared meals themselves and 34.9%(n=15) had received nutritional advise from healthcare professionals. 17 patients (39.5%) self-reported weight loss over the past year, and of these 76.5% (n=13) had objective weight loss documented. Only 2.3% (n=1) were concerned and seek advice from healthcare professionals. 50% (n=12) of the remaining 24 patients who self-reported no weight loss had objective weight loss in clinic. 26 (60.5%) patients had objective weight loss. A higher proportion of the weight loss cohort lived alone (30.8% vs 23.5%), had no home care packages(HCP) (65.4% vs 47.1%), did not take nutritional supplement (76.9% vs 58.8%), had no dentures ( 42.5% vs 23.5%) and had no diagnosis of dementia (57.7% vs 47.1%). Of those who lost weight, 34.6% (n=9) lost significant amount (&gt;5%) of weight, including 4 (15.4%) who lost &gt;10%. Conclusion 2 out of 3 of our community dwelling, older patients lost weight, with one third having lost significant amount. Awareness is poor with 50% not recognising their weight loss and only one third ever sought nutritional advice. Patients who lost weight were more likely to be living alone with no formal community supports.

144 The Use of a Multidisciplinary Team Discharge “Huddle” to Improve Patient Flow and Planning

Abstract Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.

121 Patients with Prolonged Lengths of Stay. A Point Prevalence Study

Abstract Background A hospital's trolley count is often highlighted as a measure of its performance. However there is a more complex reality for each organisation in accessing suitable resources for often frail older patients to improve care and capacity. Coupled with this is the need for pathways that identify these patients early in their admission and access the appropriate specialist care. In 2018, 65% of this hospital's bed days were occupied by those whose hospital stay was greater than 14 days. Nationally this was 57%. We undertook to review processes locally around the care of older acute patients. Methods On the 20th November 2018 we conducted a chart audit of 85 in-patients who had been in the acute setting for more than 14 days. A proforma was completed for each patient by a doctor and multi-disciplinary team member. Results The length of stay ranged from 15 – 527 days with the median being 41 days. The average age was 76 years. A history of falls/dementia/“acopia” was recorded on admission in 57%. The mean time for referral to MDT was 5 days. Social history was only documented in 47% of cases. Ward transfers was a significant issue with 69% moving wards at least once and 9% moving three times or more. A care planning meeting had not been held in 49% of cases. Over 17% of charts audited were awaiting home care package hours whilst 20% were awaiting long term care. In 62% of cases there was no ongoing medical reason keeping them in hospital and 56% of this cohort could have been cared for elsewhere. Conclusion Deficits in clear communication and appropriate timely planning for patients resulted in significant delays in discharge. The findings of our research informed a decision to conduct a root and branch analysis of discharge planning utilising the Lean Six Sigma model.

134 Does a Purely Occipital Lobe Stroke Lead to Significant Long Term Disability and Handicap?

Abstract Background Occipital lobe strokes are characterised by a visual field deficit (VFD) and the absence of a motor deficit. A persistent VFD may have significant long-term implications for a patient and their lifestyle. Our aim was to assess the overall impact of these events particularly patients’ ability to return to driving. Methods All patients admitted with an acute occipital lobe stroke to a Dublin teaching hospital in 2017 were identified. Case notes were retrospectively reviewed to identify patients’ pre-stroke function, stroke pathology, neurological losses and further vascular events. A follow up phone call was made 18 months after the event to assess if previous drivers had returned to driving and required the installation of formalised home supports after discharge. Results In 2017, 37 of 311 stroke patients admitted had a confirmed occipital lobe stroke. 33 of these patients (89.1%) had ischemic events. The median age was 76 (50-93) years old. Twenty-nine patients were able to undergo formal cognitive testing; the median Montreal Cognitive Assessment (MOCA) was 18 (2-29). 15 patients (40.5%) had underlying Atrial Fibrillation with one (6.7%) of this cohort being identified post discharge; 14 (85.7%) of those patients with ischemic strokes were anticoagulated for atrial fibrillation. The median length of stay was 33.9 days, with a range of 2-391 days. Further vascular events occurred in 2 (5.8%) of the patients. A follow up phone call was made to the 15 patients who drove prior to their event. 12 patients (80%) could not resume driving due to persistent VFD. One (7%) of the previous drivers had a home care package installed since discharge. Conclusion A persistent VFD results in long term problems including an increased risk of further vascular events, a reduction in overall independence and quality of life following an occipital lobe stroke. This study has led to a business plan for a dedicated hemianopia clinic.

225 Assessment of Well-being after Stroke

Abstract Background Studies have shown that people who have had a stroke are more likely to experience a lower sense of overall well-being, including cognitive impairment, mental health issues, and physical function, than similarly aged people1. Cognitive impairment and memory dysfunction following stroke diagnosis can significantly impact patients’ quality of life2. The aim of this study was to identify how stroke has affected patients at a university teaching hospital stroke clinic in terms of memory, mood and how they are managing at home. Methods Thirty anonymous patient questionnaires were completed at a stroke clinic in April 2019. 100% response rate was obtained. Questions included how patients found their mood and memory, and how they were managing at home following their stroke diagnosis. Results 50% of respondents reported having memory difficulties post-stroke. 57% described low mood since their stroke. 43% required additional help following discharge home, with 69% of this extra help coming from family support. 13% felt they need more help at home than they currently have, with one of these four respondents awaiting a home care package. 20% of patients received further rehabilitation as an outpatient on discharge. Conclusion This study highlights significant concerns from patients following stroke with regard to their memory and mood. This emphasises the importance of formal assessment of mood and memory both during admission and on an ongoing basis post discharge. A significant proportion of patients required additional help at home with family members providing the majority of this support.

An early investigation of individual budget expenditures in the era of consumer-directed care.

To identify the key categories of consumer expenditures following the introduction of consumer-directed care (CDC) in the Australian community aged care sector. Income and expenditure data were extracted from monthly budget statements and categorised. Expenditures by category were examined by home care package level, length of time receiving CDC and socio-demographic characteristics. A total of 150 older people in receipt of CDC in South Australia and New South Wales were approached, of whom 95 (63%) consented to participate. Hours of formal care support received was a key driver of expenditure. On average, approximately 53% of total expenditure was allocated to care services, 20% to administration and 17% to case management. This study was undertaken during the initial stages of the transition to CDC. Further research should investigate the longer-term budgetary impacts of the transition to CDC for consumers and the sector.