- Email: [email protected]
Discharge Planning from the acute sector for people over the age of 65
DISCHARGE PLANNING from the acute sector for people over the age of 65 This paper reports the findings relating to discharge planning from a larger study (Hegney et al 2001) that aimed to investigate options to improve care co-ordination between the aged, community, acute and primary care sectors for the elderly residents of a large provincial town. The data, which were collected from a wide variety of aged care stakeholders in the region, are consistent with previous Australian studies. First, it appears that inappropriate discharge from acute hospitals occurs in Toowoomba because there is a perceived lack of information regarding the available community care options and a lack of suitable models to support people's care needs within their own homes. Second, inappropriate discharge practices from acute hospitals occur due to a lack of knowledge and communication on the part of health professionals employed in these settings with regard to the on-going health care needs of elderly people. Third, there is little discharge planning occurring that includes the general practitioner in post-discharge care. Finally, inappropriate discharge can also be attributed to the lack of sub-acute/step-down/rehabilitation options and long waiting lists for community home care services in the region. By Desley Hegney, Alexandra McCarthy, Mary Beth de la Rue, Paul Fahey, Don Gorman, Kris Martin-McDonald, Grace Pretty and Deborah Sundin-Huard. • Key words: discharge planning, acute/community interface, older people, health care co-ordination.
Introduction This
project
convalescent places for the elderly w h o arose
from
concerns
are discharged from acute health facili-
expressed by (he aged care provider com-
ties. There was also a perception amongst
munity in Toowoomba regarding the ade-
aged care providers that the hospitals in
q u a c y ol h e a l t h care provision tor the
the region experienced significant pres-
elderly people of the region. Stakeholder
sure to maintain high levels of inpatient
concerns that related to discharge plan-
acuity, which reputedly led to inappropri-
ning i n c l u d e d a p e r c e i v e d lack of sub-
ate early discharge of elderly people. Fur-
acute, slow-stream rehabilitation
thermore, there were long waiting lists for
or
Desley Hegney RN BA(Hons) PhD FRCNA FCN(NSW), Head, Centre for Rural and Remote Area Health, University of Southern Queensland Alexandra McCarthy RN MN MRCNA, Senior Lecturer and Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland, Email: [email protected] Mary Beth de la Rue RN DipAppSc(N Admin) BAppSc(Nsg) GradDipEdfTert) MN PhD FRCNA, Lecturer, Department of Nursing, University of Southern Queensland Paul Fahey BSc MMSc, Department of Mathematics and Computing, University of Southern Queensland Don Gorman RN (EndMH) DipNEd BEd MEd EdD FRCNA FANZCMHN, Department of Nursing, University of Southern Queensland Kris Martin-McDonald RN BAppSc(Nsg) MEd PhD, Senior Lecturer, Department of Nursing, University of Southern Queensland Grace Pretty BSc(Hons) MSc PhD MAPS, Department of Psychology, University of Southern Queensland Deborah Sundin-Huard RN BN(Hons), Research Assistant, Department of Nursing, University of Southern Queensland Collegian Vol 9 No.1! 2002
15
[REFEREED ARTICLE!
Fhs* (JU'iito i indicate t h o t a n Mdvo«?cH*y r o l e IH p£srar";y8*irSy i m p o r t a n t in t h e cJisebarcfe p l a ^ m m * pm^&sss, b e c a u s e e l d e r l y p e o p l e &md th&h c a r e r s an?, makincg c h o i c e s for their f u t u r e at a t i m e
Croup members (63%), particularly when this nurse acts as an advocate for the aged person to e n s u r e their c h o i c e s are not ignored. T h e role of the C L N is, in consultation with hospital staff, to identify those people at risk of injury or continued ill health after discharge. T h e y initiate the discharge care planning of these more
esrss pes ir U I ; M
complex cases, organising ACAT assess-
residential aged care p l a c e m e n t after a
the continuum of care, were the focus of
ments and referring clients to community
hospital episode in the region,- and evi-
t h e parent s t u d y ( H e g n c y ct al 2 0 0 1 ) .
or residential services as necessary. T h e
dence to suggest that the general practi-
This paper examines these issues in terms
C L N also increasingly initiates case con-
tioners in the region were not effectively
of discharge planning only.
ferencing with the patient's GP, medical specialist, family members, nurses, allied
managing the chronic and complex care n e e d s ol t h e i r e l d e r l y p a t i e n t s in t h e
health professionals and community ser-
home, resulting in an unnecessarily high
Method Research questions
rate of re-hospitalisation or nursing h o m e
T h e overall research q u e s t i o n s for this
placement.
study were:
vices to facilitate care over the continuum. T h e data i n d i c a t e that an a d v o c a c y
1. W h a t are the issues and their underly-
role is particularly important in the discharge planning process, because elderly
Background to the study
ing causes with regard to the health
T h e provincial city of Toowoomba had a
and support needs of older people in
people and their carers are making choic-
population in June 2000 of 87 644. It is
T o o w o o m b a w h o have e x p e r i e n c e d
es for their future at a lime when they are particularly vulnerable. In 12 of the 15
ihe major c e n t r e s e r v i c i n g t h e largely
admission to an acute facility and who
a g r i c u l t u r a l D a r l i n g D o w n s Statistical
require access to further services upon
interviews with elderly clients, it became
Division (SD), which has a total popula-
discharge?
evident that many perceived they were
tion of 230 736 ( Q u e e n s l a n d G o v e r n -
2. W h a t are the p o s s i b l e o p t i o n s a n d
d e p e n d e n t u p o n o t h e r s to m a k e t h e i r
ment 2001). Consistent with the national
solutions with regard to the health and
future care choices for them (80%). Por
data that indicates there are more elderly
s u p p o r t n e e d s of o l d e r p e o p l e in
four of these clients, this loss of indepen-
people in rural than metropolitan areas,
Toowoomba w h o have experienced
dence was acceptable on the grounds that
the Darling Downs SD has an older pop-
admission to an acute facility and who
they trusted the people making
ulation than many other areas of Queens-
require access to further services upon
choice for them (26%). For eight, the loss
land, including t h e capital of Brisbane.
discharge?
of independence resulted in anger, a sense of powerlcssness, or a d e t e r m i n a t i o n to
For example, in 1996 the Darling D o w n s SD recorded the equal third highest proportion ol people aged over 65 years in t h e State of Q u e e n s l a n d (n = 23 234,12.5%) (Australian Bureau of Statistics [ABS] 1997). T h e elderly p o p u l a t i o n is even more c o n c e n t r a t e d within
the
Toowoomba City boundary, with I 1 541
Sampling, inclusion criteria, data collection and data analysis
city itself (ABS 1997).
control whatever aspect of the discharge process that they could (53%).
T h e study involved a complex multimethod, multi-site and multi-agency where (Hegney et al 2001). A brief out-
Services available upon discharge by Statistical Local Area in Toowoomba community
line is provided in Table 1.
T h e r e are 37 c o m m u n i t y s e r v i c e s in
a p p r o a c h that is d e s c r i b e d in full else-
elderly people, or I 3.8% of the total population of T o o w o o m b a , resident in the
the
T o o w o o m b a . H o w e v e r , t h e H o m e and
Ethics
C o m m u n i t y C a r e ( H A C C ) s e r v i c e s in
Ethics clearance was o b t a i n e d from the
Toowoomba provide the majority of ser-
U n i v e r s i t y of S o u t h e r n
Queensland's
vices to t h e t a r g e t p o p u l a t i o n of this
elderly Australians are admitted for acute
H u m a n Research and Ethics C o m m i t t e e
study. Data supplied for O c t o b e r 2 0 0 0
care, the regularity with which they arc
(Ref : H O l R E A l 3 2 ) , t h e T o o w o o m b a
i n d i c a t e t h a t H A C C c a t e r e d for 71 1
d i s c h a r g e d i n t o c o n t i n u i n g care (Aus-
Health Service District and Blue Care.
clients that m o n t h , of which 550 (77%)
Given the frequency with
which
tralian Institute of H e a l t h and Welfare [ A 1 H W ] 1999, H a g a n & C o o p e r 1999)
were female and 161 ( 2 3 % ) male. Four
and the local problems identified by aged
Results Discharge planning
care stakeholders that were the impetus
hundred and eighty-three (68%) H A C C clients were living alone. T h e remaining
T h e majority of interviewees and focus
288 (32%) lived with a partner, family or
for this study, it is reasonable to assume
group participants believed that discharge
carer. Further, data provided by ACAT on
that there is a consistent need for access
planning should c o m m e n c e early in the
t h o s e clients w h o had b e e n assessed in
to longer term, sub-acute health care fol-
acute hospital episode. T h e recent intro-
2 0 0 0 i n d i c a t e d t h a t of t h e 878 c l i e n t s
lowing an e p i s o d e of hospitalisation in
d u c t i o n of t h e C l i n i c a l Liaison N u r s e
assessed for either aged care or C A C P s
t h e T o o w o o m b a r e g i o n . Issues at t h e
( C l . N ) in the private acute care s e c t o r
p a c k a g e s , 225 (25%) were receiving
interface of a c u t e a n d o n g o i n g h e a l t h
was viewed as a positive development in
h o m e help H A C C services, 186 (2 1%)
care lollowing an acute episode, across
this d i r e c t i o n by ten of t h e Reference
were receiving h o m e nursing 1 I A C C ser-
16
Collegian Vol 9 No 3 2002
TABLE 1: DATA COLLECTION FOR THE T O O W O O M B A C O M M U N I T Y DEVELOPMENT PROJECT Data collection source
Type of data collection
Residential Aged Care Facilities (RACF), HACC, ACAT, Retirement Villages (letterbox drop of survey), carers* in community (telephone used to recruit)
Survey - purposive sampling. (Distributed by RACFs, HACC and ACAT, letterbox drop and telephone used to identify carers). Collected resident and carer data on demographics; details of and issues around hospital admission
RACF (low care patients)
Focus group - 2 facilities
Number
Number
approached
participated
rate
491
71 clients 54 carers
25.4%
20
N/A
_____
16
Participation
N/A
RACF (high care patients)
Interviews
10
RACF, patients on waiting list; CACPs and admission data
Survey (completed by RACF staff) - demographics and needs of residents, services provided by facility, issues surrounding care provision
21 facilities
19 facilities
R A C F - C D H A C data
De-identified data demographics, service needs
All facilities
Allfacilities100%
Community Service Providers
Survey data - demographics and service needs of clients; range of services provided. Many did not have these records
37 facilities
6 provided useable data
1 6.2%
HACC data
De-identified data - picture for one month. Did not have ability to capture data for 1 year. Client demographics and services needed
1 HACC service
1
100%
ACAT data on clients in 2000
De-identified data demographics of clients, service needed
1 ACAT service
Provided data for 12 month period
100%
GPs
Survey (distributed by the Division of General Practice)
50
12
24%
Persons receiving aged care services hospitalised in last 12 months
Survey
491
71
15%
Community carers of eligible patients
Interviews
10
10
N/A
Community carers of eligible patients
Focus groups
5
5
N/A
Community carers of eligible patients
Surveys
532
54
9%
Key stakeholders (reference group and others)
Interviews
19
19
100%
Health care providers
Focus groups (two held) Surveys of aged care facility staff
13 50
13 22
100% 44%
Key stakeholders
Discussion at meetings - 1 w i t h 4 CACPs providers; 2 Queensland Council of Ageing meetings - approximately 20 people per meeting
3 meetings
3 meetings
100%
Hospital admission data - t w o private and one public hospitals
DRGs, length of stay, demographics, referral source, waiting times for assessment and placement, discharge destination.
Data from all three facilities
One facility could provide limited data
100%
Hospital morbidity and mortality data
(All postcodes of study provided by AIHW) - DRGs, gender and age group for 1998 to 2000 for all males and females over 65 years of age
N/A
Data provided by A I H W
N/A
Acute public hospital long stay patients over 65 years
Interview - long stay w a s defined as a patient w h o had been in an acute facility for more than 35 days.
20
15
N/A
Hospital admission/discharge staff
Interviews
3
3
N/A
1
1
90.5%
- one admission/liaison nurse at each hospital - one person responsible for 'hospital in home program'
'Carers defined as those w h o invest significant personal and/or financial resources in the care of an elderly person Collegian Vol 9 No3 2002
17
[REFEREED ARTICLE]
vices,- a n d 4 3 ( 5 % ) w e r e
receiving
preparing to leave hospital. T h o s e w h o
cussed with t h e client and their family.
CACPs. Analysis of the data according to
did experience p r o b l e m s indicated that
T h e consensus of t h e Reference C r o u p
the five Statistical Local Areas (SLAs) of
hospital organisational procedures caused
was that inappropriate discharge occurred
Toowoornba indicated that there were
c o n c e r n . T h i s w a s also a m a j o r issue
when there was a lack of adequate sup-
strong statistically significant
differences
raised by 23 health care providers (23%),
port, poor timing, or the person was not
b e t w e e n t h e SLAs and those w h o were
19 patients (22%), and 11 carers (16%).
placed in the optimum facility due to the
living alone, living with a partner, living
The
lack of community services.
with relatives or had other living arrange-
p r o v i d e r s was insufficient
major
issue for h e a l t h
service
inlormation
ments (p>.001) (see Table 2). However,
provided for follow-up management. For
t h e r e w a s weak statistical e v i d e n c e of
carers, it was the lack of support provided
Waiting lists for home services and subsequent delays in discharge Data supplied by the H o m e and Commu-
a s s o c i a t i o n b e t w e e n t h e use of h o m e
b y h o s p i t a l staff for p a c k i n g u p t h e
c a r e / h o m e help and SLA ( p > . 0 2 5 ) (see
patient's b e l o n g i n g s , or dressing the
nity Care ( H A C C ) team for the m o n t h of
l a b l e 3), a n d t h e r e was n o e v i d e n c e of
patient prior to discharge.
February 2001 indicated that at least 200
association between the use of home nurs-
Fifteen providers (15%) also perceived
elderly p e o p l e in T o o w o o r n b a w e r e on
ing services and SLA (see Table 4). These
problems with the provision of transition
their waiting lists for home help, and that
results suggest that whilst there were dif-
services and short-term care. In contrast,
there was generally a m a x i m u m of t w o
f e r e n c e s in t h e living a r r a n g e m e n t s of
only four patients (5%) and three carers
weeks wait for domiciliary services from
ACAT clients in 2000, there were no dif-
(5%) reported the provision ol transport
the lime of referral. H A C C did report,
ferences in the availability ol home nurs-
as problematic prior to discharge. Addi-
however, a I 2 to 18 month wait for some
i n g s e r v i c e d e l i v e r y by g e o g r a p h i c a l
tionally, providers placed more emphasis
home care services if the person was not a
location in Toowoornba.
on the importance of mental health dur-
H A C C recipient prior to their hospital
ing the transition to discharge, with IK
a d m i s s i o n . If t h e y w e r e r e c e i v i n g a
t h e r e w e r e l o n g d e l a y s in w a i t i n g for
(18%) indicating that this was an issue in
H A C C service before admission for an
H A C C services and CACPs packages for
comparison to four (5%) patients and five
acute episode, there was no waiting peri-
many people requiring these services in
(7%)
od for this to he reinstated.
Toowoornba.
were expanded upon during the individual
H o w e v e r , as will be discussed later,
c a r e r s . These p r o v i d e r c o n c e r n s
interviews c o n d u c t e d with 19 Reference C r o u p members. Twelve members of the
Lack of rehabilitation and step-down post acute episode
Twenty-five (29%) elderly inpatients and
Reference Group (63%) believed that dis-
All ol t h e R e f e r e n c e C r o u p m e m b e r s
17 (25%) of their carers w h o responded
charge planning should be initiated early
identified the shortfall of care available to
to the survey reported no difficulties in
in the hospital episode and should be dis-
a group ol at-risk aged people discharged
Issues on discharge
from hospital to their own h o m e . AccordTABLE 2: LIVING ARRANGEMENTS BY SLA - PERCENTAGE SLA
North W e s t
Living alone
Living w i t h
Living w i t h
partner
relatives
40.2
17.2
19.5
ing to these participants, there was a periOther living
o d after discharge when rcadmission or a
23.1
for this c o h o r t . T h i s was when deficits
new admission was more likely to occur
North East
43
35.5
9.3
12 1
h a d n o t b e e n i d e n t i l i e d in h o s p i t a l or
West
41 7
36.6
17.6
4.2
appropriate step-down facilities were n o t
Central
46.3
22.6
10.2
20.9
available. As a result, elderly people were
South East
43.9
22.4
9.7
, 24
re-hospitalised due to falls or an inability to a d e q u a t e l y m e e t t h e i r h y g i e n e a n d nutrition needs when they were sent
TABLE 3: USE 0 F H O M E CARE / H O M E HELP
PbH( "ENTAGES BY SLA
home following an acute episode. Further-
SLA
Horn e help
North W e s t
21.6
North East
28
West
31.8
68.2
unnecessarily in a nursing h o m e for their
Central
27 5
72.5
own p r o t e c t i o n . T h i s perception of t h e
South East
18.9
81.1
Reference C r o u p members was confirmed
No h o m e lelp 78.4 ' 71
m o r e , it a p p e a r e d t h a t w h e n p o t e n t i a l problems are identified prior to discharge, these aged people are sometimes placed
by t h e morbidity data that indicated in TABLE 4: USE 0 F HOWIE N UHSINC3 - PERCENTAGES> BY SLA SLA
Horn e nursing
No home nursing
2000 that no O R G for rehabilitation was linked to the acute or private hospitals in Toowoornba.
North W e s t
22.2
77.8
North East
20.6
79.2
A slow-stream rehabilitation model of
West
22.6
77.4
care to address this shortfall was consid-
Central
21.9
j
78.1
ered necessary by 12 aged recipients of
South East
17.9
I 82 1
care ( 3 4 % ) , eight of their carers ( 8 0 % ) and 14 members of the Reference C r o u p
18
Collegian Vol
[This] can be a real problem because the fact that they don't get any help when they go home may mean that their convalescence is protracted or may even tip them into that area where they actually need HAC.C services .. there needs to he some sort of interim support program.
(74%). This would allow the aged client ihe o p p o r t u n i t y to recover fully before r e t u r n i n g to their former place of residence.
The adequacy of services after discharge
McCallum & Bye 1998). It appears, therefore, that a reasonable discharge planning filler is provided by directing attention to those w h o already have had hospital stays longer than average for their condition. It is a p p a r e n t from the T o o w o o m b a data that the two private hospitals emphasise
Further, o t h e r providers w h o were
Questionnaire items probed the difficulties that elderly people, their carers and
interviewed staled that aged care clients
service p r o v i d e r s p e r c e i v e d u p o n dis-
had deteriorated after a hospital admis-
charge, in addition to the additional sup-
sion. 1 hey explained:
the identification of this c o h o r t by the employment of the CLN. Use of community post
ports they required and their suggestions to facilitate service delivery during this time. T h e burden on caregivers was obvi-
We f i n d a n u m b e r of p r o b l e m s - skin
It was n o t p o s s i b l e in this s t u d y , for
integrity problems that we never had in
methodological reasons, to calculate the
the first place.
ous from these data. Forty carers (40%)
percentage of uptake of community ser-
They (aged patients post discharge) always come back worse. 1 have to tell you in all the years I've worked in aged care, that rarely does anybody come back better. They come back worse, particularly the low care.
reported much more difficulty with the elderly person's activities of daily living than either the elderly person (n = 3l or 29%) or service providers (n= 16 or 15%). Service providers did, however, indicate
services
discharge
vices after hospital discharge by elderly people in Toowoomba. O t h e r Australian studies, however, indicate that post-acute clients accounted for more than half of all referrals to c o m m u n i t y nursing services (Fine et al 1997) and that one in four dis-
more often that the elderly person needed other supports post-discharge, particu-
Discussion
c h a r g e d clients utilised c o m m u n i t y ser-
larly those related to mental health (n = 26
Discharge
vices upon returning home (McCallum &
or 25%)), than patients and carers (n=18
T h e data collected from residents, health
Bye 1998). Nursing and h o m e help ser-
planning
or 17% and n = 1 8 or 15% respectively).
care providers and carers indicated that
vices appear to be the most c o m m o n l y
T h i s result could be attributed to their
many elderly people admitted to hospital
accessed (Street 1995, Fine et al 1997,
g r e a t e r k n o w l e d g e of the supports that
were at risk of re-hospitalisalion (either as
McCallum & Rye 1998).
are n o t a v a i l a b l e . ' M e n t a l h e a l t h ' was
a new a d m i s s i o n or a r e - a d m i s s i o n ) il
defined as issues such as fear of b e i n g
their potential problems were not identi-
alone, feelings of c o n c e r n or a p p r e h e n -
fied early in their hospital episode, and
I h e results of this s t u d y (for e x a m p l e
sion, crying, depression and so on.
referral to residential or community care
only 17 (31.4%) carers stating there were
Carer burden
was not implemented as soon as possible
no problems related to discharge of their
after discharge 11 was apparent from the
caree to their care) indicate that those
data that t h e r e were t w o issues taking
discharged into the c o m m u n i t y arc at a
A major theme from the survey data was
place. First, carers, patients and providers
greater risk of precipitating carer burden.
t h e n e e d for a d d i t i o n a l s u p p o r t a n d
of
services
In particular, 40 carers (74%) r e p o r t e d
i m p r o v e m e n t s to b e i n t r o d u c e d w i t h
expressed the view that patients dis-
issues related to managing the activities
regard to transition services/short term
c h a r g e d from the acute s e c t o r w i t h o u t
of daily living of their caree in the days
care. For e x a m p l e , 16 carers ( 1 8 % ) , 10
community services on discharge deterio-
after leaving the hospital. Further, b o t h
providers (28%), and 10 patients (18%)
rated while they waited for c o m m u n i t y
carers and general practitioners expressed
identified a need for additional support in
services. Second, those patients who
the view that many elderly people were
the short-term, and 19 patients (22%), 17
remained in hospital waiting for admis-
discharged home before they were men-
p r o v i d e r s ( 2 3 % ) , a n d 14 c a r e r s ( 1 8 % )
sion to an RACF were likely to deterio-
tally a n d / o r p h y s i c a l l y r e a d y for dis-
believed that this area required improve-
rate due to the lack of rehabilitation or
charge. In some cases, carers were advised
ment. Areas identified included hospital
step-down beds available
t h a t if t h e y c o u l d n o t c o p e w i t h t h e
Transition services/short
term care
aged
community
care
staff to p r o v i d e h o m e visits, sufficient
Similar Australian studies reinforce
community care staff, a c o n t a c t number
this finding, and indicate that in particu-
to ring to discuss health concerns, volun-
lar, d i s c h a r g e p l a n n i n g involving p o o r
teers to visit for a talk, more home help
a s s e s s m e n t a n d d o c u m e n t a t i o n in t h e
when needed and more home nursing ser-
acute phase compromises client outcomes
vices.
on their return to their previous place of
Additionally, the data collected from
residence (McCallum & Bye 1998). Fur-
meetings with the CACPs providers, from
ther, the literature suggests that a greater
the focus g r o u p s and from i n t e r v i e w s
p r o p o r t i o n of t h e elderly w h o require
indicated a need for immediate home care
community services after discharge from
s u p p o r t on d i s c h a r g e for p a t i e n t s w h o
hospital arc likely to be those who under-
had complex and chronic care needs. As
go a long hospital stay for a complex con-
one provider stated:
d i t i o n ( S t r e e t 1 9 9 5 , Fine et al 1 9 9 7 ,
client, then the only option was for an RACF placement. This has been raised as an issue in previous studies where, despite the presence of a carer, there was concern that the inadequate interface between the acute and community sectors and the carers necessitated premature institutionalisation or repeat hospital admission of the elderly person (hiealy 1998). This further e m p h a s i s e d the need for a d e q u a t e and early assessment in the acute system and communication networks between the carers, general practitioners, community Collegian Vol 9 No 3 2002
19
services and the acute hospital sector.
in co-ordinated care. However, Australian
Brisbane in September 2001 indicates that
There is evidence in the results to sug-
data ( C D H A C 200 l b ) have s u g g e s t e d
the Commonwealth Carelink program is a
gest that an extension ol current commu-
that models of care in which GPs are the
relatively recent strategy, and to date its
nity services to i n c o r p o r a t e h i g h care
main care co-ordinator lend to emphasise
efficacy has not been formally evaluated.
clients would facilitate the elderly per-
the medical aspects of the care plan at the
However, if this program does meet its
son's return to home after an acute hospi-
expense of the o t h e r holistic aspects of
objectives of providing information on
tal episode, and allow them to remain in
care and communication processes. Non-
not only the services available locally but
(heir h o m e r a t h e r than e n t e r an RACF
medical care co-ordinalors, such as CLNs
eligibility criteria, it is apparent that it will
( C o m m o n w e a l t h D e p a r t m e n t of H e a l t h
and designated case managers, are more
overcome the lack of information on ser-
and Aged Care [ C D H A C ] 2001a) Simi-
likely
other
vices not only for providers but also for
larly, the Extended Aged Care at H o m e
p r o v i d e r s a n d to formulate c a r e plans
the residents ol Toowoomba (McCauley
(EACH) services that are currently being
inclusive
et al 1997, Reed & Morgan 1999, Cheek
trialled in various States in Australia oiler
( C D H A C 200 ib).
to
communicate of
with
community
services
et al 1999). It is possible, therefore, that C o m m o n w e a l t h C a r e l i n k C e n t r e s may o v e r c o m e some of the issues raised by
The corwensus of the Reference O r o y p ot Service providers in the regions mclieated t h a t there was a s h o r t f a l l of care available; t o elderly people discharged t o their o w n homes In the region am:J thai in^-acloiisskMu was fikeiy f o r t h i s cohort,,
Toowoomba people regarding their lack of knowledge of the availability of services within Toowoomba.
Conclusion T h e data from this study indicate that communication and liaison between the primary care providers (general practitioners), the acute care sector (both public a n d private), the c o m m u n i t y sector
care at least equivalent to high-level resi-
As a result of this study, two options
dential care. EACH services facilitate care
for p o s t - d i s c h a r g e care for the elderly
aged care facilities
p l a n n i n g , meet t h e e x p r e s s e d needs ot
emerged ( H e g n e y et al 2001). First, the
Toowoomba region.
carers and clients, are cost effective and
current C L N model that is of proven effi-
O n e of the major issues arising from
are considered viable in rural areas such
cacy in the private sector in Toowoomba
these T o o w o o m b a data c o n c e r n e d what
as Toowoomba ( C D H A C 2001a).
could be introduced into the public sec-
the research team defined as the 'mental
tor. T h e success of this would be condi-
health' of the patients and their carers. It
(private and public) and the residential is p o o r
in
the
tional u p o n t h e q u a l i t y and e x t e n t of
is apparent that when discharge occurs
T h e consensus of the Reference C r o u p of
c o m m u n i c a t i o n and case c o n f e r e n c i n g
before the patient and carer feel ready, or
service providers in the region indicated
between the GP, the C L N and the hospi-
lacks communication between providers,
that there was a shortfall of care available
tal staff. Second, in the longer term, key
patients and their carers, it is of no bene-
to elderly people discharged to their own
s t a k e h o l d e r s s h o u l d c o n s i d e r h o w the
fit to any one concerned with the care of
h o m e s in the region and that re-admis-
i m p l e m e n t a t i o n ol a case m a n a g e m e n t
the elderly. T h e introduction of a slow-
sion was likely for this c o h o r t . T h e s e
/advocate model might operate with
stream, step-down or rehabilitation unit
findings correlate with o t h e r Australian
regard to discharge planning and access
w i t h i n T o o w o o m b a w o u l d a l l o w for
research, which reports that one in four
to appropriate services in the Toowoom-
greater preparation for discharge, particu-
elderly patients are re-hospitalised within
ba r e g i o n . T h i s s e c o n d o p t i o n w o u l d
larly discharge back to t h e c o m m u n i t y
six m o n t h s of the initial acute hospital
decrease the current duplication of assess-
for those clients w h o have c h r o n i c and
episode (Fine et al 1997) with an average
ments and services. It would also ensure
complex care needs. Further, extension of
of 2.7 admissions for each elderly person
that holistic care would be provided by
E A C H packages to T o o w o o m b a w o u l d
(McCallum & Bye 1998). Fine, Sitsky and
all the necessary health professionals.
allow elderly people requiring high care,
Re-admission after acute
H o e w (1999) argue that
discharge
subsequent
T h e study also found that there was a
admission is more likely for patients after
lack of awareness on the part of carers,
hospitalisation if they are still dependent
residents and health prolessionals (partic-
on others to accomplish their activities of
ularly CPs) with regard to the types and
daily living al discharge.
cost of post-acute services available to the elderly in Toowoomba.
Commonwealth
The role of GPs, liaison nurses and
Carelink C e n t r e s , which are funded by
case managers in discharge
the C D H A C , are designed to be a single
T h e results of this s t u d y i n d i c a t e t h a t
point of contact for clients, health profes-
there is a need for better communication
sionals and carers s e e k i n g i n f o r m a t i o n
amongst all aged care service providers in
regarding the community and residential
order to facilitate greater C P involvement
service options available. A forum held in
20
Collegian Vol 9 No 3 2002
w h o wish to stay at h o m e , to r e m a i n there longer.
Further research T h i s study m a d e 26 r e c o m m e n d a t i o n s ( H e g n e y et al 2001). T h e main task of the research team, working in collaboration with the acute hospitals, community aged care providers and residential aged care facilities is to operationalisc these recommendations. T h e research team and
[REFEREED ARTICLE]
Reference Group believe the recommendations provide a guide to the develop-
teristics for statistical load ateas. Queensland AC,PS, Australian Institute o f H e a l t h a n d Welfare 1999
A g e d C a r e Issues A f f e c t i n g A u s t r a l i a , T h e
Ohter Austynluiiis
incorporates adequate discharge plan-
A G E - I 2 . A I H W , Canberra
and r e h a b i l i t a t i o n , inclusion of general
at a glance A I I I W
Cat N o .
C h e e k J, f i a l l a n t y n e A , T u c k e r M 1999 Copnuf with crisis, won' Australian families semen foy and select an titled (.arc facility
for a family
member upon dis-
charge from an acute cafe setting.
adequate community service provision. It
Research i n t o N u r s i n g a n d A l l i e d
come the majority ol the issues raised in this research and would be of benefit to similarly sized provincial cities in Australia.
Centre for Health
Care, U n i v e r s i t y o f S o u t h Australia, Adelaide Commonwealth
Department o( Health a n d
A g e d Care 2001a Evaluation of the extended ailed tare at home pilot program C D H A C , Canberra Commonwealth
D e p a r t m e n t of H e a l t h a n d
A g e d Care 2001b The Australian coordinated care trials: final
technical
national
evaluation
tepoil.
C D H A C , Canberra
Acknowledgements T h i s study was funded by a grant From
delivery models at the boundaries of aged care progreims
the
Social Policy Research C e n t r e , U n i v e r s i t y o l
Commonwealth
Department
of
extends its sincere thanks to the elderly
Fine M , T u r v e y K , D o y l e J 1997 The provision of services.
Social
Policy
people, their carers, members of the Ref-
Research C e n t r e , U n i v e r s i t y o f N e w S o u t h
erence Croup and service providers who
Wales, Sydney
participated in the study.
H e g n e y D , d c la Rue B, G o r m a n D , M a r t i n M c D o n a l d K, M c C a r t h y A , Pretty C , Sundin[ luard D 2001 Toowoomba community development planning project' acute health scivice.'aged cute interjaie -consultancy
i V k C a l l u m .1, Bye R 1998 Improving post-acute caie outcomes for older people C e n t r e o f 1 i e a l t h O u t comes a n d I n n o v a t i o n s Research, U n i v e r s i t y of Western Sydney, M a c A r t h u r M c A u l e y W , Travis S, S a f e w r i g h t M 1997 Pers e l e c t i o n process. Qualitative
Q u e e n s l a n d G o v e r n m e n t 2001 Coipiipitijiify cabinet 23/07/2001: woomba.htm ple from hospital t o care homes: i m p l i c a t i o n s
C o m m o n w e a l t h Department o( H e a l t h and
20(4):8l9-825
12/02/2001;
Care,
http://www.oesr.qld.gnv.au/daa/
pubhcations/tommunity_cab/toowoomba/too
for
Aged
Health Research
7(21:236-254
pital admissions and discharges, older Australia)!;
Australian Bureau o f Statistics 1997 Census ojpopulation and housing, selected social and housing charac-
report. L l n i v c r s i t y o f S o u t h e r n
(Queensland, T o o w o o m b a
Reed J, M o r g a n D 1999 D i s c h a r g i n g older peo-
H a g a n P, C o o p e r C 1999 Some characteristics of hos-
References
24/01/2001:
repott May 200 1 - Toowoomba. U R L accessed
N e w South Wales, Sydney
post-hospitalisation
U R L accessed
h t t p i ' V w w w cota o r g au'agecareh.htm
sonal accounts o f the nursing h o m e search and
Fine M , Silsky I., H o c w A 1999. Stocktake of set vice
Health and Aged Care. The project team
H e a l t h , F a m i l y Services s. Veteran's A f f a i r s Committee.
practitioners into discharge planning, and
is envisaged that this model would over-
President
C o u n c i l o n the A g e i n g (Australia! Seminar o n
ment of a unified system of care w h i c h
ning, the use of step-down, slow-stream
I l e n l y J 1998 A d d r e s s b y N a t i o n a l
AUS Catalogue N o . 2015.3. ABS, Canberra
Canberra.
U R L accessed
http://www.heallh.gov.au/pubs/
hlsocc/ocpanew8a.hlm
nursing.
Journal
of Advanced
Nursing
Street P 1995 Posl-ncuff community services C e n t r e for A p p l i e d G e r o n t o l o g y , Bundoora L x t e n d e d Care C e n t r e , M e l b o u r n e
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.www.maynegroup.com C o l l e g i a n V o l 9 N o 3 2002
21
Introduction This
project
convalescent places for the elderly w h o arose
from
concerns
are discharged from acute health facili-
expressed by (he aged care provider com-
ties. There was also a perception amongst
munity in Toowoomba regarding the ade-
aged care providers that the hospitals in
q u a c y ol h e a l t h care provision tor the
the region experienced significant pres-
elderly people of the region. Stakeholder
sure to maintain high levels of inpatient
concerns that related to discharge plan-
acuity, which reputedly led to inappropri-
ning i n c l u d e d a p e r c e i v e d lack of sub-
ate early discharge of elderly people. Fur-
acute, slow-stream rehabilitation
thermore, there were long waiting lists for
or
Desley Hegney RN BA(Hons) PhD FRCNA FCN(NSW), Head, Centre for Rural and Remote Area Health, University of Southern Queensland Alexandra McCarthy RN MN MRCNA, Senior Lecturer and Research Fellow, Centre for Rural and Remote Area Health, University of Southern Queensland, Email: [email protected] Mary Beth de la Rue RN DipAppSc(N Admin) BAppSc(Nsg) GradDipEdfTert) MN PhD FRCNA, Lecturer, Department of Nursing, University of Southern Queensland Paul Fahey BSc MMSc, Department of Mathematics and Computing, University of Southern Queensland Don Gorman RN (EndMH) DipNEd BEd MEd EdD FRCNA FANZCMHN, Department of Nursing, University of Southern Queensland Kris Martin-McDonald RN BAppSc(Nsg) MEd PhD, Senior Lecturer, Department of Nursing, University of Southern Queensland Grace Pretty BSc(Hons) MSc PhD MAPS, Department of Psychology, University of Southern Queensland Deborah Sundin-Huard RN BN(Hons), Research Assistant, Department of Nursing, University of Southern Queensland Collegian Vol 9 No.1! 2002
15
[REFEREED ARTICLE!
Fhs* (JU'iito i indicate t h o t a n Mdvo«?cH*y r o l e IH p£srar";y8*irSy i m p o r t a n t in t h e cJisebarcfe p l a ^ m m * pm^&sss, b e c a u s e e l d e r l y p e o p l e &md th&h c a r e r s an?, makincg c h o i c e s for their f u t u r e at a t i m e
Croup members (63%), particularly when this nurse acts as an advocate for the aged person to e n s u r e their c h o i c e s are not ignored. T h e role of the C L N is, in consultation with hospital staff, to identify those people at risk of injury or continued ill health after discharge. T h e y initiate the discharge care planning of these more
esrss pes ir U I ; M
complex cases, organising ACAT assess-
residential aged care p l a c e m e n t after a
the continuum of care, were the focus of
ments and referring clients to community
hospital episode in the region,- and evi-
t h e parent s t u d y ( H e g n c y ct al 2 0 0 1 ) .
or residential services as necessary. T h e
dence to suggest that the general practi-
This paper examines these issues in terms
C L N also increasingly initiates case con-
tioners in the region were not effectively
of discharge planning only.
ferencing with the patient's GP, medical specialist, family members, nurses, allied
managing the chronic and complex care n e e d s ol t h e i r e l d e r l y p a t i e n t s in t h e
health professionals and community ser-
home, resulting in an unnecessarily high
Method Research questions
rate of re-hospitalisation or nursing h o m e
T h e overall research q u e s t i o n s for this
placement.
study were:
vices to facilitate care over the continuum. T h e data i n d i c a t e that an a d v o c a c y
1. W h a t are the issues and their underly-
role is particularly important in the discharge planning process, because elderly
Background to the study
ing causes with regard to the health
T h e provincial city of Toowoomba had a
and support needs of older people in
people and their carers are making choic-
population in June 2000 of 87 644. It is
T o o w o o m b a w h o have e x p e r i e n c e d
es for their future at a lime when they are particularly vulnerable. In 12 of the 15
ihe major c e n t r e s e r v i c i n g t h e largely
admission to an acute facility and who
a g r i c u l t u r a l D a r l i n g D o w n s Statistical
require access to further services upon
interviews with elderly clients, it became
Division (SD), which has a total popula-
discharge?
evident that many perceived they were
tion of 230 736 ( Q u e e n s l a n d G o v e r n -
2. W h a t are the p o s s i b l e o p t i o n s a n d
d e p e n d e n t u p o n o t h e r s to m a k e t h e i r
ment 2001). Consistent with the national
solutions with regard to the health and
future care choices for them (80%). Por
data that indicates there are more elderly
s u p p o r t n e e d s of o l d e r p e o p l e in
four of these clients, this loss of indepen-
people in rural than metropolitan areas,
Toowoomba w h o have experienced
dence was acceptable on the grounds that
the Darling Downs SD has an older pop-
admission to an acute facility and who
they trusted the people making
ulation than many other areas of Queens-
require access to further services upon
choice for them (26%). For eight, the loss
land, including t h e capital of Brisbane.
discharge?
of independence resulted in anger, a sense of powerlcssness, or a d e t e r m i n a t i o n to
For example, in 1996 the Darling D o w n s SD recorded the equal third highest proportion ol people aged over 65 years in t h e State of Q u e e n s l a n d (n = 23 234,12.5%) (Australian Bureau of Statistics [ABS] 1997). T h e elderly p o p u l a t i o n is even more c o n c e n t r a t e d within
the
Toowoomba City boundary, with I 1 541
Sampling, inclusion criteria, data collection and data analysis
city itself (ABS 1997).
control whatever aspect of the discharge process that they could (53%).
T h e study involved a complex multimethod, multi-site and multi-agency where (Hegney et al 2001). A brief out-
Services available upon discharge by Statistical Local Area in Toowoomba community
line is provided in Table 1.
T h e r e are 37 c o m m u n i t y s e r v i c e s in
a p p r o a c h that is d e s c r i b e d in full else-
elderly people, or I 3.8% of the total population of T o o w o o m b a , resident in the
the
T o o w o o m b a . H o w e v e r , t h e H o m e and
Ethics
C o m m u n i t y C a r e ( H A C C ) s e r v i c e s in
Ethics clearance was o b t a i n e d from the
Toowoomba provide the majority of ser-
U n i v e r s i t y of S o u t h e r n
Queensland's
vices to t h e t a r g e t p o p u l a t i o n of this
elderly Australians are admitted for acute
H u m a n Research and Ethics C o m m i t t e e
study. Data supplied for O c t o b e r 2 0 0 0
care, the regularity with which they arc
(Ref : H O l R E A l 3 2 ) , t h e T o o w o o m b a
i n d i c a t e t h a t H A C C c a t e r e d for 71 1
d i s c h a r g e d i n t o c o n t i n u i n g care (Aus-
Health Service District and Blue Care.
clients that m o n t h , of which 550 (77%)
Given the frequency with
which
tralian Institute of H e a l t h and Welfare [ A 1 H W ] 1999, H a g a n & C o o p e r 1999)
were female and 161 ( 2 3 % ) male. Four
and the local problems identified by aged
Results Discharge planning
care stakeholders that were the impetus
hundred and eighty-three (68%) H A C C clients were living alone. T h e remaining
T h e majority of interviewees and focus
288 (32%) lived with a partner, family or
for this study, it is reasonable to assume
group participants believed that discharge
carer. Further, data provided by ACAT on
that there is a consistent need for access
planning should c o m m e n c e early in the
t h o s e clients w h o had b e e n assessed in
to longer term, sub-acute health care fol-
acute hospital episode. T h e recent intro-
2 0 0 0 i n d i c a t e d t h a t of t h e 878 c l i e n t s
lowing an e p i s o d e of hospitalisation in
d u c t i o n of t h e C l i n i c a l Liaison N u r s e
assessed for either aged care or C A C P s
t h e T o o w o o m b a r e g i o n . Issues at t h e
( C l . N ) in the private acute care s e c t o r
p a c k a g e s , 225 (25%) were receiving
interface of a c u t e a n d o n g o i n g h e a l t h
was viewed as a positive development in
h o m e help H A C C services, 186 (2 1%)
care lollowing an acute episode, across
this d i r e c t i o n by ten of t h e Reference
were receiving h o m e nursing 1 I A C C ser-
16
Collegian Vol 9 No 3 2002
TABLE 1: DATA COLLECTION FOR THE T O O W O O M B A C O M M U N I T Y DEVELOPMENT PROJECT Data collection source
Type of data collection
Residential Aged Care Facilities (RACF), HACC, ACAT, Retirement Villages (letterbox drop of survey), carers* in community (telephone used to recruit)
Survey - purposive sampling. (Distributed by RACFs, HACC and ACAT, letterbox drop and telephone used to identify carers). Collected resident and carer data on demographics; details of and issues around hospital admission
RACF (low care patients)
Focus group - 2 facilities
Number
Number
approached
participated
rate
491
71 clients 54 carers
25.4%
20
N/A
_____
16
Participation
N/A
RACF (high care patients)
Interviews
10
RACF, patients on waiting list; CACPs and admission data
Survey (completed by RACF staff) - demographics and needs of residents, services provided by facility, issues surrounding care provision
21 facilities
19 facilities
R A C F - C D H A C data
De-identified data demographics, service needs
All facilities
Allfacilities100%
Community Service Providers
Survey data - demographics and service needs of clients; range of services provided. Many did not have these records
37 facilities
6 provided useable data
1 6.2%
HACC data
De-identified data - picture for one month. Did not have ability to capture data for 1 year. Client demographics and services needed
1 HACC service
1
100%
ACAT data on clients in 2000
De-identified data demographics of clients, service needed
1 ACAT service
Provided data for 12 month period
100%
GPs
Survey (distributed by the Division of General Practice)
50
12
24%
Persons receiving aged care services hospitalised in last 12 months
Survey
491
71
15%
Community carers of eligible patients
Interviews
10
10
N/A
Community carers of eligible patients
Focus groups
5
5
N/A
Community carers of eligible patients
Surveys
532
54
9%
Key stakeholders (reference group and others)
Interviews
19
19
100%
Health care providers
Focus groups (two held) Surveys of aged care facility staff
13 50
13 22
100% 44%
Key stakeholders
Discussion at meetings - 1 w i t h 4 CACPs providers; 2 Queensland Council of Ageing meetings - approximately 20 people per meeting
3 meetings
3 meetings
100%
Hospital admission data - t w o private and one public hospitals
DRGs, length of stay, demographics, referral source, waiting times for assessment and placement, discharge destination.
Data from all three facilities
One facility could provide limited data
100%
Hospital morbidity and mortality data
(All postcodes of study provided by AIHW) - DRGs, gender and age group for 1998 to 2000 for all males and females over 65 years of age
N/A
Data provided by A I H W
N/A
Acute public hospital long stay patients over 65 years
Interview - long stay w a s defined as a patient w h o had been in an acute facility for more than 35 days.
20
15
N/A
Hospital admission/discharge staff
Interviews
3
3
N/A
1
1
90.5%
- one admission/liaison nurse at each hospital - one person responsible for 'hospital in home program'
'Carers defined as those w h o invest significant personal and/or financial resources in the care of an elderly person Collegian Vol 9 No3 2002
17
[REFEREED ARTICLE]
vices,- a n d 4 3 ( 5 % ) w e r e
receiving
preparing to leave hospital. T h o s e w h o
cussed with t h e client and their family.
CACPs. Analysis of the data according to
did experience p r o b l e m s indicated that
T h e consensus of t h e Reference C r o u p
the five Statistical Local Areas (SLAs) of
hospital organisational procedures caused
was that inappropriate discharge occurred
Toowoornba indicated that there were
c o n c e r n . T h i s w a s also a m a j o r issue
when there was a lack of adequate sup-
strong statistically significant
differences
raised by 23 health care providers (23%),
port, poor timing, or the person was not
b e t w e e n t h e SLAs and those w h o were
19 patients (22%), and 11 carers (16%).
placed in the optimum facility due to the
living alone, living with a partner, living
The
lack of community services.
with relatives or had other living arrange-
p r o v i d e r s was insufficient
major
issue for h e a l t h
service
inlormation
ments (p>.001) (see Table 2). However,
provided for follow-up management. For
t h e r e w a s weak statistical e v i d e n c e of
carers, it was the lack of support provided
Waiting lists for home services and subsequent delays in discharge Data supplied by the H o m e and Commu-
a s s o c i a t i o n b e t w e e n t h e use of h o m e
b y h o s p i t a l staff for p a c k i n g u p t h e
c a r e / h o m e help and SLA ( p > . 0 2 5 ) (see
patient's b e l o n g i n g s , or dressing the
nity Care ( H A C C ) team for the m o n t h of
l a b l e 3), a n d t h e r e was n o e v i d e n c e of
patient prior to discharge.
February 2001 indicated that at least 200
association between the use of home nurs-
Fifteen providers (15%) also perceived
elderly p e o p l e in T o o w o o r n b a w e r e on
ing services and SLA (see Table 4). These
problems with the provision of transition
their waiting lists for home help, and that
results suggest that whilst there were dif-
services and short-term care. In contrast,
there was generally a m a x i m u m of t w o
f e r e n c e s in t h e living a r r a n g e m e n t s of
only four patients (5%) and three carers
weeks wait for domiciliary services from
ACAT clients in 2000, there were no dif-
(5%) reported the provision ol transport
the lime of referral. H A C C did report,
ferences in the availability ol home nurs-
as problematic prior to discharge. Addi-
however, a I 2 to 18 month wait for some
i n g s e r v i c e d e l i v e r y by g e o g r a p h i c a l
tionally, providers placed more emphasis
home care services if the person was not a
location in Toowoornba.
on the importance of mental health dur-
H A C C recipient prior to their hospital
ing the transition to discharge, with IK
a d m i s s i o n . If t h e y w e r e r e c e i v i n g a
t h e r e w e r e l o n g d e l a y s in w a i t i n g for
(18%) indicating that this was an issue in
H A C C service before admission for an
H A C C services and CACPs packages for
comparison to four (5%) patients and five
acute episode, there was no waiting peri-
many people requiring these services in
(7%)
od for this to he reinstated.
Toowoornba.
were expanded upon during the individual
H o w e v e r , as will be discussed later,
c a r e r s . These p r o v i d e r c o n c e r n s
interviews c o n d u c t e d with 19 Reference C r o u p members. Twelve members of the
Lack of rehabilitation and step-down post acute episode
Twenty-five (29%) elderly inpatients and
Reference Group (63%) believed that dis-
All ol t h e R e f e r e n c e C r o u p m e m b e r s
17 (25%) of their carers w h o responded
charge planning should be initiated early
identified the shortfall of care available to
to the survey reported no difficulties in
in the hospital episode and should be dis-
a group ol at-risk aged people discharged
Issues on discharge
from hospital to their own h o m e . AccordTABLE 2: LIVING ARRANGEMENTS BY SLA - PERCENTAGE SLA
North W e s t
Living alone
Living w i t h
Living w i t h
partner
relatives
40.2
17.2
19.5
ing to these participants, there was a periOther living
o d after discharge when rcadmission or a
23.1
for this c o h o r t . T h i s was when deficits
new admission was more likely to occur
North East
43
35.5
9.3
12 1
h a d n o t b e e n i d e n t i l i e d in h o s p i t a l or
West
41 7
36.6
17.6
4.2
appropriate step-down facilities were n o t
Central
46.3
22.6
10.2
20.9
available. As a result, elderly people were
South East
43.9
22.4
9.7
, 24
re-hospitalised due to falls or an inability to a d e q u a t e l y m e e t t h e i r h y g i e n e a n d nutrition needs when they were sent
TABLE 3: USE 0 F H O M E CARE / H O M E HELP
PbH( "ENTAGES BY SLA
home following an acute episode. Further-
SLA
Horn e help
North W e s t
21.6
North East
28
West
31.8
68.2
unnecessarily in a nursing h o m e for their
Central
27 5
72.5
own p r o t e c t i o n . T h i s perception of t h e
South East
18.9
81.1
Reference C r o u p members was confirmed
No h o m e lelp 78.4 ' 71
m o r e , it a p p e a r e d t h a t w h e n p o t e n t i a l problems are identified prior to discharge, these aged people are sometimes placed
by t h e morbidity data that indicated in TABLE 4: USE 0 F HOWIE N UHSINC3 - PERCENTAGES> BY SLA SLA
Horn e nursing
No home nursing
2000 that no O R G for rehabilitation was linked to the acute or private hospitals in Toowoornba.
North W e s t
22.2
77.8
North East
20.6
79.2
A slow-stream rehabilitation model of
West
22.6
77.4
care to address this shortfall was consid-
Central
21.9
j
78.1
ered necessary by 12 aged recipients of
South East
17.9
I 82 1
care ( 3 4 % ) , eight of their carers ( 8 0 % ) and 14 members of the Reference C r o u p
18
Collegian Vol
[This] can be a real problem because the fact that they don't get any help when they go home may mean that their convalescence is protracted or may even tip them into that area where they actually need HAC.C services .. there needs to he some sort of interim support program.
(74%). This would allow the aged client ihe o p p o r t u n i t y to recover fully before r e t u r n i n g to their former place of residence.
The adequacy of services after discharge
McCallum & Bye 1998). It appears, therefore, that a reasonable discharge planning filler is provided by directing attention to those w h o already have had hospital stays longer than average for their condition. It is a p p a r e n t from the T o o w o o m b a data that the two private hospitals emphasise
Further, o t h e r providers w h o were
Questionnaire items probed the difficulties that elderly people, their carers and
interviewed staled that aged care clients
service p r o v i d e r s p e r c e i v e d u p o n dis-
had deteriorated after a hospital admis-
charge, in addition to the additional sup-
sion. 1 hey explained:
the identification of this c o h o r t by the employment of the CLN. Use of community post
ports they required and their suggestions to facilitate service delivery during this time. T h e burden on caregivers was obvi-
We f i n d a n u m b e r of p r o b l e m s - skin
It was n o t p o s s i b l e in this s t u d y , for
integrity problems that we never had in
methodological reasons, to calculate the
the first place.
ous from these data. Forty carers (40%)
percentage of uptake of community ser-
They (aged patients post discharge) always come back worse. 1 have to tell you in all the years I've worked in aged care, that rarely does anybody come back better. They come back worse, particularly the low care.
reported much more difficulty with the elderly person's activities of daily living than either the elderly person (n = 3l or 29%) or service providers (n= 16 or 15%). Service providers did, however, indicate
services
discharge
vices after hospital discharge by elderly people in Toowoomba. O t h e r Australian studies, however, indicate that post-acute clients accounted for more than half of all referrals to c o m m u n i t y nursing services (Fine et al 1997) and that one in four dis-
more often that the elderly person needed other supports post-discharge, particu-
Discussion
c h a r g e d clients utilised c o m m u n i t y ser-
larly those related to mental health (n = 26
Discharge
vices upon returning home (McCallum &
or 25%)), than patients and carers (n=18
T h e data collected from residents, health
Bye 1998). Nursing and h o m e help ser-
planning
or 17% and n = 1 8 or 15% respectively).
care providers and carers indicated that
vices appear to be the most c o m m o n l y
T h i s result could be attributed to their
many elderly people admitted to hospital
accessed (Street 1995, Fine et al 1997,
g r e a t e r k n o w l e d g e of the supports that
were at risk of re-hospitalisalion (either as
McCallum & Rye 1998).
are n o t a v a i l a b l e . ' M e n t a l h e a l t h ' was
a new a d m i s s i o n or a r e - a d m i s s i o n ) il
defined as issues such as fear of b e i n g
their potential problems were not identi-
alone, feelings of c o n c e r n or a p p r e h e n -
fied early in their hospital episode, and
I h e results of this s t u d y (for e x a m p l e
sion, crying, depression and so on.
referral to residential or community care
only 17 (31.4%) carers stating there were
Carer burden
was not implemented as soon as possible
no problems related to discharge of their
after discharge 11 was apparent from the
caree to their care) indicate that those
data that t h e r e were t w o issues taking
discharged into the c o m m u n i t y arc at a
A major theme from the survey data was
place. First, carers, patients and providers
greater risk of precipitating carer burden.
t h e n e e d for a d d i t i o n a l s u p p o r t a n d
of
services
In particular, 40 carers (74%) r e p o r t e d
i m p r o v e m e n t s to b e i n t r o d u c e d w i t h
expressed the view that patients dis-
issues related to managing the activities
regard to transition services/short term
c h a r g e d from the acute s e c t o r w i t h o u t
of daily living of their caree in the days
care. For e x a m p l e , 16 carers ( 1 8 % ) , 10
community services on discharge deterio-
after leaving the hospital. Further, b o t h
providers (28%), and 10 patients (18%)
rated while they waited for c o m m u n i t y
carers and general practitioners expressed
identified a need for additional support in
services. Second, those patients who
the view that many elderly people were
the short-term, and 19 patients (22%), 17
remained in hospital waiting for admis-
discharged home before they were men-
p r o v i d e r s ( 2 3 % ) , a n d 14 c a r e r s ( 1 8 % )
sion to an RACF were likely to deterio-
tally a n d / o r p h y s i c a l l y r e a d y for dis-
believed that this area required improve-
rate due to the lack of rehabilitation or
charge. In some cases, carers were advised
ment. Areas identified included hospital
step-down beds available
t h a t if t h e y c o u l d n o t c o p e w i t h t h e
Transition services/short
term care
aged
community
care
staff to p r o v i d e h o m e visits, sufficient
Similar Australian studies reinforce
community care staff, a c o n t a c t number
this finding, and indicate that in particu-
to ring to discuss health concerns, volun-
lar, d i s c h a r g e p l a n n i n g involving p o o r
teers to visit for a talk, more home help
a s s e s s m e n t a n d d o c u m e n t a t i o n in t h e
when needed and more home nursing ser-
acute phase compromises client outcomes
vices.
on their return to their previous place of
Additionally, the data collected from
residence (McCallum & Bye 1998). Fur-
meetings with the CACPs providers, from
ther, the literature suggests that a greater
the focus g r o u p s and from i n t e r v i e w s
p r o p o r t i o n of t h e elderly w h o require
indicated a need for immediate home care
community services after discharge from
s u p p o r t on d i s c h a r g e for p a t i e n t s w h o
hospital arc likely to be those who under-
had complex and chronic care needs. As
go a long hospital stay for a complex con-
one provider stated:
d i t i o n ( S t r e e t 1 9 9 5 , Fine et al 1 9 9 7 ,
client, then the only option was for an RACF placement. This has been raised as an issue in previous studies where, despite the presence of a carer, there was concern that the inadequate interface between the acute and community sectors and the carers necessitated premature institutionalisation or repeat hospital admission of the elderly person (hiealy 1998). This further e m p h a s i s e d the need for a d e q u a t e and early assessment in the acute system and communication networks between the carers, general practitioners, community Collegian Vol 9 No 3 2002
19
services and the acute hospital sector.
in co-ordinated care. However, Australian
Brisbane in September 2001 indicates that
There is evidence in the results to sug-
data ( C D H A C 200 l b ) have s u g g e s t e d
the Commonwealth Carelink program is a
gest that an extension ol current commu-
that models of care in which GPs are the
relatively recent strategy, and to date its
nity services to i n c o r p o r a t e h i g h care
main care co-ordinator lend to emphasise
efficacy has not been formally evaluated.
clients would facilitate the elderly per-
the medical aspects of the care plan at the
However, if this program does meet its
son's return to home after an acute hospi-
expense of the o t h e r holistic aspects of
objectives of providing information on
tal episode, and allow them to remain in
care and communication processes. Non-
not only the services available locally but
(heir h o m e r a t h e r than e n t e r an RACF
medical care co-ordinalors, such as CLNs
eligibility criteria, it is apparent that it will
( C o m m o n w e a l t h D e p a r t m e n t of H e a l t h
and designated case managers, are more
overcome the lack of information on ser-
and Aged Care [ C D H A C ] 2001a) Simi-
likely
other
vices not only for providers but also for
larly, the Extended Aged Care at H o m e
p r o v i d e r s a n d to formulate c a r e plans
the residents ol Toowoomba (McCauley
(EACH) services that are currently being
inclusive
et al 1997, Reed & Morgan 1999, Cheek
trialled in various States in Australia oiler
( C D H A C 200 ib).
to
communicate of
with
community
services
et al 1999). It is possible, therefore, that C o m m o n w e a l t h C a r e l i n k C e n t r e s may o v e r c o m e some of the issues raised by
The corwensus of the Reference O r o y p ot Service providers in the regions mclieated t h a t there was a s h o r t f a l l of care available; t o elderly people discharged t o their o w n homes In the region am:J thai in^-acloiisskMu was fikeiy f o r t h i s cohort,,
Toowoomba people regarding their lack of knowledge of the availability of services within Toowoomba.
Conclusion T h e data from this study indicate that communication and liaison between the primary care providers (general practitioners), the acute care sector (both public a n d private), the c o m m u n i t y sector
care at least equivalent to high-level resi-
As a result of this study, two options
dential care. EACH services facilitate care
for p o s t - d i s c h a r g e care for the elderly
aged care facilities
p l a n n i n g , meet t h e e x p r e s s e d needs ot
emerged ( H e g n e y et al 2001). First, the
Toowoomba region.
carers and clients, are cost effective and
current C L N model that is of proven effi-
O n e of the major issues arising from
are considered viable in rural areas such
cacy in the private sector in Toowoomba
these T o o w o o m b a data c o n c e r n e d what
as Toowoomba ( C D H A C 2001a).
could be introduced into the public sec-
the research team defined as the 'mental
tor. T h e success of this would be condi-
health' of the patients and their carers. It
(private and public) and the residential is p o o r
in
the
tional u p o n t h e q u a l i t y and e x t e n t of
is apparent that when discharge occurs
T h e consensus of the Reference C r o u p of
c o m m u n i c a t i o n and case c o n f e r e n c i n g
before the patient and carer feel ready, or
service providers in the region indicated
between the GP, the C L N and the hospi-
lacks communication between providers,
that there was a shortfall of care available
tal staff. Second, in the longer term, key
patients and their carers, it is of no bene-
to elderly people discharged to their own
s t a k e h o l d e r s s h o u l d c o n s i d e r h o w the
fit to any one concerned with the care of
h o m e s in the region and that re-admis-
i m p l e m e n t a t i o n ol a case m a n a g e m e n t
the elderly. T h e introduction of a slow-
sion was likely for this c o h o r t . T h e s e
/advocate model might operate with
stream, step-down or rehabilitation unit
findings correlate with o t h e r Australian
regard to discharge planning and access
w i t h i n T o o w o o m b a w o u l d a l l o w for
research, which reports that one in four
to appropriate services in the Toowoom-
greater preparation for discharge, particu-
elderly patients are re-hospitalised within
ba r e g i o n . T h i s s e c o n d o p t i o n w o u l d
larly discharge back to t h e c o m m u n i t y
six m o n t h s of the initial acute hospital
decrease the current duplication of assess-
for those clients w h o have c h r o n i c and
episode (Fine et al 1997) with an average
ments and services. It would also ensure
complex care needs. Further, extension of
of 2.7 admissions for each elderly person
that holistic care would be provided by
E A C H packages to T o o w o o m b a w o u l d
(McCallum & Bye 1998). Fine, Sitsky and
all the necessary health professionals.
allow elderly people requiring high care,
Re-admission after acute
H o e w (1999) argue that
discharge
subsequent
T h e study also found that there was a
admission is more likely for patients after
lack of awareness on the part of carers,
hospitalisation if they are still dependent
residents and health prolessionals (partic-
on others to accomplish their activities of
ularly CPs) with regard to the types and
daily living al discharge.
cost of post-acute services available to the elderly in Toowoomba.
Commonwealth
The role of GPs, liaison nurses and
Carelink C e n t r e s , which are funded by
case managers in discharge
the C D H A C , are designed to be a single
T h e results of this s t u d y i n d i c a t e t h a t
point of contact for clients, health profes-
there is a need for better communication
sionals and carers s e e k i n g i n f o r m a t i o n
amongst all aged care service providers in
regarding the community and residential
order to facilitate greater C P involvement
service options available. A forum held in
20
Collegian Vol 9 No 3 2002
w h o wish to stay at h o m e , to r e m a i n there longer.
Further research T h i s study m a d e 26 r e c o m m e n d a t i o n s ( H e g n e y et al 2001). T h e main task of the research team, working in collaboration with the acute hospitals, community aged care providers and residential aged care facilities is to operationalisc these recommendations. T h e research team and
[REFEREED ARTICLE]
Reference Group believe the recommendations provide a guide to the develop-
teristics for statistical load ateas. Queensland AC,PS, Australian Institute o f H e a l t h a n d Welfare 1999
A g e d C a r e Issues A f f e c t i n g A u s t r a l i a , T h e
Ohter Austynluiiis
incorporates adequate discharge plan-
A G E - I 2 . A I H W , Canberra
and r e h a b i l i t a t i o n , inclusion of general
at a glance A I I I W
Cat N o .
C h e e k J, f i a l l a n t y n e A , T u c k e r M 1999 Copnuf with crisis, won' Australian families semen foy and select an titled (.arc facility
for a family
member upon dis-
charge from an acute cafe setting.
adequate community service provision. It
Research i n t o N u r s i n g a n d A l l i e d
come the majority ol the issues raised in this research and would be of benefit to similarly sized provincial cities in Australia.
Centre for Health
Care, U n i v e r s i t y o f S o u t h Australia, Adelaide Commonwealth
Department o( Health a n d
A g e d Care 2001a Evaluation of the extended ailed tare at home pilot program C D H A C , Canberra Commonwealth
D e p a r t m e n t of H e a l t h a n d
A g e d Care 2001b The Australian coordinated care trials: final
technical
national
evaluation
tepoil.
C D H A C , Canberra
Acknowledgements T h i s study was funded by a grant From
delivery models at the boundaries of aged care progreims
the
Social Policy Research C e n t r e , U n i v e r s i t y o l
Commonwealth
Department
of
extends its sincere thanks to the elderly
Fine M , T u r v e y K , D o y l e J 1997 The provision of services.
Social
Policy
people, their carers, members of the Ref-
Research C e n t r e , U n i v e r s i t y o f N e w S o u t h
erence Croup and service providers who
Wales, Sydney
participated in the study.
H e g n e y D , d c la Rue B, G o r m a n D , M a r t i n M c D o n a l d K, M c C a r t h y A , Pretty C , Sundin[ luard D 2001 Toowoomba community development planning project' acute health scivice.'aged cute interjaie -consultancy
i V k C a l l u m .1, Bye R 1998 Improving post-acute caie outcomes for older people C e n t r e o f 1 i e a l t h O u t comes a n d I n n o v a t i o n s Research, U n i v e r s i t y of Western Sydney, M a c A r t h u r M c A u l e y W , Travis S, S a f e w r i g h t M 1997 Pers e l e c t i o n process. Qualitative
Q u e e n s l a n d G o v e r n m e n t 2001 Coipiipitijiify cabinet 23/07/2001: woomba.htm ple from hospital t o care homes: i m p l i c a t i o n s
C o m m o n w e a l t h Department o( H e a l t h and
20(4):8l9-825
12/02/2001;
Care,
http://www.oesr.qld.gnv.au/daa/
pubhcations/tommunity_cab/toowoomba/too
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7(21:236-254
pital admissions and discharges, older Australia)!;
Australian Bureau o f Statistics 1997 Census ojpopulation and housing, selected social and housing charac-
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(Queensland, T o o w o o m b a
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