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					 Improving care for older people

Transition Care Program:
Victorian Update

Nicole Doran
Ambulatory and Coordinated Care
Department of Health

November 2009

Department of Health

• Policy directions
   –   NPA:Sub-acute
   –   COAG Long Stay Older Patients’ Initiative
   –   Sub-acute Services Planning Framework
   –   HIP Guidelines
   –   Right care/Right time/Right place
   –   FIM across Rehab, GEM and Restorative Care
• Improved pathways and models of care
   –   Acute GEM
   –   Restorative Care
   –   Residential In Reach
   –   HARP: Better care for older people (HARP BCOP)
• Innovative resources
   – Best care for older people everywhere: The toolkit
Sub-acute Planning Framework
                            Capability and Access Planning Framework

              Service Capability                                           Service Access

 Role delineation          Program designation             Utilisation analysis      Forecasting analysis

     3 service classes             Service description           Public vs Private           Burden of disease
                                    and patient mix

                                       Catchment                 Regional patterns          Demographic change
                                   Clinical staff levels         Casemix analysis              Acute activity
           Inpatient                and involvement                                              increase
                               Networking, integration                Trends                  Latent Demand
         Ambulatory              and relationships
      sub-acute services
                               Quality standards and                                          Models of Care
      5 service levels          clinical guidelines

                              Infrastructure, equipment                                          Regional
                               and supporting services                                        Self-Sufficiency

                                        Teaching                                              Level 5 Services
                                      and research
What drives demand?

Population-based Factors                                            Service Delivery Framework

                                          Latent Demand                      Models of Care
     Burden of Disease

         Demographic Change                                   Regional Self-Sufficiency

                         Acute Activity                   Level 5 Services

                                          SUB-ACUTE DEMAND
Forecasting for Sub-acute Services


                     3.5%                                          3.4%


              2.5%                                                                              2.50%
       2.5%                                                                2.40%
                             2.30%                2.30%
                                                                                   2.2% 2.2%
                                     2.1% 2.1%




                     Rural                Urban                    Rural                Urban

              2006/07 - 2013/14      2006/07 - 2013/14      2013/14 - 2018/19      2013/14 - 2018/20

                                      Level 2/3 rehab     GEM      SACS
Sub-acute Service System

• Sub-acute bed based services
    •   Rehabilitation (adult and paediatric)
    •   Geriatric Evaluation and Management/Restorative Care
    •   41 facilities – 23 in metro/18 rural region
    •   Over 1800 beds
    •    50% rehabilitation and 50% GEM
    •   75% in metro/25% in rural regions

• Substitution and diversion services
    •   Hospital in the Home
    •   Post Acute Care
    •   Sub-acute Ambulatory Care Services
    •   Chronic and Complex Care Services: HARP, Family Choice Program,
        Victorian Respiratory Support Service

• Transition Care Program
    • Facility and Home based packages
Integrated guidelines

 Enable better client journey
 across the care continuum

 Patient flow unhampered by
 program boundaries

 Right care, right place, right
Impact of ageing on acute care

• People over 85 years                    Older persons use of acute care services
  will increase from 1.6%
  of the population to         60%

  around 5 – 7%

• In the next 20 years         40%                                           Forecast % separations

  50 % of acute care
                                                                             from acute for patients
                                                                             over 70 years

  beddays will be used for
                                                                             Forecast % of beddays in

  patients over 70 years
                                                                             acute for patients over 70
                               20%                                           years

• Patients over 85 years
  will utilise 14.5 % of the   0%

  acute care beddays                 2007-08   2013-14   2018-19   2026-27
 The people who use or service:
 Our patients are older and frailer

• 52% of people                              Increasing Frailty on admission

  admitted to sub-acute    90

  services are 80 years
  or older                           68.11            67.93              68.13              67.2


• 40% patients in                    51.03            50.56
  rehabilitation are >80

• Frailer on admission          2005/06          2006/07            2007/08            2008/09

  and discharge
                                              Admission Barthel    Discharge Barthel
Older people use hospitals differently

• More complex needs

• Multiple diagnoses

• Increased risk areas
Sub-acute and Residential Aged care
Access Indicator Project
1. Number of patients within the health service (acute & subacute beds) awaiting a
    residential care or TCP placement.
    An indicator to reflect patient flow

2. Average inpatient length of stay (LOS) in subacute care per month
    An indicator to reflect efficiency

3   a) Average Admission Barthel score per month
    b) Average discharge Barthel score per month
    c) Average Barthel improvement per day
    An indicator to reflect effectiveness, complexity and measure improvement but not
    necessarily access

4. Formal separations per subacute bed per month
    An indicator to measure efficiency

5. Number of subacute referrals accepted per bed per month
    An indicator to reflect the demand on the system

6. Number of people in acute beds waiting for subacute beds
    An indicator to reflect patient flow
Geriatric medicine patient journey

Usual care pathway: 57 inpatient days

              Acute Inpatient           Sub-acute Inpatient (GEM)
 ED            25 days                         35 days

Better care pathway: 14 inpatient days

           GEM Plus             Transition Care Program
 APU        14 days               56 days at home
Residential Aged Care journey

Usual care pathway: 57 inpatient days

        ED          Acute Inpatient     Sub-acute Inpatient (GEM)
RACS   20 hrs        25 days                   35 days

Better care pathway: HITH/HARP In reach

          RACS         HITH or HARP In-reach
Resources to support improved care
Move to Functional Improvement Measure (FIM)

• Health service driven
  revisions to VAED to
  incorporate FIM measures

• Movement away from data
  based on diagnosis/acute
  focus, to patient focus

• GEM uses Barthel Index,
  move to FIM to align service

• Incorporate measures of
 What will we achieve

 Improved access and equity of
 Improved consistency of service
 Better patient journeys
 Avoidance of unnecessary
  hospital admissions
 Prevention of functional decline
 Minimised long term care needs
 Avoidance of premature entry
  into RACS
 Better patient experience

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