Reforming
community services
Professor Matthew Parsons
Clinical chair (gerontology), Waikato DHB / University of Auckland
Change drivers
Enhancing community
services
Sorting out our funding
models
Age-group
2001
2011
Change 2001-11
N (000s)
%
N (000s)
%
0-4
281
7
258
6
-23
-8
5-14
597
15
564
13
-33
-6
15-24
534
14
640
15
+106
+20
25-34
549
14
522
12
-27
-5
35-44
604
16
586
14
-18
-4
45-54
507
13
613
14
+106
+21
55-64
350
9
489
12
+139
+40
65-74
252
6
314
7
+56
+22
75+
210
5
263
6
+53
+25
3,884
99
4,249
99
+365
TOTAL
N (000s)
%
+9
Implications
Change drivers
Enhancing community
services
Sorting out our funding
models
Key features of Home Care
Low funding (NZ: 17.7%; US: 25%; Mean:
30.4%, of total long term care, OECD, 2005)
No regular assessments or reviews
High staff turnover(49%)
No / minimal health professional input
No / minimal training for support
workers
No travel time or costs
Ratio of ‘coordinator’ to clients 1:450
We had to try
something...
...NEW
Restorative Home Support
• Care management
• Use of health professional ‘coordinators’
• Training (Health professionals=postgraduate; support workers=national
training programme)
• Assessment and regular reviews
• Use of goals to inform services
• Functional rehabilitation
Nelly Bell, 86…
Significant investment in evaluation
1. King, A.I., Parsons, M., Robinson, E., & Jörgensen, D. (2011). Assessing the impact of a
restorative home care service in New Zealand: a cluster randomised controlled trial. Health
Soc Care Community, 10.1111/j.1365-2524.2011.01039.x.
2. King, A.I., Parsons, M., & Robinson, E. (2012). A restorative home care intervention in New
Zealand: perceptions of paid caregivers. Health Soc Care Community, 20 (1), p70-79,
10.1111/j.1365-2524.2011.01020.x.
3. Parsons, M., Senior, H., Kerse, N., Chen, M.H., Jacobs, S., Vanderhoorn, S., & Anderson,
C. (2011). Should care managers for older adults be located in primary care? A randomized
controlled trial. J Am Geriatr Soc, 60 (1), p86-92, 10.1111/j.1532-5415.2011.03763.x.
4. Parsons M, Senior HEJ, Kerse N, Chen M-h, Jacobs S, Vanderhoorn S, et al. The
Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE):
a pre-planned meta-analysis of three independent randomised controlled trial evaluations of
ageing in place initiatives in New Zealand. Age and Ageing. 2012 August 22, 2012.
5. Parsons J, & Parsons, M. Evaluation of the impact of implementation of a focused goal
facilitation tool for older people receiving homecare. Health & Social Care in the
Community. in press.
6. Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of
homecare services for older people: does it make a difference? Age and Ageing.
2012;41(1):24-9.
To increase hospital capacity...
• Supported Discharge Teams have been
developed to:
– Facilitate a timely and coordinated discharge
home for older people who are medically stable
and require ongoing support at home
– Provide a flexible and rapid response to avoid
admission and increase independence following
an acute illness at home,
– Maximise rehabilitation potential to reduce
requirement for long term supports including
delaying residential care.
Growing evidence
Supported Discharge Teams in NZ
• Waikato DHB launched START
(Supported Transfer & Accelerated
Rehabilitation Team), Nov 2010
– Supported Discharge Team
– Rapid Response Team
• Canterbury DHB to introduce
supported discharge team in 2013
C.R.E.S.T.
• Community, Rehabilitation and
Enablement Support Team implemented
in 3 weeks, launched 3 weeks after
earthquake.
We are evaluating START
• Randomised controlled trial, A total of 180
participants will provide 80 per cent power
to detect a 20 per cent reduction in length
of hospital in-patient stay
Mean days in hospital
Length of in-patient stay, admission prior to randomisation
25
Why?
20
• Immediate
responsive
service
15
• Intensive
input, up to 4
visits per day
10
5
11.7
9.2
Control
Intervention
0
N=93, error bars=1SD
• Active pull
system
(liaison)
All in-patient activity
Control
Intervention
30
Median days
25
20
15
10
5
0
11
14.8
Pre trial (4 months pre)
N=93, error bars=1SD
9
4.5
Post trial (4 months post)
Change drivers
Enhancing community
services
Sorting out our funding
models
Our funding was all wrong
“fee per service”
• Disincentive to discharge clients
• Creates unfavourable work conditions for
support workers
• Inability to meet client needs
• Inflexible responses
• Duplication of assessments
We have been looking for
alternatives
• Casemix, a form of bulk funding,
– Used in hospitals
– Linked to DRGs
– Patients in each group have similar conditions
– Similar inputs and same price
• But...it hasn’t worked in the community
Forget diagnosis, what
about needs?
• interRAI introduced, 2006 to current
– Contact assessment for non-complex
– Home Care for complex
• Cluster analysis of assessment data
– 5 non-complex casemix groups
– 5 lead complex case groups (33 in total)
START HERE
Supervision /
assistance
required to
complete
Unstable conditions that affect
cogniton. ADLs, behaviour or mood
OR
Acutely unwell or exacerbation of
long term condition
OR
Physiotherapy required
OR
Occupational Therapy required
no
3.a.
Personal care
(stable)
3.b.
Personal care
(flexible)
Average hours
= 4 per week
(may need OT/
PT)
3/12 reviews
by Health Prof.
Annual Contact
Assessment
3/12 Reviews by
Advanced Support
Worker, Annual Contact
Assessment
Average hours =
3 per week
NOTE: clients must
have a shopping need
to populate 2a or 2b
Independent
or set-up help
only
Stairs – how a full flight of 12 -14 stairs is managed
OR
Mobility – moving around on one level
OR
Preparing meals – includes planning meals, assembling
ingredients, cooking, setting out food and utensils
OR
Weekly shopping for groceries – includes compiling list,
accessing transport, completion of purchasing groceries,
transport of groceries and safe storage
Independent
or set-up help
only
yes
LIAISON
WITH
Specialist
services
Supervision /
assistance
required to
complete
Housework – includes
doing dishes, dusting,
making bed, tidying
up, laundry
Unstable conditions that
affect cogniton. ADLs,
behaviour or mood
OR
Acutely unwell or
exacerbation of long
term condition
OR
Physiotherapy required
OR
Occupational Therapy
required
Supervision /
assistance
required to
complete
Independent
or set-up help
only
yes
no
Clients MUST have Community
Services card to access this
service
Showering / Bathing – full
shower / bath including
transfers in and out of bath /
shower. Includes washing of
all parts of the body other
than back and hair
OR
Personal hygiene – includes
combing hair, brushing teeth,
applying make-up, washing
and drying face and hands
2.b.
Housework
& shopping
(flexible)
Average
hours =
2.2 per
week
3/12 reviews by
Health Prof. Annual
Contact Assessment
2.a.
Housework
& shopping
(stable)
Average
hours =
1.2 per
week
6/12 Reviews by
Advanced Support
Worker, Annual
Contact Assessment
1b
Housework only
1a
Housework only
No funded service
Use of Independent
Living Manual
Careful consideration
of allocations and
consult peers prior to
establishing services
Calculating funding distribution
Assessment
Casemix group
Specified
funding amount
(Case-weights)
Provider A
Total
clients in
each
category
calculated
in each
quarter
Total
Home
Budget
Provider B
Provider C
Conclusion
• We are getting there
• Now for national implementation
• Ongoing development of clinical
pathways
• Quality frameworks and
benchmarking