MAX REID draws attention to the growing demand for a service model that addresses the specific needs of older people with both age-related and mental health needs.
The Ministry of Health’s 2006 document Te Kōkiri: The Mental Health and Addiction Action Plan 2006–2015 envisaged that, within 10 years, people with experience of mental illness and addiction, and their families and whānau, would be “having their needs addressed earlier through access to a broad range and choice of services that are responsive to their communities”. It outlined the Ministry’s aim to deliver a more integrated model that coordinated early access to primary health care alongside community-based specialist mental health and addiction services.
While this goal may have been achieved for many in our community, for one significant – and growing – cohort, it has yet to be realised. It is well recognised that older people are New Zealand’s fastest growing demographic group, and specialist health services are already beginning to feel the fiscal pressure arising from such growth. By 2021, 2.3 per cent of the population will be aged 85 years and over. Based on current rates of expenditure, they will consume around 15 per cent of Vote Health expenditure.
Such projections have particular relevance for the development and delivery of mental health and addictions services for older people. While three per cent of the general population live with enduring serious mental illness, it is estimated that this proportion doubles to six per cent for those aged 65 years and over. Similarly, it is estimated that 25 per cent of people aged 65+ have symptoms of depression severe enough to warrant clinical intervention.
In 2011, in response to this projected increase in demand for mental health and addiction services amongst New Zealand’s ageing population, the Ministry of Health produced Mental Health and Addiction Services for Older People – a guideline for district health boards on an integrated approach to mental health and addiction services for older people and dementia services for people of any age.
The document noted the need to provide specialist mental health and addiction services not only to people aged 65 years and over, but also with a degree of flexibility, in order to meet the needs of those people with both mental health and addiction conditions and age-related health conditions. The recommendation of the Ministry’s guideline – allowing access to funded age-related health services for those aged under 65 with both mental health and addiction conditions and age-related health needs – reflects a similar impact of enduring mental illness and chronic addiction upon life expectancy.
Despite such recommendations and rhetoric, however, there remains a significant lack of integration between DHB-funded specialist mental health and addiction services, and health services for older people. Put bluntly, specialist mental health and addiction services are neither contracted nor funded to carry a level of gerontology or aged care related expertise, nor are aged care providers contracted or funded to carry a level of mental health and addictions expertise. The implications of this gap are highlighted in the following case study.
Case study: meet Marjory
Marjory is a 56-year-old New Zealander of European descent. Diagnosed with schizophrenia, she has lived in the same council flat for the past 15 years. While she has no local family support, Marjory receives regular support from a DHB-contracted mental health team, and she has developed a strong rapport with visiting staff. Others in the complex of flats receive similar support – and a strong sense of community exists among the residents.
Four weeks ago, Marjory tripped and fell at the clothesline, fracturing her hip. She was admitted to hospital and underwent successful hip replacement surgery. On assessment pre-discharge, it was determined that both Marjory’s short-medium term convalescence and the early presentation of other age-related health conditions warranted a level of registered nursing coordination of her care. Given the immediate issue of her mobility, it was decided that this care could most effectively be provided to Marjory in a rest home setting. The only bed available at the time of her discharge was some 10 kilometres from where Marjory had previously lived.
Towards a solution
The decision to admit Marjory to an aged residential care facility was largely a pragmatic one. Marjory’s need to re-mobilise, the need for a level of registered nursing coordination of her care, together with her mental health needs, would have made for a complex package of care were she to return to her council flat. District nursing, home support, and mental health support would all have been needed – potentially involving coordination across a number of different agencies.
But was this the right decision for Marjory?
Marjory’s placement in an aged residential care facility, separated from her community and friends, has increased her sense of loneliness and distress, exacerbating her mental illness. Nor should the impact on Marjory’s mental wellbeing be seen as unusual. The decline in mental health status upon admission to aged residential care for those with existing mental disorders is well documented, as is the increased likelihood of developing a mental illness (particularly depression) while in an aged residential care setting. The New Zealand Guidelines Group suggests, for example, that while the prevalence of depressive disorders among community-dwelling adults aged 65 and over in New Zealand is about two per cent for men and five per cent for women, older adults in residential care are at much higher risk of depression, with a prevalence of about 18 per cent at rest home level.
There is also extensive research from both New Zealand and overseas that evidences that, regardless of an older person’s mental health status, admission to an aged residential care facility – even if only for a short period of respite care – can dramatically reduce function in terms of activities of daily living.
One immediate alternative to the current pathway that Marjory’s case study reflects would be to fund a level of integrated specialist mental health and aged care registered nursing expertise in the community. Other such specialisations have already demonstrated their worth. For example, wound care nurses at clinical nurse specialist level (employed by home support providers, albeit on a trial basis) not only provide specialist wound care support to community-based clients upon their discharge from hospital, but they also make available a level of wound care advice and training into aged care facilities, obviating the need for unnecessary admission to hospital.
Older persons mental health nurse specialist
The availability of an equivalent ‘older persons mental health’ CNS position would not only have addressed a number of concerns that Marjory’s case study highlights but would also have offered potentially wider utility.
Remember, a key reason for Marjory’s admission to rest home level care was to provide a level of registered nursing (RN) coordination of her care, in conjunction with ‘on site’ caregiving support. It is important to note that only RN coordination of care was required. Had Marjory’s convalescence required a higher level of nursing input, she would have been admitted to hospital-level aged residential care, where 24/7 RN oversight would have been available.
Were a community-based aged care and/or mental health provider to employ a registered nurse with both mental health and addiction expertise and aged care expertise, such RN coordination would be able to be offered in conjunction with a restoration of Marjory’s existing lower level mental health support. This would address the ‘integration’ component that Marjory’s admission to an aged care facility was, however pragmatically, designed to ensure. It would also enable Marjory’s return to her flat and the community and support staff with which she already held such a strong connection.
The establishment of such a CNS position would create a number of other opportunities. As earlier indicated, aged residential care facilities are themselves neither contracted nor funded to provide specialist mental health support for their residents. Yet clearly there are a growing number of residents being admitted with – or acquiring – significant mental health needs. Such facilities (and of course, their residents) would benefit from the availability of staff training in this area, and the ready accessibility of specialist mental health and addiction advice, tailored to the particular needs of older people. The need for specialist mental health and addiction support spans the breadth of aged residential care (including, for example, residents with Korsakoff’s syndrome – the result of long-term alcohol addiction – admitted to dementia-level care).
A further opportunity relates to older people with mental illness or addiction being discharged from either medical hospital wards or mental health wards back into the community. Frequently discharge is delayed – either because of inadequate inpatient resources for discharge planning (in the case of medical wards) or the unavailability of suitable community placements or support (in the case of mental health unit discharges). Various ‘facilitated early discharge’ models have demonstrated their worth – including the highly successful ‘Meet and Greet’ service piloted by Canterbury District Health Board in partnership with Healthcare of New Zealand and the Nurse Maude Association. Evaluation of the pilot demonstrated not only a significant saving to the DHB in terms of hospital bed days, but as importantly, a significant reduction in readmission rates for those patients whose discharge had been coordinated via the pilot service.
Yet there are no equivalent facilitated early discharge models designed to coordinate the transition of older people with mental health needs back into the community, despite clear evidence that many patients remain on mental health wards not because they are continuing to improve, but simply because of difficulties coordinating either their discharge or community placement.
United States author and facilitator Mark Friedman, suggests that funders – in whatever sector – have, to date, largely judged the outcome of services solely on the basis of volume (have we delivered the volume of service we have been funded for?) and quality (in the case of the New Zealand health sector, are we maintaining HDSS certification?). Only in very recent years are New Zealand health funders beginning to ask the more critical question, ‘What difference does it make?’ Any provider wishing to remain ‘ahead of the game’ in terms of service development, needs to be able to demonstrate that the services they are providing do, in fact, make a tangible and measurable difference. Fundamentally, as important as contractual compliance and adherence to Health and Disability Service Standards unquestionably is, surely every aged care provider should be assessing their success by the tangible difference that their services make to those who utilise them.
Max Reid is currently acting area manager for Access Home Health (Southern Region), and policy, research and communications adviser for Dunedin North MP and Associate Opposition health spokesperson, Dr David Clark. Please contact firstname.lastname@example.org for references to this article.