The challenges of providing a full continuum of care
Providing seamless care from the home, to residential aged care, to an acute hospital setting appears to be a universal goal. Families want it, the Government wants it, aged care facilities and home support services providers want it … so why aren’t we quite there yet? By JUDE BARBACK.
Continuum. It’s a good word, and sounds even better when paired with ‘care’, as it implies continuous, seamless healthcare, at the right level, at the right time. ‘Continuum of care’ is a phrase often associated with aged care facilities and implies the ability of a facility to provide the care needed by an individual at whatever level required, transitioning between the levels with ease. A retirement village, for example, that boasts a full continuum of care to its residents, is one that may have a service for providing care to residents as needed while they are still living relatively independently within their villa or apartment, to the provision of rest-home level care, to hospital-level care.
But if we look at continuum of care in its wider societal context, the process of providing care from the individual at home, to residential aged care, to the acute hospital setting is harder to navigate. This is largely because our health system still lacks the level of integration required to deliver seamless transitional care.
New Zealand’s healthcare system is built upon a history of fragmentation that it has struggled to overcome. Jacqueline Cumming provides an interesting overview in her 2011 article, Integrated care in New Zealand which helps to explain why achieving integration is not entirely straightforward.
In the mid-to-late 1800s, early governments supported a vast mix of providers and funding models to deliver health services to a rapidly growing
New Zealand population. This fragmentation of health service delivery has proven difficult to shake off, despite many attempts to bring about a more integrated health care system through reforms.
There was the introduction of the Social Security Act in 1938, which aimed to introduce universal free care for many health services as part of plans to establish a single, national health service, but this did little to dislodge the firmly entrenched user pays system, and major separation in the planning, funding, and provision of services only served to increase fragmentation further.
The 1980s reforms saw a renewed focus on integrating planning and funding functions, and public health and secondary care service provision, at a district level, through the establishment of 14 Area Health Boards.
The 1990s reforms helped to further integrate planning and funding responsibilities, this time into four Regional Health Authorities. This resulted in a more collaborative and consistent approach to funding services and a greater emphasis on prevention and primary care. However planning and funding was separated from provision; contracting mechanisms were introduced for providers – a system which helped promote competition and in doing so, enabled more choice for users, but also led to more fragmentation as there was less incentive for providers to collaborate with each other.
Eventually, by the late 1990s, the four Regional Health Authorities merged into a single, national Health Funding Authority, which set out to develop general practice services into multi-disciplinary teams, or Public Health Service Organisations.
Before this plan had time to be realised, the next set of reforms were underway, with the establishment of 21 District Health Boards, which were responsible for funding and provision of hospital service, and funding and contracting for community services, and later, primary care.
In 2001, the Primary Health Care Strategy was released, which saw the establishment of 80 Primary Health Organisations, which were held responsible for the health of their enrolled populations, and funded on a capitation basis.
However, by the end of the 2000s, there were still concerns that little had actually changed in terms of how services, especially primary care services, were delivered to the user. Care became more focused on the patient, rather than the institution, and alliances were formed to bring together clusters of PHOs, each alliance aiming to improve coordination of care through devolution of funding and services from District Health Boards into the community as well as improve coordination of services between primary care providers and hospitals.
Barriers for integration
Cumming believes that, in spite of these reforms, the main challenge lies in encouraging a wide range of providers who currently operate separately at the primary care level – GPs, nurses, pharmacists, physiotherapists, social workers and so on – to work together under a single budget. Primary care services need to better link with secondary care and support services.
This was echoed by the Aged Residential Care Service Review, carried out by the NZACA and Grant Thornton New Zealand Ltd and published in September 2010. The review found that through the close integration of health services, this approach makes it possible to improve the resident’s experience, improve provider coordination, and reduce unnecessary services and costs. The review suggests the introduction of aged care services teams, whereby a group of aged care professionals come together with common incentives, tools, and a shared philosophy to provide a full continuum of care services from home and community support, to residential care, to acute hospitalisation, to hospice, and to social work.
Many hurdles need to be overcome in the current culture for such an approach to truly work, not least the alignment of operations of different providers and the sharing of financial risk across organisational boundaries.
Any barriers to achieving a continuum of care are largely “symptomatic of the healthcare system”, confirms Grainne Moss, Bupa’s General Manager for Rehab and Care Services. Moss acknowledges that in striving for a more integrated system, there is the challenge of balancing the necessary level of specialism with holistic breadth.
Tensions between DHBs and residential aged care facilities
One major obstacle that exists, to varying degrees, is a tension and even sometimes mistrust between DHBs and the residential aged care and home and community support sectors.
This was exemplified recently by the reaction of Chris Fleming, the district health boards’ lead chief executive for health of older people to news that the New Zealand Aged Care Association intended to conduct a self-funded review of the aged care sector in an election year. Fleming describes the timing of the review as “cynical”, saying that the focus should be on finding solutions to problems raised in the 2010 Grant Thornton review, rather than on undertaking another stocktake. Meanwhile Martin Taylor, chief executive of NZACA, says the second review is “important for all parties”.
Tensions can also be felt at individual facilities. Rachael Hall, manager of Selwyn Wilson Carlile rest home in Hamilton says liaising with the DHB is not always straightforward. She says one particular problem is when a patient is assessed at Waikato Hospital for referral to a residential aged care facility, but then there can be a delay of up to a week before the patient is discharged to the facility, without re-assessment. A week, says Hall, is a really long time when it comes to the health of an older person, and often they have regressed in that time and need to be transferred back to the acute hospital setting, causing unnecessary expense and concern for the resident and family.
Jeremy Leach, General Manager Marketing & Village Operations at Oceania reports similar experiences. “We have had instances where the resident has had to be returned to hospital in less than 24 hours – distressing for all parties.”
Leach agrees it is “critical” for the operator to have a resident assessed correctly so the right level of care can be provided immediately when the resident arrives and to avoid premature discharge.
Hall agrees there is an impatience for hospitals to discharge. This is no doubt caused by a pressure on the number of beds available, a constant challenge for DHBs.
The same pressures exist in residential care facilities.
“As operators ideally need to run their facilities at 100 per cent occupancy to achieve some form of financial return, there will ultimately be no excess capacity in the aged care sector, and in many areas it will be challenging to find a place from time to time,” says Leach.
Due to the high demand, there isn’t really a strong feeling of competition among aged care facilities. While larger operators sometimes have the option of providing a temporary position in another of their facilities until space becomes available, often ‘competing’ facilities that are in close proximity of each other will assist each other. Hall says that when faced with a situation when more hospital-level beds are needed than available, residents can be temporarily transferred to a neighbouring facility.
If necessary, facilities convert beds from rest home-level to hospital-level. Under their certified level of service, facilities are free to do this, as long as they don’t breach the number of dementia beds allowed of 20 per unit. At times it may not be appropriate, for example, if a hoist or other specialist equipment that is in the hospital part of the facility is needed.
Interestingly, supply and demand patterns are slowly shifting within aged care facilities. Grainne Moss of Bupa says due to the ageing population, the need for rest home beds appears to be dwindling, while that for hospital-level beds and specialised dementia beds is increasing. Moss says that a consequence of keeping older people well for longer, is an increase in acuity of residents both in hospital and dementia care.
An inadvertent barrier to providing the appropriate level of care, is often the resident’s family. Many in the sector, including Oceania and Bupa have a “person-centred care plan” which involves family input into the process and helps to manage expectations.
Moss says families generally show a preference for the homely feel of rest home rooms, until the resident’s health wanes and then the family desperately wants the reassurance of a more sterile acute hospital room. They will often want acute level care whereas it is often not the best thing, says Moss, especially if the patient has dementia, as it can be confusing and disorientating with the unfamiliar surroundings and all the bright lights and noises. Bupa works with families to develop advanced care plans and talk about these concerns and issues prior to any event.
Wendy Taylor, manager of Ryman’s Hilda Ross retirement village in Hamilton, says the assessment process and social worker at the hospital work with the village to help keep families informed of a resident’s changing care needs.
Steps toward collaboration
Certainly there do appear to be productive steps being taken towards improving the relationships between DHBs and the residential aged care sector.
Hall says there is plenty of opportunity to give feedback, through forums, for example. She says she also has a very good relationship with, the funding and planning manager at Waikato DHB, whom she describes as “very proactive” at following up on incidents when reported.
“High quality communication between the operator and the hospital is important; there is no doubt that relationships between key staff help facilitate this,” says Leach. “Our facility managers and admission staff like to work closely with the hospital staff, and in many instances they visit the resident in the hospital before they are discharged into our care.”
Moss agrees, saying she enjoys creative relationships with portfolio managers for aged care for 17 DHBs. She says most of these managers have been in their role for a long time and are knowledgeable, passionate about what they do and take a practical approach to their work. “There are relationships of trust with provider and purchasers, which is a major help in delivering better care.”
A good example of burgeoning trust between the DHBs and residential aged care sector can be seen in the work led by Waitemata DHB. Nurse practitioner Dr Michael Boyd, was instrumental in developing the DHB’s Residential Aged Care Integration Programme (RACIP) in which a group of nurses, gerontology specialists, and members of DHBs came up with 18 geriatric issues, providing the basis for the RN Care Guides, now used extensively in care facilities. In addition to advancing aged care initiatives, the development of the programme also helped in building important and strategic relationships between the DHBs and the sector.Boyd says the involvement of the aged care staff from the outset of the programme led to greater ‘buy-in’ for the programme and a greater trust of DHB partnerships.
Boyd believes multi-disciplinary teams, including a DHB geriatrician, GP, gerontology nurse specialist,facility senior nurse and pharmacist, are the way forwards for aged care facilities. Research on this topic led by geriatrician Professor Martin Connolly will be published later this year.
Although it is disappointing that more funding hasn’t been forthcoming from the Government for residential aged care, Moss believes the Ministry’s appointment of Dr Shankar Sankaran as Chief Advisor, Older People’s Health in March 2011 has been an excellent move. Sankaran’s role is to provide leadership in supporting the Aged Residential Care Services and integrating with primary care to provide specialist support to primary health care professionals. Moss says other DHBs are following his lead with many things, such as conducting medication reviews with GPs. With an 0800 number available for facilities to contact him, he is accessible to the sector. Moss believes Sankaran’s appointment is a practical answer to helping facilities achieve continuum of care.
But more can be done. With 34,000 residential aged care beds, compared with 8000 acute care beds, Moss believes the aged care sector plays a significant part. “It needs to get out of the shadows,” she says.
Making home support services a priority
However, it appears there is more to be done to improve the partnership between the home and community support services sector and the DHBs.
Better, Sooner, More Convenient Primary Health Care, the Ministry of Health’s policy direction, is aiming to achieve better integration by creating an environment where primary health care professionals in the community work with one another and with hospital-based clinicians to deliver co-ordinated care to people in their own community.
While great in theory, many in the sector believe more needs to be done to integrate community care with other health services.
Grainne Moss of Bupa is one. “At a strategic level the Ministry has pushed for more integration between primary and secondary care, but there needs to be more integration with community care. Better, Sooner, More Convenient needs to be extended to community services more,” she says.
Julie Haggie, chief executive of New Zealand Home Health Association (NZHHA) agrees, saying there is definitely room for improved integration between home support and other health services.
“People living at home need to get access to clinical care at home and after hours to reduce the likelihood, frequency, and duration of hospital attendance. There should also be more intensive support to help them rehabilitate after an event such as a fall or stroke,” she says.
It is not a unique dilemma.Other countries are also striving to bridge the gap between home-based support with primary and secondary care.
The PACE programme in the United States has found some middle ground in its community centres, which give elderly people access not only to health care but to aspects of home-support services such as meals, laundry, bathing, and even transport to the clinic.
In New South Wales, the new Hospital in the Home (HITH) programme is becoming increasingly popular with patients and has been deemed to be as clinically effective as in-hospital treatment. Under HITH, patients receive the same treatment as they would in hospital for a variety of acute and sub-acute conditions, allowing them to remain in their own home for longer.
The HITH programme also frees up much needed space in the hospital system.
In Australia, there is much concern over rising health costs and emergency departments failing to meet national standards. It is hoped that HITH will help ease the financial pressure on hospitals by reducing bed block by allowing patients to be discharged earlier and cutting inpatient bed day costs.
There are similar initiatives underway in New Zealand, too.
Don Gray, the Ministry of Health’s deputy director general of policy, points to Primary Options for Acute Care (POAC) as New Zealand’s answer to programmes like HITH. POAC is a service allowing doctors to access investigations, care or treatment for their patient, as an alternative to an acute hospital admission. It includes a range of community diagnostic, therapeutic and logistic services such as GP or nurse home visits, home help, diagnostic procedures like X-Ray and ultrasound, intravenous therapy and even transport to and from primary care locations.The programme works across Auckland, Counties Manukau and Waitemata DHBs.
Gray says that in addition to POAC there are a number of initiatives, both under Better, Sooner, More Convenient initiatives and a broader programme to move services closer to home, and develop close links between primary health care, secondary health services and home support services.
The Waikato DHB’s START programme and the Canterbury DHB’s CREST programme are both examples of such community rehabilitation initiatives.
Gray says there is also now specialist clinical support offered by certain DHBs for primary health and aged care providers. Counties Manukau and Waitemata DHBs are leading the way in this aspect. “[Waitemata] has developed a proactive community gerontology service using health of older people specialists, including gerontology nurse specialists, to provide interdisciplinary reviews, education sessions and phone support to health professionals working in the community and residential care.”
Minister of Health, Tony Ryall, in his letter of expectation for DHBs this year stated that DHBs are expected to “work with primary and community care to provide integrated services for older people that support their continued safe, independent living at home”.
While this expectation is seemingly being met by various initiatives across the country, it appears some are meeting the task at hand better than others. Older people are to an extent reliant on their region’s DHB’s approach to providing integrated services. Those who fall outside the remits of the DHBs in the wider Auckland region, for example, may have good cause to feel hard done by.
The way that many DHBs have pared back the number of provider contracts, placing further squeeze on the sector, indicates a change in focus on home-based care.
The recent example of Southern District Health Board failing to include Presbyterian Support Otago as one of its chosen providers, is evidence of the tensions running high between DHBs and providers.
Across the ditch
It is interesting to reflect on what is happening in Australia with home care. Australia Minister for Ageing Mark Butler said Living Longer Living Better – Australia’s equivalent policy to Better, Sooner, More Convenient – acknowledged in its long-term forecasting that the nature of aged care was changing, with older people wishing to remain in their homes and communities for longer. Subsequently, over the next 10 years, the Australian government would more than double home care packages across Australia.
However, Gerard Mansour, chief executive of Leading Age Services Australia told Australia’s Aged Care INsite that he believes there is more work to be done in getting the balance right. “Social interaction at this time [of life] is critically important – we know that – and it’s counterproductive if we allow someone to remain in their own home but they’re enormously isolated,” he said.
Bells and whistles
In both Australia and New Zealand, and in many countries, modern technology makes it more achievable to provide a seamless continuum of care. Assessment tools, case conferences and electronic medical record platforms are all aimed at facilitating consistent and clear communication across the team.
Electronic personalised care plans, used increasingly in the home support sector, allow a multi-disciplinary approach to care and assist with any transitions.
However, technology is not always without its problems. While many facilities and operators have expressed enthusiasm for the assessment tool interRAI, many have reservations.
Grainne Moss says Bupa is taking a ‘wait and see’ approach to interRAI. Their caution is based on the experiences of some DHBs who are really struggling with it and have hundreds of interRAI referrals outstanding, meaning that they are not keeping up with the patient as they transition through care.
The mixture of enthusiasm and caution towards interRAI is indicative of the push-pull felt in many corners of New Zealand’s healthcare system, as each party strives to push their agenda forward while at the same time collaborating with other parties to achieve the seamless provision of appropriate care at the right time. The love-hate relationships between DHBs and facilities and home support providers, and the variation of services offered from one DHB to another, both hint at the tensions felt in achieving the integration needed to deliver a smooth continuum of care.