Transcript LIFTING YOUR HORIZONS 2011 AND BEYOND

Lifting Your Horizons 2011 and Beyond
REDESIGN OF SERVICES
FOR OLDER PEOPLE
Dr E Spellacy
Bay Of Plenty DHB
HealthCare Providers New Zealand Inaugural Conference 8-10 August 2005
BACKGROUND TO REDESIGN
THE AGE OF AGEING

Life Expectancy has doubled over the last 200 years
 Previously not changed for thousands of years, so we
have no cultural history to help us adjust
 The increase in life expectancy is not slowing and
progresses by 2 years every decade
(due to environmental, nutritional, and medical changes)


Longevity has also shown an accelerating increase over
the last 20 – 30 years
Death rates in > 80 year-olds are falling
HEALTH IN OLDER PEOPLE

Ageing processes change the response and capacity of
physiological systems

Presentation, investigation and treatment of disease is
different from that in younger people

Even minor loss of health may cause significant unstable
disability and drive functional support needs

Access to specialised rehabilitation is essential

Extensive community and primary linkages are required

This population is driving major changes in the health
sector
AGEING: IMPACT ISSUES (1)
 Societal culture and attitude – impact of ageism increases
 Social determinants become more relevant
 Education, training and information needs change and
increase for all
 Change in disease patterns impact on health sector culture,
staffing mix, and professional practice - not just costs
 Capacity and partnerships become more critical
 Workforce development, and the related role of the
community and volunteers, assume a high priority
AGEING: IMPACT ISSUES (2)
 Bi-directional influence on business, commercial services and
local economy
 Housing – issues include range, types, perceptions, stock,
sole living, cognitive loss, ‘housing’ separated from ‘care’
 Cognitive impairment more prevalent
 ‘Ageing in place’ induced residential sector changes
 Palliative services for older people differentiated
 Purchasing framework mirrors ‘continuum of care’
NZ’s STRATEGIC JOURNEY
1997 Facing the Future: A Strategic Plan
(Prime Ministerial Task Force on Positive Ageing)
2000 Report of the N.H.C. on Health Care for Older People
2001 The NZ Positive Ageing Strategy & Action Plan
2001 The NZ Disability Strategy
2002 The NZ Health Strategy
2002 Maori Health Strategy
2002 Health of Older People Strategy
2003 Assessment Guidelines for Older People
2004 Guideline for Specialist Health Services for Older
People
BABY BOOMERS
2011
• First wave reach 65 years; with cultural, financial and
workforce impact
• Window for redesign closing, but some leeway for need
• Chronic conditions are top priority for DHBs
• Community services are now first call on resources
• ‘Ageing in place’ strategy enacted, residential care mainly at
hospital level with av. age of entry to residential care 90+
• Rest home provision at population targeted levels
• HOOPS implemented
2021
• Boomers reaching 75 years. More people > 65 than < 15
• Superannuation and Health/DSS first call on all govt. expend.
BABY BOOMER IMPACT
from 2011 – 2021 onwards
We cannot afford to deliver, even to current best
practice, unless radically new models of promotion,
prevention and intervention are in place
THE MAJOR CHALLENGES
FOR BOP DHB
 POPULATION GROWTH
 PROPORTION OF OLDER PEOPLE
 Plus heterogeneity of districts
Acknowledging: a) the health needs of other populations
and communities e.g. children, Maori, those with chronic
conditions, rural dwellers
b) wider issues such as workforce, site
improvement, and broader determinants of health
BOP DEMOGRAPHY 2001-11
 Population increase 14% v 7.3 % nationally over the decade
(20% in the western BOP)
 Highest % growth in > 75 year group - 40% (5,000)
65 - 74 group - 30% (4,500)
45 - 64 group - 33% (14,000)
 Very high relative percentage > 65y (18% in western BOP)
 Sixth largest absolute DHB population > 65 in N.Z.
 Discrepancy between specialised services and the older
population is a major DHB challenge for quality, reputation
and sustainability
HEALTH OF OLDER PEOPLE
STRATEGY
THE VISION:
Older people participate to their fullest ability
in decisions about their health and wellbeing
and in family, whanau and community life.
They are supported in this by co-ordinated and
responsive health and disability support
programmes.
LIFE COURSE INTERVENTION (diagrammatic)
Individual health profiles may profoundly influence the course
LIFE COURSE INTERVENTION STRATEGIES
Impact strategies for effecting fitness gap changes envisioned in the cyclical life
course pathways of Older People
Older Person Function for Independance
Education For
Health
Lifestyle Risk
Factors &
Env ironment
Ageing In Place
Lif esty le
Assessment &
Rehabilitation
Rev iew & Support
for Resilience
Fit
ne
ss
Ga
p
Older Person
Palliativ e Care
Y ears
PATHWAY DIRECTION
OUTLINE
Which way into our future?
WE NEED TO KNOW
• What is this ageing?
• Who are the old?
• Why are they different?
• What has it got to do with disability?
• What has NZ been doing about this?
• What are our time lines?
• How are overseas countries approaching this?
• What are other Districts doing?
• What are we doing in BOP?
• What else should we be thinking about?
HEALTH FUTURES: 2020 VISIONS
Institute of Policy Studies 1997
Drivers:
• Advance of medical technology
• Need to ration resources
• Impact of ageing
• Growth in information technology
• Greater consumer expectations of service
Questions:
• Where do we want to be ?
• What do we have to do to get there ?
• When does it need to be done ?
• Who has to do it ?
SOME KEY ISSUES
IDENTIFIED IN OVERSEAS
STRATEGIES
Australian directions in aged care: 2001
1. A constructive approach
2. Improve funding approaches
3. Regional development and delivery
4. Unbundling accommodation and care services
N.S.W. Framework for integrated support
and management of older people in the
NSW health care system
Standards:
1. Care & support of older people and their families/carers
2. Leadership and management structure
Key Issues:
Dementia
Systems approach
Prevention, continuity and research for chronic and
complex disease
Admission as a sentinel event
NATIONAL SERVICE FRAMEWORK
FOR OLDER PEOPLE (U.K.)
STANDARDS
One:
Ageism; services provided on clinical need alone
Two:
Person-centered; individuals treated by integrated services
Three:
Intermediate care; transition support for independence
Four:
General hospital care; right skill sets and specialist teams
Five:
Stroke; reduce incidence and deliver an integrated service
Six:
Falls; reduce incidence, treat and rehabilitate
Seven:
Mental health; promotion, treat and manage dementia and depression
Eight:
Promote healthy and active life; extend healthy life, councils
Medicines management
Local delivery of services
JOSEPH ROWNTREE FOUNDATION
 Older people shaping policy and practice (2004)
 From welfare to wellbeing - planning for an ageing
society (2004)
Key Issues:
Vision and culture; ageism and discrimination; poverty and
income; information and resources for choice; market needs
as consumers; quality and life; housing and support options;
strategy resourcing and commissioning at all levels
INTEGRATED CARE SYSTEMS
Many examples from different countries, not an end in
themselves, tend to focus on frail groups, generally not
cheaper, may reduce hospital admissions, often preferred
by patients, require established primary sector
competencies, capacities and systems
e.g.
S.I.P.A. Montreal;
Metropolitan Jewish Health System N.Y.; P.A.C.E.;
Minnesota Senior Health Options Programme; Texas
Starplus; Wisconsin Partnership
Also U.K. examples
REDESIGN OF SERVICES FOR
OLDER PEOPLE INITIATIVE
Provides a design blueprint and path for the District’s
implementation of the HOOP Strategy by 2010
• Utilises the DHB’s Programmes of Care Framework
• Incorporates other National Strategies & Guidelines
• Facilitates one of the Board’s principle health outcomes
“Healthy, Independent and Dignified Ageing”
• Provides blueprint recommendations for management and
funding consideration
Activities along the Care Continuum
Publicly Funded Provider Roles for Populations of Increasing Need
Population with an Population with
BOPDHB
Population with
Population at risk early condition and advanced condition
General Population
end-stage
PoC
of a condition
few other
and multiple
condition
Framework
conditions
conditions
Promotive/
Preventive
Detective
Curative/
Maintenance
Recovery/
Rehabilitation
‘Continuity’
Management
Public Health
Health Promotion
Health Protection
Community
Development
Primary Care Expert / Specialist Care
General Practitioner
Practice Nurse
Primary Health Care
Nurse Practitioner
Community Health
Allied Health
NGO
Pharmacists
Supportive Care
Supportive
Care
Support for
Daily Living
Support for
Family/Whanau
Primary Health
Organisations
Multidisciplinary Teams
Secondary Care
Tertiary Care
Condition-Specific Care
CONTINUUM OF CARE
Figure 2:
Specialist health services for older people as part of a continuum of care
(public and private providers)
Communitybased
services
Community
Health
Support
Services
SHSOP
Acute/
Medical/
Surgical
Adult Mental
Health
Specialist
Palliative
Care
Home visit
Home visit
Home visit
Home care
Respite
Psychiatry Geriatric
of old age services
Health
promotion
Disease
prevention
Fr i e n d s
PHOs
Other primary
care
Supported living
Respite care
Community
therapy*
Rehabilitationfocused home
support
Community/
marae-based
clinics
Community/
marae-based
clinics
Community/
marae-based
clinics
Nursing
Carer support
Outpatient clinics
Outpatient clinics
Outpatient clinics
Pharmacy
Equipment
Diagnostics
Modifications
Vision
Injury
prevention
Hearing
Rapid response – supported discharge
Dental
Elder abuse
prevention
Podiatry
Assessment and service
co-ordination
ACC case management
Integrated
referral/access
Accident & Emergency Department
Hospital-based
services/
residential care
services
*
Residential care
Inpatient
Inpatient
Inpatient
Includes physiotherapy, occupational therapy, speech language, chiropractics, acupuncture etc.
Hospice
Why Does Frailty Matter ?
 Well-being declines
 Complex needs increase
 Societal and financial costs escalate
(note year pre-death)
 Health and social outcomes difficult to align with
resource use
Key feature in National and District Health strategies,
frameworks and guidelines but few studies to assess
need or effectiveness of interventions
Frailty is more than this
♥ Recent research is concerned with defining characteristics of frailty
♥ Diminished ability exists to perform practical and social ADLs
♥ The importance of social and environmental factors especially for
the old-old is now acknowledged
♥ Like intrinsic and extrinsic risk factors for falls it has personal (physical,
cognitive) and environmental factors (social, interpersonal, institutional,
legal)
♥ Often a transitional phase exists
♥ Both physical and social factors may have preventable and remediable
aspects
Reflected in current international criteria
OUTCOMES should:
1.
2.
3.
Improve systems and processes for
specialist health services for older people
Contribute to an integrated continuum of
services
Support ongoing quality improvement
and sustainability
Character of the Initiative
The character IS to:

Align service development to the Health of Older People
Strategy (HOOPS)

Align service development with the BOP Programmes of
Care

Enhance co-operation, co-ordination and coherency

Understand existing services for maximizing what is
currently working well

To develop services that meet the needs of older people
now and beyond 2011
Character of the Initiative
The character IS NOT to:

Fit services into facilities or current constraints

Endorse the status quo

Have a “throw the baby out with the bath water”
approach

Impede healthy outcomes in the longer term

Disregard the service requirements of other population
groups
Charter Format: rather than T.O.R.
A Project profile: purpose, background, sponsor, advisor
B Steering group: purpose, membership, operational
aspects, steering group competencies, functions,
meetings, reporting, quorum
C Attributes and outcomes
D Risk management
E Key components: character, vision statement, guiding
principles
F Project plan: structure, phases, existing services,
domain approach, working parties, communication
strategy, evaluation and review
G Appendices
Attributes & Outcomes
Summary for Practical Planning Recommendations
• be relevant for the district
• work alongside Maori Health Services, with guidance
• support the ‘continuum of care’ concept to reduce duplication
and gaps
• use local expertise and capability
• meet real needs without shying away from innovation
• improve communication and advocate for older people
• not disregard the needs of other population groups
• welcome the participation of communities and consumers
• link with other agencies and authorities
• be understandable and flexible, open to review and evaluation
• as far as possible withstand health system change !
DOMAIN AREAS
a lu
at
io
n
Inte rs e ctoral
Ev
&
ra
l
Ru
Consumer
Health Service
User
Steering
Group
Psychiatry f or
Old Age
ea
H
lth
is
D
&
n
io on
ot nti
e
om v
Pr Pre
Primary Health
Sector including
PHO's
Palliative Care
f or Older People
ea
se
Long Term
Support
Disability
Local Authoritie s
Phar
ms &
L
ab s
NonGovernment
Organisations &
Voluntary Sector
Specialist Health
Services
l&
ra
tu
ul ity
, c un
al m y
ci m f et
So co sa
Maori Health
Services
Project Plan
Phase One
July 2004
August
Sept – Nov
•Formation of steering
group
•Definition of pathway,
issues and work-streams
•Project outline
•Project plan
•Scoping of project completed
•Work-streams prioritised
according to DHB decision
matrix grid
•Working parties established
with defined objectives
•Coherency
•Working parties in progress
•Clarification of key issues,
linkages, themes, with design
landscape taking form
•Foundation issues have
resolution plans
Identifying interim products
Dec – Jan
•Interim time point, workshop
•Report end January 05
•Indication of timeframe for
project consequences that are
realistic, highlighting extensions
if necessary
•Pick up recommendations
•Decision mandate
Purchaser feedback on interim
products, as needed
Project Plan (cont.)
Phase Two
Phase Three
Feb – May 2005
June 2005
July 2005
September
•Re-scope as needed
•Information correlated
•Working parties reclustered.
•Redesign
recommendations
aligned and presented,
1–15 year solutions.
•Redesign
recommendations
reviewed by Funder.
•Business case
implementation.
•Major redesign options
formulated
Interim projects
identified.
Early pilot
implementation as
needed and feasible.
•Final report.
•Organisation
business cases
prepared
•On-going redesign
and development
RSOP Initiative Activities (1)
Charter preparation and endorsement
Communication of Initiative, with initial gaps rectified
Education and awareness raising, ongoing core activity
Attitudes and age, profiling of leadership of change and marketing
of “great ageing”
Steering Group evolution including transfer of knowledge
Identification, scoping and development of seeding/germination
and foundation products
Early Directions
SEEDING/GERMINATION PRODUCTS
• Restorative rehabilitation ward pilot plan
• ‘Elder abuse’ coordinated district prevention service (Rights Issue)
• ‘Continuum of provider’ post-rehabilitation agreement
• Orthogeriatric collaboration (osteoporosis, fractures and prevention)
• Early recommendations re SHSOP core development
• Resource directory → centre linked to access and community network
• Professionally co-ordinated volunteer service
FOUNDATION PROGRAMMES
• Alignment of priorities for these services: PHOs, DHB, HOOPS
• Stocktake of basic to mid-level education & training availabilities
• Assessment Guidelines for Older People preparation → InterRAI
• End of life-course palliative care initial liaison
• Mental health for older people co-development
RSOP Initiative Activities(2)
Information gathering on district, national and international strategies, directions,
services and research. Incorporation into education and information opportunities
as above.
Focus Groups with NGO’s, community organisations, health service users and
interested others to further inform about RSOP, gain advice on engagement with
RSOP and gather views on service improvements.
Specific consultation and relationship meetings with key organisations, services
and individuals
Minor involvement with other projects/groups e.g. site redevelopment
Strategies to keep abreast and be included in district directions, discussions and
decisions.
“Morphing” of the above into a nascent district framework for specialised health
services for older people.
Focus Groups
Purpose
• To inform people about the Redesign Initiative and its
objectives
• To ask for community contribution to the Redesign and how
this contribution could continue in the future
• To glean ideas and suggestions about improvement in
specialised services and to identify the most significant gaps
in service provision
Focus Group Questions
• What are the most important areas for the BOP DHB to put resources
into so that older people can stay fit, healthy and independent at home?
• What suggestions do you have for how all the people involved in services
for older people could communicate and link more effectively?
• What could be done to improve health and support for older people in
rural areas?
• How can we better support and develop Maori health services for older
people?
• What are the changes we need to make in all our services to support
older people with cognitive loss (dementia) and other mental health
problems?
Focus Group Questions
cont.
• How can we effectively ensure that older people, their
groups and organisations, are involved in the on-going
planning and delivery of health and support services for older
people?
• Please give us your three (3) most urgent gaps in service
that need to be addressed.
• Please give us your five (5) greatest ideas for how health
and support for older people could be improved.
Purpose of Mid-point Workshop:
Was not
Was

To allow a dedicated time for the
Steering Group to review the emerging
redesign framework and revealed
underlying issues

To report on the detail of the work
of phase 1

To repeat, review, or reproduce
the background material already
covered or presented in phase 1

To consolidate and endorse
components to be included in the
indicative report

To provide an opportune time for this as
phase 1 transitioned to phase 2

To ensure unanimity of thought
patterns

To allow the incorporation of other
‘brains’ and experiences before
channeling of directions

To work out the operational detail
of change

To achieve early consensus on the
2011 Design

To be constrained by the present
or our attitude to it

To know all the answers
Overall: to have 2 days that positively influenced our redesign, our practice, and our
district. Concept worked well
CONTENTS OF THE REDESIGN
Continuum of Care Pathway
 BOP emerging design and pathway is compatible with
other NZ redesign models but has characteristics specific
for this district
 Overseas models of interest for some sub-groups of older
people cannot be considered until significant local
development work has occurred, but the design will not
restrict these future options
 Outline of the detailed redesign directions follows:
Key Redesign Components for B.O.P.
1. Informed participating older people supported by their key individuals or groups
2. Populations are aggregations of people who live in communities; the
neighbourhood community should be the core unit of the redesign, cross-linked by
communities of interest
3. Communities have a need to participate for healthy ageing, whilst district agencies
have a capacity need for them to participate
4. The range of participatory assessments and processes must be smoothly and
promptly coordinated and translated into acceptable effective interventions for
quality ‘ageing in place’
5. Cooperative interaction with primary health teams and agencies for all services is
central to the continuum of care
6. Dynamic interchange of knowledge and health care plans between S.H.S.O.P.,
other specialist services and primary health teams will drive progress
Key Redesign Components for B.O.P. (cont.)
7. The maturing implementation of the NZ PH&D Act 2000 ‘calls out’ for
the DHB to ensure the ‘provider arm’ reflects the population focus and
has a leverage function for improved population health outcomes. A
coherent associated move away from the business format of unit
outputs to an aligned ‘service-based’ delivery pattern has much to
recommend it, including the potential for hospital culture change
8. The rapid development of S.H.S.O.P. across the district with a
coordinated unified direction is an essential driver; and is not possible
without changing from a facility-based to a service-based structure
9. Ageism needs mitigation through leadership, competent understanding,
societal role modeling, lifestyle and economy changes; thus producing
the changed expectations of ageing which influence the reality
10.Positive change in the broader determinants of health has no age
restriction in its influence and requires intersectoral resourcing
11.Practicalities of implementation must be recognised with regard to major
areas of resource rationing
‘Whānau Capacities’
Prof Mason Durie
“….It’s about building Maori Communities:
Skills, Strategies, Structures, Systems…”
Capacity
Manaakitia
Pupuri Taonga
Whakamana
Whakatakato Tikanga
Whakapumau Tikanga
Whakawhanaungatanga
Function
Whanau care
Guardianship
Empowerment
Planning
Cultural endorsement
Whanau consensus
Focus
Wellbeing of Whanau members
Management of Whanau estate
Whanau participation in society
Future generations
Whanau members, Whanau protocols
Whanau cohesiveness
Maori

Highest relative growth rate of all populations for >65
years

Absolute numbers still low in the short to medium term

HOOPS and other national/mainstream directions for the
health of older people are in line with many traditional
Maori values - but are poorly known to many small Maori
providers

Maori providers have often developed services in relative
isolation from the mainstream, using innovation and
knowledge of their people
Maori
Priority for next two years is - in keeping with the Treaty

Knowledge exchange

Relationship building

Integral in all aspects/domains of service development

Capability for future capacity building
Preparatory to enhanced Maori Health Services for
Older People under the guidance of, and in partnership
with, the Runanga
THE REDESIGN REPORT

PART 1: Specialist Health Services for Older People and
other secondary services
 PART 2: Access and resources to support quality
‘ageing in place’
 PART 3: Primary health
 PART 4: Palliation and end of life services
 PART 5: Information, participation and inclusion
 PART 6: Sectors laying the foundations for health
 PART 7: Leadership – consequences for management
and governance
Part 1: Specialist Health Services for Older
People and Other Secondary Services
 Current
organisational climate
 S.H.S.O.P. – ‘Health in Ageing’
 Musculo-skeletal services
 Organised stroke services
 S.M.H.S.O.P. – psychiatry of old age
 Clinical linkages with other secondary
services
S.H.S.O.P. Recommendations
(High Level Summary)
 Service structure established
 Staff capacity and capability enhanced - all disciplines,
especially nursing, with positive discrimination for catch-up
 General wards liaison capacity, including leading role in
05/06 required ‘Organised Stroke Service’
 Community teams formed, including supported discharge
 Ambulatory prevention, including emergency presentation
 Community and emergency admissions
 Market leader and educator role recognised
Part 2: Access and Resources to
Support Quality ‘Ageing in Place’
 Integrated
access
 Home based support issues
 Disability and the community
 Local priorities
 Accountability for individuals
 Residences and the residential sector
Part 3: Primary Health
 Older
people as a PHO population
 Scope
of the PHO for this population
 Cohesive
 Scope
capabilities
of primary services
Part 4: Palliation and End of Life
Services

Relationship to life-course
 Integrating curative and palliative therapies –
a paradigm shift
 Special needs of older people- a paradigm expansion
 Role of continuity
 Specialised services including hospice services
 Fragmentation related to funding streams
 Generalist and specialist palliative services
Redesigned framework for district palliative services
Part 5: Information, Participation
and Inclusion
 Informed
people
 Communities caring through support nets
 Community mosaic influencing change in
the district
 Utilising community capacity for service
delivery
 Combating ageism: inclusion and rights
Part 6: Sectors Building the
Foundations for Health
 Education
and training for quality
 Workforce
development within the District
 ‘Positive Ageing’
within the Bay of Plenty,
through intersectorial initiatives
Workforce development for an
older population






Relationship between demography, demand,
labour, services and culture
Workforce development implications
Workforce planning considerations
Workforce development within the organisation
Training and development
Role boundaries, capabilities, competencies and
skills
Part 7: Causes & Consequences
 Leadership
 Management
 Governance
Executive Management
Issues requiring specific knowledgeable leadership
e.g. Getting the ‘Age of Ageing’ on the executive and
management table
Leading ‘Positive Ageing’ across all sectors
Workforce planning - dual focus
Public health - shift in approach
Communication
Hospital culture
Backing leaders
Governance
Personal Health v Disability v ‘Public’ Health
“Health, disability & environment
are inextricably linked in older people”
Therefore, which Board Sub-committee leads the
development of services for older people and
fosters the continuum of care ?
(notably the core ‘Specialist Health Services For Older People’)
Service Development and Planning Team BO P DHB
Acknowledgements
Sponsor: Ron Dunham, CEO, BOP DHB
Advisor: Sharon Kletchko, Director Planning and
Service Development, BOP DHB
Project Manager: Amanda Lacey