CREST (Community Rehabilitation Enablement & Support Team)

1. CREST(Community Rehabilitation Enablement & Support Team) CREST Community, Rehabilitation, Enablement, Support Team Dr Anne Roche Paulina Baird April 2013

2. How it started Demographics • 13.5% of the Canterbury population is over 65 • Estimated to rise to 20% in 2020 • Number of 85+ will double • 85+ year olds utilise 3x health care resources of other age groups

3. Pressure on aged care and hospital beds • Prior to the earthquake plans were in place to plan and implement a support discharge programme in Canterbury. • The earthquake resulted in a loss of 106 medical beds and 635 ARC beds • We needed to progress the supported discharge initiative rapidly to reduce facility constraints

4. What is CREST? • CREST is a community based rehabilitative supported discharge and admission avoidance servicefor older people. • It works with an interdisciplinary team • a liaison team (covering both hospital and primary care) • a case manager (physiotherapist, OT, RN) that establish rehabilitation plans • a coordinator (community provider RN) who supervise teams of well-trained Key Support Workers. • CREST provides clients with up to 4 visits a day, 7 days a week

5. Why CREST? • Hospital is not the best location to rehabilitate and care for older people • 25-50% older people lose some function in hospital, and 66% have not regained function 3 months later • CREST improves client function and independence and increases the time the client spends at home • Designed to reduce: • length of stay in hospital • residential care placement • need for long-term home care

6. Eligibility Criteria • Age > 65 years • Medically stable – ready for discharge from hospital • At risk of readmission, or entering ARC • Potential for partial or complete recovery with suitable home rehabilitation within six weeks. • The client is able to stand and transfer with one person (with or without the help of a resident carer). • The client consents to being treated at home by the team and aware of the objectives set by the IDT • The client has had a recent acute illness or injury or is at a borderline level of function with an associated reduction in ADL and/or EADL

7. Making disability worseworse • Physical inactivity and disuse aggravate medical conditions such as diabetes, heart disease and causes deconditioning • Hospitalisation induces inactivity and dependence, “ wrapping older people in cotton wool”. Risk of adverse events 10 x higher > 65y • Preclinical disability can be recognised and averted with health promoting interventions, e.g. activity, nutrition • Ageing, Health Risks and Cumulative Disability NEJM 1998.338:1035-41

8. Transition to hometo home • Discontinuity in clinical responsibility • Uncertainty about changes to medication, what medications already at home, whether prescription will be filled etc • Uncertainty about physical environment, resilience of family, perceived risk • Little consideration of what is important for the person

9. Referral Process for CREST

10. Client Pathway

11. CREST is growing… Goals • SMART • S pecific • M easurable (meaningful to pt) • A ttainable • R ealistic • T ime oriented • Goal Ladder- client identifies “distal goal”- where they want to be, proximal goals are the steps required, how they get there.

12. Commenced HBSS x 2hrs week Grocery shopping (& coffee) with Liz by x Attending church with friend by x CREST discharge Preparing breakfast and snacks by x Walking to dairy (450 metres) by x One 2 hour visit x3 week Walking to car and getting in with help by x For pain to be 3/10 - getting in/out bed by x To be able to defrost and heat MoW by xxx Withdraw weekend visits Walking to letter box independently by xxx Dressing independently at home by xxx Withdraw AM visits CREST x3 a day x7 Washing independently at home by xxx Dressing independently within 5 days Withdraw night visits Drawing curtains independently by x Getting in / out of bed independently by x Hosp. discharge Walking to toilet independently day or night by 3 days Walking to ward doors within 2 days

14. Goal ladder continued

15. Patient examples • Mr CG age 93,lives with wife. • Admitted May 2 with abdominal pain due to constipation • Previous admission April 20 with NSTEMI and exacerbation heart failure. Urinary retention- D/C with IDC and plan for trail of void at home (DN) • Presented to ED May 1 with abdo pain

16. Mr GC • Constipation resolved, recatheterised with flip flow valve, LRTI and UTI treated • Apprehensive about discharge • CREST- CM present when he got home, helped to settle, distal goal- get out into garden, twice daily KSW- showering, walks, Physio- chair raiser, frame, exercise programme. • Became independent w shower, D/C 30/5

17. Primary Care CREST • Gradual extension into Primary Care since Dec 2011 • Initial pilot, 4 General Practices, Referral to OPH Clinical Nurse Specialist who screened potential candidates • Patients need to be well enough for GP management at home, but would benefit from increased support, with rehabilitation focus to enhance recovery. • OPH triage team redirected some referrals for respite care etc to CREST

18. Primary Care CREST • October 2012: 8 referrals from General Practice, 13 internal referrals from Older Persons Health Community Teams- triage, Clinical Assessors, patients seen on visits by Geriatrician and/ or Community Gerontology Nurses • Steady increase in numbers • March 2013: 18 referrals from GP, 19 referrals internal referrals

19. Primary Care CREST- patient example Care CREST • 75 yr old woman, referred for respite care • Morbid obesity, exacerbation of back pain, had pushed personal alarm 3 times in 10 days • Supportive daughter away on holiday • Bipolar Affective Disorder, currently depressed • Had been incontinent in bed, unable to get up to the toilet because of back pain. Sleeping in Lazy Boy chair • Seen by CREST Liaison, increased supports at home, practical assistance to get mattress and bedding cleaned

20. Patient example continued • Seen by Physiotherapist and Occupational therapist • Goals identified • Care plan around encouraging independence in shower, frequent supervised walks, sleeping in bed • Referred to Medication Management Service , Dietitian and Psychiatric Services for the Elderly • Back pain resolved, able to return to baseline package of care at home, more confident about ability to stay at home in medium term

21. CREST (tip) of an iceberg • Intervention and close observation at home can unmask previously unidentified problems • Cognitive impairment • Anxiety, made worse by social isolation • Shortness of breath, made worse by anxiety. • Co-ordinators inform Primary Care Team. CREST can assist in appropriate response/ referrals/ discussion with family etc.

22. Quality and Improvement • Group structure • Operational Group to discuss day to day issues • Data collection, monitoring through Quality Group • Sign off from Steering group • Case Managers / Providers • Monthly educational training sessions and peer reviews • On-going improvement • Continual Process improvement Process – what's working well • Tool development – how do we do it better • Training and development – do we have the right skill mix

28. Admissions to ARC • During the 2011/12 Year • During the 2012 Year

29. Client Survey • Approximately 1500 surveys were sent out in January 2013 • 80% surveys returned • 90% clients satisfied or very satisfied with the overall CREST service • 84% believed they set obtainable goals • 73% of clients received between 1 – 6 hours of care per week while on CREST • 78% of clients believe that CREST works well with other health services in the home • 76.5% of clients believed they were able to do what they wanted with the assistance of their support worker