Does Transition Care have a Future?

1. Does Transition Care have a Future? Leon Flicker Director WA Centre For Health and Ageing A presentation for the 2nd National Transition Care Forum November 2009

2. What is the Past of the Transition Care Program? Why did it come into being and where is it headed? Firstly, the context……….

4. What would happen if there is a constant improvement in life expectancy? Men Women

5. Projected populations – pyramid to coffin? Not just an increase in life expectancy but migration!

7. Years of Life Lost to Disability

8. Access to beds for older people in acute and aged care facilities – This will a problem for at least the next 20 years

9. An Illustrative Case • 82 year old woman • Blind, Bipolar disorder, frail – normally lives in a hostel, walks with a frame • Fall – Fractured right ischium, comminuted fracture of head of right humerus • Initial orthopedic management – non-weight bearing 6 weeks • Pressure applied – “touch” weight bearing when tolerated …TCP? Rehab? NH?

10. The Past - Where did the TCP come from? • Some history of how subacute and transition care came into being • Evidence of variable resource provision and role of these resources around Australia • Brief discussion on how and why these resources fit together

11. A meta-analysis, largely based on IPD has confirmed the benefits of inpatient geriatric assessment and rehabilitation with a reduction in death at 6 months, odds ratio (OR) of 0.65 [0.46, 0.91], with benefits on decreased rates of institutionalisation, physical and cognitive function (Lancet 1993; 342:1032) Increased benefits were associated with medical control over recommendations and perhaps explains some of the heterogeneity between studies. Similarly organised inpatient stroke unit care has also shown benefits, with a reduction in death or institutionalisation of 0.76 [0.65, 0.90] and inpatient rehabilitation of older patients with proximal femoral fractures has demonstrated a trend for benefits, OR of death and deterioration in function of 0.83 [0.64, 1.07]. (Cochrane Library) Assessment & Rehabilitation - Evidence of Efficacy

12. How did subacute care develop in Australia? 1. State run nursing homes – e.g. Lidcombe Hospital, Mount Royal Hospital, Mount Henry Hospital….. These hospitals became more involved in people who did not stay forever but were admitted for a shorter period of 14 to 60 days. 2. Arose directly in a secondary or tertiary hospital often as a component of a regional geriatric unit • Various state programs followed to try and redistribute resources on a more equitable basis Costs: $500+ per bed day and distinguished by specialist medical care and comprehensive multidisciplinary teams

13. Decline in availability of hospital beds in Australia ~ 3% pa Residential care places declined from 99 to 82 places per 1000 population aged 70+ The Australian aged population (65+) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. Trends in the use of hospital beds and aged care beds by older people in Australia: 1993–2002Gray LC et al, MJA 2004; 181:478

14. Trends in the use of hospital beds by older people in Australia:1993–2002Gray LC et al, MJA 2004; 181:478 (2)

15. In the same period Subacute care beds increased in number but decreased on a per capita basisAged Acute Care and Assessment beds by State/Territory

16. Aged Care Rehabilitation Beds per 1000 70+ for 2001 and 1992

17. New government recognized the problem in capital funding – tried loans for high level care - aborted Met the problem of inadequate numbers of nursing home beds by “Ageing in Place” Deregulated the amount of time for “nursing care” Introduced an accreditation agency Problems of very old stock in some states – particularly Victoria which struggled Problem compounded by State Governments, particularly Victoria, getting out of State funded nursing homes and foregoing licenses which never resulted in beds Exacerbated problems of Phantom beds- government were slow to act Sentinel events received widespread publicity Kerosene Baths Crisis in Aged Care 1998-2001 The Perfect Storm

18. It commissioned a number of projects to seek real data to unravel the problem with minimal Australian government/jurisdictions squabbling. They included Examination of Length of Stay for Older Persons in Acute and Sub-Acute Sectors included (1) Desktop Analysis, (existing National Hospital Morbidity) (2) Hospital Survey (3) Case Study Analysis (29) (Aged Care Evaluation & Management Advisors) Service Provision for Older People in the Acute - Aged Care System (counting the beds very difficult because the jurisdictions obfuscate this) (Dorevitch, Gray et al) Feasibility study on linking hospital morbidity and residential aged care data to examine the interface between the two sectors (AIHW) Mapping of Services at the Interfaces of Acute and Aged Care (Howe & Rosewarne) There were LOTS!! It produced a National Action Plan What did COAWG do?

19. On the 17th April 2002 a hospital census of over 65 year olds took place. The second part was completed for the same set of patients at midnight on 8th May 2002 Of a total of 617 hospitals around Australia, 611 hospitals returned surveys covering 99.9% of hospital beds in Australia. 16,104 of the estimated 17,745 patients in hospital were surveyed (1,641 patients were deliberately not surveyed as they were in ICU or other high dependency ward and/or had surgery on the day of the survey). A Hospital Census of 65+

20. Proportion of older people for whom another form of care was considered more appropriate

21. Type of care recommended for patients in hospital

22. The National Action Plan identified critical steps for reform and Recommended structural and system changes Delineated responsibilities Suggests resource priorities for achieving change to assist jurisdictions make decisions on resource allocation, and Outlined actions and milestones that will determine progress towards achieving the proposed improvements. FROM HOSPITAL TO HOME – IMPROVING CARE OUTCOMES FOR OLDER PEOPLE:National Action Plan for Improving the Care of Older People across the Acute-Aged Care continuum

23. Never produced benchmarks for subacute care or even had accurate reporting The planning benchmarks for residential aged care are still not being met in a number of regions. The balance of the services delivered within the overall aged care planning benchmark has altered over the years in line with community expectations for greater community-based care – there has been expansion but not necessarily coordinated. Principle 1: Older people have access to an appropriate level of health and aged care services that match their changing needs.

24. In 2002, approximately 2000 older people nationally were waiting in hospital beds for residential aged care. Goal: Transition care services are established through joint collaboration to cater for the needs of older people who are eligible for residential aged care and who may benefit from a time-limited non-hospital program of extended care following a hospital episode. Principle 4: Older people have access to transition care services within the acute-aged care continuum

25. Transition care: will it deliver?Gray et al, MJA 2008; 188 (4): 251-253 • Our crude estimates show the estimated annual cost of transition care at $150 million to be equivalent to: • around 400 acute hospital beds at $1000 per day, or • 850 subacute beds at $500 per day, or • 2100 permanent residential care places at $200 per day.

26. Transition Care: what is it and what are its outcomes?Cameron I Davies O. MJA 2007; 187: 197-198

27. Number of Beds in WA Queuing Analogy • A residential care bed is like a city parking spot • Acute and subacute beds function as the highways (turning most of the people away from the city) • Only 90 parking spots appear each week • Closing residential care beds is like closing down a parking station • Opening up new services e.g. TCP opens up a new lane but if the service avoids residential care then we have bypassed the city Length of stay Res TCP Subacute Acute 3 years 50 days 25 days 5 days

28. The Future - What is TCP? • Transition care provides short-term care that seeks to optimise the functioning and independence of older people after a hospital stay. • Transition care is goal-oriented, time-limited and therapy-focussed. • It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, as well as social work, nursing support and/or personal care.

29. What is TCP? (2) • It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely. • The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and subacute care (rehabilitation, geriatric evaluation and management) and who need more time and support to make a decision on their long term aged care options. It is NOT subacute care!!!

30. The Future of Subacute Care in Australia • Currently this looks rosy – COAG process has prioritized this area fox expansion Australian Govt has provided $500 over 4 years to increase services by 20% • NB This money will not provide an increase of 20% in bed based services as it is inadequate • There is an urgent need to more explicitly define subacute care and count it to prevent cost shifting

32. We are recommending National Access Targets across the continuum of health services including …aged care assessment NEED SUBACUTE TARGETS!! • The second element in redesigning the health system to meet emerging challenges is to connect and integrate health and aged care services for people over the course of their lives.

33. Healthy Australia Accord • Shifting Australia’s health system towards ‘one health system’, by realigning the roles and responsibilities of the Commonwealth and state governments, with the Commonwealth having full policy and government funding responsibility for aged care • This will create a new interface and will need to be carefully managed • E.g. If the Australian Government takes over subacute care, and ambulatory care for older people, this may create a huge barrier to acute care

34. The interface between subacute care and bed based TCP will need careful management to prevent duplication and waste. Similarly the the interface between the ambulatory rehabilitation programs (Day Hospital, RITH, domiciliary therapy, community physiotherapy, outpatient therapy...) will also need careful management. What are the equivalents for palliative care and psychogeriatrics? Greater need for Coordination

35. To what will TCP evolve to? • Will it become the almost usual interim strategy for both ambulatory and bed based care? • Older people enter this program before a CACP or EACH or and HACC service? What about the equivalent for psychogeriatric and palliative care? • All older people go into this program before entering permanent high level care from hospital. • Will it become slow stream rehabilitation, slow stream palliative care, slow stream psychogeriatric care…………

36. In my view… • The future of TCP is dependent on delivering on what it was meant to - providing flexible options for people leaving hospital who for some reason are not suitable for another program or can be accommodated in TCP whilst another program is unable to be accessed. • It functions as both another lane but also occasionally bypasses the city.