National Clinical Programme for Older People‘Transforming Care of Older People in Ireland’

26th May 2015

'Models of integrated care for community-dwelling frail older people’

Lorna Roe Centre for Health Policy and Management, Trinity College

Dublin

This work was funded by the HRB in Ireland under Grant No. PHD/2007/16

•Myriad of services: GP ,Public Health Nurse, Older persons psychiatry , Ophthalmology, Home Help, Respite care, Carers Allowance *, Home Adaptation Grant *, Free Travel Card *, Living Alone Allowance *, Fuel Allowance*,Household Benefits *, Alzheimer's Society *,ALONE *,Day Care, Counsellor/ Psychological, Occupational therapy, Chiropody, Social worker, Meals on wheels, Retirement Group*, RESIDENTIAL CARE

• Numerous providers: by many sectors (public healthcare, private healthcare, local authority, vol org) and different Government Departments and different organisations and teams.

INFO OVERLOAD for the average Joe. 50% of older people go see their GP to get information on services & 20% contact the HSE (Murphy 2012)

Yet: •The HSE only delivers half of these services•GPs report feeling unable to deal with such patient complexity

Murphy, C (2012) The distribution and determinants of home-based social care utilisation in older person: Irish and Comparative Perspectives

Irish supports for frail older people

Integrated care??

• Organisational strategy– Mental health /Homeless / CDM/ Frailty– Within health sector only – Health & other sectors

• Chief aim: to reduce undesirable outcomes through the better coordination of care

• Impetus: demographic ageing + change in the nature of need among older people toward increasing patient complexity requiring ‘complex care’

Integrated care for frail older people. Let’s scratch the surface...

• What are models of integrated care?

• What are others doing internationally?

• How can we better understand our own care system?• What patterns of care are occurring within our care system

today?• What can we learn about coordinating care from the frail older

people?

5

1. Conceptualising integrated care?

Yet, coordination of services was noted in principle in The Care of the Aged report in 1968, in the Years Ahead Report 1988 and within the work of the NCAOP and later in strategies of ‘integrated care’ in the 2000s.

Much conceptual over lap between ‘care coordination’ and ‘integrated care’ (Kodner 2002; McDonald et al, 2007) however integrated care is a separate strategy involving:

•Comprehensive geriatric assessment•Single entry point •Case management •Multidisciplinary team•Financial incentives•Electronic transfer of information

6

2. What’s happening internationally?

Linkage • LinkAge Plus

UK• Chains of

Care Finland• Chains of

Care Sweden• Buurtzorg

Netherlands

Coordinated • Program of Research to

Integrate the Services for the Maintenance of Autonomy (PRISMA) Canada

• Hong Kong • Vittorio Veneto, Italy• Roverto, Italy• Senior Care Options

USA• Coordinating Care for

Older People (COPA) France

Integrated• Social Health Maintenance

Organisation II (SHMO II) USA• Program of All inclusive Care

for the Elderly (PACE) USA• Systàme de services intégrés

pour personnes âgées en perte d'autonomie (SIPA) Canada

• New York Visiting Nurse Scheme (NY VNS) USA

• Coordinate Home Care Trial Australia

• Illawarra, Australia

Much good intent.. (But) • The frail

– Who are the frail- no measurement tool identified – Why is the model created for the frail

• Keep people out of hospital and/or nursing home • Or improve quality of life?

• The intervention– Weak theoretical base: Who does what, where when, why?– Inadequate description of design and development – Inadequate description of processes – How can we understand the context of these interventions

8

3. What’s happening in our own care system

• Used a sub-sample of TILDA data identifying those frail aged >65+ (n=756)

• Question: Are there patterns of care within the frail older population across the ‘whole system of care’ in Ireland?

• Analytical Strategy: Latent Class Analysis to model unobserved trends between 23 different services captured by TILDA. – 23 services variables from the GP to hospital and community care.

Also created an informal care ‘service’ variable.– 4 groups of people emerged from the LCA analysis

www.tilda.ie

3. The Irish Longitudinal Study on Ageing

1. Low Users (50% of the frail)– Low P of use across all services, 20% chance of carer, 0.02 P of seeing a

PHN! – Mainly ‘younger old’, living with others, most don't drive– just above FI threshold, approx 1/3rd MM, fell last year, disabled and

approx ½ worry about falling, 60% perceive health as poor.

2. ‘Well managed, considering’ (28% of the frail) – 2nd highest P to use community services & 2nd lowest P to use

hospital services intensively. – 58% chance of having an informal carer, 50% chance to see PHN, 42%

chance of above avg GP use – ‘Very old’ women (<75years), half live alone, 66% cannot drive, 70%

disability but most barely above frailty threshold, 46% MM, lowest prevalence of falls (25%) but second highest fear of falling (67%), 64% perceive health as poor.

3, ‘Unsupported Hospital Users’ (19% of the frail) – High P of an overnight hosp adm and an above avg length of stay, 33%

chance of carer, 50% chance of seeing GP intensively , 40% chance of seeing a PHN, less than 20% chance of receiving community services

– No age or gender differences, 60% live with others, 57% still drive, – Majority low FI score but majority (72%) perceive health as poor, 40%

fell and 62% fear falling, 48% MM and 43% Disability

4, ‘Throw Everything At Them’ (3% of the frail)– 95% chance of PHN, 85% chance Informal carer, P<0.70 of above

average use of all hospital services but highest P of community services

– No age differences, mainly female, 66% cannot drive, 86% poor perception of health

– 67% v frail + MM, 62% fell last year and 80% fear falling, 95% disability

Preliminary thoughts• Management of frailty in Ireland

– not a homogenous pattern of care within the health care system – Unpacking & understanding these patterns

• Why do these patterns occur do the patterns matter in terms of outcomes over time; QOL, service use, frailty score.

• The healthcare system: We know that frailty drives service use (across all services) by comparison to pre frail and not frail (Roe, 2015) and even multimorbidity (5+ chronic conditions) (McDaid,

2014) Yet...– Very low P of use of community care across all the groups– Notable increase for group 4 but does the system intervene too late?

(Ref; McDaid O (2014) ‘The Chronic Ills of Multimorbidity’ Doctoral thesisRoe (2015) “The impact of frailty on health and social care utilisation in Ireland” Presentation to the IGS October, 2014)

The Older People Remaining At Home project

• AP funded project run by AFI in conjunction with HSE Services for Older People. Consists of a model of IC: – Support Coordinators to case manage approx 40 clients – Local Steering Group

• Qualitative interviews exploring the process or action of coordinating care and barriers or enablers to coordination – 10 frail older people* in two sites **– Two Support Coordinators*** – Data collected recently so the following are preliminary themes.

*Frailty defined and measured by Rockwoods Frailty Deficit using the Single Assessment Tool for Older People (Interrai Home Care Assessment form) indicators which can be linked back to TILDA

** Sites in Donneybrook/Ranelagh in South Dublin and Skerries in North Dublin *** In Donneybrook a Social Worker was seconded to the project, and a Public Health Nurse filled the role in Skerries

4. Coordinating care The experience from the community

• Gentleman with a post operative disability and difficulty with ADLs advised – ‘you’d to admit him to hospital in order to get him into rehabilitation”

• Time and time again care in the home established after a visit to hospital – “who set up the home help from Beaumont? The girl in the, what is

she called? Discharge Nurse? ...She was in touch with the district nurse here, nurse X. Yeah, and they had it organised for when I came home.”

Hospital: A gateway to community

Brokerage

Couple in their eighties, husband (an ex- Professor from a top Irish university) has Parkinson's and early stage dementia and wife has back problems.

• “what on earth is a Public Health Nurse, we don’t know what their role is or what they do”

• Don’t know what they’re entitled to or what is around them locally to help. Only received a disability parking disc through the OPRAH case manager & that “opened the world back up to us”.

• Applied for a home help through the PHN in 2013, husband had a bad fall again in January 2015 & it’s only now they get the help. Husband asked me ‘how long do you think we’ll get this for, is it more than a few weeks?”– Home helps; pattern of applying, waiting, health crisis and hospital stay,

then home help.

Ongoing case management

Complicated by issues with trust, pride, independence...need to slowly build up relationship and persist with suggestions.

“ She kept at me to go to the centre, I said ah, I said no, and then she made me promise that I’d go for one day and just one day to see what it was like...and I still didn’t do that..but she was going into a house down the town (one day) and she met me coming out on the path and asked me to go ...So I had to say yes I would, so I went that day centre and I’m going since.

We do exercise and everything in it, that’s really helping me, yeah...I’m able to kind of pull, put, fix my collars ...I wasn’t able to (before)... I’m the whole day there and its great and I’ve met lovely people there.”

The work of linking services • “God love him, the only thing he wanted me to do for him was get him a lift

to mass, because he used to drive to Mass every day and he wasn’t driving. So anyway, I went to the priests and he said no, it’s too much of a commitment. So I then actually went through somebody else and she got him someone, and sure he was made up because he got to Mass every Sunday... transport’s huge, it comes again and again and again..” (OPRAH Case Manager/District Nurse)

• “But giving out the information, I suppose that’s been the biggest thing, you know...a lot of the time as a community nurse as well, we’d give them out the forms, you know, we give them out the forms for a grant, and that was your job done as that was just as far as you could go. But now you can, you can follow it up and you can do it with them, ask their permission, if the family’s alright, if I follow up with this” (OPRAH Case Manager/District Nurse)

Who’s captaining the ship?!!

– Fragmentation: Medics manage medical need and PHN manage social care needs. Psycho social needs are left untreated.

– Management and monitoring: Older people have no idea when their next appointment is or what their care plan might look like. Stress!

– Overall care: The care for these individuals is a complicated, delicate model of care. Largely left to older people, their spouses and carers to overall manage. • Healthcare professionals may reschedule and create an

avalanche of phone calls to rearrange care. They describe being ‘always on the go’ to appointments, and feeling exhausted.

• Many use old notebooks to try record everything.Is that what we equate as ‘integrated care’??!!

1. What is your evidence base?– How to measure, assess and manage frailty? How to design good

models of care?

2. Do we have the components to facilitate an integrated model? – Service levels in the community, the infrastructure to transfer of

information quickly and safely, new staff roles for case manament?

3. Should we incorporate a patient centred design to improve coordination?– Can solutions come from older people themselves?

4. What are our goals– 3 square meals a day and stay out of hospital VS managing complex

needs and improving Quality of Life.

Discussion & Conclusion

Acknowledgements

19

TILDA participants for their ongoing commitment to the project.

OPRAH participants for their warm welcomed into their homes and sharing their stories and tea!

Prof Charles NormandDr Aisling O’HalloranProf John Brown

Dr Arthur White