white paper report - tcp group …white paper report prepared by: editor: dawn o’ shea ......

WHITE PAPER REPORT

Prepared by:

Editor: Dawn O’ Shea

5/16/2014

The aim of Ireland’s first national homecare conference on Friday March 28th was to provide policy makers, care professionals, service providers, patients, carers and all stakeholders with a clear picture of the current state of home care in Ireland and offered an opportunity to examine the issues that will influence the sector into the future. The following pages are a summary of the results of what was discussed on that inaugural day which we hope will assist in laying the foundations for a second conference in 2015.

Mernagh Communications 35 Llewellyn Lawn Dublin 14. Ireland

Phone: 01-4440536 Web: www.mernaghcommunications.com 2 | P a g e

Summary of Report:

Speaker: Tony O’ Brien Role: CEO of the HSE Title of talk: DO BETTER OR DO IT DIFFERENTLY

The White Paper on Universal Health Insurance offers an opportunity to redefine how healthcare is delivered, according to

the HSE Director General

The launch of the Government’s White Paper on Universal Health Insurance provides an opportunity to redefine how health

care is delivered in this country, the Director General of the HSE said, and he urged the homecare sector to ensure that its

voice is heard in the discussion of how our health services are structured into the future.

Addressing the inaugural National Homecare Conference, Tony O’Brien said there is a need to fundamentally reshape how

healthcare is provided.

“We can either seek to do everything we are doing now but do it better, or we can do it differently,” he said.

The HSE chief said the current system involves an over-reliance on acute care and an under-reliance on community services

and homecare. By not investing in homecare and community services, the system drives people to more expensive models of

care, he remarked.

“Traditionally, over the years, when financial pressures in the health sector have emerged and the pressure to balance

budgets arises, things that are not protected by absolute statute are the things that tend to suffer cuts. Consequently, we have

the illogical consequence that homecare hours and homecare supports suffer the burden of reductions in expenditure whereas

much more expensive types of care continue to be protected.”

“The aim here is to create a degree of certainty that the health system will no longer do that,” Mr O’Brien said.

He added that changes may be needed in relation to the Fair Deal nursing home support scheme. The availability and

certainty around funding for residential care is skewing people away from considering the option of homecare, he said.

The introduction of the single assessment tool later this year will go some way towards addressing that issue, he said. The

initiative will determine the most appropriate package of care – be that residential or homecare – based on the older person’s

individual needs.

The national clinical care programmes aim to further strengthen community and homecare services for older people in an

effort to avoid unnecessary hospital admission and to support early discharge from acute hospitals.

Government policy is focused on redirecting healthcare delivery from the acute hospital sector and more towards

independent healthy living and community care. This is necessary, Mr O’Brien said, not only from a quality of life

perspective but is also crucial in terms of the sustainability of our health services.

“In the national conversation that is about to begin, it is important that your voices are raised very strongly to ensure that the

incentives, the policies and the way our system is structured, will facilitate that,” he told homecare providers.

“We have legislative and financial processes that promote the most expensive forms of care and which encourage people to

believe that they cannot rely on the health service to maintain them in their own homes. To be fair there is some evidence

over the years that enable that view to be a realistic view. We need to change that view.”

“The health service is committed to working with you as we go through this process to ensure that view can be changed,” he

told members of the industry.

“As a health service, we will continue to provide homecare and community supports. We will continue our drive towards

integrated models of care across all services and we will continue the modernisation of the way our workforce is deployed in

order to bring maximum benefit to our population and reform our services to provide effective, safe, high quality personal

and social services,” Mr O’Brien said.



Speaker: Hugh O’ Connor Role: National Age Friendly Cities & Counties Programme Manager Title of talk: Simple solutions to common problems

Society’s view of ageing needs to change. Ageing should be seen as an achievement and something to be celebrated,

according to Hugh O’Connor, Programme Manager of the National Age Friendly Cities and Counties initiative.

“In the past, policy would have viewed population ageing as a challenge, something that impacts on the sustainability of our

public finances due to the implications for health services and pension costs, but ageing very much presents huge

opportunities,” Mr O’Connor said.

“The Age Friendly Cities and Counties Programme tries to respond to the multifaceted opportunities and challenges that

ageing presents. The ambition is to provide a structure and set of supports that allow local authorities to take the lead at a

community level to change the way ageing is viewed and how services are planned and delivered locally,” he explained.

By listening to older people, identifying their needs and involving the older person in developing solutions to those needs,

there is an opportunity to create a more age-friendly and inclusive society, he said.

Ireland’s Age Friendly Cities and Counties Programme is part of an international effort coordinated by the World Health

Organisation which defines an age-friendly community as one which recognises diversity among older people, promotes the

inclusion of the older person in the community, respects the decisions of the individual, and anticipates and responds to age-

related needs and preferences.

The programme brings together statutory and voluntary agencies in local areas with the aim of creating an environment

which supports and celebrates the older person within the community. Under the leadership of the local authority and the

regional county manager, older people are invited to participate in a consultation process to identify issues which positively

and negatively affect the older person. On foot of the consultation process, local representatives from the HSE, An Garda

Síochána, universities and voluntary agencies, come together to devise solutions.

The programme was launched in Ireland in 2009 and, to date, 19 of the 34 local authorities have implemented the initiative.

The ambition is to roll the programme out across all local authority areas by the end of 2015.

“Very often relatively small, modest, low-cost changes can make a huge difference at a local level. Keeping it simple is

often the answer but the key is to keep the voice of the older person at the centre of the process,” Mr O’Connor said.

A range of initiatives have been developed by local authorities to meet the needs of the older person in their regions. In

Fingal, older people participating in the consultation process identified difficulty in relation to attending hospital

appointments. The cost of taxis to and from the hospital was often as much as €60, and while the HSE and Beaumont

hospital both ran a bus service, the hospital had a high level of no-shows, particularly among older patients. In response to

the issue, the HSE, Beaumont Hospital and a voluntary transport provider collaborated to develop a health route bus service

which transports older people to and from the hospital for a nominal fee. The result has been a reduction in health service

transport costs, a major drop in no-shows at the hospital, and a more amenable option for older people.

In one of its most ambitious projects to date, the programme is currently launching a community-based interagency initiative

aimed at providing older people with the supports they need to remain living in their own homes.

The OPRAH (Older People Remaining At Home) project is being launched in six pilot sites throughout the country – one in

Limerick, one in Kilkenny and four in Dublin. OPRAH hopes to reduce hospital attendances and premature admissions to

long-stay nursing home facilities.

The project will provide up to 40 older people in each pilot area with a designated support manager who will carry out an

assessment to determine each individual’s physical, emotional, social and mobility needs. Personalised support plans will

then be developed with local health services and voluntary organisations to address each person’s specific situation.

The Age Friendly Cities and Counties Programme is structured and delivered by local authorities and is coordinated by Age

Friendly Ireland. Further information is available at www.agefriendlycounties.com.



Speaker: John Sweeney Role: Director of Healthcare Informed Title of Talk: Care standard regulations for home care HIQA regulations are inevitable for the home care sector but it is likely that health insurance requirements will force the

industry to implement quality care standards even sooner. That was the message from John Sweeney, Director of Health

Care Informed and an authority on healthcare quality accreditation and risk management.

Mr Sweeney pointed to the private hospital sector as an example of what lies ahead for the homecare industry. While private

hospitals do not, as yet, fall under any statutory quality regulations, a substantial number of facilities have sought external

quality assurance in order to meet health insurer requirements.

Many of the leading private hospitals, such as the Blackrock Clinic and Bon Secours group, have sought external validation

from the Joint Commission International (JCI), one of the leading international healthcare accreditation bodies. However,

although JCI also provides quality care standards for homecare services, only one homecare provider in Ireland has sought

and acquired JCI accreditation, Mr Sweeney pointed out.

“That in itself raises questions about where we are,” he said. Of the 53 homecare organisations operating in Ireland, eight

have achieved quality certification such as the Q mark. However, Mr Sweeney pointed out that quality assurances such as

the Q mark only relate to the operation of the business and do not assess or validate the actual quality of care that is provided

to the service user.

Homecare providers profess to have a strong focus on quality care and the importance of delivering a high level of service to

users, yet only one homecare organisation has sought external assurance of that ethos.

“Currently we are in a scenario where homecare is rapidly expanding. We have a continued demand for quality care but we

are not in a position to be able to put our hand up and say ‘yes, you can count on the quality of care we provide’ even though

we all profess to that ethos,” he pointed out.

Evidence suggests that when standards are implemented, there will be a 10% reduction in the number of service providers,

Mr Sweeney cautioned.

“That figure is almost consistent across all regulated environments,” he said. “It may be due to providers deciding that

compliance is too much of an investment or it may be the regulatory bodies themselves that bring it about.”

He advised service providers to start preparing now for the inevitable introduction of regulations and care standards. The JCI

homecare standards and the National Standards for Safer Better Care give a clear indication of what will be contained in

future regulations.

“The National Standards for Safer Better Care has a lot of information that tells you how regulation in all sectors is going to

work. Once regulation arrives, it’s about essentially taking that format and making it specific for the sector.”

“If you are wondering what kind of measurable elements they are going to be looking at when it comes to regulation, take a

look at the JCI accreditation for home care and we already know what the key aspects are and what is important in providing

care in the home,” he said.

One of the key elements will be to assess the care provided as it relates to the service user. The onus will be on providers to

appropriately assess the needs of the individual being cared for and to deliver care that meets those needs, according to Mr

Sweeney.



Speaker: Tadgh Daly Role: CEO of Nursing Homes Ireland Title of Talk: Focus on developing continuum of care

Community services must resist efforts to pit one against the other in terms of policy and funding, Tadhg Daly, CEO of

Nursing Homes Ireland warned.

“One of the dangers that we will fall into if we are not careful, is that people will start pitting one against the other,

suggesting somehow that it’s residential versus homecare or homecare versus residential care,” he told the inaugural

National Homecare Conference.

“In fact, nothing could be further from the truth,” he said. “Given the age demographic, given the large numbers that are

requiring care, a whole range of services are required to meet the needs of that population.”

Efforts need to be focused on developing and embedding the continuum of care between homecare and resident services.

There needs to be a focus on expanding the provision of services in the community and creating a continuum between

nursing homes, day care, respite, rehabilitation, convalescence, short-stay care and independent living, according to the NHI

CEO.

The NHI has lodged a submission to the Fair Deal review process calling for a new funding process to be established to

support older people in accessing homecare. The submission calls for a funding model to be created for homecare funding

which mirrors the Fair Deal model for nursing home support.

“In our submission we have argued that it should be a mirror scheme to replicate Fair Deal which would have its own

legislative basis to provide a statutory process for homecare provision,” Mr Daly explained.

The scheme should be based on the principle of money follows the patient and should incorporate a uniform assessment tool

and a co-payment model to make homecare an affordable and accessible option, he said. The focus must be on dedicated

ring-fenced funding for homecare services and equitable access for those who require homecare, he added.



Speaker: Stephen McMahon Role: CEO of the Irish Patients Association Title of Talk: Keeping the patient at the heart of homecare

At the heart of all healthcare services must be the recognition that the patient is an individual who has the right to be heard

and to be treated with dignity, Stephen McMahon, CEO of the Irish Patients Association told the inaugural National

Healthcare Conference.

“What is really important in healthcare is the patient. That’s the reason we are all here,” Mr McMahon pointed out. “And the

first need of any patient is to be treated with dignity.”

He quoted an old Nigerian proverb which says ‘no matter how shattered is the spirit shrine, the spirit is there all the same’.

Home carers and homecare providers must keep that value at the centre of all that they do, he said.

There has been a lot of talk about patient-centred healthcare in recent times but this is a concept which must not just be given

lip service, he stressed.

“Patient-centred care is not just a buzz word. There are principles to patient-centred care. It means access to healthcare

services warranted by the patient’s condition. It means providing information that is appropriate, relevant and timely. It is

about empowering and motivating patients to take responsibility for their healthcare and to allow for patients to be as

independent as possible,” he explained.

He urged home carers to be a real caring presence in their clients’ lives.

“That is the value that home carers have, to be that caring presence in someone’s life. It means not just following policy. It’s

easy to do a check list of policy requirements from HIQA or any other policy group but we have to be able to look at the

wider picture.”

“Patients need to be able to trust the system. Whether that system is in the acute hospital sector or out in the community, at

the end of the day, patients and their families want to be able to trust the people who are caring for them,” he said.



Speaker: Andrew McFarlane Role: Centre Manager, The Netwell Centre Title of Talk: Technology holds the key to independent living for older people

The Great Northern Haven project in Dundalk is an example of how technological advances can achieve the Government’s

aim of supporting older people to live independently for longer.

It is a unique collaboration between local authorities, the HSE, industry partners and Dundalk Institute of Technology, and is

a shining example of how advances in technology can be used to improve the quality of life of older people.

The initiative, which was opened in 2010, is unique on a global level. The purpose-built residential complex comprises 16

individual units fitted with the latest technology and sustainable energy tools which, combined with local community

supports, serve to assist the older residents in maintaining their independence.

The development is fitted with 2,500 sensors which monitor the day-to-day activity of residents. The data collated from

these sensors is not only being used to better determine the needs of older people over time, but is also linked to practical

applications which assist local services in meeting the residents’ needs.

Speaking at the 1st National Homecare Conference, Andrew MacFarlane from the Netwell Centre at Dundalk Institute of

Technology, said the project has clearly shown that the application of ambient assisted living technologies can have a

significant impact on the lives of older people.

Great Northern Haven shows that technology does work and has the potential to facilitate Government policy in moving

healthcare from the acute hospital to the community setting. Unfortunately, Mr Macfarlane said, the opportunities are not

being availed off.

“A common thread in terms of the use of ICT and care is that that pace of technological change very much outstrips the pace

of organisational change,” he said.

“Government policy is to move healthcare away from acute care and more towards independent healthy living and

community-based health services, but you have to ask yourself, is the budget following that policy?”

Telehealth technologies have been extensively piloted but the widespread application of these tools is still absent.

“At the end of the day, these are real people with real lives. The big question here is how we can use technology to create the

connections between all the different groups that support people to live in their own homes so that they don’t end up in

residential care.”

“There has got to be another way, other opportunities in terms of how we deliver these services and we would argue that

technology is a big part of that. Whether it is an active 90 year old or a bed-ridden child, they all share the one goal and that

goal is to live out their years in the comfort of their own homes rather than in an institution,” Mr MacFarlane said.



Speaker: Bevan Ritchie Role: Clinical Nurse Manager, LauraLynn Ireland Title of Talk: 1,600 children in Ireland living with life-limiting conditions

Just as with older people, the ideal situation for a child with a life-limiting condition is to be cared for in their own homes.

Unfortunately, not all children are given this opportunity and many end up dying in acute hospitals, Bevan Ritchie, CNS

with LauraLynn said.

At any one time there are up to 1,600 children in Ireland living with a life-limiting condition (LLC). About 370 children die

every year from LLCs.

“All the research says that children and their families want the child to be cared for at home and in particular they want to

die at home. In order to do that we need to provide seamless, quality care regardless of where the child lives or what the

diagnosis is,” Mr Ritchie said.

There are considerable advantages to the child being cared for at home. “It’s where they feel comfortable,” he said. “It

diminishes feelings of fear, isolation and helplessness, but only if there is adequate support.”

But, he added, there are also major difficulties to consider. Many of these children have complex conditions and require a lot

of technology, equipment, aids and medications. A myriad of agencies and healthcare professionals can be involved which

can leave parents juggling a range of hospital appointments and home visits.

LauraLynn recommends that each family should have a single key worker who would act as liaison and coordinator between

all the different agencies and professionals. The HSE, in partnership with the Irish Hospice Foundation, funds eight outreach

nurses around the country who act in this capacity. However, Mr Ritchie said, the programme is already overwhelmed with

the numbers requiring care.

Later this year LauraLynn will roll out a pilot LauraLynn@home project in two sites. Under the scheme, two teams will be

assigned to families to provide planned short in-home breaks and respite. It is hoped that the teams will also be able to

respond to crisis situations and deliver end-of-life support.

Children’s palliative care is a relatively new specialty and an expanding, complex area for the homecare sector. LauraLynn

offers a range of educational programmes on a variety of topics relevant to caring for children with LLCs including

medication management, pain and symptom management, and end-of-life care. The training is specifically tailored to nurses

and carers. Further information is available at www.lauralynn.ie.

http://www.lauralynn.ie/



Speaker: Geoffrey Shannon Role: Special Rapportuer on Child Protection Title of Talk: Making the protection of children a priority for all

The Children First Bill applies to all organisations that provide a service to a child where a parent or guardian may not be

present, regardless of whether the organisation is a State agency, a voluntary body or a private provider. The Bill specifically

refers to healthcare, therapeutic and disability services.

Dr Geoffrey Shannon, Chief Rapporteur on Child Protection, said that while the new laws come with considerable

obligations, they are a necessary step in ensuring that the mistakes of the past are not repeated.

Dr Shannon was co-author of the Report of the Independent Child Death Review Group which examined the deaths of 196

children who were in the care of the State between 2000 and 2010. “Nothing predicts the future like the past,” he said, “and

those who are unaware of history are bound to repeat it.”

“There certainly seems to have been a failure to learn from past mistakes,” he said. “The same mistakes seem to crop up

again and again and that is why it is important that there is a robust risk assessment in place and that is hugely important in a

homecare setting.”

“There is an obligation on all of us to be proactive. It’s a positive obligation, that there is not a situation where we sit idly by

and let harm occur. Early intervention is hugely important. It’s something we have not been good at in this jurisdiction at a

number of levels. It’s about supporting people before problems emerge,” Dr Shannon said.

All organisations which fall within the remit of the Children First Bill are required to appoint a designated officer, prepare a

keeping children safe plan, vet and train staff, and actively support employees to promote best practice in child welfare and

protection. The obligations apply to services provided by all State organisations, including the HSE, irrespective of whether

the services are delivered by the organisation, its agencies or a private provider.

“We are on a journey and that journey involves responding to the needs of vulnerable people. We have come a long way in

terms of protecting children but only when we fully hear the voice of the vulnerable will we be in a position to say that we

are a country that does cherish all the children of our nation equally,” Dr Shannon said.



Speaker: Niamh Maher Role: Senior Dietitian, LHO North Dublin HSE Title of Talk: Preventing malnutrition in the home-bound patient Over 140,000 Irish people are currently malnourished. Half are over the age of 75. It is estimated that 6,500 nursing home

residents and 2,600 hospital in-patients are malnourished. But by far the most affected groups are elderly patients living in

their own homes and younger adults with serious illnesses. Almost 67,000 elderly people living in their own homes are

clinically malnourished.

Malnutrition is a major but hidden problem that must be addressed. Carers should have basic nutritional training and should

be alert to the signs and consequences of malnutrition in their clients, according to Niamh Maher, community dietitian with

North Dublin HSE and a member of the Irish Society for Clinical Nutrition and Metabolism.

Malnutrition can have significant health implications, Ms Maher said. Malnourished people are three-times more likely to

develop infections and have twice as many GP visits and hospital admissions. When a malnourished patient is admitted to

hospital, the hospital stay is likely to be 30% longer than that of a well-nourished patient. More importantly, a malnourished

individual is up to three-times more likely to die within six months compared to somebody who is well nourished with the

same diagnosis.

Ms Maher stressed that a person does not need to be thin to be malnourished. “Malnutrition is not always apparent to the

naked eye,” she said. “While you think traditionally of someone who is very thin, malnutrition is predominantly associated

with muscle wasting.”

She called on homecare providers to ensure that carers are equipped with the necessary knowledge and skills to support

clients in maintaining a good nutritional status and to be in a position to refer the patient to the proper supports if there is a

suspicion of malnutrition.

“The role of the carer is really to raise the red flag,” she said. “If a client appears to be losing weight and not eating, the

carer’s role is to bring that to the attention of the GP or public health nurse. It needs to be escalated. If we ignore

malnutrition then it’s not going to get treated.”

“Homecare providers should ensure that all carers have basic nutritional training to make sure that the advice that they are

bringing into the home and the decisions that they are making around providing food are based on fact and a good

understanding of what healthy eating really is.”

She encouraged the use of the Malnutrition Universal Screening Tool (MUST) to accurately determine an individual’s

nutritional status. The MUST tool is easy to use and has been validated across a variety of healthcare settings. She also

advised regular weighing and stressed that weight should be documented so that there is a clear record over time.

Simple practical approaches can often make a considerable difference in maintain good nutrition. Ms Maher suggested

involving the client in mealtimes and cooking, allowing plenty of time to eat with lots of encouragement, and ensuring that

food is warm. She encouraged self-feeding when possible, even if this means hand-over-hand assistance or incorporating

finger food.

Where a client refuses food, she encouraged carers to try to identify the cause. Some may be embarrassed about eating in

front of others, as can happen with Parkinson’s patients, she said. Others may be afraid to eat, particularly if they have had a

choking incident in the past. If appetite is low, the patient may be suffering from low mood and may need to be referred for

support.



Speaker: Nicola Fewer Role: Clinical Nurse Manager, Mooncoin Residential Care Centre Title of Talk: Managing difficult behaviours in dementia patients

Dementia can bring with it many challenging behaviours but carers must remember that the patient cannot control this

behaviour and is suffering from a physical condition they have no power over. That was the message from Nicola Fewer,

CNM at Mooncoin Residential Care Centre and a trainer in dementia care.

“You need to remember that you cannot change the person, you can’t make them react the way you want them to react. The

person you are caring for has a brain disorder that shapes who he or she has become,” she told carers at the first National

Homecare Conference.

She reminded the audience that any efforts to control or change the patient’s behaviour will most likely be unsuccessful or

be met with resistance, but some simple, compassionate approaches can make a difference.

She advised carers to try to accommodate behaviours where possible. If the person insists on sleeping on the floor, then

place a mattress on the floor to make him more comfortable, she suggested.

“It is important to understand that all behaviour is triggered. It doesn’t occur out of the blue,” she added. It might be

something a person did or said that triggered a behaviour or it could be a change in the physical environment.”

“The root to changing behaviour is disrupting the patterns we create. Try a different approach or a different consequence,”

she advised. However, she added that the multiple factors that influence troubling behaviours and the natural progression of

the disease means that the solutions that are effective today may not be effective tomorrow.

“The key is to be creative and flexible in your strategies,” she said.

Angry outbursts and aggression can be particularly difficult behaviours to manage. Ms Fewer reminded the audience that the

person with dementia cannot reflect on their unacceptable behaviour and cannot learn to control it. Consequently,

confronting the person or trying to reason with him or her will not be effective. Ms Fewer recommended that carers should

give the individual space to be angry by themselves, provided they are not a danger to themselves or others. She stressed that

carers should avoid physical contact during an angry outburst as this can trigger physical violence from the patient. She

suggested distracting the person with a more pleasurable topic or activity. Most importantly, she said, don’t take the anger or

aggression personally.

When caring for a person with dementia, it is essential that the carer tries to put themselves in the patient’s shoes, Ms Fewer

said.

“Try to put yourself in the person’s situation. Look at the body language and imagine how they might be feeling and what

they might be trying to express,” she said. “Ask yourself what happened just before the problem behaviour started.”

“As a caregiver, you cannot control the person you are caring for but you can control your own behaviour and the

environment and atmosphere you create while giving care. Changing our own behaviour will often result in a change in the

patient’s behaviour,” she said.



Closing Remarks:

I would like to take this opportunity to sincerely thank all parties involved in making this inaugural event

happen including our speakers, exhibitors, delegates and a special thanks to our platinum sponsor for 2014

myhomecare.ie.

I look forward to seeing you all in 2015 for the second National Homecare Conference, of which a location and

venue will be announced in the coming months.

Sincerely yours,

Andrew Mernagh

Mernagh Communications

35 Llewellyn Lawn

Rathfarnham

Dublin 14

Phone: 087-2911028

Email:[email protected]

white paper report - tcp group …white paper report prepared by: editor: dawn o’ shea ......

Documents