New models of care: making integrated out-of-hospital care a reality
Dr Ayman Shenouda
As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities.
Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge.
We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions.
We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings.
For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting.
But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems.
This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care.
It is about bringing teams together consolidating different points of access to care and providing that care in the home.
This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery.
Hospital in the Home
Recently I met a doctor who is working hard to realise this vision for his community in Townsville.
Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital.
For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville.
Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups.
These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model.
Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital.
What makes the model work?
Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting.
Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion.
Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers.
It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home.
The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist.
These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment.
The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners.
The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills.
This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting.
Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services.
Hospital in the Nursing Home (HINH)
I believe a step-up approach within nursing homes is another way to apply this model.
The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care.
However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model.
We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital.
It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments.
Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home.
Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission.
But technology is only an enabler and we need to focus on investing in the model that underpins that technology.
In summary some key enablers for getting the model to work.
Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past.
Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key.
It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base.
Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need.
Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF.
The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult.
This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care. This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care.
It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there.
Whole care continuum
The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP.
Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home.
As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back.
We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality.
Raising the Care Factor: Royal Commission into Aged Care
Dr Ayman Shenouda
There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care.
I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve.
This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents.
What have we learnt?
Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind.
The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years.
The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive.
It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009.
Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift:
"…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies".
Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here.
The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers.
Ensuring quality care
This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction.
Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector.
I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission.
One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model.
This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised.
Ensuring a key role of general practice in aged care service provision is integral to the solution.
The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time.
It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review.
What are the priorities?
A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness.
Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS.
Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement.
Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this.
More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity.
In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team.
These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences.
Training and roles
Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care.
In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios.
The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles.
Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets.
They must be properly paid and qualified for what is a role which carries with it a lot of responsibility.
Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents.
But RNs who work for nursing homes also tend to earn less than those working for other major employers.
In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure.
Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night.
This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care.
New models of nursing-home care
It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place.
There are also excellent models of care within Australia but we need a funding system to prioritise support of their development.
We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing.
These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
24 November 2017
Dr Ayman Shenouda
National Aged Care Quality Regulatory Processes Review
The recent Review of National Aged Care Quality Regulatory Processes was released on 25 October. The review looked at past failures in terms of the limitations of the regulatory controls to recognise abuse and care issues. It’s emphasis, therefore, was on improved regulatory measures to improve national monitoring arrangements.
Aged Care Minister Ken Wyatt, in his announcement on releasing the report, stated that the majority of facilities provide excellent care and are working to continually improve services. Some might argue that media reports of endemic abuse in nursing homes paint a very different picture. That aside, the Minister stated that focus was on seeing improvements to the system that can address those not delivering quality care.
Aged care safety and quality
It is appropriate for the review to have a core focus on safety and quality. The capacity of the current regulatory environment to protect residents from ‘restrictive practices’ is of course appropriate. A key recommendation was the use of unannounced audits across Australia’s residential aged care facilities (RACF). This is a positive outcome and the commitment by the government to implement this recommendation quickly is also positive news.
There were 10 recommendations in total to improve aged care resident protections through more transparent compliance and monitoring. Other key recommendations included establishing an independent Aged Care Quality Commission with provision for a quality commissioner, complaints commissioner, consumer commissioner as well as a chief clinical advisor. This new commission would develop and maintain a centralised database with the view of creating a star-rated system on provider performance.
In addition, there would be more protections to curb abuse which would see a recommendation from the Australian Law Reform Commission for a new independent serious incident response scheme (SIRS). On accreditation and compliance, the unannounced visits were the major recommendation with more public disclosure on matters of non-compliance. In addition, if supported, there would be strengthened controls around medication reviews and compliance. Medication reviews were recommended on admission, after hospitalisation, upon deterioration or when changing medication regimes.
Where’s the focus on general practice?
This is an important body of work but again we see a lack of insight into the key role of general practice in aged care service provision. This is another example of a review which has missed an opportunity to ensure a stronger role for GPs. There should have been scope to work through key issues including those areas of clinical governance as a key quality enhancement measure.
It’s all very well to make sure that there are controls to pick up those not doing the right thing. But doesn’t it make better policy sense to place an equal emphasis on why the issues are there in the first place?
It is very disappointing that this review did not extend to service solutions through general practice.
This oversight being on the back of the recent Productivity Commission’s 5-year productivity review – Shifting the Dial - which also underplayed the role of general practice in a discussion which focussed on prevention and primary care.
To a certain extent, even the changes in Victoria with the voluntary assisted dying legislation seem to lack a focus on service capability. Palliative care is one area which lacks clarity in terms of roles and most certainly there is a lack of data, fed by physician only item numbers, which can only constrain services and planning. GPs too do a lot in this area but this mostly goes unnoticed and underfunded. Ensuring there are funding levels to enabling access to palliative care services should be a priority moving forward.
Valuing general practice
Why is there a lack of focus on general practice? It’s clear that success in terms of prevention makes us far less visible. Such is our role that if we do it well then it goes unnoticed. Best practice interventions for heart disease and stroke, for example, will translate over time through improvements in data. But there’s a very limited audience with not many from outside of the profession interested in this level of detail.
The RACGP has made strong investments in recent years to lift our profile. However, the lack of focus is still a key problem. This is evident in this latest report where glaring service solutions – solutions to lift quality - have been again overlooked.
The missing GP perspective
In a recent Medical Observer article by Professor Leanne Rowe, ‘Why are GPs missing for the national aged care review?’, this lack of focus was also seen as a key issue which limited the report’s findings. The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities.
Those obvious service issues, central to ensuring quality, were ignored. A focus on quality needs to also look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
The role of the GP is clearly limited due to low rates of reimbursement through the MBS. Optimal models of care cannot work in an underfunded service environment.
GP-led care or collaborative care solutions are relevant to achieving those safeguards for residents sought through this review. Stronger integration of GPs and improved collaboration with aged care staff and formalising these models of care would assure safe and high quality coordinated care for residents.
More broadly, variable skillsets are important factors that impact on quality of care standards in these facilities. Inadequate staffing levels including the need for more skilled nursing staff is central to many of the quality and compliance issues central to this review. The recent Senate community affairs committee report made specific recommendations in this regard and again it is very relevant to a review focused on quality.
Ensuring there are transparent and workable processes in place to uphold standards and community expectations in terms of care is very important. The recommendations offered through this review will go a long way towards strengthening these. But a great deal of the issues relates to the corporate ownership structure of the RACFs. More specifically, the limitations that brings in terms of ensuring quality service provision.
Improving the lives of older Australians needs a firm policy focus and we’re starting to see that through this Minister. There is an opportunity to build off this review to fix some of those glaring issues limiting the quality of care. I’d like to see a stronger role prioritised for general practice and formalised in national policy. Limitations in terms of remuneration which also fail to capture the complexity of this care needs addressing. Valuing the role of the aged care workforce more broadly is central to ensuring quality outcomes. There’s so much more to be done here to ensure older Australians receive the care they deserve and we cannot afford to drop the focus on GP-led care solutions
Changing our healthcare system starts in the consulting room
15 September 2017
Dr Ayman Shenouda
There’s been a lot of discussion around empowering the patient more in their treatment decisions. That we need to shift our focus toward a system that empowers and facilitates choice. But undermining a shared decision-making model – one which has room to provide for both clinical choice and patient choice – is our healthcare system. We have a system which is based on a disease-based model of care which leaves little room to take into account the context of the patient's illness. A system that can allow us to refocus on the patient-centered, personal and unique experience of “illness” must be prioritised.
Patient experience in the health system is so vitally important and has to be valued. For me, changing our healthcare system really starts in the consulting room. It’s that doctor-patient relationship that I really value. And this often goes unnoticed by our decision makers – but it is here where lasting change can be realised. Discussions in general practice are of great value for helping patients take charge of their own health. A more focussed effort here not only helps to improve health but will support quality reform measures which can reduce costs.
Research shows us the benefits of a shared decision-making model approach. These include knowledge gain by patients, more confidence in decisions, and more active patient involvement. Studies have shown that, in many cases, informed patients elect for more conservative treatment options.
Preparing for the challenges ahead
The health system cannot cope with what it is facing. Health care demand on the system is reaching crisis point with public spending at unsustainable levels. Empowering patients is most certainly part of the solution if we are ever going to meet rising demand with an ageing population. But to do this, empowerment needs to be met with a system that can facilitate choice.
Recently I attended an event organised by the RACGP NSW Faculty delivered by an ICU Physician who led an impressive discussion around frailty. He spoke about the elderly intensive care unit (ICU) patient and poor outcomes. More specifically, the need to identify frail patients at high risk of poor outcomes and plan accordingly.
We were brought across a study which investigated the effects of frailty on clinical outcomes of patients in an ICU. It used a frailty index (FI) which was derived from comprehensive geriatric assessment parameters. It found that the use of a FI could be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs. Another study found frailty is common in patients admitted to ICU and is associated with worsened outcomes. It recommended that this vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans.
Identifying patients at high risk of poor outcomes is key here. But the system cannot identify what frail means, nor does it empower GP decision making at the cold face. Applying the FI is one way to ensure we’re not placing patients where there is no real benefit. But the culture within hospitals makes it hard to implement this tool. Enabling end-of-life discussions particularly at a point when there is a crisis situation is also a barrier.
Planning for end of life and putting in place an Advance Care Plan early is essential. GPs are very good at this. It should be undertaken as part of the Over-75 Health Check. and helps equip the patient, and their family, well for what lies ahead. It’s a good time to talk to the patient about prevention, maintaining functionality, minimising pain or complexity of disease as well as strategies to address them. It is also time to start the discussion around being frail and their expectations around that.
High price for poor outcomes
We know that more than 30 percent of patients admitted to intensive care units never make it out. Those that do rarely make it back to their own home. It costs around $4,000 per night in ICU . This spend can be better utilised if redirected to support patients in their own home.
I know from my own elderly patients’ experience that it is often hard for the patient not to end up in ICU. The system makes it hard to facilitate this care in the community. And it’s hard to take on the system during a crisis. It takes a strong family who is across their loved one's wishes.
Care in the community
I recall consulting at my surgery in The Rock some years ago and receiving an urgent phone call. It was the daughter of my 82-year-old patient and she needed my help in preventing the transfer of her mother from Wagga Base to Sydney. She told me the specialist was transferring her and that the family did not want her to go through this and that her mum didn’t want this either. They understood that their mum was in a critical condition but wanted her close to home.
I immediately made the call to the Specialist Respiratory Physician who explained she had a flouting clot in her pulmonary artery and needed an embolectomy and a filter in her IVC. The specialist had already discussed her case with the Cardiothoracic Surgeon in Sydney and organised the transfer. I explained that the family had called and that this was not what my patient, nor her family, wanted. I also explained that I was prepared to look after her in the community. Fortunately, the specialist at Wagga was comfortable provided she sign a discharge against medical advice.
This patient lived for a further five years. She was able to attend her grandson’s wedding in Sydney two years before she died peacefully at her home with her family around her. A testament to her strength and also that of her family. They ensured she stayed in Wagga to receive care an appropriate level of care in the community. They insisted that she was not transferred to a Sydney hospital where she was likely to end up in ICU and never to come home.
Making the system work
How can we ensure that the system can default to enable care in the community, rather than automatically preference for tertiary care? While there exists a frailty tool there’s reluctance to use it. There’s plenty of GPs happy to care for their patients in the community if that’s their choice. But rarely will the patient’s GP be consulted at that critical stage. There is also limited funding to facilitate this care.
A reality check is well-overdue in terms of outcomes particularly in dealing with the frail. We’re missing the point on where to focus care. This needs to be where there is the greater need and where the efficiencies can be found. And this is not on a system which is disease focussed and already crippled by expensive treatments. To prevent waste, more realistic expectations around outcomes can be achieved through person centred care enabling empowerment. One of the strengths of general practice is the unique relationship between patients and their GPs. Patient centred communication and shared decision making is the foundation on which our health system can be remodelled. Let’s prioritise it.
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 Kizilarslanoglu, M.C., Civelek, R., Kilic, M.K. et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res (2017) 29: 247. https://doi.org/10.1007/s40520-016-0557-y
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