A Generalist Model of Community Health and Aged Care (Broe, 2004)
Community Health and Aged Care Program
Randwick-Botany Community and Prince of Wales Hospital
- BACKGROUND
Over the past 25 to 35 years the basic elements of a local community health system, for older people with chronic disease and disability, have been developed in urban and rural NSW, and across Australia, with the collaboration of several initiatives:
Firstly, the development of Community Health or Hospital based Aged Care Assessment Teams (ACATs) from 1984 onwards. ACATs now cover most of urban and rural Australia. Most ACATs in NSW, using combined Commonwealth and State funding, expanded their initial gate-keeping role from the late 1980s onwards to include a wider role in case management, service provision and service development.
Secondly, there is the development of hospital based geriatric medicine and rehabilitation programs from the 1970’s serving the same local community as ACATs and covering most urban and many rural areas of Australia.
The majority (around 70%) of ACATs interact with the local geriatric medicine services covering the same geographic base. The interaction is less well developed in some rural areas, where geriatric medicine services and geriatrician positions are underfunded, and in Queensland (which developed sector Geriatric medicine services, and regionalised Health Services generally, later than other states).
Thirdly, the development over the past 10 years, of a number of services covering the acute care/community care interface including Post Acute Care Services (PACS), Hospital in the Home (HITH), INREACH services from Community Health into the Hospital and other projects funded through National Demonstration Hospital Projects (NDHP).
Finally, there have been some recent initiatives to extend the role of General Practitioners into chronic and complex care with the formation of local General Practice Divisions and new Medicare funding for Enhanced Primary Care Items aimed at chronic and complex care in the community.
Over this 25-year period local combinations of federal and state funding for aged care have put core services on the ground for most local communities. Many outstanding issues remain unsolved including: (i) coordination of multiple services on a local population base; (ii) access to services for those in need; (iii) integration of local hospital services with the local community programs for chronic care; (iv) better integration of General Practitioners into aged care and chronic disease management systems.
- PROPOSAL
The proposal is to combine the 3 core services, (i) Hospital Geriatric Medicine (ii) Post Acute Care Services (iii) Community Health ACAT Services and Generalist Community Teams – that currently provide Hospital and Community Care for people with chronic disease and disability – into a Program of Community Health and Aged Care in each Health Sector. This will provide a comprehensive generalist Service for people with a broad range of chronic diseases and age-related disabilities in the hospital and in its local community. Such a Program will support the role of local General Practitioners and General Practice Divisions in chronic and complex care and Aged Care beyond the constraints inherent in the current Fee-for-Service, Episodic Care model
The optimal population base for these services, to enable effective coordination and integration, is around 250,000 people or a planning figure of 20,000 to 30,000 people 65 years and over in metropolitan areas, modified for rural areas.
- DEMOGRAPHY OF AGEING AND DISABILITY
- Population ageing
Population ageing over the past 30 years, has been accompanied by a changing pattern of chronic disease and disability. This change particularly affects the growing number who have reached 80 years of age and over, the most rapidly increasing population group in Australia.
Population based studies show mortality rates declining in those 80 years and over; these are the successful survivors of the age of non-communicable diseases; however overall disability rates are not decreasing. This process of “ageing of the aged” and increasing lifespan is not fully understood, however it is in part due to a decline in the incidence of rapidly fatal non communicable diseases – initially a decline in fatal heart and lung disease and stroke, and more recently a decline in cancer incidence. This process has been assisted by greater public health attention to major physical late-life risk factors for these disorders such as smoking, diet and physical activity. However, Mental Health (anxiety and depression) Life-course Social Determinants (parenting, education, inequality) and Chronic Disease management have not been adequately addressed in Public Health or Community Health Programs.
- Chronic disease and disability.
During the 20th century curative medicine, and the acute care system in hospitals, has seen a decline in General Medicine, the rise of super-specialities and the division of patient care amongst highly trained but increasingly narrow organ system specialists. The importance of chronic disease in hospital settings, as well as in community care and prevention, has only recently been recognised and has not been adequately addressed.
The acute hospital model of care, based on organ system specialties with single episodes of illness, has been applied in the community to HIV, diabetes and cancer medicine with some success; this Chronic Care Model is currently being extended in NSW Health to the care of heart failure and lung disease. However, this model has limited application, for both prevention and management of chronic disease, in an ageing population with multiple pathology due to shared risk factors such as smoking, diet, exercise, hypertension, obesity, depression, anxiety and childhood risk factors.
Furthermore, with advanced ageing, and declining incidence of heart attack stroke and vascular diseases, new disease transitions are occuring; “non- fatal” slowly progressive chronic disorders are becoming major causes of disability in the community and are major causes of comorbidities and complications in people with acute disease requiring hospital admission.
- New disease transitions
The first group of non-fatal, or slowly fatal, chronic disorders are the late onset neurodegenerative diseases which rise rapidly in incidence over 75 years of age to affect a majority of older people over 85 years. These include not only the dementias (which have gained most attention and support to date), but also disorders of gait and balance causing falls and social isolation; disorders of movement causing motor slowing and immobility; and disorders of vision and hearing
The second group of non-fatal disabling disorders of old age are the bone and joint diseases (osteoarthritis and osteoporosis) which rise in prevalence in the “young-old” (60-80 years), however these taper off in advanced age (80+) as causes of serious disability, with better risk factor management and prevention of osteoporosis and with declining occupational risks for osteoarthritis.
- Summation of chronic disorders and the concept of the “Frail Aged”
The neurosensory disorders summate with the musculoskeletal disorders in many older people, to cause the functional decline and disability often attributed to “ageing”. This summation produces the “multifactorial syndromes of ageing”: these common syndromes include Instability and falls, Immobility and Isolation, Incontinence, susceptibility to iatrogenic disease, Impaired cognition and behaviour change with age-related ‘apathy’ predominating.
These syndromes are due, not to ageing per se, but to a complex mixture of multiple chronic disease processes. The syndrome of “frailty” or the “frail aged”, defines a group of older people who show early cognitive decline, motor slowing, gait ataxia, apathy and inertia and sensory loss. The frail aged have a complex mix of multiple deficits due to early (pre-clinical) neuro sensory disorders which summate with somatic (physical) disorders of old age to produce the syndrome of “frailty”. This growing group of frail older people are at high risk of further deterioration of cognitive and motor function, and of delirium, if they develop acute systemic illness, adverse drug reactions, or require hospitalisation.
Prevention of chronic disease, the principles of self-management of chronic disease, and provision of disability services in the community, all require a generalist local community model aimed at the rising proportion of aged and disabled people in the community. Transfer of the hospital model of organ system speciality care to the community sector, for the smaller numbers of people with single chronic diseases eg. severe heart failure or chronic lung disease, can play only a limited role in overall chronic disease management.
3.5 Primary Care
Primary care services are provided by General Practitioners, nurses and multidisciplinary generalist Community Health Services. Population ageing, and the increasing dominance of chronic disease for health services in general, has led to initiatives to strengthen the role of primary care in chronic and complex care as well as initiatives such as ‘coordinated care trials’.
The rise of chronic disease and the need for complex care, in an Australian setting of general practitioners who are funded primarily on a fee for service base, requires the development of supporting community structures.
The major local structures to coordinate basic care for the frail aged and disabled with the General Practitioner, are currently fractured and often disparate Community Health Services, including generalist community nursing, allied health and ACAT services together with supporting HACC services, attempting to work in conjunction with the hospital based geriatric medicine services.
3.6 Community Health
The extent and nature of Community Health Services are not easily described
or summarised as the organisation, management and delivery of Community Health varies widely within local Health Areas. Generalist teams may be based in Community Health Centres that remain organised on the 1970s model serving small populations (60 to 80,000) in relative isolation from hospital-based services or they may be co-located with specialist community health services. Generalist Community Nurses (on the Sydney Home Nursing Model and WA Silver Chain) may serve larger populations from a separate base. ACAT teams, based in Community Health in most local sectors, have commonly developed extended functions using additional HACC and State Government funding, to include a case management and service organisation role in the community as well as their delegation and gatekeeping role for nursing homes and hostels. Dementia Nurses (in teams of 2-3 nurses) may be co-located with ACATs, as are Community Rehabilitation Teams in some Health sectors. Health promotion activities may be located within community Health. Specialist Community Health Services in Mental Health, Drug and Alcohol, Palliative Care and HIV/AIDS and Clinical Nurse Consultants in these and other areas may be co-located with generalist teams or separately located in Area Health Services or Hospitals.
Importantly – in 2004 – whatever the organisational model of Community Health and Aged Care, some components of a generalist model, including Community Nursing Services, generalist community teams and ACATs, are currently present in all health areas and serve most local NSW communities.
- AIMS AND OBJECTIVES OF THE GENERALIST COMMUNITY HEALTH AND AGED CARE MODEL
4.1 The aim of the generalist community health and aged care service can be stated as: to promote healthy lifestyle and healthy ageing and to improve the quality of life of consumers of the service with, or at risk of, chronic disease, functional impairment and disability of all causes
4.2 The Service Objectives to carry out this aim can be stated as: provision of comprehensive health maintenance: health care, continuing care, health promotion and disease prevention:
- to target a group consisting of older people, disabled people and those at risk of disability
- on a sector or local community base
- within their homes and within health and community facilities
- services to be determined by the needs of local consumers rather than by the interests of service providers and professional
- delivery of services in a user friendly, responsive and integrated manner.
4.3 Outcomes
The specific outcomes expected of the service can be stated as:
- promotion of healthy ageing and prevention of functional impairment, disability and disease
- treatment of disease to improve or cure the symptoms or the disease itself knew line education in chronic disease itself
- rehabilitation of disability where that occurs
- provision of compensatory measures or services for people with residual disability.
- DEFINITION OF A LOCAL COMMUNITY
The appropriate local community base for Community Health and Aged Care Services has been achieved in metropolitan and rural NSW through attention to the following planning principles: a local geographic base including transport, a defined population base, a local Hospital Casualty and community consultation defining the local pattern of population ageing, healthy ageing, and disability.
Application of these principles has resulted – in metropolitan Sydney – in the development of 17 local community aged care planning sectors – each with an ACAT and aged care and rehabilitation services – which have remained locally intact over the past 20 years, despite many changes in Area Health Service boundaries.
Metropolitan Adelaide and Perth, Victoria and Tasmania have developed services on a similar population/geographic base, which have proved to be viable over the same period. The large areas of rural Australia have also been serviced albeit with more difficulty and less effective funding for some services. Around 130 to 150 local sector services with ACATs have been set up across metropolitan and regional Australia.
5.1 Population Base: to be efficient and effective for consumers, and to allow good communication between the multiple players providing core aged care and disability services on the ground, each “local community” has a minimum population of 15,000 people 65 years and over and a maximum population of 30,000 people 65 years and over. This corresponds to a total population of around 150,000 to 250,000 people. Rural populations will inevitably vary from these planning figures essentially because of the distances involved.
5.2 Geographic Area: the area covered will depend on population density, whether it is a rural or urban service, and the local community networks. Each local sector planning area is made up of local government areas (LGAs) which are linked by a sense of local community as well as by transport and communications. As a general principal sector planning areas should not divide LGA boundaries. These service boundaries for aged care in NSW are those used to currently define catchments for ACAT teams, Nursing Home/Hostel bed numbers and ratios, and Geriatric Medicine/General Rehabilitation services developed in consultation with Federal DoHA and state resources.
5.3 Consumer Consultation: the definition of a local community, together with its patterns of healthy ageing and disability, facilitates building the service on the basis of local needs assessment and community consultation.
- TARGET GROUPS
The Target Groups for a local sector Community Health and Aged Care Service are:
- Older people with continuing care needs requiring coordinated multidisciplinary care within the local community and its hospitals and institutions;
- Younger adults whose disability continuing care needs are not covered by other service providers;
- People at risk of chronic disease in need of health promotion, prevention and self-management.
Target Group inclusions and exclusions:
- The target group for Aged Care service delivery does not include all older consumers (defined as those 65 years and over) in the local community at any point in time: healthy older people, as individuals, are often best served by individual health professionals including their family physicians, local specialists and allied health professionals.
- The principal target group, in both demographic and numerical terms, is the “old-old”-defined as people 80 years and above i.e., the population which carries the most disability or is at most risk of disability, and of late onset diseases with a multifactorial functional, social and medical basis to their disabilities.
- The target group of the service also includes adult disabled and people with chronic disease under 65 years of age who have continuing care needs in the community-and who do not come into a target group of other appropriate services eg. mental health, rehabilitation, developmental disability, palliative care or organ system specialties.
- The target group in terms of health promotion, health education and prevention of age-related diseases and disabilities includes a broad range of both younger and older community living people who are at risk of later-onset disease and disability. The younger population-below the 6th to 7th decade-are appropriately serviced across a wider population than the local sector in conjunction with specific chronic disease groups (diabetes, heart disease, respiratory diseases etc). However, the local sector needs to participate in health promotion and prevention for its principle target group in demographic terms ie. those people aged 80 and above, as well as specific populations at risk (eg. those at risk of falls, immobility, isolation, cognitive decline etc).
- CORE COMPONENTS OF A GENERALIST COMMUNITY HEALTH AND AGED CARE SERVICE
The core components of the service for the target groups defined in 6. will be determined by
- the general planning principles for services outlined in 4.5.
- specific organisational and service delivery factors in each community.
However the following components are present in most local urban communities and some rural communities:
7.1 Hospital Sector
Geriatric Medicine Service
The core hospital component of the proposed Program is the Hospital based Geriatric Medicine Service. This service should provide (i) acute care (for the complex older population from emergency with acute on chronic illness multiple pathology and furnish functional/cognitive impairment) (ii) Geriatric Rehabilitation beds (iii) a consultative service to medical and surgical wards with close links to the Emergency Department (iv) close links with discharge planners and the local community.
Other important components of a fully developed hospital service, that may be available to collaborate with the core Program in larger hospitals, include: a psychogeriatric service, an orthogeriatric service, a stroke service, rehabilitation medical services, pulmonary and cardiac rehabilitation and allied health rehabilitation services.
7.2 Acute Care Community Care Interface – The Emerging Sector
Post Acute Care Services
There is a good argument for including post acute care services (PACS) as a core component of any integrated Program. This has been implemented in the Prince of Wales Program in Community Health and Aged Care for Randwick-Botany, however other models involving coordination of PACS activities with a local Program in Community Health and Aged Care could be equally effective depending on local circumstances.
PACs is an important component of an emerging group of services developed to span the acute care/community care interface over the past ten years. Their development is in response to the ongoing process of de-
institutionalisation of healthcare and pressures for reducing length in stay, downsizing hospitals and treating acute illness and acute exacerbations of chronic disease in the community whenever possible; with the reasonable objective of improving quality of life and outcomes and a less likely objective of reducing overall health costs.
While PACS is aimed at both young and old people with acute and chronic illness and may involve all super-speciality groups, it will increasingly service an older and more disabled population. The increased throughput will place increasing demands on community services and HACC services generally as well as on Community Health. The issues of integration of hospital services with local community programs for chronic and continuing care and effective integration of General Practitioners into continuing care systems are equally important for PACS and Hospital in the Home (HITH) as for Aged Care and Chronic and Complex Care initiatives.
7.4 Generic Community Services and Supports
Carers and Care Respite services
Home Care NSW
Home and Community Care Programs
Nutritional services including delivered meals
NGOs and CACP delegations
Transport services
Consumer organisations
Individual or Group General Practitioners
General Practice Divisions
The support of aged and disabled people in the community, and those with chronic and complex disorders, involves an enormous range of older new players, from the consumers and family cares themselves (who provide 85% of aged care) through Ageing and Disability Department (ADD) services and HACC funded services, NGOs, Child and Family Services, private nursing allied health and medical services, nursing homes hostels and supported accommodation, and local General Practitioners. Additional strains are being placed on all these services by Australia wide changes in the Tertiary and District Hospital systems and the emerging post acute care and early discharge systems that are part of these changes.
The development of local Programs in Community Health and Aged Care would provide an effective system, at a local community levels or sector, to define and resolve some of the outstanding issues that remain including: (i) coordination of multiple services on a local population base and access to services for those in need- a local single entry point for consumers; (ii)
integration of local hospital services with the local community programs for chronic care, disability and health promotion; (iii) effective integration of General Practitioners into age care disability and chronic disease systems at a local level.
Professor G A (Tony) Broe
Director
Community Health and Aged Care Program
Randwick-Botany Community and Prince of Wales Hospital