Health of Older People Strategic Plan 2012-2017

Main cover photo - Courtesy of Ross Brown, Vision Media

Health of Older People Strategy2012-2017

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ContentsForeword 3

Executive Overview 5

Goals and Objectives 7

Summary of Standards and Recommendations 9A. Community health, prevention and information 9

B. Person-centred care 9

C. Integrated care and community services 9

D. Hospital care 10

E. Aged residential care 10

F. Dementia and Mental Health in Older People 11

G. Stroke and TIA 11

H. Falls and Bone Health 11

I. Medications Management 11

Drivers for Change 13 Our ageing population 13

Definitionof“olderpeople” 14

Olderpeopleandhealthcarecosts 14

Opportunities 15

Underpinning Principles 17

Services Covered by This Strategy 18

Standards and Recommendations 19A. Community health, prevention and information

Recommendations 19

B. Person-centred care 22

Culturally appropriate care 22

Tackling elder abuse 22

Advance care planning 23

Recommendations 23

C. Integrated Care and Community Services 23

Integrated Care 23

Moreflexiblecareinthecommunity 25

Needs assessment and service co-ordination 26

Recommendations 27

D. Hospital Care 28

Intermediate Care 30

Allied Health 31

Recommendations 31

E. Aged Residential Care 33

Recommendations 34

F. Dementia and Mental Health in Older People 35

Promoting good mental health 35

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Earlyidentificationandtreatment 35

Secure residential facilities 36

Recommendations 37G. Stroke and Transient Ischaemic Attack (TIA) 37 Preventing stroke 38 Organised stroke services 38

Recommendations 38

H. Falls and Bone Health 39

Preventing falls 39

Treatingosteoporosis 40

Recommendations: 40

I. MedicationsManagement 41

Medicinesreconciliation 41

Regularreviewofolderpeople’smedicines 43

Recommendations 43

Delivery 44 Workforce 44

Recommendations 45

Implementation Plan and Next Steps 47

Supporting Information 48 DevelopmentoftheStrategy 48

BackgroundDocuments 48

Appendices 49 Appendix1:TermsandAbbreviations 50

Appendix2:IntermediateCareService-ProposedModel 51

Appendix3:MeasuresofSuccess 52

Appendix4:Acknowledgements 55

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Foreword

The New Zealand Health of Older People Strategy was published in 2002 and set out the Government’s policy for the future direction of health and support services forolderpeople.Itidentifiedtheneedforsignificantchange in the way services are provided and a framework for implementing those changes. Eight objectiveswereidentified:

1. Older people, their families and whanau are able to make well-informed choices about options for healthy living, health care and/or disability support needs.

2. Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

3. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

4. ThehealthanddisabilitysupportneedsofolderMāoriandtheirwhanauwillbemetbyappropriate,integrated health care and disability support services.

5. Population-based health initiatives and programmes will promote health and wellbeing in older age.

6. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

7. Admission to general hospital services will be integrated with any community-based care and support that an older person requires.

8. Olderpeoplewithhighandcomplexhealthanddisabilitysupportneedswillhaveaccesstoflexible,timely and co-ordinated services and living options that take account of family and whanau carers for people who are disabled.

Within these objectives, the Ministry of Health identifiedanumberofkeyactionsincluding:

• Promotingpositiveattitudestowardsolderpeople;• Betterinformationforolderpeopleandtheircarers;• Afocusonhealthpromotionandprevention,

including physical activity, better nutrition, reduced socialisolation,andfallsprevention;

• Earlydetectionandbettermanagementofillnessand chronic disease, including older people living in ruralareas;

• Processestotackleelderabuse;• Provisionofcommunity-basedrehabilitation,

includingareviewoftheneedforIntermediateCare;• Areviewofspecialistservicesforolderpeople,

includingmentalhealthservices;

• Strengtheningthehealthworkforcetomeettheneedsofanageingpopulation;

• Integratedcarebetweensecondaryservicesand community-based ones, including a single, comprehensiveintegratedassessmentprocess;

• Supportingolderpeopletoliveintheirownhomesforaslongaspossible;

• Betteradvancecareplanning,includingpalliativecarewhenappropriate,forthoseinlongtermcare;

• Theprovisionofafullrangeofculturallyappropriate health and disability support services forolderMāori.

The Ministry of Health and District Health Boards are responsible for implementing this strategy. There is a growing recognition that population ageing is a significantfactorintheBayofPlenty.Thedistricthasone of the highest proportions of older people in New Zealand (Ministry of Health, 2007) and is projected to grow further.

While the Bay of Plenty District Health Board (BOPDHB) has been a leader in developing innovative models of care and investing in services that support people to continuelivingintheirownhomes,thecurrentfiscalclimate has necessitated a re-think about how we can meet the demographic challenges of the future.

The purpose of this document is to review current services for older people in line with the New Zealand strategy, current Government policy, international and New Zealand best practice, and identify and prioritise actions for local services to meet the challenges ahead. Given our ageing population, making savings orsignificantreductionsinservicesforolderpeopleisunrealistic. However, implementation of this strategy will result in better management of the current and predicted rate of growth to levels that will be more sustainable in the future.

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ExecutiveOverview

The Bay of Plenty’s population is ageing, with the number of people aged over 80 predicted to growatarateofapproximately6% per annum. For New Zealand asawhole,healthexpenditureconsumed by older people is projectedtoincreasefrom40%in2002 to 63% in 2051. Most older people are well, independent and living in their own homes. However, disease and chronic conditions are more common in old age.

TheBOPDHB’sBoardhasidentifiedthatweneedtolive within our means, avoid duplication and consider services“insteadof”ratherthan“aswellas”.However,thecurrentannualplanningcycleisnotfitforpurposeto address the impact and opportunities arising from an ageing population. Therefore, the purpose of this strategyistoprovideanover-archingfiveyearplantodo this.

Health of older people is a priority area for the GovernmentandhasbeenidentifiedintheMinister’sLettersofExpectationsforthelasttwoyears.TheBOPDHB’sBoardhasalsoidentifiedhealthofolderpeople as a priority, and aims to be proactive in the management of services for the future given the predicted population increase and the associated high cost of care for this group.

Better care; better valueAgreatdealofevidenceexiststhatbetterqualityhealth and disability care for older people can result in improved health outcomes and reduced projected costs in the future. Healthcare in older people is more complexthanintheyoung.Whatare,infact,medicalproblems are often labelled as inevitableconsequencesof“oldage”thatcannotbetreated.Thisattitude leads to unnecessary disability and costs, and the opportunity for diagnosis, treatment and rehabilitation is lost.

It is preferable to keep older people independent and living in their own homes for as long as possible. This costs less and is preferred by the vast majority of service users. However, this requires a change in focus and a different way of doing things. Increasing demand over time will not be able to be met merely by rampinguptheexistingsystemsof care. Systems need to change

in order to respond to increased demand alongside a relative constriction of supply.

ThisStrategyidentifiesninestandardsthatencompassthe Government’s Health of Older People Strategy (2002) as well as health problems that are particularly significantforolderpeople,namely: • Stroke;• Fallsandbonehealth;• Dementiaandmentalhealthinolderpeople;and• Medicationsmanagement.

In each of these areas, timely intervention by evidence-based services reduces long-term needs and healthcare costs, but these services are not uniformly available and access to them can be haphazard.

Minister of Health’s Letters of ExpectationsThe Minister of Health each year outlines his expectationsforDistrictHealthBoardsinhisLetterofExpectations,whichenablesustoplanandprioritiseactivity for the coming year. In the 2012/13 year, the Minister’sexpectationsreinforcetheGovernment’scommitment to a public health system that delivers

“better,sooner,moreconvenient”care and improves health outcomes for patients within constrained funding increases. AllDHBsareexpectedtoworkco-operatively with the Ministry of Health on implementing the Government’s commitments.

The number of people in the Bay of Plenty over 80 years is predicted to grow at a rate of approximately 6% per annum.

Health expenditure consumed by older people is projected to increase from 40% in 2002, to 63% in 2051.

Systems need to change in order to respond to increased demand alongside a relative constriction of supply.

1 Stats NZ DHB Forecast Sep 2011.

2 MinistryofHealth.PopulationAgeingandHealthExpenditure:NewZealand2002-2051.

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Particularexpectationsforolderpeopleincludebetterengagement with primary / community care to develop integrated services for older people that support their continued safe, independent living at home, especially after hospital discharge, and an emphasis on developing organised stroke services and better dementia care.3

CARE – Compassion, Attitude, Responsiveness and ExcellenceThe Board reviewed the BOPDHB’s values and chose CAREasourvaluesacronym–“Compassion,Attitude,ResponsivenessandExcellence”.CAREreflectsvalues of importance to the DHB. The Runanga has affirmedHePouOrangaTangataWhenua4 (HPO) and believes there is good alignment between the HPO principles and CARE.

This StrategyEach standard in this Strategy links to the eight objectives and actions in the Government’s national Health of Older People Strategy, the Minister’s priorities, and the Board’s values, and sets out relevant background information, the evidence-base where thisexists,examplesofgoodpracticeintheBayofPlenty and elsewhere, and the case for change. A set of recommendations follows. This Strategy does not include an implementation plan and it is recommended thatoneisdevelopedaspartofournextstepstoachieve the Strategy’s objectives (see Chapter 10 – Implementationplanandnextsteps).

It is envisaged that, while this document will form a basis for the strategic direction for health of older people services, it will be reviewed annually to ensure its assumptions and recommendations remain valid and up to date.

3 By letters dated 26 January and 3 February 2012.

4HPOrepresentstheculminationofovertwoyearsofconsultation,workshops,huianddevelopmentworkbetweenTeRunangaHauora

oTeMoanaaToi(theMāoriHealthRunanga),theBOPDHB,whanau,hapu,Iwi,thehealthsectorandthewidercommunityoftheBay

of Plenty (Te Moana a Toi). HPO provides a conceptual framework for Toiora: optimum health and well-being, that is acceptable to the

collective of Iwi within Te Moana a Toi.

Our vision

Healthy, thriving communitiesKia Momoho Te Hāpori Ōranga

Our mission

Enabling communities to achieve good health, independence and access to quality services.

Our values - CARE

Compassion, attitude, responsiveness, excellence.

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Goals and Objectives

GoalThe goal of this Strategy is to provide direction to the BayofPlentyhealthanddisabilitysectorforthenextfiveyearsby,incollaborationwithourstakeholders,identifying areas where the DHB intends to focus its time, energy and resources. The content of this Strategy will also inform our Annual and Regional Plans.

ObjectivesThe objectives of this Strategy are to provide quality health and disability services for our growing older population that:

• Promote,improve,andsupporthealthy,independentanddignifiedageing;

• Haveanintegratedapproachacrossthecontinuumofcare;

• Reducethedemandonrelatedhighcostserviceexpendituretolevelsthatcanbesustainedwithincurrentfinancialconstraints;

• Reduceduplicationinthehealthsystem;• Aresimple,streamlinedandefficient.

Our goal is to provide direction to the Bay of Plenty health and disability sector for the next five years by, in collaboration with our stakeholders, identifying areas where the DHB intends to focus its time, energy and resources.

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Summary of Standards and Recommendations

Listed below is a summary of the standards and recommendations. The full version and associated commentary is covered in Chapter 8.

A. Community health, prevention and information

1. Promote risk assessment for all people over the age of 75 years.

2. Promoteproactiveriskstratificationforallthosewho have not received an InterRAI assessment.

3. Introduce targeted interventions for those at highest risk to avoid or reduce health deterioration and subsequent hospital admission and/or dependence on residential care.

4. Provideolderpeopleandtheircarerswithclearand accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change.

5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB.

6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the World Health Organisation (WHO) Global Age-Friendly CitiesGuidelines.Provideadviceandexpertiseonpopulation ageing through representation on the Population Ageing Technical Advisory Group, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required.

7. Actively contribute to the review of the SmartGrowth Strategy5 in the Western Bay of Plenty and make advice available to local government in the Eastern Bay of Plenty.

B. Person-centred care 1. Reviewanyexisting“blanket”upperage-limited

BOPDHB policies that may be barriers to older people accessing appropriate services, particularly forMāori.

2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person-centred care.

3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse.

4. EnhanceaccesstohealthservicesforolderMāorithroughaknowledgeexchangebetweenMāoriand mainstream providers to support mainstream responsiveness. Increase capacity and capability to meetthehealthanddisabilityneedsofolderMāoriand their whanau by promoting training targeted to the Aged Care and non-regulated health and disability workforce.

5. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co-operative Guidelines and training programme.

C. Integrated care and community services

1. Progress integrated models of care. Evaluate outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay Primary Health Alliance (EBPHA) Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team (SLAT) pilot onstratifiedassessmentinprimarycare)toinformrecommendations for further structural changes to primary care.

2. DevelopspecificBayNavigatorpathwaysthatare relevant to older people e.g. falls prevention, osteoporosis, dementia, Transient Ischemic Attack (TIA), ie stroke.

3. Improve access to specialist advice by primary care.4. Promoteandsupporteducationforagedresidential

care and home and community support providers by primary care.

5. Implement a redesign of home and community support services in conjunction with the Midland Region DHBs as part of a regional project to a restorative model of care. Consider changes the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate.

5 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The programme is being

led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with

communitygroupsandgovernmentagenciessuchastheNZTransportAgency.ThecontextfortheStrategyisasub-regionfacinglong

term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues

and protection of the core values that make the sub-region such a desirable place to live, work and play. A review of the SmartGrowth

Strategy commenced in 2011.

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6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge.

7. Consider implications arising from amending the current criteria for access to service assessed and co-ordinated by Support Net by removing the requirementforadisabilitylastinglongerthansixmonths.

8. Review needs assessment and service co-ordination (NASC) functions carried out by district nursing for short term support services.

9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with the national business case and implementation plan.

10. Review funding and contracts for provision of NASC services in light of recommendations above.

11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read-only access to InterRAI to home and community support providers.

12. Develop a seamless user-friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.

D. Hospital care1. Specialist Services for Older People are developed

in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health,2004).

2. Expandthespecialistgeriatricworkforcetorecommended levels (including geriatricians, registrarsandjuniormedicalofficers,nursingandallied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for Specialist Health Services for Older People to work within acute medical, surgical and orthopaedic services.

3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler for a number of recommendations in this Strategy.

4. Developanacutegeriatricwardinadditiontotheexisting39-bed(HealthInAgeing)HIAunit,which would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a condition with significantmortalityandmorbidity).Thisisalsoanenabler to develop an organised stoke service (refer to Section G).

5. Throughtheprovisionofexpandedgeriatric

workforce, provide essential specialist services to Whakataneandexpandexistingcommunitywork,education,“in-reach”services,adviceandeducationto support primary and community care, service and pathway development and outpatient capacity.

6. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver Comprehensive Geriatric Assessment in the future.

7. Makebetteruseofexistingresourcesbydevelopingdifferent, cost effective, evidence-based models of care such as increased community rehabilitation or “IntermediateCare”

8. Make funding provisions to increase the numbers of beds for specialist Geriatric Medicine services in line with national recommendations for the proportion of beds to the population of the Bay of Plenty and the planned redevelopment of Tauranga Hospital by 2017.

9. Implement better communication between secondary and primary care on discharge from hospital, so that any Comprehensive Geriatric Assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.

E. Aged residential care1. Plan and budget appropriately for the forecast

growth in demand in aged residential care. 2. Manage demand on scarce high cost resources by

developingnewflexible,integratedandrestorativemodels of care with Aged Residential Care (ARC) e.g. short term care, Intermediate Care, integrated community facilities.

3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D)

4. FundandsupportrolloutoftheInterRAILongTermCare Tool (refer to Section C) in ARC in accordance with the national business case.

5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service.

6. Streamline contracts and auditing processes to reduce compliance costs.

7. Consider ways in which Primary Care and Aged Residential Care can identify those nearing the end of their lives and offer/implement Advanced Care Planning.

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F. Dementia and Mental Health in Older People

1. Promote recognition and assessment of mental health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia.

2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities.

3. Improve access to specialist advice and support for community providers.

4. Improvesupporttoprimarycarersofpeoplewithdementia through education and training and a rangeofflexiblerespite,dayandhomebasedsupport options.

5. Introduce training requirements in service specificationsforhomebasedsupportserviceswhere staff work with people with dementia.

6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator.

7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the nextfiveyearsandmakeappropriatebudgetprovision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the Western Bay of Plenty and Eastern Bay of Plenty.

8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular re-assessments of people to identify changes in levels of need.

9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care.

10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatricunitsandsupportexistingproviderstoimprove quality of care and environment.

G. Stroke and TIA1. Complete the development of a TIA pathway

through Bay Navigator.2. Establish an organised stroke service – see Section

D on the development of an acute geriatric ward.3. Increase the number of specialist geriatric medicine

workforce to provide appropriate treatment of TIAs and Stroke – see Section D.

4. Continuewithon-goingspecificthrombolysistraining for Emergency Department (ED) and general medical registrars/consultants in accordance with international best practice.

5. Develop a BOPDHB stroke guideline that sets out how the national New Zealand Clinical Guidelines for Stroke will be implemented locally.

H. Falls and Bone Health1. Assess the impact of Accident Compensation

Corporation’s withdrawal of funding for falls prevention programmes for older people.

2. Promote a population-based falls prevention strategy forolderpeople,includingtheidentificationofthoseatrisk of falls living in their own home or in care homes.

3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis.

4. Developaspecialistfallsserviceforpeoplewithrecurrentfalls,“unexplainedfalls”ordizziness.Assess how this could work across the Bay of Plenty, working with GPs in more rural areas.

5. Implement a falls pathway through Bay Navigator that facilitates the evidence-based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care.

6. Implement an osteoporosis pathway through Bay Navigator that links with the falls pathway, facilitating the evidence-based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.

I. Medications Management1. Adopt Health Quality and Safety Commission

(HQSC) national medication safety programme for identificationofhighriskpatientpopulationsandprovide Medicines Reconciliation for all patients identifiedashighriskofadmissiontohospitalintheBOPDHB region.

2. Develop the role of Clinical Pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including (ARC). This will include medication reconciliationforcomplexpatientsontransferofcare or discharge.

3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers).

4. Participateinthedevelopmentofmedicationmanagement processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.

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Our ageing populationNew Zealand is an ageing society. The Western Bay of Plenty’s warm sunny climate and pleasant coastal geography have provided an attractive retirement destinationformanydecades.Thedistrictexperiencesone of the highest proportions of older people in New Zealand and the annual growth rate is the highest in the Midland region. Our population of people aged over65isprojectedtogrowby84%inthe20yearsbetween 2006 and 2026, the majority in the Western Bay of Plenty.6 However, the populations of rural or smaller towns in the Bay of Plenty, particularly the Eastern Bay of Plenty, while declining are also ageing. By contrast, the Eastern Bay of Plenty has a high Māoribirthrateandarelativelyhighproportionofpeople aged less than 20 years.

In 2011, the number of people in the BOP aged over 65wasapproximately37,500.Ofparticularimportanceis the estimated number of people aged over 80 that ispredictedtogrowatarateofapproximately7%perannum, from less than 3,000 in 2006 to 35,000 in 2050 (see Figures 1 and 2).

Most older people are well, independent and living in their own homes. However, as a group they have a much greater need for health and disability services thantheyoung,soasignificantproportionofhealthand social care resources are directed at their needs.

Disease and chronic conditions are more common in old age. The (WHO) describes care for chronic conditionsasbeing“thehealthcarechallengeofthiscentury”withsuchconditionscurrentlyresponsiblefor60% of the global burden of disease.7 It recommends a new approach that integrates health and welfare services, connects families and communities, and the development of programmes that delay the onset of disability, ameliorate its trajectory and enhance older people’s capacity to take better care of themselves.

Other factors driving the need for change include:

• Peoplewithcomplexhealthneedsarelivinglonger;• Thegrowingnumberofpeoplelivingwithdementia;• IncreasedutilisationofMāoriasaresultofmore

appropriateandculturallyresponsiveservices;• Changingfamilystructures,withmorepeopleliving

alone with little or no family support, or carers who are themselves elderly.

Society has changed - retirement is no longer seen as a preparation for decline. Older people are active participants in society and attitudes towards ageing are changing. However, for frail older people in particular, there are reports of poor, and in the worst cases, discriminatory, services. This is usually inadvertent, a result of failure to keep pace with advances in the capacity of professionals to make a difference. What are in fact medical problems are often labelled as inevitableconsequencesof“oldage”thatcannotbetreated.Suchattitudesareexemplifiedinspecificareas such as the lack of access to specialist geriatric care, rehabilitation and stroke services.

Drivers for Change

6 Statistics New Zealand DHB Forecast: September 2011.

7 InnovativeCareforChronicConditions:BuildingBlocksforAction.GenevaWorldHealthOrganisation;2002.

Figure 2

Figure 1

BOPDHB Forecast Annualised Growth Rate:2006-2026[SOURCE: Stats NZ DHB Forecast September 2011]

4%

3%

2%

1%

0%Under 65s Over 65s

3.96%

0.60%

BOPDHB Forecast Annualised Growth Rate:2006-2026[SOURCE: Stats NZ DHB Forecast September 2011]

8%

7%

6%

5%

4%

3%

2%

1%

0%65-69 70-74 75-79 80-84 85+

3.23%4.07% 3.73% 3.45%

6.94%

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Definition of “older people”Older people are not a uniform group and they have a wide range of needs. They may be broadly seen as three groups:

• Entering old age – people who have completed their career in paid employment and/or child rearing.Thisisasocially-constructeddefinitionof old age, but generally means retirement age (over 65). These people are usually active and independent and many remain so. The goals of health and disability services are to promote andextendhealthy,activelife,andto“compressmorbidity”(theperiodthatmaybespentinfrailtyand dependency before death).

• Transitional phase – people who are in transition between healthy, active life and frailty. This transition often occurs around age 75-85 but can occur at any stage. The goals of health and disability services are to identify emerging problems ahead of crisis, and ensure effective responses that will prevent crises and reduce long-term dependency.

• Frail older people – people who are vulnerable as a result of several interacting health problems and disability. Frailty is often, but not necessarily, experiencedinlateoldage(over85),soservicesfor older people should be designed with their needs in mind. The goals of health and disability services are to anticipate and respond to problems, recognisingthecomplexinteractionofphysical,mental and social care factors, which can compromise independence and quality of life.

Older people and healthcare costsInNewZealand,expenditureonpersonalhealthanddisability support for the over 85s is the highest for anyagegroupwithayearlypercapitaexpenditureof$13,640forwomenand$12,144formen(2006figures).Ourageingpopulationhasobviousandserious implications for health services in the future.

In2011,therewereapproximately5,900peopleayear receiving long term support services funded by BOPDHB.Ofthese,approximately1,500peoplewerein full time residential care at any one time. Of these, 770areatresthomelevel,and740athospitallevel.Resthomelevelcaretotalexpenditure(volumeandcost)hasgrownbyonly2.6%overthelastfiveyearsreflectingourincreasedinvestmentinhomeandcommunitysupportservices(seeFigures3and4).

However, hospital level care has grown by 65% (cost and volume) over the same period (see Figure 5),reflectingthefactthatpeopleareeitherenteringresidential care at higher levels or have changing needs. The total cost of residential care in the Bay of Plentywas$44millionintheyearendingJune2011.

Figure 3

Figure 4

Figure 5

BOPDHB - Residential Care: Hospital Expenditure

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BOPDHB - Home Support Expenditure

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ThereportPopulationAgeingandHealthExpenditure:New Zealand 2002-2051, published by Public Health Intelligence, Ministry of Health, predicts that the share oftotalGovernmenthealthexpenditureconsumedbyolderpeopleisprojectedtoincreasefrom40%in2002to 63% in 2051. Population ageing will drive increased healthexpenditurebecausepercapitahealthexpenditureisstronglyrelatedtoage.

In the BOPDHB, older people account for the largest increase in hospital admissions. In 2010 in Tauranga hospital, 63% of all acute and elective medical admissions were in people aged over 65. Of these themajorityofpatientswereaged75-84.In2011,ateam of specialists in Geriatric Medicine performed a snapshot audit of in-patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services.

OpportunitiesDuetomedicaladvanceswehavegainedanextra20yearsoflifeexpectancy.Thereisaneedtoknowmoreabout advanced age as the oldest age group is the fastest growing and disability and dependence restricts qualityoflifeandresultsinexcesshealthandwelfarespending. Life and Living in Advanced Age a Cohort Study in New Zealand (LILACS NZ), is a longitudinal cohort study enrolling those in the top survival group: aged85+fornon-Māoriand80-90yearsforMāorilooking at the health and well-being of 1200 elderly peopleintheBayofPlentyregion.Earlyfindingsfromthe study are due out this year and can inform our Strategy further.

Older people are a resource for their families, communities and economies in supportive and enabling living environments. The (WHO) regards active ageing as a lifelong process shaped by several factors that alone and acting together favour health, participation and security in older adult life. Active, civil and social engagement factors have been shown to be keyinfluencesonanolderperson’shealth.

Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible.

A review of the SmartGrowth Strategy – 50 year growth strategyfortheWesternBayofPlenty,hasidentifiedpopulation ageing as a key factor shaping our region and the necessity for a collaborative multi-agency approach to planning. Local Government policies and plansarebeginningtoreflectanawarenessoftheir

abilitytoinfluencepositiveageing.

Advancements in technology, telecare and telemedicine are being used to complement models of care. In the Eastern Bay of Plenty, the Better Sooner More Convenient (BSMC) primary care business case is using telemedicine to assist with the management of older people with chronic health conditions in remote or rural areas. Learnings from the initial pilot can be used to inform our strategy further.

Māorihavethehighestrelativegrowthrateofallpopulations for people age over 65. Strategic direction for services for older people and other mainstream/national directions are in line with many traditional Māorivalues.KaupapaMāoriprovidershaveoftendeveloped services in relative isolation from the mainstream, using innovation and knowledge of their people.ThereareopportunitiesforMāoriprovidersto share their knowledge for the development and responsiveness of mainstream services.

There are numerous positive developments nationally, regionally and locally that impact on services for older people. The Ministry of Health is currently developing anewservicespecificationforhomeandcommunitysupport services that has a restorative focus, includes enhanced training requirements for support workers, includes compliance against Home and Community SectorStandards,andallowsforaflexiblepurchasingmodel.Theservicespecificationisscheduledtobecomplete and ready for use by October 2012.

A number of integration initiatives across and secondary and primary care services are taking place resulting from the Government’s Better Sooner More Convenient Primary Care policy, including the Eastern Bay of Plenty which has a focus on the management ofpeoplewithcomplexchronicconditions.Promotionand support of the Whanau Ora approach to service delivery and integrated contracts provide opportunities for holistic, client and whanau centred service delivery.

Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible.

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There is further work being developed nationally arising from the Grant Thornton Aged Residential Care Services Review 2010. We can learn from various developments and pilots to inform our work further.

The BOPDHB has been a leader of many developments in services for older people, providing uswithanexcellentfoundationonwhichtofurtherdevelop the recommendations in this Strategy. ExamplesincludetheuseoftheInterRAIToolsforallassessments of older people for long term support services;theimplementationoftheCommunityResponseTeamfocusingonadmissionavoidance;establishmentofamodelforflexiblerestorativehomebasedsupportservices;andKaupapaMāoriearlyintervention and support services including dedicated respite care.

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This strategy has been developed with the following principles in mind:

1. Treaty of Waitangi – recognition of the Treaty of Waitangi as the founding document of New Zealand and acknowledgement of Treaty principles, thatMāoriwillhaveanequalroleindeveloping and implementing health strategiesforMāori.

2. Promoting health in older age – focus on a wellness model that takes into account all the factors affecting an older person’s health, including strengthening local authority and community liaison throughpromotionof“AgeFriendlyCommunities”,“PositiveAgeing”and“WhanauOra”strategies.

3. Person-centred – older people are respected, treated with dignity, and all adult service developmentandreconfigurationisexecutedwiththe needs of older people in mind.

4. “Ageinginplace”–theplacethatisthemostappropriate for an older person to live is usually their own home. If required, access to high quality aged residential care is available and health service access for those residents is equitable.

5. Integration – services will be co-ordinated and work together so that older people receive the right servicefromtherightprovider,firsttime.

6. Preventative and restorative – a strong focus on

preventing illness and injury occurring or getting worse through health promotion, early treatment and access to rehabilitation.

7. Best use of resources and living within our means–weareoperatingwithinatighterfinancialframework and our rate of funding growth has significantlyreduced.Weconsiderthemostefficientandinnovativeuseofresourceswithinaconstrainedfiscalenvironment,avoidduplicationandconsiderservices“insteadof”ratherthan“aswellas”.

Underpinning Principles

The Bay of Plenty District Health Board’s vision for older people is: ‘healthy, independent and dignified ageing’.

8. Collaboration and partnership – the knowledge andexperienceofolderpeople,theirfamiliesand whanau, and people working in services will be valued and utilised in all planning and implementation.

9. Evidence-based – initiatives and service redesign will be evidence-based and take in to account examplesofinnovationandgoodpracticeelsewhere.

10. Leadership – the opportunities and implications of population ageing require the highest levels of leadership in all service providers.

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Services Covered by This Strategy

ExistinghealthofolderpeopleservicesfortheBOPDHB generally refers to specialist health services for older people and long term disability support services for those aged over 65 (or those over 50 with age-related needs). These are:

However, this Strategy is not restricted to current and existingserviceprovisionanditisrecognisedthatthepreferred model is one that supports health and well-being with a focus on prevention.

Specialist health services

• Primarycare• DHBAlliedHealth• Districtnursing• Pharmacy• MentalHealthServicesforOlderPeople• Palliativecare• DepartmentofHealthinAgeing(based

at Tauranga Hospital)

Long-term disability support services

• NeedsAssessmentandService Co-ordination

• Homebasedsupportservices–generally includes home help and personal care

• Limitedshorttermsupportservicesfollowing an admission to hospital

• Dayservices• KaumatuaandKuiaEarlyIntervention

Services• Respitecareandcarersupport• Informationandadvocacyservices

such as Alzheimers Tauranga, Stroke Foundation, and Age Concern.

• Accreditedvisitingservices• Agedresidentialcare

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Standards and Recommendations

A. Community health, prevention and informationNational StrategyPopulation-based health initiatives and programmes will promote health and wellbeing in older age.

Older people, their families and whanau are able to make well-informed choices about options for healthy living, health care and/or disability support needs.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

There is a growing body of evidence to suggest that modificationofriskfactorsfordiseaseeveninoldagecanhavehealthbenefitsfortheindividualwithincreased or maintained levels of functional ability as well as disease prevention.8

Active ageing depends on avarietyofinfluencesordeterminants that surround individuals, families and whanau. They include material conditions as well as social and health factors (see Figure 6).

Figure 6 – Determinants of Active Ageing9

A framework for promoting active ageing has been developed by the (WHO) known as the Global Age-FriendlyCitiesGuidelines.Strongevidenceexiststhat by developing policies and promoting activity that promotes active ageing, reductions in functional decline in older people can be achieved and thereby reducing dependency on funded disability support services.Belowisanextractfromtheguidelines:

“These determinants have to be understood from a life course perspective that recognises that older people are not a homogeneous group and that individual diversity increases with age. This is expressed...[see Figure 7 below] which illustrates that functional capacity (such as muscular strength and cardiovascular output) increases in childhood, peaks in early adulthood and eventually declines. The rate of decline is largely determined by factors related to lifestyle, as well as external social, environmental and economic factors. From an individual and societal perspective, it is important to remember that the speed

of decline can be influenced and may be reversible at any age through individual and public policy measures, such as promoting an age-friendly living environment.

Because active ageing is a lifelong process an age-friendly city is not just ‘elderly friendly’. Barrier-free buildings and streets enhance the mobility and

independence of people with disabilities, young as well as old.

Secure neighbourhoods allow children, younger women and older people to venture outside in confidence to participate in physically active leisure and in social activities. Families experience less stress when their older members have the community support

and health services they need. The whole community benefits from the participation of older

people in volunteer or paid work. Finally, the local economy profits from the patronage of older adult consumers. The operative word in age-friendly social and physical urban settings is enablement.”

8 British Geriatric Society: Compendium of Guidelines. BGS, London, 1997.

9 World Health Organisation Global Age-Friendly Cities Guide

“…an age-friendly city is not just ‘elderly friendly’. Barrier-free buildings and streets enhance the mobility and independence of people with disabilities, young as well as old.”

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10NationalInstituteforHealthandClinicalExcellence(NICE).Theassessmentandpreventionoffallsinolderpeople.ClinicalGuideline21,

2004andStrokeFoundation/NewZealandGuidelinesGroup.NewZealandClinicalGuidelinesforStrokeManagement,2010].

Activities that promote healthy active life for older people include:• Widermulti-sectorinitiativestopromote“positive

ageing”:health,well-beingandindependenceinoldage;

• Optimisingtheopportunitiesforhealth,participationandsecurityinordertoenhancequalityoflife;

• Recognisingthewiderangeofcapabilitiesandresources among older people, and respecting their decisionsandlifestylechoices;

• Protectingthosewhoaremostvulnerable;• Promotinginclusionofolderpeopleandtheir

contributiontoallareasofcommunitylife;• Accesstomainstreamhealthpromotionand

diseasepreventionprogrammes;• Healthpromotionactivitiesofspecificbenefitto

olderpeople,tailoredwherenecessarytoreflectcultural diversity.

The WHO Global Age-Friendly Cities recommends a programme of development that encompasses eight characteristics of age-friendly communities: transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support and health services, outdoor spaces and buildings.

The BOPDHB and SmartGrowth have collaborated to establish the Population Ageing Technical Advisory Group (PATAG) which advises its two partners on the opportunities and issues related to population ageing. The BOPDHB, through PATAG, promotes the WHO Global Age-Friendly Cities programme and

development of policies, structures, environment, servicesandpoliciesthatreflectthedeterminantsofactive ageing.

Olderpeoplebenefitalsofromincreasingphysicalactivity, improved diet and nutrition, and immunisation programmesforinfluenza.Theyalsobenefitfromspecificstrategiestopreventfallsandtheirconsequences and to prevent stroke.10

Many older people and their carers are poorly informed about their health problems, often assuming they are inevitable consequences of old age, an attitude sometimes reinforced by health professionals and carers. They may be unaware of what services are available to help them remain healthy and independent in their own homes. Adult children and whanau members are not necessarily well prepared to become carers of their parents later in life. For example,knowingwhatisimportantforolderpeopleto maintain function and independence, and being able to recognise a treatable medical condition. By learning to care for an older person, people also learn about how to care for themselves as they move into older age. Because unpaid carers, family and whanau make up the vast majority of carers for older people, investment in education for this group would have far reachingbenefits.HealthpromotionforolderpeopleisnotspecificallyfundedthroughPublicHealthUnitssosolutions would need to be found locally.

International research shows that poor health literacy is linked to poor health status and may also be a strongcontributortohealthinequalities.Māoriaged50-

Figure 7 – Kalache & Kickbusch

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65yearshavesignificantlylowerskillstoobtain,processand understand basic health information in order to make informed and appropriate health decisions comparedtonon-Māori.11 Health literacy is broadly definedassomeone’sabilitytogetandusebasichealthinformation needed to make good health decisions. It’s morethanabouttheabilitytoreadandwrite;itisaboutunderstanding a range of health messages, from mass media campaigns to what a doctor or nurse prescribes, and even correctly following instructions on medicine labels. It also includes health professionals giving clear and appropriate messages, and health services being user-friendly.

The introduction of proactive care for those at highest riskisarguablythemostsignificantchangeandhasthepotentialtoresultinthegreatestimpact.Identificationof those at highest risk should occur to ensure that resourcesareintensifiedforthoseatgreatestrisk.Thisis known as proportional universalism.

A two pronged approach is recommended.• Proactive:Riskstratificationforthoseathighest

risk(varioustoolsexistsomeofwhichareselfadministered);and

• Reactive:useofInterRAI(whichrequirestrainedhealth care professionals to administer).

It is acknowledged that risk assessment is not aninterventionbutanidentificationtoolthereforeintervention is required to manage risk. The provision of intermediate care referred to later in this Strategy to manage risk is an essential component to this model. In alignment with the Government’s policy of Better, Sooner, More Convenient healthcare, if the care required is not acute or highly specialised, then the care provision should be in primary care.

There are a number of ways that enhanced intermediate care can be provided and various recommendations are made within the Strategy. However, the majority of intermediate care provision willneedtocomefromrealignmentofexistingresources and as appropriate a transfer of resources from secondary to primary where a greater impact at the same or reduced cost is anticipated.

In essence, this Strategy recognises the imperative to

stratify and manage risk providing increasing intensity (such as intermediate care) for those at highest risk. This should ensure effective usage of scarce resource and aligns with the Strategy’s objectives.

Recommendations1. Promote risk assessment for all people over the

age of 75 years. 2. Promoteproactiveriskstratificationforallthose

who have not received an InterRAI assessment. 3. Introduce targeted interventions for those at highest

risk to avoid or reduce health deterioration and subsequent hospital admission and/or dependence on residential care.

4. Provideolderpeopleandtheircarerswithclearand accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change.

5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB.

6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the WHO Global Age-Friendly Cities Guidelines, Provideadviceandexpertiseonpopulationageing through representation on the PATAG, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required.

7. Actively contribute to the review of the SmartGrowth Strategy12 in the Western Bay of Plenty and make advice available to local government in the Eastern Bay of Plenty.

8. Promote physical activity, better nutrition (including increased calcium and vitamin D) and annual influenzavaccinesforolderpeoplethroughpubliceducation and collaboration with Primary Care and Aged Residential Care.

9. Promote health literacy and education (both formal and informal) for older people and unpaid carers. Work with education providers and other agencies to develop targeted education and training programmes for families and unpaid carers.

11 TatauKuraTangata:HealthofOlderMāoriChartBook.

12 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The programme is being

led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with

communitygroupsandgovernmentagenciessuchastheNZTransportAgency.ThecontextfortheStrategyisasub-regionfacinglong

term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues

and protection of the core values that make the sub-region such a desirable place to live, work and play. A review of the SmartGrowth

Strategy commenced in 2011.

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B. Person-centred careNational StrategyPolicy and service planning will support quality health and disability support programmes integrated around the needs of older people.

The health and disability support needs of older Māoriandtheirwhanauwillbemetbyappropriate,integrated health care and disability support services.

Older people and their carers should receive person-centred care and services which respect them as individuals and are arranged around their needs. Person-centred care requires managers and professionals to:

• Listentoolderpeople;• Recogniseindividualdifferencesandspecific

needsincludingculturalandreligiousdifferences;• Communicateinwaysthatmeettheneedsofall

users and carers, including those with sensory impairment, physical or mental frailty, or those whosepreferredlanguageisnotEnglish;

• Respecttheirdignityandprivacy,meetingpersonalhygiene needs sensitively

• Inhospital,ifpatientschoosetoweartheirownclothes,enablethemtodoso;

• Supportthosewithalongtermillnessordisabilityandtheircarerstodevelopexpertiseintheirowncare;

• Enableolderpeopletomakeinformedchoices,involvingtheminalldecisionsabouttheircare;

• Involveandsupportcarerswheneverpossible;• Recognisethesignsofpossibleelderabuseand

take action if necessary.

Denying access to services on the basis of age alone is not acceptable. Decisions about treatment and health care should be made on the basis of health needs and abilitytobenefitratherthanapatient’sagealone.

Culturally appropriate careWeacknowledgethatMāoridevelop age-related conditions at an earlier age than average and that there are disparities and inequalities in access to support andhealthservicesbyMāori.

KaumatuaareveryimportantintheleadershipechelonsofMāoridomandIwi.Assuch,programmesthatareculturallystrongthatcanprovideMāorimodelswithin service delivery are an essential part of the support system of kaumatua. Drawing strength from

traditional practices strengthens the spiritual and cultural dimensions of kaumatua contributing to overall well being.

Māoricomprise14%ofthetotalpopulationand2%ofthose over 80 years. However, they have the highest relative growth rate of all populations for people aged over65.OfthoseMāoriwhoreachage75,manyhavemultiple health problems but may not have readily available whanau to care for and support them due to migration of whanau members from rural to urban areas, often for employment. This leads to disparities inbothlongevityanddisabilitylevelsforMāori.DemographicprojectionssuggestthatMāoripeoplecanexpecttolivelongerthancurrently,potentiallyexpandingthepopulationofMāorilivingtoadvancedage and increasing the disparities in disability.

Strategic direction for services for older people and other mainstream/national directions are in line with manytraditionalMāorivalues.KaupapaMāoriprovidershave often developed services in relative isolation from the mainstream, using the innovation and knowledge of theirpeople.ThereareopportunitiesforMāoriprovidersto share their knowledge for the development and increased responsiveness of mainstream services.

Tackling elder abuseAbuseofanolderpersonisdefinedasanypatternof behaviour that causes physical, psychological or financialharm.Itcanbeintentionalorunintentional.Abuse or neglect occurs in a relationship of trust and anyone with a long-term disability is at increased risk.

Institutional abuse occurs when an institution actively or passively allows, or accepts, any form of abuse or neglect to occur. This may arise from the action or inaction of an individual as an employee, or it may be embodied in organisational systems that fail to provide adequately for the safety and well being of individual patients or service users.

The BOPDHB has a clinical policy inplace:“OlderPerson–Abuseand Neglect Management and Reporting”,supportedbyanElderAbuse Co-ordinator. Any staff member who suspects abuse or neglect of an older person, or

to whom abuse/neglect is disclosed, has a mandatory responsibility (now a legal requirement) for reporting of that abuse. The policy outlines ten principles of adult protection services to help guide decision making, and outlines what action should be taken either in an emergency, or in a non-urgent situation.

Kaumatua are very important in the leadership echelons of Māoridom and Iwi.

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Advance care planningAdvance care planning (ACP) is a voluntary process of discussion and review to help individuals (who have the capacity to do so) who have been diagnosed with a terminal illness anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment and / or an advance decision to refuse a treatment in specificcircumstances.Thesecanbereferredtobythose responsible for their care or treatment (whether professional staff or family or carers) in the event that they lose their capacity to participate in decision making once their illness progresses. Primary care is encouraged to identify its patients nearing the end of life so that the wishes of the patient and their family are identifiedandsystemsputinplacetoallowappropriatecare to happen when the time comes.

In New Zealand the Advance Care Planning Co-operative has developed a guideline for the New Zealand healthcare workforce in response to the increasing focus on the need for clear and accurate information and guidance regarding advance care planning. The intended audience encompasses providers, funders and planners in all areas of health care. Training tools which have been developed are intended for health professionals.

Formal outcomes of advance care planning might include one or more of the following:

• Advancestatementstoinformsubsequentbestinterestsdecisions;

• Advancedirectiveswhicharelegallybindingifvalidandapplicabletothecircumstancesatthetime;

• AppointmentofaPowerofAttorney(“healthandwelfare”and/or“propertyandaffairs”).

Not everyone will wish to make such records. But for those who have the capacity and desire to participate, advanced care planning can be an integral part of the wider care planning process. The BOPDHB has endorsed the principles and approach developed by the Advance Care Planning Co-operative for use throughout the DHB where appropriate.

Recommendations1. Reviewanyexisting“blanket”upperage-limited

policies in BOPDHB that may be barriers to older people accessing appropriate services, particularly forMāori.

2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person-centred care.

3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse.

4. EnhanceaccesstohealthservicesforolderMāorithroughaknowledgeexchangebetweenMāoriand mainstream providers to support mainstream responsiveness. Increase capacity and capability to meetthehealthanddisabilityneedsofolderMāoriandtheirwhānaubypromotingtrainingtargetedto the Aged Care and non-regulated health and disability workforce.

5. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co-operative Guidelines and training programme.

C. Integrated Care and Community ServicesNational StrategyPolicy and service planning will support quality health and disability support programmes integrated around the needs of older people.

Olderpeoplewithhighandcomplexhealthanddisabilitysupportneedswillhaveaccesstoflexible,timely and co-ordinated services and living options that take account of family and whanau carer needs.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

Integrated CareThe majority of medical care for older people is carried out in general practice. It is recognised that primary, community focused, fully integrated health systems improve health outcomes, access

to and delivery of care and an improved quality of life, for patients.13

It is recognised that primary, community focused, fully integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients.

13Starfield,B,2005,WorldHealthOrganisation,2008.

14ReporttotheMinistryofHealthonIntegratedCareInitiativesinselectedNewZealandHealthNetworks–Baird,J&Smith,P:Nov.2011

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Whilethereisnosingleaccepteddefinitionofintegratedcare,mostdefinitionsincludereferencestoco-ordination,“complementarity”,seamlessnessandcontinuity for the client.14

Disease and chronic conditions are more common in old age. As part of the Government’s plan for Better, Sooner, More Convenient (BSMC) Primary Health Care, the (BSMC) Eastern Bay of Plenty Business Case has, as one of its priorities, a focus on chronic disease management. A pilot being conducted by Te Whiringa Ora in the Eastern Bay of Plenty is developingamodelofcarethatreflectsconnectivityand integration between primary and specialist services and case management for people with multiple chronic conditions who are rural or isolated and have had frequent admissions to hospital. Early results support the use of telemedicine for patient monitoring, encouraging self-management and using a holistic model of case management and support.

The Midland Health Network Older Person’s Service Level Alliance Team (SLAT) is piloting a number of initiatives across the continuum of care for older people. In the Western Bay of Plenty, Bay Navigator is being developed as an online access point for clinical

staff across primary and secondary care, enabling them to follow evidence-based clinical guidelines that deliverbetteroutcomesforpatients.Forexample,by following the new Bay Navigator TIA (transient ischaemic attack) Guideline, eight out of 10 strokes followingaTIAcanbeprevented,withanapproximatesaving of $2.5 million per annum in the BOP alone.

While the lessons and outcomes from these initiatives are still emerging, they are demonstrating a shift to a greater degree of primary care-based proactive management. Thereasonwhythereisasignificantopportunityforimprovementsinefficiencyisthatthepatientsbeingtargetedbyintegratedcareaccountforsignificantcosts.Ifcollaborative, targeted and intensive care of older people and those with long term conditions can be implemented (with the consequential reduction of avoidable hospital admissions, lower spend on medicines and rest-home costs)thentherewillbesignificantbenefits.

Significantbenefitscanalsobegainedbyimprovingthe capacity and capability of general practice to be able to better identify, manage and support older people with long term conditions and avoid admissions to hospital. There is a range of ways that this can be achieved including:

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• Populationscreeningfortargetedgroups,suchaspeople over the age of 75 for early detection and intervention;

• Carryingoutneedsassessmentsforlongtermsupportsforolderpeople;

• Promotingscreeningandself-assessment;• Improvingaccesstospecialistadviceviaprimary

care.

Primary care can also play a role in helping to support residential care and home and community providers through provision of training and education programmes, and developing better links with this sector. The Primary Nurse Liaison currently provides education available for staff of aged care providers to attend where appropriate. It is recommended that this is supported to continue.

More flexible care in the communityInthelastfiveyears,inlinewithGovernmentpolicy,the BOPDHB has been investing in strategies that improve older people’s ability to remain independent and living in their own homes. As a result, there has been an increase in the percentage of the eligible population over 65 that access home and community support services and a decrease in the percentage of thepopulationinmoreexpensiveresthomelevelcare.However, there is much still to be done.

While considerable advances have been made in implementing a restorative model of care in home and community support services by the BOPDHB, the traditional model of care for older people is a disability support model. Currently the majority of home based support services (HBSS) in the Bay of Plenty, both long and short term, are delivered using a traditional model of service delivery, generally a task orientated approach and delivered in hours of support, with the minimum allocation being one hour. This time is allocated in a structured way (weekly, fortnightly etc) and is not flexibletomeetindividualorchangingneeds.Fundingisuncapped,thegrowthindemandexceedsdemographicgrowth and is not sustainable within current funding availability. A new approach is required.

Illness,orexacerbationsofchronicdisease,oftenhasfunctional consequences in older people, but they do not necessarily need to be admitted to hospital if they can be assessed in their own home, treated, and temporary additional support put in place. The most common reasons for avoidable admission to hospital are:

• Fallsandminorinjuries/fractures;• Mildexacerbationsofachronicdisease;• Minorinfections;

• Gradual(andpredictable)inabilitytocopeathome– reaching a crisis point.

Sometimes older people do need to be in hospital and they do have a right to a medical diagnosis. However, accesstoaGeneralorNursePractitionercanbedifficult,especially out of hours. The Ministry, in its Health of Older People Strategy, has committed to assessing options to reduce cost barriers for older people accessing primary health care. However, many older people are admitted to hospital unnecessarily because of the lack of alternatives. CurrentlyHBSScontractsarenotflexibleenoughtoallow for intensive support periods when they are required without reassessment and sometimes lengthy delays. This often results in an unplanned admission to hospital via the Emergency Department.

Rather than the traditional emphasis on household tasks and personal care, a more tailored response using a restorative approach and endorsing a wider variety of interventions/services that support a return to independence is both valued by service users and has benefitslongertermacrossthehealthsystem.

HBSS can also play a vital role in supporting people to remain living in their own homes rather than moving to an Aged Care facility, thus alleviating some of the shortfall in residential care/nursing home beds.

National and regional work in line with this thinking includes the development of a new national service specificationbytheMinistryofHealththatpromotesa restorative approach across the board. Alongside this, Auckland University has developed a system to determine“casemix”whichcanbeusedtoseteligibilityandtheservicedeliveryapproach.Thecasemixmodel is useful for tailoring the response to different client groups and early outcomes are that there are opportunitiesforimprovedefficienciesbyproviders.

The temporary nature and urgent requirement to provide intensive services to some older people would appear to sit well within the restorative bulk funded model of care, but in reality it does not. Older people requiring additional support have the propensity to dominate service provision/resources from the providers – who understandably wish to reduce their care (and therefore their on-going costs) as soon as possible. This can lead to hospital admission/re-admission, over utilisation of allied health services or admission to a residential care facility, compounding the problem and wasting resources. In reality intensive servicesarebetter“ringfenced”withinasmallanduniquelyfundedcontractwithclearexpectations,auditable outcomes and provider accountability.

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The Midland DHBs15 propose to align their activity inthisareatoachieveefficienciesandstreamlineservice delivery through a collaborative redesign project.Thisprojectincludesareviewthefindingsofa number of concurrent activities happening nationally includingtheAucklandCaseMixmodel,andarecentredesign project occurring in Capital and Coast DHB and changes recently implemented by the Accident Compensation Corporation in this area.

The Midland project is in its early days, however the aligned regional approach is based on the following recommendations:

• Servicesaredeliveredwitharestorativeapproachacrosstheboardandareflexibleandabletobedeliveredinsmallertimeslots;

• Supportworkersareabletoadministerandsupervise medications, deliver advanced personal careandsuperviseexerciseprogrammes;

• Thereisafocusonservicesthataimtopreventadmissionstohospitalandagedresidentialcare;

• Thereareincentivesforproviderstoworkproactively with people to restore function and independence and thereby reduce services over timewhereappropriate;

• Thereislessprovisionoflowneedhouseholdmanagementtasksexceptwherenecessaryforhealthandhygienereasons;

• Increasedtrainingrequirementsforsupportworkers;

• Servicesarebulkfundedwithinacappedbudgetbased on a package of care approach.

ThenationalservicespecificationdevelopedbytheMinistry of Health aligns with this approach. The redesign project has been included in the 2012/13 Regional Services Plan. Additional resource or a dedicated project manager may be required to ensure project deliverables are achieved within a time frame that meets individual DHB requirements.

Needs assessment and service co-ordinationEligibility for and access to all long term funded support services (both home based and in aged residential care) is through a needs assessment carried out by the DHB Needs Assessment and Service Co-ordination Agency, Support Net. Effective and standardised needs assessment and service co-ordination services are crucial for ensuring people have good information, equity of access to services and receive the right care at the right time. InterRAI is an internationally developed, standardised and validated needs assessment process that gives a

consistent objective measure of a person’s needs and enables information to be shared on patient assessment and care requirements. InterRAI is a comprehensive, multidimensional needs assessment which leads to provision of services that improve the health and well-being of older people and their carers. The implementation of InterRAI is being rolled out throughout the country. Assessors are required to be clinically trained when using the comprehensive tool. While some DHBs have only recently commenced using InterRAI this year, BOPDHB was an early adopter of InterRAI and the Home Care Tool and ContactToolshavebeeninuseforapproximatelysixyearsintheBayofPlenty,givingusconsiderableexperienceintheuseandpotentialofthetools.

There are a number of developments which may impact on NASC services in the future including:

1. AnInterRAItoolspecificallydesignedforusein long term aged residential care (the InterRAI Long Term Care Tool) is currently being rolled out in aged residential care nationally as part of a national business case developed collaboratively between DHBs and the New Zealand Aged Care Association. InterRAI LTC Tool is designed to improve assessment and care planning, thereby improving quality in aged care. It can also be used by providers to determine changes in levels of care and consequent approvals for changes in funding levels, although this has yet to be approved by DHBs,giventhepotentialfinancialimpacts.

2. As the number of people requiring assessment increases and the focus shifts to supporting peoplewithcomplexneedsinthehome,thereisa need to consider the most effective way to carry out needs assessments. Auckland DHB Case Mixmodelreallocatesneedsassessmentandallocation of service responsibilities to providers where people’s needs are considered to be non-complex,whileneedsassessmentsforpeoplewithcomplexneedsarecarriedoutbytheNASC.Thisenables resources to be used more effectively and incentivises providers to work proactively with people, to reduce reliance on funded services over time where appropriate. Quality requirements and monitoring can be included through the contractual terms of the agreement to reduce risk of inappropriate service reduction or gaming.

3. Assessments for short term support services following a discharge from hospital do not use InterRAI. Currently assessments are carried

15 The Midland DHBs comprise the BOPDHB, Lakes, Waikato, Taranaki and Tairawhiti.

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out by district nursing services in accordance with historical practice. However the Short Term Support Services Review for BOPDHB carried out in 2007 recommended that InterRAI be used for all assessments for older people, for both short term and long term care to improve equity of access to services and continuity of care, but this has not been able to be progressed. It is recommended that this process is reviewed alongside any reviews of NASC services generally arising from activity outlined above.

4. Notallassessmentscarriedoutinsecondaryservices use InterRAI, leading to inconsistent access to long term residential care following discharge from hospital. There is now a national requirement for all assessments in secondary services to be using InterRAI by 30 June 2012. BOPDHB is currently implementing this.

5. ThecurrentNASCcriteria(disabilitylastingsixmonthsormore)cancreateartificialbarrierstoco-ordinating and integrating services and inequities of access to services. Alongside moves towards seamless and integrated service provision, it is appropriate to review the eligibility criteria.

Impacts on the contracting and funding model for NASC service will need consideration resulting from the activity outlined above. However, Support Net is wellpositionedtoadapttochanges.Forexample,a number of assessments are currently carried out through a sub-contract process, including in kaupapa Māoriservicesandprimarycare.

Information technology and management is a key enabler to progressing person-centred integrated models of care. The potential of InterRAI has not been fully realised.Forexample,makingtheinformationavailableto service providers can streamline the way in which support services are accessed and delivered and reduce the need for multiple assessments. Work is currently under way with home and community providers to make InterRAI assessments available electronically.

Recommendations 1. Progress integrated models of care. Evaluate

outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay PHA Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team(SLAT)pilotonstratifiedassessmentinprimary care) to inform recommendations for further structural changes to primary care.

2. DevelopspecificBayNavigatorpathwaysthatare relevant to older people e.g. falls prevention, osteoporosis, dementia and TIA.

3. Improve access to specialist advice via primary care4. Promoteandsupporteducationforagedresidential

care and home and community support providers by primary care.

5. Implement a redesign of HBSS in conjunction with the Midland Region DHBs as part of a regional project to a restorative model of care. Consider changes to the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate.

6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge.

7. Consider implications arising from amending the current criteria for access to service assessed and co-ordinated by Support Net by removing the requirementforadisabilitylastinglongerthansixmonths.

8. Review NASC functions carried out by district nursing for short term support services.

9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with national business case and implementation plan.

10. Review funding and contracts for provision of NASC Services in light of recommendations above.

11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read-only access to InterRAI to home and community support providers.

12. Develop a seamless user-friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.

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D. Hospital CareNational StrategyPolicy and service planning will support quality health and disability support programmes integrated around the needs of older people.

Admission to general hospital services will be integrated with any community-based care and support that an older person requires.

Once in hospital, older people are at highest risk of acquired disability, cognitive decline or admission to residential care, either as a consequence of illness or as a consequence of treatment following hospital admission. Older people’s health needs are more complex,usuallywithco-existingmedical,functional,psychological and social needs that are often misunderstood and require a different approach to care while in hospital and after discharge.

Acute illness in older people often has functional consequences, and patients may require a period of rehabilitation to regain function and independence. Rehabilitationisaspecifichealthinterventionwitha strong evidence base. This need not take place in hospital if a patient is medically stable, and in many regionsitdoesnot(e.g.theUnitedKingdom,Australiaand parts of New Zealand). However, the BOP lacks community-based alternatives to hospital in-patient rehabilitation after an acute illness.

Comprehensive geriatric assessment (CGA) is the assessment of a patient by a specialist team that is led by a doctor trained in Geriatric Medicine, followed by interventions and goal setting agreed with the patient and carers. It is a form of specialist organised geriatric care. It covers the following areas:

• Medicaldiagnoses;• Reviewofmedicinesandconcordancewithdrug

therapy;• Socialcircumstances;• Assessmentofcognitivefunctionandmood;• Functionalability(ieabilitytoperformactivitiesof

dailyliving);• Environment;• Economiccircumstances.

CGA should inform discharge planning and the InterRAI needs assessment process (see Section C).

Meta-analysis of randomised controlled trials shows that patients who undergo CGA after emergency admission to hospital are more likely to be discharged to their own home, less likely to need residential care, lesslikelytoexperiencedeteriorationandmorelikelyto have better cognition compared with those who receive general medical care.16 Outcomes are most improved when hospital care is delivered in specialist geriatric wards rather than by mobile teams. In studies, “comprehensiveassessment”thatdoesnotincludeadoctor trained in Geriatric Medicine does not have the same positive outcomes.

The reasons for this are that older people tend to be medicallycomplex.TheRoyalCollegeofPhysiciansofLondon and British Geriatric Society stated in 2001:

“At the core of Geriatric Medicine as a specialty is the recognition that older people with serious medical problems do not present in a textbook fashion, but with falls, confusion, immobility, incontinence, yet are perceived as a failure to cope or in need of social care. This misconception that an older person’s health needs are social leads to a prosthetic approach, replacing those tasks they cannot do themselves rather than making a medical diagnosis. Thus the opportunity for treatment and rehabilitation is lost, a major criticism of some current services for older people. Old age medicine is complex and a failure to attempt to assess people’s problems as medical are unacceptable.”

Comprehensive Geriatric Assessment can be delivered in a range of acute hospital settings:

• In the ED:Forexample,NHSLanarkshiredemonstrated a reduction in admissions by 6% for olderpeoplethroughan“AcuteCareoftheElderly”(ACE) team based in the Emergency Department.17

• In surgical wards: The sub-specialty of Orthogeriatrics involves a specialist geriatrician sharing care with orthopaedic consultants. This means older people admitted with fractures receive a multi-factorial falls assessment and treatment for osteoporosis when they otherwise would not. “ProactiveCareofOlderPeopleundergoingSurgery(POPS)and“SystematicCareofOlderPeople in Elective Surgery (SCOPES) are other programmesdevelopedintheUKthatdemonstratereduced complication rates, reduced length of stay and better functional outcomes on discharge for older people undergoing surgery.18

16 Ellis G, Whitehead MA, Robinson D et al. Comprehensive Geriatric Assessment for older adults admitted to hospital: met-analysis of

randomisedcontrolledtrials.BMJ2011;343:d6553].

17 DrGrahamEllis,ConsultantGeriatrician,NHSLanarkshire,UK.

18 British Geriatric Society www.bgs.org.uk POPS special interest group and SCOPES: adam.gordon@nottingham.ac.uk].

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19StrokeUnitTrialistsCollaboration.Organisedin-patient(strokeunit)careforstroke.CochraneDatabaseSystReview2007,issue4.

CD000197.

20 Fjaertoft H, Rohweder G and Indredavik B. Stroke unit care combined with early supported discharge improves 5 year outcome. Stroke

2011;42:1707-11.

21BaztanJ,Suarez-GarciaFM,Lopez-ArrietaJetal.Efficiencyofacutegeriatricunits:ameta-analysisofcontrolledstudies.RevEsp

GeriatrGerontol2011;46(4):186-92].

• In dedicated Acute Stroke Units: Specialist stroke unit care means that patients are more likely to be independent and living at home following a stroke.19 Stroke unit care means complications are identifiedandtreatedearlier,andcombinedwithearly supported discharge (eg via Intermediate Care), this results in reduced length of stay.20

• In acute geriatric wards: Acute geriatric unit caresignificantlyreduceslengthofstay,hospitalcosts, leads to improved function on discharge and increases the likelihood of returning home, compared to usual hospital care.21

Demand on hospital services will continue to grow with an ageing population, particularly for specialist services for older people. The Government’s Guidelines for Specialist services for Older People weredevelopedin2004.TheGuidelinesprovide

DHBs with a framework for progressively developing specialist health services for older people that provide anexpertservice,buildoninitiativesinotherpartsofthe health system (such as primary care), disseminate knowledge and develop collaborative partnerships that deliver integrated services to vulnerable older people, their whanau and carers. Access to Comprehensive Geriatric Assessment by community home based support providers can improve quality, effectiveness and timeliness of service provision and reduce unnecessary errors, duplication and admissions to hospital.

The majority of medical admissions to secondary services are for people aged over 65 (63% in BOP in 2010). However, the vast majority of older people admitted to hospital in the BOP do not receive specialist care. There is a Health in Ageing (HIA)

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service in Tauranga Hospital (but not in Whakatane). This consists of a 39-bed rehabilitation focussed unit, withlimited“in-reach”services.Thecurrentnumberof specialists in geriatric medicine is below what is nationally recommended for our population to deliver a basic service. In 2011, the number of geriatricians was increased to three, however a recent independent reviewbyDrFredHirstindicatedaminimumoffivefull time equivalent (FTE) geriatricians is required to deliver proper specialist services and provide input to Whakatane, with one FTE being a community geriatrician.

The current specialists in Geriatric Medicine have recommendedawayforwardtoexpandnumberstoarecommendedminimumlevelofsixwithinexistingFTE for physicians. This would allow the conversion ofanexistinggeneralmedicalwardtoanacutegeriatricwardinadditiontotheexisting39-bedHIAunit, a plan this Strategy supports. The acute geriatric ward would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency, specialist care for older people with delirium(aconditionwithsignificantmortalityandmorbidity), and potentially enable co-location of stroke patients in an organised stroke service (refer to section G).Anexpandedgeriatricserviceandworkforcewouldalso allow essential specialist services to be provided toWhakatane,andexpandexistingcommunitywork,education,“in-reach”services,increasedspecialist advice to primary care, service and pathway development and outpatient capacity.

In the redevelopment of Tauranga and Whakatane hospitals, provision has been made for an increased number of beds for HIA in line with national benchmarks for the proportion of bed numbers to the population aged over 65. However, increases have beendeferreduntil2017andwillrequiresignificantfunding.

In the meantime, without the ability to fund any increased capacity, our focus will be on improving the care of acute admissions for older people, managing patients better to reduce length of stay, and developing new models of care that are better suited to older people as well as being more cost effective, such as proper acute geriatric unit care and community-based rehabilitation or“IntermediateCare”.

Intermediate CareIn 2011, a team of specialists in geriatric medicine performed a snapshot audit of in-patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services.

Intermediate Care offers a co-ordinated service that links acute hospital care, community health services and social care to make more effective use of hospital capacity by providing Comprehensive Geriatric Assessment and rehabilitation in alternative settings. Evaluation of Intermediate Care services elsewhere has demonstrated reduced length of stay in hospital and higher patient satisfaction. Outcomes are as least as good as traditional acute hospital care.

“IntermediateCare”describesservicesthatmeetallthe following criteria:

• Targetedatpeoplewhowouldotherwisehavehad an unnecessary, prolonged hospital stay, or inappropriate admission to acute inpatient care, or longtermresidentialcare;

• Providedonthebasisofacomprehensivegeriatricassessment (that includes a geriatrician) resulting in a structured care plan that involves active rehabilitationandopportunityforrecovery;

• Hasaplannedoutcomeofmaximisingindependence and typically enabling patients to resumelivingathome;

• Istimelimited,typicallynolongerthan6weeks,andoftenaslittleas1-2weeks;

• Involvesmulti-disciplinaryworking,withasingleassessment framework, single professional records and shared protocols.

Intermediate Care is geared towards both admission avoidance,andearlydischarge;andencompassesrehabilitation at home, as well as in a community Intermediate Care facility (see diagram in Supporting

Informationsection).Examplesof Intermediate Care services in New Zealand include the Community Rehabilitation, Enablement and Support Team (CREST) service in Canterbury and the Supported Transfer and Rehabilitation Teams (START) service in the Waikato. These services feature community based rehabilitative supported discharge service (either in the person’s home or in a

residential facility), a rapid response service, and a

Our focus will be on improving the care of acute admissions for older people, managing patients better to reduce length of stay, and developing new models of care that are better suited to older people.

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multidisciplinary team (general practice, community service providers and older person health specialist services).

ElementsoftheseservicescurrentlyexistintheBOPthatcan be incorporated as part of any future Intermediate Care service. The Western Bay of Plenty has two “transitionalcare”bedsinanagedresidentialcarefacility targeted towards older people who have been admitted to hospital following a fracture and are not yet ready for rehabilitation, and a Community Response Team (CRT) that focuses on admission avoidance. Community Primary Options (CPO) funding for general practice provides for the ability for GPs to admit a patient to residential care for a few days to avoid an admission to hospital or after a discharge. However, if patients require more support that can be provided at home or through CPO funding, there are limited options for GPs or the CRT to refer or admit patients to more appropriate cheaper care in the community such as an Intermediate Care facility or increased temporary support in the home.

The introduction of an Intermediate Care service would reduce length of stay for older people across all hospital specialties. It would allow the HIA in-patient servicetofocusonolderpatientswithmorecomplexmedical and rehabilitation needs (e.g. acute stroke) and also mitigate the projected increased need for HIA beds in the future.

Allied HealthWith a focus on a comprehensive geriatric assessment, rehabilitation and restoration of function and independence are key elements to the success of a number of the services for older people recommendedinthisStrategy.Examplesincludethe Intermediate Care Service, acute geriatric ward, organised stroke service and the redesign of home based support services including assessment and treatment by allied health professionals (particularly physiotherapy and occupational therapy).

Currently there is limited access to both hospital and community allied health across the BOP, but particularly in the Western Bay of Plenty. There are no foreseeable plans to address this shortage.

In developing this Strategy, consistent messages were received from hospital and community based services and older people themselves about the importance of access to allied health professionals as a fundamental enabler to many of the recommendations in the Strategy. Manypeopledescribeddifficultieswithaccessingsufficient(evenbasic)alliedhealthtreatmentandadviceduetoinsufficientstaffinglevels.Itisstronglyrecommended that options to address increased access

to allied health professionals is addressed as an essential part of the implementation plan.

Recommendations1. Specialist services for older people are developed

in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health,2004).

2. Expandthespecialistgeriatricworkforcetorecommended levels (including geriatricians, registrars and junior doctors, nursing and allied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for specialist health services for older people to work within acute medical, surgical and orthopaedic services.

3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler to implement a number of recommendations in this Strategy.

4. Developanacutegeriatricwardinadditiontotheexisting39-bedHIAunit,whichwouldincorporateacomprehensive geriatric assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a conditionwithsignificantmortalityandmorbidity).This is also an enabler to develop an organised stoke service (refer to section G).

5. Throughtheprovisionofanexpandedgeriatricworkforce, provide essential specialist services to Whakataneandexpandexistingcommunitywork,education,“in-reach”services,adviceandeducationto support primary and community care, service and pathway development and outpatient capacity.

6. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver a comprehensive geriatric assessment in the future.

7. Makebetteruseofexistingresourcesbydeveloping different, cost effective, evidence-based models of care such as increased community rehabilitationor“IntermediateCare”.

8. Make funding provisions to increase the numbers of beds for specialist geriatric medicine services in line with national recommendations for the proportion of beds to the population of the BOP and the planned redevelopment of Tauranga Hospital by 2017.

9. Implement better communication between secondary and primary care on discharge from hospital, so that any comprehensive geriatric assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.

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E. Aged Residential CareNational StrategyOlder people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

(ARC) is a scarce, high cost resource. People are entering residential care at an older age and with higher support needs. The number of people requiring residential care, particularly at hospital and dementia levels of care is predicted to grow. Currently, there areinsufficient“Stage3”securedementiacareandpsychogeriatric beds available in the BOP which can lead to hospital stays lasting several months for some patients. A comprehensive review of the future needs for residential care carried out by Grant Thornton in 2010 sets out the predicted increase in bed numbers overthenext20years.22 ARC is a demand driven service purchased by DHBs for people over 65 who have health and disability related needs and are assessed as needing ARC. BOPDHB purchases capacity in ARC facilities throughout the BOP. ARC providers are private organisations following legislative and contract changes made in 2006, DHBs no longer have the ability to control the number of beds purchased in ARC providers facilities. Availability of beds is market driven and there is no guarantee of any level of occupancy by the DHB and providers accept this level of commercial risk.

Access to residential care is through the Needs Assessment and Service Coordination (NASC) process. Only those people who have been assessed as eligible and needing full time residential care will be able to access a funded bed. The assessment process used is InterRAI (refer to Section C). Thresholds for entry to access are reviewed and all other options for communitycareareexploredbeforetheBOPDHBagrees to grant access to an ARC bed.

Contracts for services and the price paid for ARC beds are negotiated and set nationally through DHBs and the providers’ representative body, the majority of whom belong to the New Zealand Aged Care Association. All DHBs sign up to this process, which then prohibits the development of local funding models or options. Price increases negotiated for ARC through thisprocessinthelastfewyearshaveexceededthelevel of cost pressure funding generally received by DHBs through the funding envelope.

FundingforARCisamixtureofDHBfunding(for

fully subsidised residents who meet eligibility criteria throughafinancialmeanstest),privatepayments,and client contributions through their national superannuation. People who do not qualify for a DHB subsidy (they have assets higher than the required threshold) are required to pay for the cost of their care, butthisisnomorethanthemaximumcontributioneachweek.Themaximumcontributionisthesamefor all residents, regardless of the level of care they are assessed as requiring. It is an amount set by legislation each year and is equal to the weekly cost of rest home level care (the lowest level of care). The differencebetweenthemaximumcontributionandthecost of higher levels of care if required, eg hospital level care, is topped up by the DHB.

Approximately5.2%ofpeopleagedover65intheBayof Plenty live in an ARC facility. This compares to a range ofapproximately5-7%nationally.Theproportionhasbeen declining overall, but particularly at rest home level, as the BOPDHB has invested more in home support servicesthatenable“ageinginplace”.However,theproportion of people in higher levels of ARC has been increasingduetohigheracuityandcomplexityofcare.

Arangeoffactorsinfluencetheproportionofpeoplewho access ARC including availability of community services eg medication supervision, respite care, day programmesandhomesupport;wherepeoplelive,what family or whanau support they have, and the health and wellbeing of a primary carer.

TheutilisationratebyMāoriofresidentialcareislowincomparisontonon-Māori,largelyduetocultureandwhanau structures encouraging and enabling support and care to be provided at home. However, this is changing asfamilystructureschangeandyoungerMāoriaremoving away from home, often in search of employment. In the Western Bay of Plenty many older people do not have family nearby and many live on their own.

The average age of people accessing ARC is currently 84years11months.Thishasimplicationsforgrowthin demand for ARC as the growth rate for people over age85isincreasingattherateofapproximately6%per annum.

Hospital level care has steadily grown at the rate of between 5% and 9% each year for the last 5 years. Thislevelofgrowthwillcontinuewiththeinfluenceofpopulation ageing and higher levels of disability. This has inevitable cost implications for the DHB because of the funding mechanism set out above and the DHB needs to plan and budget for this appropriately.

22 Grant Thornton. Aged Residential Care Service Review. Sep 2010. wwwgrantthornton.co.nz.

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ToensurewewillhavesufficientARCcapacityinthecommunity, commercial commitment and an element of risk by private organisations based on forecast modelling and demand projections is required. Investment in new buildings requires time and money and therefore a long lead in time to develop new capacity.

The funding and focus of ARC is currently on long-term care and support. To better manage future demand andmaximisethishighcostspecialisedresource,much more focus could be directed to preventative and rehabilitative care, with development of short-term service options. Currently, services are stand-alone with little community services integration. The ARCcontractdoesnotallowforflexibility.Therearefew incentives for restorative care (i.e. reversal of functionalloss).YetthereisconsiderableexpertiseinARC, and investment in facilities in central community locations that could be better utilised.

Moreflexibleservicescouldprovide:

• Residentialcare(mediumandhighneedscare);• Intermediatecarebeds(temporarycare-home

basedrehabilitation–(refertoSectionD);• Palliativecare;• Day,nightandweekendcare;• Acommunityelectronicmonitoringbase(forfalls

prevention,medicationmanagement,diabetesetc);• Co-ordinationofagedcareeducationandaccess

toavailableservices;• Abaseforprimarycareandcommunityallied

health providers (aligned with the integrated family healthcentremodel);

• Socialmeetingpointsforolderpeopleandtheirfamilies.

The current ARC access and funding regulations make itdifficulttore-entercommunitybasedcareduetoincome/asset testing (assets, usually the family home, often have been sold when entering ARC to pay for the cost of care). In the current environment where funding follows eligible residents, there is little opportunity to manage the growing demand for ARC.

Furthermore, the cost component of providing accommodation and catering services in ARC is high and alternative models could be considered. Forexample,accommodationandcateringcouldbeprovided by specialist private sector providers with the health care component provided by health care providers.

Recommendations 1. Plan and budget appropriately for the forecast

growth in demand in aged residential care. 2. Manage demand on scarce high cost resources by

developingnewflexible,integratedandrestorativemodels of care with ARC e.g. short term care, Intermediate Care, integrated community facilities.

3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D)

4. Fundandsupportroll-outoftheInterRAILongTerm Care Tool (refer to Section C) in ARC in accordance with the national business case.

5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service.

6. Streamline contracts and auditing processes to reduce compliance costs.

7. Consider ways in which Primary Care and Aged Residential Care can identify those nearing the end of their lives and offer/implement Advanced Care Planning.

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F. Dementia and Mental Health in Older People National StrategyPopulation-based health initiatives and programmes will promote health and wellbeing in older age.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

The number of older people with dementia is rising rapidly.Nationally,dementiaaffects40,746people.By2050itisestimatedtherewillbe146,699peoplelivingwith dementia. The prevalence of Alzheimer’s Dementia (AD) strongly correlates with age (see the table below). Of all the patients under mental health services for older peopleintheBOP,approximately80%havedementiaand 20% have other mental health disorders.

Prevalence of Alzheimer’s Dementia (AD), 2006:

Age 65-69 75-79 85-89 90-95

Prevalence (%) 1.1% 4.7% 15.2% 26%

AD represents 60-70% of all dementia in New Zealand (thisfiguredoesnotinclude“mildcognitiveimpairment”orearlydementiawhichcarriesasignificantriskofprogressing to AD).

Mentalhealthproblemsamongolderpeopleexacta large social and economic toll on patients, their families and carers, as well as the statutory agencies. Under-detection of mental illness in older people is widespread due to the nature of symptoms and the fact that many older people live alone. Depression in people aged 65+ is especially under diagnosed, and this is particularly true of residents in care homes. Mental health problems may be perceived by older people and their families, as well as by professionals, asaninevitableconsequenceof“oldage”andnotashealth problems which can respond to treatment.

Promoting good mental healthPromoting mental health is as important in older people as in younger people. Interventions at a population level to promote good mental health include educational activities, and creative and social pursuits. Specificadditionalinterventionswhichpromotegoodmental health in older people include tackling social

isolation and providing bereavement support. Older people in residential care and nursing homes and those receiving day care should be able to participate in a range of stimulating group or one-to-one activities. These can include reminiscence, art therapy, news-based discussions, aromatherapy, games and quizzes, adult education and drama. Older people should be offered a choice of activities matched to their needs and preferences. An appropriate environment can also aid orientation and help to avoid visual and sensory confusion.

Continued engagement for older people in valued rolesinthecommunity,includingflexibleoptionsforolder people to continue working should they choose, also promotes good mental health (see the wider determinants of health in Section A).

Early identification and treatmentMost people with mental health problems will be diagnosed and cared for in primary care with the support of social services, but specialist mental health services should be available to develop care pathways with primary care and be consulted when needed. A range of specialist services should be available, from diagnosingandtreatingmorecomplexproblems,to providing community and in-patient services for those with a clinical need. The emphasis should be on promoting the independence of older people with mental health problems and supporting them and their carers in the community whenever possible. The BOPDHB has a specialist mental health service for older people. However, services that focus on early identificationofdementia,supportandpreventativeinterventions are very limited.

Earlyidentificationofpeoplewithdementiaenablessupport to be put in place earlier to prevent further loss of function and to support primary carers to take a break.Flexibleoptionsinthecommunityforsupportingpeople with dementia are required to reduce carer strain and delay entry to residential care for as long as possible.

There few services in the BOP that focus on people in the early stages of dementia. A report to the Disability Issues Directorate of the Ministry of Health recommends“MemoryAssessmentCentres”forquality improvement in the diagnosis of dementia. International research has shown services that focus on the early stages of cognitive impairment can significantlyimprovehealthandsocialcareoutcomes,delay admission to residential care, improve well-being of full time carers, prevent unnecessary admission to hospital and reduce health care costs in the long term.

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A memory pilot undertaken by mental health services for older people (MHSOP) in the BOP in 2011demonstratedasignificantdemandforearlyintervention services for people with dementia.

Currently in the BOP, specialist assessment for dementia is spread across three services including MHSOP, HIA and neurology. While all services have contact in various ways, there is no co-ordinated or targeted service delivery, and there is little coordination or integration with primary care. A coordinated approach, with greater integration with primary care is recommended. A business case is currently under development for the establishment of a coordinated dementia service, incorporating an early intervention service.

Secure residential facilitiesSpecialist residential facilities (secure dementia facilities and psychogeriatric level care) throughout the BOP operate at close to 100% occupancy, making placementinthecommunitydifficultandincreasinglengthofstayinhospital.Thereisaneedtoexpandpsychogeriatric level capacity in the community, particularly in the geographical areas at either end of the BOP, namely the west of Western Bay of Plenty and the Eastern Bay of Plenty.

The acuity of older people who present to specialist mental health services is increasing. When there is a shortage of suitable options in the community to enable a safe and well supported discharge, this impacts negatively on average length of stay in hospital.

To further manage the growth in demand for psychogeriatric level care, careful management of access to this high cost scarce resource is required to ensure those most in need have access to this level of care when required. The assessment process and access criteria differs across different DHBs and impacts on capacity. This is a national issue and there is a need for a standardised assessment process and access criteria. Locally, bed availability can be actively managed by ensuring people in psychogeriatric facilities are appropriately assessed and re-assessed regularly for changes in their care needs.

New models of care and knowledge about the importance of the environment of secure dementia units are being developed locally and internationally. Quality facilities and care in line with best practice has been shown to reduce admission to hospital, improve resident outcomes, reduce the need for psychotropic medicationandgiveconfidencetofamilymemberswhen residential care is required. Residential providers

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need support to be the best they can and develop innovative facilities and models of care for people with dementia as well as access to specialist assessment and advice when required. A set of best practice guidelines is recommended to support provider care and development.

Recommendations 1. Promote recognition and assessment of mental

health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia.

2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities.

3. Improve access to specialist advice and support for community providers.

4. Improvesupporttoprimarycarersofpeoplewithdementia through education and training and a rangeofflexiblerespite,dayandhomebasedsupport options.

5. Introduce training requirements in service specificationsforhomebasedsupportserviceswhere staff work with people with dementia.

6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator.

7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the nextfiveyearsandmakeappropriatebudgetprovision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the Western Bay of Plenty and Eastern Bay of Plenty.

8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular re-assessments of people to identify changes in levels of need.

9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care.

10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatric units and support existingproviderstoimprovequalityofcareandenvironment.

G. Stroke and Transient Ischaemic Attack (TIA)National StrategyPopulation-based health initiatives and programmes will promote health and wellbeing in older age.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers

The Ministry of Health and New Zealand Stroke Foundation published the national Guidelines for Stroke Management Implementation Plan in 2011. A national acute stroke audit commissioned by the Ministry in 2009 found that:

• NewZealanderscurrentlydonothavesufficientaccess to organised acute stroke services.

• Onlyeightoutof21DHBsatthetimeprovidedstroke services that are consistent with international best practice, and only 39% of patients in the audit received care in a stroke unit.

The Implementation Plan is clear that all DHBs shouldprovidean“organisedstrokeservice”,andall people admitted to hospital with a stroke should expecttobemanagedinastrokeunitbyateamofhealthprofessionalswithexpertiseinstrokeandrehabilitation.DHBsarealsoexpectedtodeveloporganised stroke services as signalled in the DHB annual planning guidelines for 2012/13 and to develop regionalstrokeserviceswithinexistingresources.

Keyobjectivesforlarge(populationgreaterthan200,000) DHBs are:

• TheyshouldprovideanacuteTIAservice;• Theyshouldprovideanacutethrombolysisservice

orapathwaytoaccessone;• Inter-disciplinaryteamsshouldutilisecurrentstroke

protocolsforstrokemanagement;• Theyshouldprovideorganisedstrokecareina

designated geographical area under the care of a designatedstrokephysician;

• Theyshouldproviderehabilitationinadedicatedarea(i.e. a stroke rehabilitation unit) under the coordinated careofateamexperiencedinstrokerehabilitationincludingadesignatedstrokephysician;

• Theyshouldimplementongoingeducationforstaff,patientsandfamilies/caregivers;

Preventing strokeThe Ministry of Health has recently produced best practice guidelines on better prevention of cardiovascular diseases – including a toolkit for DHBs. The risk factors for cardiovascular (heart) disease and stroke are the same. Heart disease occurs because ofdiseaseinthearteriessupplyingtheheart;strokeoccurs because of disease in the arteries supplying the brain. Stroke is the third leading cause of death in New Zealand after heart disease and all cancers combined. It is also a major cause of neurological disability. There is a large volume of evidence to show that early detection and management of risk factors for stroke can prevent stroke from happening.

It is only in recent years that the risk of stroke after a transient ischaemic attack (TIA) has been appreciated. ATIAisdefinedasstrokesymptomsandsignsthatresolvecompletelywithin24hours.TIAsaresometimesreferredtoas“mini-strokes”butthereis nothing minor about a TIA. A person’s risk of a disabling stroke after a TIA can be as high as 12% in thenextsevendaysand80%ofallstrokesfollowingaTIAcanbeprevented.Thereareatleast540TIAseach year in the Bay of Plenty DHB. By treating TIA as an emergency, and following the evidence-based New Zealand TIA guidelines, we could prevent around 52 disabling strokes and save over $2.5 million each year in stroke-related care.

StrokeisahealthgainpriorityareaforMāori.Māoridevelop risk factors for stroke earlier. Prevalence, morbidity, and mortality from stroke are all higher in MāorithaninpeopleofEuropeanorigin.Healthcareproviders must recognise the cultural values and beliefsthatinfluencetheeffectivenessofservicesforMāoripeoplewithTIAandstroke.Māorimaybelesslikely to present to hospital with symptoms of a TIA or stroke, particularly in more rural areas. A TIA pathway is currently being developed through Bay Navigator to promote best practice but disparity in services between the Western and Eastern Bay of Plenty is evident (and being addressed).

Organised stroke servicesIn Tauranga Hospital at the moment, patients with high risk TIAs are admitted to hospital and seen by a specialist stroke physician and nurse. All outpatient referrals from the ED or GPs are seen in a TIA clinic withinoneweek.Manypatientswith“low-disabilitystrokes”whoonlyrequireadmissiontohospitalfora

few days are managed by general physicians with the advice of the stroke physician and nurse who then follow patients up in clinic.

For patients with a major disability following stroke, randomised controlled trial evidence shows that outcomesaresignificantlyimprovedifcareisprovidedonageographicallydefinedstrokeunitrunby a specialist team of nurses, therapists and stroke physician(s). The best outcomes are found in units that are co-located with the stroke rehabilitation unit. Specialist stroke unit care means that patients are more likely to be independent and living at home following a stroke.23 There is no such unit in the BOP.

Recent Ministerial emphasis on the importance of stroke units supports the development of an acute stroke unit. It is recognised that this will need to be achieved within current funding resources. However, in line with the rest of this Strategy, provision of community-based rehabilitation (eg Intermediate Care), would free up beds currently being used in hospital for slow-stream rehabilitation so that an acute stroke unit could be created in the most appropriate area (refer to recommendations in Section D).

An organised stroke service is also dependent on an appropriate workforce, as outlined in Section D.

Recommendations1. Complete the development of a TIA pathway

through Bay Navigator .2. Establish an organised stroke service - Refer

also to Section D on the development of an acute geriatric ward.

3. Increase the number of specialist geriatric medicine workforce to provide appropriate treatment of TIAs and Stroke - refer to Section D.

4. Continuewithon-goingspecificthrombolysistraining for ED and general medical Registrars/Consultants in accordance with international best practice.

5. Develop a BOPDHB Stroke Guideline that sets out how the national NZ Clinical Guidelines for Stroke will be implemented locally.

23StrokeUnitTrialistsCollaboration.Organisedin-patient(strokeunit)careforstroke.CochraneDatabaseSystReview2007,issue4.

CD000197.

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H. Falls and Bone HealthNational StrategyPopulation-based health initiatives and programmes will promote health and wellbeing in older age.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged over 75. It is estimated that one-third of community-dwelling over 65s fall each year, usually in their own home with no obvious hazard. There is good evidence that interventions to prevent falls reduce an older person’s risk of falling in the future. The national Health ofOlderPeopleStrategyspecificallyhighlightsfallsasan area for action.

One in three women and one in twelve men over 50 are affected by osteoporosis, which increases the risk of fracture following a fall. Osteoporosis is called the silent epidemic because of its symptomless development and the lack of public awareness. Osteoporosisisnotjustan“oldpeople’sdisease”.Young people with low bone density can get osteoporosis too.

• Morethan3,000NewZealandersbreakahipeachyear.Thisfigureisexpectedtoriseto4,800intenyears time, as our population ages.

• Aboutaquarterofpeoplewhofractureahipdiewithin a year from related complications. One third never return home, and those that do lose their mobility and independence.

• Morewomenarehospitalisedwithahipfracturedue to osteoporosis than through breast cancer.

The prevalence of osteoporosis is predicted to increase by 30% from 2007 to 2020 due to population ageing.24 The total health cost of osteoporosis through fractures in New Zealand in 2007 was more than $1.15 billion or $3 million per day. Problems with both falls and osteoporosis can be detected early and treated successfully, preventing injuries, fractures and disability.

What is little understood by the public, and many health professionals, is that falls in older people are not accidents, but are the result of medical problems, many of which are treatable. In one study of older people presenting to the ED with a fall, patients had an average offiveriskfactorsforfalls–themostcommonbeingdisorders of gait and balance, inappropriate medications, problems with blood pressure, visual impairment and cardiovascular disorders. Falls in a later life are also acommonsymptomofpreviouslyunidentifiedhealthproblems which need to be managed.

A fall can precipitate admission to long-term care. After an osteoporotic fracture, 50% of people can no longer live independently. Hip fractures are the most common serious injury related to falls in older people, costing onaverageof$24,000perpersonforacutetreatmentand rehabilitation, resulting in an annual cost to New Zealand of around $18 million per year.25 Of this, around half is for acute hospital care and half for long term disability services or aged residential care.

Preventing fallsPreviously, the Accident Compensation Corporation (ACC) was the lead agency for funding falls prevention programmes for people aged over 65. However, in 2010 ACC discontinued funding for falls prevention programmes for older people, but retained promotion of Vitamin D use in older people to prevent falls. There is currently no falls prevention strategy or service in the BOPDHB. There are three levels of approach to falls prevention:

A population-based strategy • Includingthepromotionofexerciseandactivities

that promote muscle strength and balance (eg Tai Chi classes).

• AnincreasedintakeofcalciumandvitaminDinthediet for older people.

• Ensuringthatpavementsarekeptclearandingood repair, and there is adequate street lighting .

• Makingpropertysafer–manyfallsinolderpeoplearerelatedto“homehazards”.

Preventing falls in individuals• Betteridentificationofthoseatriskoffalling–ie

those with gait and balance disorders (eg an old strokeorParkinson’sDisease);visuallyimpaired;takingfourormoremedications;thosewithhomehazards.

• Referringolderpeoplewhohavefallentoahealthprofessionalfora“fallsassessment”andinterventions as necessary.

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24OsteoporosisNZIndependentResearchReport2007

25OsteoporosisNewZealandInc.“TheBurdenofOsteoporosisinNewZealand2007to2020”.

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• Implementingmeasuresinagedresidentialcareand hospitals to prevent falls in older people.

Specialist falls service• Olderpeoplewithrecurrentfalls,“unexplained

falls”ordizzinessbenefitfromaspecialistmulti-factorial falls assessment that involves a specialist geriatrician and therapy team.

Interventions for falls usually include:

• Diagnosisandtreatmentofunderlyingmedicalproblems such as eye diseases/visual impairment, diseases causing abnormal gait and balance, correction of postural hypotension or cardiac rhythm abnormalities, discontinuing inappropriate medication,treatingbladderproblemsetc;

• Rehabilitation,includingphysiotherapytoimproveconfidenceinmobility,andoccupationaltherapytoidentifyhomeandenvironmentalhazards;

• Equipmenttoimprovethesafetyofanolderpersonathome;

• Socialcaresupportifrequired.

Individuallytailoredexerciseprogrammesadministeredbyaqualifiedprofessionalcanreducetheincidenceofsubsequent falls in older people or as part of a multiple intervention approach in those at risk. Falls prevention programmes for individuals should contain more than one intervention and focus on the individual’s particular risk factors.26 The redesign of HBSS recommended in Section C supports this approach.

Treating osteoporosisAny person who has had a fragility fracture (ie a fracture that occurred when falling from standing heightorless)shouldbeflaggedforanosteoporosisassessment.

Risk factors for osteoporosis include:• Previousfragilityfracture;• Prolongedcorticosteroidtherapy;• Prematuremenopauseorhistoryofamenorrhoea

(nottreatedtoreduceriskofosteoporosis);• Thepresenceofegliverorthyroiddisease,

malabsorption,alcoholism,rheumatoidarthritis;• Afamilyhistoryofosteoporosis(includingmaternal

hipfracture);• Lowbodymass;• Smoking.

Osteoporosismayalsobeidentifiedthrough:

• DXA(DualEnergyX-rayAbsorptiometer)bonemineralscan;

• Radiographicevidenceofvertebralfractureand/orloss of height associated with vertebral fracture.

Inwomenagedover75,aDXAscanisnotrequiredtodiagnose osteoporosis, if there is a history of previous fragility fracture and other metabolic bone diseases are excludedbyanx-rayofthefractureandbloodtests.27

There is no routine assessment and treatment for falls and osteoporosis in older people who attend ED each year in the BOPDHB with fragility fractures. The opportunity for health promotion and prevention, potentially saving millions of dollars in hip fracture care alone, is lost. The HIA department in Tauranga Hospital currently provides an orthogeriatric service for older people with fractured hips. However, the problem of falls and bone health needs to be tackled far earlier in order to make a difference.

Recommendations:1. Assess the impact of Accident Compensation

Corporation’s withdrawal of funding for falls prevention programmes for older people.

2. Promote a population-based falls prevention strategyforolderpeople,includingtheidentificationof those at risk of falls living in their own home or in care homes.

3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis.

4. Developaspecialistfallsserviceforpeoplewithrecurrentfalls,“unexplainedfalls”ordizziness.Assess how this could work across the BOP, working with GPs in more rural areas.

5. Implement a Falls Pathway through Bay Navigator that facilitates the evidence-based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care.

6. Implement an Osteoporosis Pathway through Bay Navigator that links with the Falls Pathway, facilitating the evidence-based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.

26NationalInstituteforHealthandClinicalExcellence(NICE).Theassessmentandpreventionoffallsinolderpeople.ClinicalGuideline

21,2004.

27 Royal College of Physicians and Bone and Tooth Society of Great Britain. Osteoporosis: clinical guidelines for prevention and treatment.

RCP, London, 2000 / and Osteoporosis New Zealand www.bones.org.nz.

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I. Medications ManagementNational StrategyPopulation-based health initiatives and programmes will promote health and wellbeing in older age.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Older people are high users of medications, particularly those in Aged Residential Care. Two-thirds of people over the age of 60 are taking regular medication, and over half of those with repeat prescriptions are taking more than four drugs. Medications are a valuabletherapeutictoolbuttheycancausesignificantproblems, particularly if they are not reviewed regularly:

1. Many health problems in older people are a direct result of unrecognised side effects of their medication. Up to 30% of admissions to hospital in older people may be associated with problems related to medication.28

2. As many as 50% of older people may not be taking their medicines as intended. Campaigns for people to return unwanted medicines to pharmacies confirmthatlargeamountsofmedicinesarenevertaken.“Inequivalence”inquantitiesonrepeat prescriptions mean that patients have to order different items at different times, and may unintentionally receive the same medicine on separate prescriptions. The wastage that results from this has been estimated to account for 6-10% of total prescribing costs.

3. Following discharge from hospital, changes to medication are frequently made both intentionally and unintentionally. Communication between Secondary and Primary Care is often poor. Forexample,theHIAstrokefollow-upclinicregularly sees patients who are taking dangerous combinations of powerful blood-thinning drugs which were accidentally prescribed on discharge from hospital, a recurring theme that has recently beenflaggedasaclinicalrisk.

4. Elderlypeoplehaveahigherprevalenceofpolypharmacy, which is associated with more adverse drug events. The risk of an adverse drug event has been estimated at 13% for two drugs,58%forfivedrugsand82%forsevenormore.29 As we get older, our bodies change and handle medications differently – older people are more sensitive to side effects of medications due to age-related physiological changes. As well as causing side-effects, many medicines are no longer required as we age and can be successfully withdrawn. Two large studies have shown that approximately21%ofmedicinesusedinolderpeople may be inappropriate.30 31

Other issues for older people and medicines are that their carers’ potential contribution and needs are often not recognised or addressed. Formal carers (eg home care) are discouraged from assisting older people to take their medicine, even though this could be of benefit.Familymembers,whocouldbemoreinvolvedin treatment decisions and practicalities, including administration and the recognition of possible side-effects, are often under-utilised. The redesign of HBSS outlined in Section C supports the increased ability for support workers to supervise medication adherence.

DHBs, PHARMAC and the pharmacy sector agents areplanningsignificantchangesin2012/13totheway medicines are dispensed and managed in the community. These changes seek to improve the safety, quality and effectiveness of pharmaceutical dispensing and encourage the development of a patient-centred service model that utilises the skills and competencies of community pharmacists. Pharmacists will have theflexibilitytoprovidemedicineseducationandadherence support for certain patient groups including peoplewhoare“frail,infirmorunabletomanagetheirmedicines”.Thisincludestheabilitytotailorthewaythey dispense medicines according to individual patient needandshouldbenefitolderpeoplethroughtheuse of compliance packaging to improve medication adherence.

28HanlonJT,SchmaderKE,KornkowskiMJ,etal.Adversedrugeventsinhighriskolderoutpatients.JAmGeriatrSoc.1997;45:945-948.

29FultonMM,AllenER.Polypharmacyintheelderly:ALiteratureReview.JAmerAcadNursePract.2005;17(4):123-131.

30ZahnC,SanglJ,BiermanAS,etal.Potentiallyinappropriatemedicineuseinthecommunity-dwellingelderly.JAMA2001;286(22):2823-9.

31 Curtis LH, Ostbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Int Med

2004;164(15):1621-5.

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Medicines reconciliationA high proportion of medication errors occur when patients are admitted to and discharged from hospital. Issues with medication errors on admission anddischargecanbeaddressedusing“medicinesreconciliation”.Medicinesreconciliationbypharmacistsensures that patients receive all intended medications and no unintended medications following transitions incareandsignificantlyreducesmedicationerrors.Inthe BOPDHB, there is no formal provision of medicines reconciliation in hospital. There is a pharmacist discharge support service for high-risk patients that includes medicines reconciliation on discharge, but there is no assessment process to identify high-risk patientsandconsequentlymanyarenotidentified.

Regular review of older people’s medicinesMedication reviews ensure that patients are obtainingthemaximumbenefitfromtheirmedicines.This results in better disease management, fewer exacerbationsofchronicconditions,reducedneedfor acute interventions such as GP visits and hospital admissions, improved medication adherence and fewer medication errors. Studies in general practices andagedresidentialcareintheUnitedKingdomhaveshown that every £1 spent on employing pharmacists to review patients’ medication resulted in a £2 cost saving. Currently, medication reviews in primary care are funded through a primary health organisation (PHO) contract which does not cover medication review in aged residential care. Studies have shown that people in residential care are more likely to be on a greater number of medications than a similar aged population living in the community. Compared with residential aged care facilities around the world, New Zealandfacilitieshavea42%higherdruguse.32

Recommendations1. Adopt HQSC (Health Quality and Safety

Commission) national medication safety programmeforidentificationofhighriskpatientpopulations and provide Medicines Reconciliation forallpatientsidentifiedashighriskonadmissionto hospital in BOPDHB.

2. Develop the role of a clinical pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including aged residential care. This will include medicationreconciliationforcomplexpatientsontransfer of care or discharge.

3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers).

4. Participateinthedevelopmentofmedicationmanagement processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.

32 Grant Thornton, Aged Residential Care Services Review 2010.

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Delivery

Delivering the recommendations of this Strategy willdependonareviewofourexistingworkforce,a successful implementation plan, and the highest support at Board level. We recommend that a separate implementation plan is developed following approval of this Strategy and re-presented to key stakeholders.

Funding provision, contracts and purchasing methods will need to be reviewed across most portfolios including health of older people, primary care, chronic conditions, secondary services, mental health and pharmacy to enable the recommendations to be achieved.

WorkforceThe impacts of an ageing population will place significantstressesonworkforcedemands.Strategiesfor increasing and diversifying the workforce are not well developed or focused. The workforce itself is ageing. The average age of nurses in the BOPDHB is now 52 and the average support worker is 50. Pay rates for unskilled labour are at minimum wage level or marginally above as rates for home based

support services have not been able to keep up with increases in cost of living. The skill level required by support workers is increasing to keep up with increasingcomplexityofolderpeople’ssupportneeds. The industry is not an attractive option for younger people. Working in aged care is generally low skilled, untrained and low-paid, and not highly valued by younger people. Unpaid caregivers are also undervalued. It is recognised throughout the care industry that in New Zealand we pay people less to look after our vulnerable kaumatua and kuia, and our mothers and fathers, than we pay other low-skilled workers (eg those who stack supermarket shelves). If we are to attract the right people to meet the demands that an ageing population will have on the workforce, considerable work needs to be done to change this culture. Considerable investment and multi-agency collaboration is required to attract and train the workforce of the future, particularly tailored to younger Māorischoolleavers.

Recent research published by the Department of Labour in 2009: Workforce 2020 – The Future Demand for Paid Caregivers in a Rapidly Ageing Society outlined the actual and projected number of paid caregivers needed for New Zealanders aged 65 years

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and above from 2006-2036. It estimated that in 2006 therewerearound54,700peopleovertheageof65requiringcareinNewZealand,andapproximately17,900 paid caregivers. The report projects that by 2036therewillbeapproximately147,700peopleover the age of 65 requiring care, and there will be a requirementfor48,200paidcareworkers.

The report notes the projections are based on current models of care. It further notes that the average age of paid care workers is currently 50 years old. The research makes a number of recommendations to address projected workforce shortages. The recommendations in this document align with the recommendations in the research.

In the year to December 2011, the unemployment rateforMāoriflat-linedat13.4%incomparisontothegeneral unemployment rate of 6.3%. The latest update from Statistics New Zealand’s Household Labour Force Survey shows the jobless rate of 15 to 19 year old group in the Eastern Bay of Plenty’s Rangatahi Iwiisat24.2%.Somewhanauandmokopunaarecapableoffindingemploymentorgoinginsearchofeducational opportunities outside of Eastern Bay of Plenty. However, the whanau who remain, many of whom are unemployed, and young Rangitahi who have left school with little or no educational achievement will be the main caregivers or whanau support for what will become vulnerable kaumatua. There is a need for any Health of Older People Strategy to allow inter-sectorial approaches, including Whanau ora, integrated service provisionandextendedwhanaumemberstobeemployed to provide care.

The Organisation for Economic Co-operation and Development(OECD)hasexaminedthepotentialcontributiontoefficientuseofthehealthworkforceandrecommendsskillmixchangesandthedevelopmentofnew roles, including enhancing skills among particular groups of staff as ways to address future workforce demands.

Alliedhealthprofessionalsplayasignificantroleinrehabilitation, treatment and long term support for the health and wellbeing of older people and can help alleviate projected medical and other specialist workforce shortages. However, access to community allied health therapists is limited, particularly in the Western Bay of Plenty and there are no major structural changes planned to increase the numbers or level of service. This will require a rethink about howtheseissuescanbeaddressedwithinexistingresources.

Workforce planning for an ageing population is also the subjectofspecificstrategicworkbothnationallyandlocally. Health Workforce New Zealand has developed forecasts of what the future health workforce in New Zealand will look like in 11 specialties including aged care. Some clear themes have emerged from the forecasts. They recommend:

• Makingbetteruseoftheexistinghealthworkforce,from untrained workers to highly specialist, by developingnewrolesandextendingexistingrolesto make best use of the skills of all members of the health care team.

• Afocusonprevention,rehabilitationandselfcareto underpin a shift of resources from hospital to community.

• Betteruseofthepotentialofinformationtechnology, including telemedicine.

• Developmentofregionalclinicalnetworkstomakethe best of resources and ensure provision of services to all communities.

Recommendations

1. Support the implementation of the recommendations from Health Workforce New Zealand Aged Care Workforce Service Review.

2. Promoteatransformational“cascadeofknowledge”tomitigatetheshortageofspecialistsandthesparseworkforceforthemostefficientand best clinical effect. Focus on the clinical presentations and treatment of older people, management of dementia and delirium, restorative and rehabilitation approaches.

3. Review current level of education and advice by specialist services and develop a work plan to increase education by and access to specialists in older people’s health to other sub-specialties, community agencies, Primary Care and aged residential care.

4. Supportthedevelopmentofchangedrolesegrehabilitation assistant, advanced specialty nursing, clinical advisers, care navigators (people with a sophisticated understanding of the services available and threaded links for referrals).

5. Increase the current level of service provision for community allied health to recommended levels.

6. Recognise the value of the unpaid/volunteer workforce,familyandwhanaubyprovidingspecifictraining and development opportunities for these groups.

7. MaximiseopportunitiesthroughtheBOPClinicalSchool to support the above.

8. Develop policies to increase workforce participation and retention of older workers within BOPDHB.

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9. Review contractual requirements for staff training in provider contracts and introduce where necessary minimum standards and levels of attainment against nationally relevant unit standards.

10. Collaborate with and make submissions to other government agencies such as the Department of Labourtoinfluencelongtermplanningapproachesto encourage participation in the workforce by older workers.

11. Provide incentives for community providers to include volunteers and primary carers in training programmes.

Implementation Plan andNextStepsA detailed implementation plan will be developed following a prioritisation process for the recommendations. It is envisaged that a number of work streams will be necessary to implement the recommendations in a staged process. Prioritisation of recommendations and resulting work streams will take into account Government and Board priorities, annual and regional planning commitments and funding availability and priorities. A prioritisation process will bedevelopedandrecommendedbytheExecutiveCouncil of the DHB and approved by the Board.

The Strategy Steering Group has now been disbanded following development of the Strategy. It is recommended that an implementation committee be formed to prioritise the recommendations and resulting work streams (in accordance with the prioritisation process) and oversee implementation. Membership of the implementation committee will be agreed by the DHBExecutiveCouncil.

Details of shifts in current funding, investments requiredandwhereappropriate,expectedsavings,costs avoided or reductions in forecast growth will outlined with each work stream. Approvals for contracts,fundingandservicereconfigurationwillbe subject to the current BOPDHB approval process through the Funding Management Committee.

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Supporting Information Development of the StrategyThe development of this Strategy has included:

• ReviewofoverarchingGovernmentstrategiesandpriorities for health of older people.

• Reviewofinternationaltrendsandprioritiesinhealth services for older people.

• Reviewofpreviouslocalstrategicworkandservicereviews carried out for BOPDHB and a stocktake of progress.

• ReviewofworkbeingcarriedoutbyotherDHBs and throughout the Midland Region and consideration of what can be applied to the BOP setting.

• Futuredemandanalysisandimplicationsfromthepopulation projections for the BOP and what we know about demand on current service provision.

• CollectionofbaselinedatabytheBOPDHBPlanning and Funding team to measure our success and track performance.

• Discussionandconsultationoveraperiodoftime with BOPDHB staff, clinicians, Planning and Funding Portfolio Managers in the BOPDHB and around the country but particularly in the Midland Region, and local stakeholders groups including the Population Ageing Technical Advisory Group, aboutthecurrentmodelofcare,identifiedgapsandidentifying solutions for the future.

• FormationofaSteeringGrouptoprovidedirectionand develop the Strategy. The Steering Group has broad representation from the sector and includes local specialists in geriatric medicine, providers ofagedcareandcommunityservices,MāoriHealth services, needs assessment and service co-ordination, and DHB Planning and Funding. Members are also represented on or have links with broader groups including the Population Ageing Technical Advisory Group, Positive Ageing Tauranga, Age Concern, Alzheimers Tauranga, Western Bay of Plenty PHO and Eastern Bay of Plenty Alliance Leadership Team, Disability Services and various community non Government organisations (NGOs).

• ForumswithMidlandRegionHealthofOlderPeople Portfolio Managers on potential regional activity and areas of alignment.

• Formationofadraftstrategydocumenttoinformfurther discussions and stakeholder consultation.

• Consultationandinputfromkeystakeholdergroupsincluding older people themselves and NGO providers that advocate for older people, Primary Care, all providers of community based aged care services, Cluster Leaders in Tauranga and Whakatane Hospitals.

Background DocumentsThe following documents have been considered in the development of this Strategy:

The New Zealand Health Strategy

The New Zealand Disability Strategy

The New Zealand Health of Older People Strategy

Health of Older People Strategy, 2001

Positive Ageing Strategy

The Carers’ Strategy

Guidelines for Specialist Health Services for Older People

Mental Health and Addiction Services for Older People Dementia Services Guideline

Diabetes and CVD Guidelines

Better Sooner More Convenient Health Policy

Health Needs Analysis for the Bay of Plenty

MāoriHealthPlansforBOPDHB

BOPDHB Programme of Care for Older People, 2003

Redesign of Specialist Services for Older People, 2005

Short Term Support Services Review for BOPDHB, 2007

PATAG Strategic Recommendations for Health, 2010

BOPDHB Annual Plan 2011/12 and 2012/13

Midland Regional Clinical Services Plan 2011/12 and Regional Plan 2012/13

MinistersLetterofExpectationsforDHBfor2011/12and for 2012/13

Midland Health Network Older Person’s Service Level Alliance Team Recommendations

National Service Framework for Older People, NHS (UK),2000

New Zealand Clinical Guidelines for Stroke: Implementation Plan, 2011

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Appendices Appendix 1: Terms and Abbreviations

Appendix 2: Intermediate Care Service Proposed Model

Appendix 3: Measures of Success

Appendix 4: Acknowledgements

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Appendix 1: Terms and Abbreviations

Abbreviation Definition

ARC Aged Residential Care

BOPDHB Bay of Plenty District Health Board

HBSS Home Based Support Services, generally home help and personal care.

HIA Health in Ageing, the secondary specialist geriatric service in Tauranga Hospital.

HQSC Health Quality and Safety Commission

NASC Needs assessment and service co-ordination. Access to funded long term support services requires a needs assessment be carried out by a DHB approved needs assessor. In the Bay of Plenty, the DHB NASC service is Support Net.

MHSOP Mental Health Services for Older People, the secondary specialist mental health service for older people in Tauranga and Whakatane hospitals.

SHSOP Specialist Health Services for Older People. This is the combined services of HIA and MHSOP.

STSS Short Term Support Services, generally home help and personal care provided for people after an admission to hospital.

TIA Transient Ischaemic Attack

WHO World Health Organisation

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Key:CRT = Community Response TeamAHP = Allied Health Professionals

Appendix 2: Intermediate Care Service - Proposed Model

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Appendix 3: Measures of Success

Thefollowingtableoutlinesindicatorsormeasuresofimprovedperformancethatwecanexpecttoseeasimplementation of the recommendations progresses. These measures have been selected based on availability of current data (either through our own data base or reported to us by providers through Performance Monitoring Returns). The implementation plan may identify gaps in current data collection which may require changes to our currentdatacollectionsystems,servicespecificationsorprovidercontracts.

The implementation plan will provide detail on targets for performance improvement associated with each work stream. Whereindicated,somemeasuresareexpectedtobemonitoredandreportedonintheDHBAnnualPlan2012/13.

Standards Measure of Success 2012/13

Annual plan measure

A. Community Health Prevention and Information

B. Person Centred Care

C. Integrated Care and Community Services Bay Navigator pathways that are relevant to older people are developed.

Older people, their carers, family and whanau are informed about their choices.

Government agencies and local government develop policiesthatareage-friendlyandresponsiveandreflectopportunities and impacts of population ageing.

Increase percentage of people in age residential care facilities are prescribed Vitamin D.

Increased percentage of the population of people age over65receiveinfluenzavaccine.

Increased proportion of the population who identify as Māoriareaccessingservices.

Increasedawarenessandidentificationofelderabuse

Increase in number of people diagnosed with a terminal illness have an Advance Care Plan

Reduction in the rate of growth of acute or unplanned admissions to hospital for people over the age of 65

Reduction in the rate of growth of readmissions to hospital for people over the age of 75

The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced.

The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced.

There is an increase in utilization rates for respite care and carer support

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D. Hospital Care

E. Aged Residential Care

F. Dementia

An increase in the proportion of patients over 65 admitted acutely to hospital return to live independently in their own homes

The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced.

The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced.

Reduced average length of stay in hospital for all patients over 65.

Increased access by primary and community providers to specialist geriatric advice and education. The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced.

The average length of stay in residential care is reduced.

An increase in the number of residents in long term residential care who have a comprehensive clinical assessment and care plan developed using InterRAI Long Term Care Tool.

Reduced unplanned admissions to hospital from residents in aged residential care

AnincreaseinthenumberofproviderscertifiedwiththeMinistryofHealthwhoarecertifiedforathreeyearperiod or more.

A reduction in the number of formal complaints received by the DHB

Reduced average length of stay for patients in MHSOP

Reduction in the number of acute admissions to MHSOP

A pathway for dementia care is developed through Bay Navigator.

Therateofexpectedgrowthintheproportionofthe population with dementia admitted to long term residential care is reduced.

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Standards Measure of Success Annual plan

measure

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G. Mental Health on Older People

H. Stroke and TIA

I. Falls and Bone Health

J. Medications Management

Reduced average length of stay for patients in MHSOP

Reduction in the number of acute admissions to MHSOP

A pathway for TIA is developed through Bay Navigator

Increase in percentage of patients presenting with a TIA that are treated within recommended time frames as set out in the NZ Stroke Guidelines.

Reduction in the percentage of people with a TIA who develop a disabling stroke.

An increase in the percentage of people who have a stroke who return to live independently and in their own homes.

Reduction in the number of people over 65 who present to the Emergency Department with a fracture following a fall.

Decrease in prevalence of osteoporosis

To be developed.

Standards Measure of Success Annual plan

measure

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Appendix 4: Acknowledgements

There were a range of people, including members of the community, hospital clinicians and business leaders, service providersandprimarycareproviderswhohaveallprovidedvaluableinput,adviceandexpertiseinthedevelopmentof this Strategy. BOPDHB thanks you all for your contributions. In particular we acknowledge the following people:

BronwenFoxx,CEODisabilityResourceCentre,Whakatane,MemberCPHAC/DSAC

Dorothy Stewart, Community Member, Age Concern, Elder Forum

Trevor Deane, Regional Manager, Access

Tony Lawson, Nurse Practitioner, Health in Ageing

Dr Elizabeth Spellacy, Clinical Director, Health in Ageing

DrNicolaCooper,SeniorMedicalOfficer,HealthinAgeing

Rosemarie Webb, Regional Team Leader over 65 Team, Support Net

Sharon Linwood, Clinical Co-ordinator, Mental Health Services for Older People

Sandra Fielding, Nurse Leader, Medical Cluster, BOPDHB

Joop Wieringa, Manager, Hodgson House, ARC Provider, Secretary BOP branch NZACA

JudiHarpur,ManagerNgatiKahuHauora

Enid Ratahi-Pryor, CEO Ngati Awa Social and Health Services, Eastern BOP

Alison Wieringa, Service Manager, Enliven, Presbyterian Support Northern

Philippa Jones, Primary Nurse Liaison, Western BOP PHO and Planning and Funding BOPDHB.

KiriPeita,SeniorPortfolioManager,MāoriHealthPlanningandFunding,BOPDHB

Sarah Davey, Portfolio Manager, Health of Older People, Planning and Funding, BOPDHB

Kia Momoho Te Hāpori Ōranga – Healthy, Thriving Communities

18 July 2012