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11
Healthcare OutcomesYear One
Year Two
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”
Florence Nightingale
2
Home and Older Adult ServicesCommunity Services for Older
AdultsAssessment, Treatment and Rehabilitation (Acute Care)
2005 – Acute Care
In-Reach CNS (2)
2007 – Acute Care
Nurse Practitioner Intern
2004 – Gerontology Nurse Practitioner (GNP) &
2 Gerontology Nurse Specialists
2006 – GNP Clinical Leader
2007-9 6 GNS (2 on NP pathway)
2 Wound Care Specialists for Residential Aged Care
2008 3 Resp. CNS (1 on NP pathway)
2003 – 0 Advanced Nurses
2009 – 14 advanced nurses (4 Nurse Practitioners)
Freemason s’ Department of Geriatric Medicine, University of Auckland
3
Overview of Results 17 October 2009
College of Nursing Aotearoa (NZ)Wellington
Dr Michal Boyd, RN, NP, ND
Nurse Practitioner, Waitemata DHB
Honorary Sr Lecturer
Freemasons’ Dept. of Geriatric MedicineUniversity of Auckland
4
OPAL 10/9/8 Research Aims : � To measure variation of aged care
residents dependency levels in the Waitemata, Auckland and Counties Manukau District Health Board regions and compare with data obtained in 1988, 1993 and 1998.
Ethics:� Expedited approval gained through
the Auckland Regional Ethics Committee.
Sample:� All residents in rest home, private
hospital in the Auckland, Waitemata and Counties Manukau DHB region.
� There are 153 facilities with 6823 beds, 90% response rate
Research Team:Dr Michal BoydProfessor Martin ConnollyProfessor Ngaire KerseSusan FosterJoanna BroadNoeline WhiteheadSarah Walters-Puttick
Analysis Team:Carol ChelimoMartin von RandowRoy Lay-Yee
Funded byFunded byFreemasonsFreemasons ’’ Roskill Roskill
FoundationFoundation
5
Response Rates by Facility
� 1988 - 99%� 1993 - 85%� 1998 - 65%
2008 – 90% of facilities91% of occupied Beds
ADHBADHBADHBADHB
74 total facilities74 total facilities74 total facilities74 total facilities
62 Participated62 Participated62 Participated62 Participated
84% response84% response84% response84% response
WDHB55 55 55 55 total facilitiestotal facilitiestotal facilitiestotal facilities
50 50 50 50 ParticipatedParticipatedParticipatedParticipated
91% 91% 91% 91% responseresponseresponseresponse
CMDHBCMDHBCMDHBCMDHB
41 total facilities41 total facilities41 total facilities41 total facilities
40 Participated40 Participated40 Participated40 Participated
98% response98% response98% response98% response
153153153153Participated
90%90%90%90%
153153153153Participated
90%90%90%90%
171 Total Facilities in 171 Total Facilities in 171 Total Facilities in 171 Total Facilities in Auckland RegionAuckland RegionAuckland RegionAuckland Region
171 Total Facilities in 171 Total Facilities in 171 Total Facilities in 171 Total Facilities in Auckland RegionAuckland RegionAuckland RegionAuckland Region
10101010Declined
6%6%6%6%
10101010Declined
6%6%6%6%
8 8 8 8 Withdrew
5%5%5%5%
8 8 8 8 Withdrew
5%5%5%5%
6
Auckland Residential Aged Care Beds 1988-2008
1988* (n)
% 1993* (n)
% 1998* (n)
% 2008**
(n) %
Rest Homes 6036 71% 6575 71% 6331 73% 4706 54%
Dementia Care 519 6%
Private Hospital 1963 23% 2539 28% 2312 27% 3418 39%
Psychogeriatric 82 1%
Public Hospital 490 6% 43 1% 38 0.4% 38 0.4%
Total 8489 9189 8681 8763
71 71 7360
23 28 2740
6 1 0.4 0.4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1988 1993 1998 2008
Rest Home Pvt. Hospital Public Hospital
7
2008 Facility Characteristics
Rest HomeRest HomeRest HomeRest Home53%53%53%53%
Private Private Private Private HospitalHospitalHospitalHospital12%12%12%12%
Rest Home & Rest Home & Rest Home & Rest Home & Private Private Private Private HospitalHospitalHospitalHospital35%35%35%35%
75.9% 75.9% 75.9% 75.9%
No Retirement No Retirement No Retirement No Retirement Village AffiliationVillage AffiliationVillage AffiliationVillage Affiliation
24.1% 24.1% 24.1% 24.1% Retirement Retirement Retirement Retirement
Village Village Village Village AffiliatedAffiliatedAffiliatedAffiliated
63.7% 63.7% 63.7% 63.7% Stand Stand Stand Stand AloneAloneAloneAlone
36.3% 36.3% 36.3% 36.3% Affiliated with a Affiliated with a Affiliated with a Affiliated with a
larger larger larger larger organisationorganisationorganisationorganisation
8
Older Adult Population Changes
1986total
1988RH
1988PH
1996total
1998RH
1998PH
2006total
2008RH
2008PH
>65 yrs 90,860 4,691 2,139 110,898 5,157 2,222 129,864 3,998 3,039
>85 yrs 7,230 1,944 914 10,898 2,700 1,025 15,366 2,406 1,666
9
Occupied Beds Per 1000 Population
5145
29
23 20 21
7467
53
0
10
20
30
40
50
60
70
80
1988 1998 2008
Occupied Beds per 1000 people
>65 yrs age
Rest Home Private Hsopital Total
268251
156126
95 107
395
348
265
0
50
100
150
200
250
300
350
400
450
1988 1998 2008
Occupied Beds per 1000 People
Aged >85 yrs
Rest Home Private Hsopital Total
10
Occupancy Rates
*from returned facility cover sheet Information only
8691
87 86
94
8791 89
95 96
0
10
20
30
40
50
60
70
80
90
100
1988 1993 1998 2008
Pe
rce
nt
Occ
up
ancy
Year of Census
Rest Homes Hospitals Dementia PsychGeri
69 6958
31 3142
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1988 1998 2008
Rest Home Private Hospital
11
Mean AgeAge 1988 1998 2008
(65+) RH PH Total S1 S2 S3 PH Total RH Dem PH Psych Total
Mean 82 82 82 86 85 82 83 84 85 82 85 81 85
Median 83 83 83 87 85 82 84 85 87 83 86 82 86
12
Gender
2.01.7
1.0 0.9
1.9 1.9
1.2 1.1
0
1
2
3
1988 1993 1998 2003 2008
Pe
rce
nt in
ca
re
Year
Trends in proportions of people aged 65-74 in residential care
Women Men
12.010.6
6.45.3
7.5 7.0
4.4 4.0
0
5
10
15
1988 1993 1998 2003 2008P
erc
en
t in
ca
re
Year
Trends in proportions of people aged 75-84 in residential care
Women Men
45.1 47.3
35.629.5
25.1 27.4
20.418.0
0
10
20
30
40
50
1988 1993 1998 2003 2008
Pe
rce
nt i
n c
are
Year
Trends in proportions of people aged 85+ in residential care
Women Men
13
Length of Stay
Days of Stay (65+) 1988
RH PH Total 1998
RH PH Total 2008
RH PH Total Median in years 1.84 1.44 1.70 1.82 1.63 1.85 1.68 1.64 1.69
Days of 1988 1998 2008
Stay (65+) RH %
PH %
Total %
RH %
PH %
Total %
RH %
PH %
Total %
< 3 months 9.3 14.5 10.9 9.5 12.0 10.2 10.7 15.1 12.5
3–6 months 8.8 9.9 9.1 7.9 8.0 8.0 9.1 8.3 8.8
6–9 months 8.2 8.4 8.2 6.6 7.8 6.9 6.7 6.6 6.6
9–12 months 6.0 6.9 6.3 6.7 7.9 7.0 7.0 5.8 6.5
1–2 years 20.5 21.1 20.7 18.9 20.8 19.5 19.7 19.0 19.4
> 2 years 46.3 38.6 43.9 48.1 42.3 46.3 43.4 42.6 43.1
Missing 1.0 0.6 0.8 2.4 1.3 2.0 3.4 2.6 3.1
14
Mobility Changes
40%
34%
11%14%
26%
39%
16%19%
22%
42%
15%
21%
0%
10%
20%
30%
40%
50%
Walks without Aids Walks with Stick or
Walker
Dependent
Mobility
Bedbound
Mobility
1988 1998 2008
15
Continence
81%
13%6%
68%
19%12%
63%
15%21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Continent of Faeces Incontinent of Faeces
weekly or more
Incontinent of Faeces
daily
Ax
is T
itle
Axis Title
Faecal Incontinence
1988 1998 2008
16
Memory, Orientation & WanderingMemory
50%
25%
18%
32%30%
25%
32%29% 27%
0%
10%
20%
30%
40%
50%
60%
Memory Intact Loss of memory for
recent events
Loss of memory for both
recent and remote
1988 1998 2008
Orientation to Time
28%
7% 6%8%
19%
9%8%
13%
19%
9%6%
16%
0%
5%
10%
15%
20%
25%
30%
Orientated to
Time
Mildly Disoriented
to Time
Moderately
Disoriented to
Time
Completely
Disoriented to
Time
1988 1998 2008
Awareness of surroundings
61%
23%
9%
4%2%
45%
30%
11%
6% 7%
44%
32%
16%
8%
0%
10%
20%
30%
40%
50%
60%
70%
Fully Aware Sometimes
Unaware
Ususally Unaware Totally Unaware Unable to Assess
73%
10%
3%
14%
62%
11%
5%
21%
61%
12%7%
19%
0%
10%
20%
30%
40%
50%
60%
70%
80%
No Wandering Occasional
Wandering
Persistant Wandering Not Applicable - Not
Mobile
Wandering behaviour
17
In Summary:Resident Dependency Changes
� More Dependence:� Mobility� Toileting� Urinary and Faecal
Incontinence� Wandering, Orientation &
Awareness� Night cares� Communication� Medications
� Improvements or Relatively Unchanged:� Disturbing Behaviours� Dressing and Feeding� Vision & Hearing
18
Medications
Mean number of medications for all residents in 1993, 1998 and 2008
4.4
5
7.2
0
1
2
3
4
5
6
7
8
1993 1998 2008
7.2
7.6
7.3
7.2
6.5
6.5
5.4
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
ALL FACILITIES
REST HOME
PALLIATIVE
PRIVATE HOSPITAL
RESPITE
PSYCHOGERIATRIC
DEMENTIA CARE
Mean Number of Medications
2008 mean number of medications by facility type
19
Composite Dependency Score
Based on Three 3 Major Factors� Self Care and Mobility� Continence� Memory Loss/Confusion/Behaviour/Communication
5 Dependency Categories� Independent� Some Dependency� Moderate Dependency� Appreciable Dependency� Hospital Care
20
p>0.001
Rest Home Dependency Levels 1988-2008
84%
67% 66%
16%
33% 35%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1988 1998 2008
Low Dependency High Dependency
23%
32%
29%
13%
3%
12%
19%
35%
26%
8%7%
25%
34%
26%
8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Independent Some Dependency Moderate Depenency Appreciable Dependency Hospital Level
1988 Rest Home 1998 Rest Home 2008 Rest Home
21
Rao-Scott Chi-Square p=0.0047
20%
12%17%
80%
88%83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1988 1998 2008
Low Dependency High Dependency
Hospital Level Dependency 1988-2008
1%4%
15%
44%
37%
0% 1%
7%
47%44%
0% 1%
9%
60%
31%
1%3%
13%
48%
36%
0%
10%
20%
30%
40%
50%
60%
70%
Independent Some Dependency Moderate Depenency Appreciable Dependency Hospital Level
1988 1993 1998 2008
22
Rao-Scott Chi-Square p=<0.0001
Total Composite Dependency
16
2325
23
13
9
14
28
35
14
4
16
25
35
20
0
5
10
15
20
25
30
35
40
Independent Some Dependency Moderate Dependency Appreciable Dependency Hospital Level
1988 1998 2008
64%
48%44%
36%
52%56%
0%
10%
20%
30%
40%
50%
60%
70%
1988 1998 2008
Low Dependency High Dependency
16
2325
23
13
9
14
28
35
14
4
16
25
35
20
0
5
10
15
20
25
30
35
40
Independent Some Dependency Moderate Dependency Appreciable Dependency Hospital Level
1988 1998 2008
23
In Conclusion – the data lines up with what providers are saying:
� The overall population in aged residential care:� Is Older� Stays less time� Requires more help from staff� Is significantly more dependent than before
� As the population continues to age, the proportion of people with cognitive issues will increase
� The need for aged residential care will increase as these changes occur
� Models of care need to be updated to match the population demographic changes
24
Healthcare for Older People in Residential Care Healthcare for Older People in Residential Care ----Who Cares?Who Cares?
Leon Flicker, Med J Aus 2000; 173: 77-79
Increasing needs should be met with improved organisation of services, such as:
� Provide a multidisciplinary team approach to healthcare deliveryin residential facilities
� Establish strategic partnerships with educational institutions, expert groups and professional organisations to establish what is currently accepted as best practice in residential care
� Develop nursing professional and best practice guidelines
� Allot appropriate resources to implement best practice guidelines
25
Gerontology Nurse Specialists (GNS)
� 6 full time equivalent (FTE) GNS
� Assigned geographic region
� Includes older people living independently and in aged care settings
� Bi-monthly proactive clinical coaching sessions by GNS
� 1 FTE Wound Care Specialist � Covers all facilities in the
district
� Cheri Cook, GNS� Hyeonjoo Lee, GNS� Tanya Bish, GNS� Sharon Bradshaw, WCNS� Michal Boyd, GNP� Joan O’Brien, GNS� Janet Parker, Nurse Consultant� Carole Pilcher, GNS
� Missing from photo:� Sharon Allen, WCNS� Marg Murphy, WCNS� Hayley Moyle, WCNS
26
57 Facilities in the District
All had access to:• Care Guides• Quarterly Education Sessions• Usual GNS Assessments
2 Facilities
Declined
Participation
55 FacilitiesWound Care Specialist
Clinical Coaching
Facilities Matched
by type and size
Randomised
Data from 3 Facilities excluded:
1 closed2 under formal DHB
investigation
Intervention Group: Bi-monthly GNS Clinical
Coaching and Care Coordination
27 Facilities, 1329 Beds
Control Group – No additional GNS interventions
25 Facilities, 1147 Beds
Programme
Evaluation
27
� Baseline Data Collection – Dec 2007 to Feb. 2008� Voluntary Facility Participation� Full Resident Skin Assessments by Wound Care Spec.� 26 Facilities, 1419 residents
Wound Care Specialist Intervention Evaluation
Intervention: � Benchmarking Data Sent to Facilities� Wound Care Specialist Assessments � On-site Clinical Coaching
� Post 1 year Intervention Data Collection � Dec. 2008 to March 2009� 34 Facilities, 1593 residents
28
Wound Care Bench Mark Reports
Number with wounds as % of number of residents assessed in each facility
0
10
20
30
40
50
60
70
Fac
ility
1
Fac
ility
2
Fac
ility
3
Fac
ility
4
Fac
ility
5
Fac
ility
6
Fac
ility
7
Fac
ility
8
Fac
ility
9
Fac
ility
10
Fac
ility
11
**A
VE
RA
GE
**
Fac
ility
12
Fac
ility
13
Fac
ility
14
Fac
ility
15
Fac
ility
16
Fac
ility
17
Fac
ility
18
Fac
ility
19
Fac
ility
20
Fac
ility
21
Fac
ility
22
Fac
ility
23
Fac
ility
24
Fac
ility
25
Fac
ility
26
%
Other
Leg Ulcers
Surgical
Skin tears
Skin cancer
Pressure areas
29
Resident Wounds Pre and Post Comparison
Residents with Pressure Areas by Stage
5.7%
5.0%
1.2%0.8%
6.0%
3.0%
0.9%
0.2%
0.0%1.0%
2.0%3.0%4.0%
5.0%
6.0%
7.0%
Pressure AreaStage 1
Pressure AreaStage 2
Pressure AreaStage 3
Pressure AreaStage 4
Per
cent
of
Res
iden
ts A
sses
sed
2007/08 2008/09
Pressure
Area
Stage I
Pressure
Area
Stage 2
Pressure
Area
Stage 3
Pressure
Area
Stage 4
Leg Ulcers Skin Tears
RR 1.04 0.59 0.79 0.24 0.53 0.73
CI (0.78-1.39) (0.41-0.85) (0.39-1.57) (0.068-0.87) (0.39-0.72) (0.64-0.84)
Chi Square NS p=0.004 NS p=0.018 p=<.0001 p=<.0001
Wounds Per Resident
7%
25%
4%
18%
0%
5%
10%
15%
20%
25%
30%
Leg Ulcers Skin Tears
Per
cent
of R
esid
ents
with
W
ound
s
30
GNS Intervention Evaluation Methods� Wide consultation with aged care sector during programme
development.
� Agreement reached for a staged implementation of the programme
and random assignment to stage one or stage two.
� Programme Development August 2007 to March 2008
� Stage 1 – March 2008 to Feb 2009, half facilities offered
full GNS intervention
� Stage 2 – March 2009, All facilities in the district offered
full GNS intervention
� Prospective comparison study, randomised by facility matched by
size and type (RH, PH, Both)
� Hospital Utilisation Data retrieved from DHB databases
� Evaluation Data:
� 6 Months Pre Intervention – March-Aug 2007
� 6 Months Post Intervention – March-Aug 2008
31
Post Evaluation Period:19% Increased Admissions from Residential
Aged Care compared 2008 compared to 2007
DHB to take over running of rest home Thursday Jul 03, 2008
32
Hospital UtilisationStudy Time
Increase in admissions
per 1000/bed days
Percent Increase
Pre admissions
per/1000 bed days
Post admissions
per/1000 bed days
Total Admissions Comparison 2.23 2.92 0.70* 31%
Intervention 2.29 2.68 0.39* 17%
*RR: 0.57, CI (0.44-0.73), ChiSq <.0001, Includes: Medical, Mental Health, Surgical and Rehabilitation Admissions
Medical Admissions
Comparison 1.57 2.09 0.51** 33%
Intervention 1.66 1.92 0.25** 15%
**RR: 0.50, CI (0.36-0.68), ChiSq <.0001
Surgical Admissions
Comparison 0.43 0.51 0.09 20%
Intervention 0.41 0.46 0.05 13%
RR: 0.62, CI(0.31-1.27), ChiSq: NS
Analysis: Lifeng Zhou and Delwyn ArmstrongPoisson regression model of the rate difference (‘post’ – ‘pre’)
Intervention: 1329 beds; Control: 1147 beds
33
Length of Stay Comparison
Days
*None Reached Significance
34
Facility Feedback
� “This programme offers so much to the private facilities!”
� “It is important that the relationship between all parties is positive and mutual respect is maintained…The group meetings allow for this to happen…”
� “The relationship built with our GNS has been invaluable. Her knowledge is enormous…”
� “… the nursing staff feel there is someone on our side from the DHB who we can call on at any time to share a concern with or just ask for advice.”
� “…Feel there has been a 'closing of the gap' between WDHB and Private Hospital Care.”
35
Evidence Based Care Guides DevelopmentEvidence Based Care Guides Development
� Work Group Formed with WDHB Gerontology Nursing Service, Quality Coordinator and Residential Facility Providers
� Met monthly for a year
� Completed August 2008
� Care Guides are the basis for proactive GNS relation building and clinical coaching
