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1
HOME AND COMMUNITY SUPPORT SERVICES
PROPOSAL FOR CHANGE
CONTENTS
Introduction .............................................................................................................................................. 3
HCSS Proposal for Change Outcomes Framework: .................................................................................. 5
Background to the Proposed Changes ..................................................................................................... 6
Drivers for Change ................................................................................................................................ 6
Development of ‘Restorative’ Home Based Support Services .............................................................. 8
National Home and Community Support Service Specifications ........................................................ 10
Current HBSS Provision in the Southern District ................................................................................ 12
Introduction of Care/Case Management ............................................................................................ 15
Proposed Changes .................................................................................................................................. 18
Proposal 1: Introduce a new ‘Restorative’ approach and Enhanced Quality Standards to all Home
Based Support Services (to be called Home and Community Support Services) ............................... 19
Why is this being proposed? .......................................................................................................... 20
Impact of proposal ......................................................................................................................... 21
Proposed process for affected staff and contractors ..................................................................... 22
Proposal 2: Introduce enhanced Care/Case Management for Older People with Complex Needs ... 23
Why is this being proposed? .......................................................................................................... 24
Impact of proposal ......................................................................................................................... 26
Proposed process for affected staff and contractors ..................................................................... 27
Proposal 3: Enable the Introduction of the new HCSS service and Care/Case Management model
with a revised funding and contracting approach for Health of Older People Services ..................... 28
Why is this being proposed? .......................................................................................................... 28
Impact of proposal ......................................................................................................................... 30
Proposed process for affected staff and contractors ..................................................................... 30
Proposal 4: Develop Southern District Support Unit functions to Facilitate the New Model of Care 30
Why is this being proposed? .......................................................................................................... 31
2
Impact of proposal ......................................................................................................................... 32
Proposed process for affected staff and contractors ..................................................................... 32
Feedback and Consultation .................................................................................................................... 33
Proposed Timeframes ........................................................................................................................ 34
Support ................................................................................................................................................... 34
Appendix 1: Glossary .............................................................................................................................. 36
Appendix 2: Example Goal Ladder .......................................................................................................... 37
Appendix 3: Proposed Care Referral and Assessment Process for Health of Older People Service clients
................................................................................................................................................................ 41
Appendix 4: Development of Case Mix Funding .................................................................................... 42
Appendix 5: Feedback Survey ................................................................................................................. 45
3
INTRODUCTION
Southern DHB is committed to ensuring that high quality home based support
services are provided equitably to the Southern district community. Good
service coverage in all areas of the district is critical to ensuring that people
can continue to live safely within their own homes as they age, or develop
long term conditions.
To enhance the quality of Home Based Support Services, and ensure services
are client focused and provided in a coordinated and integrated way, the
Southern District Health Board (SDHB) is proposing to make some changes to
these services, as part of a significant quality improvement initiative.
The overarching aim of the proposed changes is to support more older
people to live safely and independently in their own homes in the community.
This will be realised by achieving the following outcomes:
Providing equitable access to quality services
Supporting people to maintain functional independence and
psychosocial wellbeing
Improving the quality, safety and experience of care
Providing coordinated and integrated care at the right time and in the
right place
Achieving best value from health system resources
The changes proposed are in line with a number of national strategic drivers,
and have been initiated following a review of the community models of care
which was undertaken across the Southern district in 2011, involving significant
community consultation.
Following the 2011 review a number of recommendations were made that
would enable the Southern DHB to develop:
“a model of care that integrates health and support services in
the community for the older person”.
In summary the changes proposed in this consultation are:
4
1. Introduce a new ‘Restorative’ approach and enhanced quality
standards to all Home Based Support Services (to be called Home and
Community Support Services)
2. Introduce enhanced Care/Case Management for Older People with
complex needs
3. Enable the introduction of the new Home and Community Support
Service and Care/Case Management model with a revised funding
and contracting approach for Health of Older People Services
4. Develop Southern district Support Unit functions to facilitate the new
model of care
The purpose of this document is to consult with the Southern district
community on whether the outcomes proposed are supported, and whether
the suggested changes are the best way to achieve them.
Southern DHB is seeking feedback to: ensure that any proposed changes
enhance service provision; help inform any subsequent implementation plans;
and minimise unintended consequences.
To help facilitate some specific feedback being sought, some questions are
included in a survey at appendix 5.
This survey can be completed online at:
www.southerndhb.govt.nz/hopplanning
Or please complete the questions in appendix 5 and mark any written
feedback confidential and return to:
Health of Older People
Planning and Funding
Private Bag 1921, Dunedin
Or by email to: [email protected]
The deadline for submissions is Wednesday 18th July, 1pm.
Genuine consideration will be given to all submissions received.
5
HCSS PROPOSAL FOR CHANGE OUTCOMES FRAMEWORK:
6
BACKGROUND TO THE PROPOSED CHANGES
DRIVERS FOR CHANGE
Southern DHB wishes to support more older people to live safely and
independently in their own homes in the community, by making some
changes that will help people to maintain functional independence and
psychosocial wellbeing; improve the quality, safety and experience of care;
provide coordinated and integrated care at the right time and in the right
place; and provide equitable access to quality services.
These outcomes are supported by the following key national and local drivers
for change:
National Strategic Drivers for Change:
The Health of Older Persons Strategy (2002) identifies key actions for DHBs to
ensure: older people (and their family, whānau and carers where
appropriate) are involved in decisions about their care and support; active
approaches to care management are developed; health and disability
services support integrated care; services promote health and wellbeing;
services focus on maintaining physical and mental function ability; and
reduce depression, social isolation and loneliness.
To meet the needs of an ageing population, and an increase in the
prevalence of long-term conditions, Workforce New Zealand, in its ‘Workforce
for the care of older people’ report (2011), recommended the following:
· More consistent focus on preventing and delaying loss of function and
restoration of function where that potential exists (“caring for” cannot
be simply “doing for”, which may be counter-productive if it leads to
loss of potential capability).
· Focus on needs assessment and care planning (focusing on how to
best meet the needs and optimise the potential of the individual rather
than simply assessing their eligibility for available services)
· Co-ordination and active management of care plans with older
people, so that the various and usually multiple components of their
care plan are well-integrated (to be better sooner and more
convenient for the consumer rather than for the provider). The role of
care co-ordinator /health navigator needs to be developed.
· Building on the expertise of the small group of health practitioners
(nurse practitioners, geriatricians, allied health professionals etc) with
7
specialist expertise in care of older people, so that they focus
increasingly on developing the capability of the wider health
workforce, informal carers and older people themselves.
The Minister of Health expectations for 2012/13 further underlines these
identified requirements for service change by asking for: greater support to
older people for safe, independent living at home; improved support for
people with long-term conditions; greater service integration, particularly with
primary care; and smarter use of the workforce.
More specifically the Office of the Auditor General undertook a review of
Home Based Support Services for older people in 2011 and made a number
of recommendations on how all DHBs should improve their approach to
managing the quality of these services, including strengthening management
contracts and using performance data to drive continuous quality
improvement.
Local Drivers for Change:
Within the Southern district support services provided to Older People were
reviewed through a period of community consultation in 2011, with the
assistance of Auckland Uniservices Ltd.
Feedback from focus groups during the Community Models of Care Review in
2011 highlighted that there are genuine concerns in the Southern community
that:
We have an ageing population, an ageing workforce and subsequent
reductions in local volunteers and natural family or community supports to
help people as they age
Some older members of our community can be isolated
There is a lack of community knowledge of what services are available
and how to access them, or who to call if there is a problem (especially
outside Monday-Friday 9-5)
Concerns that there is a lack of identification of people in the community
who are at risk, or regular monitoring of those known to be frail and ill
There is frustration with a perceived lack of responsiveness and flexibility of
services to meet client needs, particularly where there are barriers
between funding streams
It is difficult for services to work together in a more proactive way to
support people’s wellbeing
There are systemic communication barriers between different services
involved in a persons care
8
Some NGO services and community supports felt they were often
underutilised due to a lack of visibility within the system, or clear referral
pathways
Transport difficulties, rural isolation and
costs of care can create difficulties
accessing services appropriately
People who work in aged care services
are highly valued but not always well
supported
There is a real desire to change some of
the structures of service provision, and
work together more innovatively and
collaboratively, to be able to better
support valued older members of our
community
The consultation culminated in a report 1
which detailed a number of
recommendations that would enable the Southern DHB to develop “a model
of care that integrates health and support services in the community for the
older person”.
The recommendations included “focusing on building on the strengths of
primary care and existing community based service delivery, to enable
improved integration between services, reduce duplication and the risk of
disconnect between multiple services that may be involved in supporting a
person’s care”.
Southern DHB now wishes to consult on the implementation of some of those
key recommendations, including the development of ‘restorative’ home
based support services and an enhanced care management model, which
will support the key national strategic directives and local drivers for change
outlined above.
DEVELOPMENT OF ‘RESTORATIVE’ HOME BASED SUPPORT SERVICES
1 A copy of the Auckland Uniservices report can be accessed at:
http://www.southerndhb.govt.nz/hopplanning
When asked what was important
with regard to home based
support services, one member of
the community stated:
“I want to feel safe,
I want to feel clean,
I want to know someone
cares”
9
Home Based Support Services are a very important service for assisting clients
in the community who have health and disability needs. They have historically
involved the delivery of an essential list of tasks that are provided for an
individual, such as assistance with washing, dressing and housework.
Recommendations following the 2011 review of community models of care
included introducing a ‘restorative home support model’ similar to many
other DHBs across the country.
Service developments in this area have been aimed at improving the quality
of service provision and ensuring that services are provided in a more holistic
way, to support the health, wellbeing and independence of clients.
One of the key changes in approach is from the historical task based, ‘do
for’, model of care (i.e. a support worker undertakes a prescribed list of tasks
for the client), towards an approach aimed at maximising a clients
independence, by helping them to do as much for themselves as possible.
Some of these services developed across New Zealand have been called
‘restorative services’ and a local example of such a service would be
Community First, which has been successfully operating in the Dunedin area
for several years.
These services have greater funding
flexibilities to help maximise a person’s
independence, and to be able to meet
client’s individual goals.
For example in the past Home Based
Support Services were funded to provide
personal care or household management
tasks only, whereas to support a person’s
independence funding may also be
needed to help facilitate attendance at
community social activities; support carers
or promote self management of chronic
conditions and healthy lifestyles.
In this revised approach service provision is
driven by the goals of the client, and their
whānau/family/carer where appropriate. Holistic care plans are aimed at
helping the client to achieve their goals and help maintain good health.
Examples of client goal’s could be to attend a family wedding; to be able to
“One of the key
changes in
approach is from
the historical task
based, ‘do for’,
model of care,
towards an
approach aimed
at maximising a
clients
independence”
10
walk to the post box; or to be able to sleep through the night without waking
up due to poorly controlled pain.
Goal based care plans are achieved through developing goal ladders, with
specific objectives to be achieved each week. Please refer to appendix 2 for
an example client goal ladder.
Service developments also include quality improvement initiatives such as:
Nationally recognised Support Worker training standards
Supervision of, and greater support for, Support Workers by registered
health professionals
Implementation of national quality sector standards
More regular reassessments of client needs, and reviews of packages
of care, to ensure services adapt to meet changing needs in a more
proactive way
Individual client and carer goal based care plans, with specific goal
ladders to help ensure goals are achieved
Coordinated input from the multidisciplinary team for those clients who
have the potential to improve their functional abilities.
These service developments have led to improved working conditions for
Support Workers through provision of better training, supervision, peer support
and career progression opportunities. Coupled with changes in funding
approaches, service developments have also enabled introduction of more
regular working hours, and improved working conditions.
NATIONAL HOME AND COMMUNITY SUPPORT SERVICE SPECIFICATIONS
Revised national Home and Community Support Service (HCSS) specifications
(which will be mandatory when finalised) are currently being developed by
the Ministry of Health to support these service changes and are being
designed to cover:
Health of Older People Service Users
Clients with Chronic Conditions
Clients with Personal Health Conditions with short term home support
needs (this includes services provided on discharge from hospital).
People with Mental Health or addiction needs should have their specific
mental health and addiction needs met through mental health services, but
11
will not be excluded from having their age related, short-term personal health
or chronic health conditions needs funded through this specification.
Please note the change in name from Home Based Support Service (HBSS) to
Home and Community Support Service (HCSS), which reflects the wider scope
of the service.
The revised specifications are in draft at present and were due for public
consultation in May 2012, but have been delayed until the end of June 2012.
The specifications have already been subject to consultation by DHBs and
sector stakeholders, and were developed in conjunction with DHB, MOH and
home based support providers input through a working group.
The draft MOH national service specifications outline a range of new
requirements for revised Home and Community Support Services (HCSS).
These can also be supplemented with additional requirements to meet the
needs of the Southern population, such as:
The provider will have a philosophy and care delivery system that
promotes and maintains Service Users’ independence; is Service User
centred and goal orientated; seeks to build on the individuals strengths
to support their ability to remain living in their home, including support
to participate in family, whānau and community activities.
Providers will conform to the Home and Community Support Sector
Standard NZS 8158:2012 (this has just been revised from the 2003
version)
Providers have an appropriate mix of staff including as a minimum a
registered nurse and registered health professional coordinators, who
can provide direction and supervision to Support Workers
Support workers will be trained to a minimum of the National
Certificate in Community Support Services (Foundation Skills Level 2)
and material equivalent to that required for unit standard 23925
(Independence).
The service will be available 24 hours a day, 7 days a week as
appropriate to meet assessed Service User needs
Services will be provided to the Service user within a maximum of 24 or
48 hours of receipt of a referral (depending on urgency)
The draft national service specifications support the intent to increase the
quality of service provision in HCSS, and the philosophical shift to provide
services in a way that maximizes independence and supports achievement
of client goals.
12
Developing a single national mandatory service specification, which includes
these changes in service approach, underlines the shift in focus to improve
the quality of services which is occurring across New Zealand.
The national service specifications also include the overarching aim to
improve health outcomes and reduce health inequalities for Māori. It is
expected that the proposed changes in service approach, to support more
holistic service provision which is based on the goals of clients and their
whānau, will assist the Southern DHB to meet the objectives of the Māori
Health Plan.
As the national service specifications cover not just health of older people
clients, but also clients with chronic conditions and personal health needs as
well, it emphasizes that essentially the same quality service needs to be
provided to everyone, regardless of age or funding stream.
CURRENT HBSS PROVISION IN THE SOUTHERN DISTRICT
Health of Older People Service Users:
Home Based Support Services are currently provided to support Older People
(and those deemed close in age and interest aged 50+) through contracts
with a number of NGO organisations, who each cover differing areas of the
district. Access to these services for the whole district is determined following
an InterRAI clinical needs assessment undertaken by a Clinical Needs Assessor
(CAN) who works within the Care Coordination Centre (previously known as
NASC and CSCC).
Clients with Chronic Conditions:
Long Term Support – Chronic Health Condition services (previously called
Interim Funding), are also provided by NGO organisations that individually
cover either the Otago or Southland area.
This service was devolved to DHBs from the MOH in 2011. Since its
establishment access criteria for this funding stream was set very high, which is
reflected in the small numbers of clients with very complex needs who
currently receive services under this umbrella. Access to this service is
determined following a needs assessment undertaken by Accessability, an
NGO Needs Assessment and Service Coordination service.
Clients with Personal Health Conditions with short term home support needs
(this includes services provided on discharge from hospital):
13
Short term Personal Health services could be needed by clients for the
following reasons:
Support required due to short term incapacity following an illness or
hospitalisation (e.g. six week post hospital discharge service)
Support for needs arising from chronic conditions or conditions in the
palliative stage
Access to these services varies across the district, most commonly through
referrals from hospital inpatient services, Community Services such as District
Nursing and Allied Health, General Practice, other health providers and Social
Workers.
Personal Health HBSS are also provided to some clients with long term chronic
illnesses in an inconsistent way across the district, either to those clients who
have not met the high criteria for specific LTS-CHC (previously called Interim
Funding) or are too young to qualify for Health of Older People Services.
Differences in service provision to these clients across the district have
depended on local referral processes and local interpretations of funding
criteria.
Personal Health Home Based Support Services are provided through a mixture
of contracting arrangements across the district, as several services which
were previously provided by hospitals have been contracted out to private
organisations over time. Current contract holders now include NGO HBSS
organisations, Rural Hospitals, Non-Hospital Rural Trusts and Southern DHB
Provider Arm Community Services, Dunedin.
There are some differences in how these services operate across the district,
depending on how they have individually developed overtime. For example,
in some areas provision is limited depending on the availability of small teams
of staff and are only provided between Monday – Friday 9am – 5pm, a
difference which is of importance to those clients who need assistance with
washing and dressing on a daily basis.
In total seventeen separate organisations currently provide some form of
Home Based Support Service within the Southern district. Each type of service
has different pricing structures and contracting arrangements, and are
accessed following different assessment and referral processes. A table
showing all the current providers is shown below:
14
Provider Age Related Service LTS-CHC
Service
Personal Health
Service
Dunedin Home Support Dunedin Otago
Healthcare NZ Dunedin, Waitaki,
Central Otago,
Clutha, Queenstown
Lakes, Southland,
Gore
Otago Gore, Dunstan,
Clutha,
Palmerston
Mosgiel Abilities Resource
Centre
Dunedin, Waitaki Otago
Presbyterian Support Otago Dunedin(Community
First, Enliven &
Individualised
Funding),
Clutha
Otago Dunstan,
Clutha,
Access Homehealth Central Otago,
Queenstown Lakes,
Southland, Gore
Southland Gore, Dunstan,
Clutha
Disabilities Resource Centre Southland, Gore Southland Gore, Dunstan
Good Partners Senior Care Individual Contract
Timeout Carers Individual Contract Southland
CCS Disability Action Individual
Contract
SDHB Community Services,
Dunedin
Dunedin City
Maniototo Hospital Ranfurly
Waitaki Hospital Oamaru
Roxburgh District Medical
Services
Roxburgh
Milton Community Health
Trust
Milton
Tuapeka Community Health
Ltd
Lawrence
Waiau Health Trust Ltd Tuatapere
West Otago Health ltd Tapanui
15
INTRODUCTION OF CARE/CASE MANAGEMENT
Recommendations following the 2011 Review of community models of care 2
included the introduction of active care management and navigation for all
older clients with complex needs. This is because “the need for navigation
and care management increases as disease complexity increases, as there is
an associated need for consumers to access different services”.
Older People with multiple long term conditions and complex health needs
are high users of health and disability care services. “Advancing age is
associated with declines in physiological reserve and physical functioning
and a higher risk of disability and dependency. Consequently, 85+ year olds
utilize three times the health care resources of other age groups…Over 50% of
people over the Age of 75 years have three or more long term conditions,
and they are also the leading cause of unequal health outcomes amongst
social groups. In New Zealand it has also been demonstrated that long term
conditions contribute the major share of inequalities in life expectancy for
Maori, people with low incomes and Pacific peoples” (Auckland Uniservices
Report 2011).
Older people with complex care needs will frequently require health care
services from multiple providers, within different care settings. With complex
patterns of service use the health care system can appear confusing and
disjointed, especially to those who are frail or without high levels of health
literacy. Increased support to these clients with high levels of need and risk of
health deterioration would help them navigate the system and enhance
seamless, integrated care between multiple providers of health care services.
Care Managers have more regular contact with clients, and their
whānau/family/carers where appropriate, to review care plans and make
sure they are continually adapted to meet changing needs and ensure
proactive and responsive service provision.
Care Management can help improve the quality of care by:
Coordinating packages of care with primary care to meet the needs
and goals of the client and their whānau/family/carer
2 A copy of the report can be accessed at: http://www.southerndhb.govt.nz/hopplanning
16
Promoting interdisciplinary collaborative care and reducing
fragmentation between services
A nominated Care Manager for each client provides a key point of
contact for the client and multiple service providers
A nominated Care Manager supports ongoing continuity of care and
navigation through the system as service needs change
The Care Manager works within a defined geographical boundary so
has a good understanding of all the local community support services
available (e.g. community social groups, NGOs), not just access to
formal funded services (e.g. respite care, HBSS, Day Activity
programmes), and can develop excellent working relationships with
local primary care and health care practitioners (e.g. Community
Pharmacists, District Nurses, Maori Mobile Nursing Service, Community
Allied Health).
Local service providers and health care professionals all know the local
Care Manager, and have good working relationships, communication
channels and regular liaison to support the client
The Care Manager works with clients to empower them to maximize
their own self care capabilities, and supports primary care in health
promotion and education
Nominated Care Managers should have an “integral working relationship with
the older person’s General Practitioner and will be able to provide an
immediate and flexible response when required”.
The report by Auckland Uniservices recommended that: “older people with
complex needs will have an identified care manager who has an excellent
relationship with their general practice and will work to ensure that all of the
care they receive will be connected. They will work within a local inter-
disciplinary team including home based support services, District Nursing,
Maori mobile nursing services, allied health, pharmacists and non-government
organisations”.
“General Practitioners and Practice Nurses, NGOs, Maori Provider
organisations and pharmacists will know who their local care manager is and
they will be able to call them directly regarding any patient issues”.
Care Management/Case Management roles have developed in a number
of health and social care settings, across different countries in the past 10-15
years. There is no single definition of what they are, and often the title of care
and case manager can be used interchangeably. Functions can vary
between ‘navigator’ roles undertaken by non-health professional ‘lay’
17
members of the community, to specific time limited interventions undertaken
by specialist health professionals.
A recent report published by the Kings Fund in November 20113 entitled
“Case Management, what it is and how it can best be implemented”
provides a useful overview of the core components of these types of role, the
benefits they can bring when implemented effectively and key factors for
success.
Definitions of case management referenced in the Kings Fund report include:
“the process of planning, coordinating, and reviewing the care of an
individual”
“a collaborative process of assessment, planning, facilitation, care
coordination, evaluation and advocacy for options and services to
meet an individual’s and family’s comprehensive health needs through
communication and available resources to promote quality cost-
effective outcomes” (p2).
Some key points raised in the Kings Fund report include:
Case management is an established tool in integrating services around
the needs of individuals with long-term conditions
It is a targeted, community-based and proactive approach to care
that involves case-finding, assessment, care planning and care co-
ordination
Where it is implemented effectively it has improved the experience of
users and carers, supporting better care outcomes, reducing utilization
of hospital-based services and enabling a more cost effective
approach to care
Case management works best as part of a wider programme of care
in which multiple strategies are employed to integrate care. These
include good access to primary care services, supporting health
promotion and primary prevention, and coordinating community-
based packages for rehabilitation and reablement.
The Auckland Uniservices report 2011 recommended that Care Management
should be introduced for older clients with complex needs by augmenting the
role of Clinical Needs Assessors working within the Care Coordination Centre
(previously called NASC and CSCC).
3 The Kings Fund report can be accessed at:
http://www.kingsfund.org.uk/publications/case_management.html
18
Complex clients are defined by Auckland Uniservices as those who require a
MDS-HC InterRAI assessment as they have any of the following:
1. Cognitive Impairment
2. Progressive Neurological condition
3. Brittle Social Support System
4. Require assistance with dressing
5. Require assistance with medication management
Since the Auckland UniServices report was produced in 2011 there have been
developments in primary care locally to roll out the Year on Year project. This
project has similar aims to increase the care/case management support
provided to older people with complex needs.
There are also imminent changes due with the national Pharmacy Services
Agreement which takes effect July 1 2012, to enable Community Pharmacists
to participate in the multidisciplinary team to assist with the management of
medication for patients with Long term Conditions (LTC). Support could
include help with medication education, reconciliation, synchronisation, and
development of a medication management plan.
Eligibility for the Pharmacy LTC service is that the patient has one or more
chronic conditions, and difficulty adhering to their medication regime, either
because of the complexity of that regime or because of their personal or long
term condition’s characteristics. Entry to the service will be by referral to and
assessment by a pharmacist. An InterRAI assessment which indicates difficulty
in managing medication also qualifies a patient for access to the LTC service.
Any developments in local care/case manager roles needs to be done in
conjunction with General Practice, Community Pharmacists, Specialist
Services and the wide range of community health professionals, NGOs and
support services that form the interdisciplinary team.
As there is no single definition for care or case managers, this paper shall use
both titles until the role has been further defined.
PROPOSED CHANGES
The proposed changes outlined below are designed to help support more
older people to live safely and independently in the community. This will be
achieved through the following:
19
Providing equitable access to quality services
Supporting people to maintain functional independence and
psychosocial wellbeing
Improving the quality, safety and experience of care
Providing coordinated and integrated care at the right time and in the
right place
Achieving best value from health system resources
To achieve these outcomes Southern DHB wishes to implement the following
changes:
1. Introduce a new ‘Restorative’ approach and enhanced quality
standards to all home based support services (to be called Home and
Community Support Services).
2. Introduce enhanced Care/Case Management for Older People with
complex needs
3. Enable the introduction of the new Home and Community Support
Service and Care/Case Management model with a revised funding
and contracting approach for Health of Older People Services
4. Develop Southern District Health Board Support Unit functions to
facilitate the new model of care
PROPOSAL 1: INTRODUCE A NEW ‘RESTORATIVE’ APPROACH AND ENHANCED QUALITY
STANDARDS TO ALL HOME BASED SUPPORT SERVICES (TO BE CALLED HOME AND
COMMUNITY SUPPORT SE RVICES)
Southern DHB proposes to introduce a new ‘restorative’ service delivery
approach that is client centred and goal driven, and is delivered in a way
which maximises client health, wellbeing and independence. To achieve this
service contracts will include the new national Home and Community
Support Service specification when finalised.
Services will be delivered in a more holistic way that supports people to
maintain functional independence and psychosocial wellbeing, as opposed
to the traditional ‘task based’ service delivery. Services will be delivered to
support achievement of client goals.
20
It is proposed that the quality of services will be improved through introducing
compliance with the revised sector standards NZS 8158:2012, and include
requirements such as minimum standards of training and supervision for
Support Workers.
It is proposed that the equity of service provision across the Southern district
will be increased by contracting with service providers who can provide
services to all eligible clients, living across the whole of the Southern district:
Health of Older People Service Users
Clients with Chronic Conditions
Clients with Personal Health Conditions with short term home support
needs.
People with Mental Health or addiction needs should have their specific
mental health and addiction needs met through mental health services, but
would not be excluded from having their age related, short-term personal
health or chronic health conditions needs funded through these services
using the revised national specification.
As these proposals will involve a significant change in service provision an RFP
process will have to be undertaken to identify suitable providers who can
provide the revised service to all eligible clients.
WHY IS THIS BEING PROPOSED?
Quality Home and Community Support Services should be provided equitably
to all eligible clients regardless of funding stream, age of client or place of
residence within the district. Service provision should also be funded equitably
within a single contracting approach and pricing structure. Services should be
client focused and support maximisation of client independence.
Having contracted providers who can deliver services to all eligible service
users, under a single service specification, would improve consistency in
service provision across the district and between different client groups. It will
also simplify current referral processes.
Southern DHB wishes to strengthen relationships with the providers of these
services by working in partnership to support quality improvement, innovation
in service development and sustainability of service delivery, to achieve the
best possible outcomes for the population of the Southern district. To do this a
competitive tendering process is the fairest way to ensure Southern DHB
contracts with providers who have the organisational vision, values, capacity
21
and capabilities that are required to deliver this important service, and meet
requirements in the revised service specifications.
It is anticipated that a competitive tendering process for service contracts
covering all eligible clients living in the Southern district could reduce the total
number of providers in the district, compared to the current structure.
Fewer providers will provide increased scope for the organisational capacity
required to meet the additional quality requirements in the revised national
service specifications. This will include compliance with the Home and
Community Support Standard NZS 8158:2012, and increased requirements for
supervision and training. These changes will support quality of service
provision.
In addition, having contracts that cover all client groups would help provide
the economies of scale required for organisations to be able to employ
sufficient staff in each area for a responsive seven day service. This is
particularly important to ensure adequate coverage of services in rural areas
where there is a limited pool of staff.
Timely service provision and equitable access to quality services in rural
communities will be key aspects of the proposed RFP evaluation criteria.
Providers will need to have locally based clinical coordinators and support
workers, which will also support the development of stakeholder relationships
and shared care planning processes, which will in turn support the continuum
of care across primary and secondary care boundaries.
IMPACT OF PROPOSAL
All current contracts with organisations providing Home Based Support
Services would be exited. This includes:
Presbyterian Support Otago (including Community First, Enliven and
Individualised Funding services)
Dunedin Home Support
Healthcare NZ
Mosgiel Abilities Resource Centre
Access Homehealth
22
Disabilities Resource Centre
Good Partners Senior Care
Timeout Carers
CCS Disability Action
Funding for Southern DHB Community Services Short Term Personal
Health service (Dunedin) would be discontinued. (SDHB Provider arm
would give contractual notice of exit for Personal Health services
provided in Palmerston)
Maniototo Hospital
Waitaki Health Services
Roxburgh District Medical Services
Milton Community Health Trust
Tuapeka Community Health Ltd
Waiau Health Trust Ltd
West Otago Health ltd
New contracts would be established with successful providers following the
proposed RFP process, for the provision of Home and Community Support
Services to all eligible clients living across the Southern district.
PROPOSED PROCESS FOR AFFECTED STAFF AND CONTRACTORS
Each organisation which holds a contract for home based support services
that were to be unsuccessful in the proposed RFP process would be expected
to manage the change process for any of their employees who would be
affected.
Those employees of current providers who provide any cleaning services
would have a right to transfer to a new provider under Subpart 1 of Part 6A of
the Employment Relations Act.
Clause 19 of Schedule B of the Employment Relations Act also applies to
affected employees of the Southern DHB Provider Arm, entitling all affected
23
DHB employees to be employed by a new provider on the same terms and
conditions as apply to them currently.
Terms and conditions include pay, hours of work, leave entitlements.
If Southern DHB employees choose not be employed by a new provider, the
Southern DHB Provider Arm would work through the other staff surplus options
available to them, depending on the specific entitlements in their
employment agreement.
The proposed RFP process would make it clear that successful providers have
obligations to accept the transfer of affected employees, and to assist with
the smooth transfer of service.
The proposed RFP will also require current service providers to furnish
appropriate information to allow the assessment of staff transfer impacts.
PROPOSAL 2: INTRODUCE ENHANCED CARE/CASE MANAGEMENT FOR OLDER PEOPLE
WITH COMPLEX NEEDS
It is proposed that an enhanced care/case management approach will be
developed for older people with ‘complex’ care needs to help achieve more
coordinated and integrated care, provided at the right time and in the right
place.
A holistic care plan, actively managed in conjunction with primary care, will
improve client’s experience of care, and better support people to maintain
functional independence and psychosocial wellbeing.
Older People will be identified as having ‘complex’ or ‘non-complex’ needs
during the care referral and screening process.
Complex clients will be deemed as those who have any of the following:
1. Cognitive Impairment
2. Progressive Neurological condition
3. Brittle Social Support System
4. Require assistance with dressing
5. Require assistance with medication management
Southern DHB propose that following the proposed RFP process successful
HCSS providers will be asked to undertake InterRAI contact assessments and
provide Care Management for Older People with ‘Non Complex’ needs.
24
This will allow Clinical Needs Assessors (who work as part of the Care
Coordination Centre) the scope to be able to work with primary care to
develop an enhanced Care/Case Management role for Older People with
‘Complex’ needs. The InterRAI MDS-HC Assessment Tool will be used to assess
the needs of all clients with Complex needs.
It is proposed that an enhanced care/case management role for older
clients with complex needs would be developed over a period of time, with
involvement and leadership from both Primary Care and Specialist services.
Care/Case Managers will be expected to develop excellent working
relationships with specific General Practices, and services providers (e.g.
pharmacists, District Nurses, NGOs, Community Activity providers) within
defined geographical areas.
Please refer to appendix 3 for a description of the proposed care referral and
assessment process for Health of Older People service clients.
This proposal does not include Short Term Personal Health Clients or clients
with long term conditions, although this is a potential area for development
which could be considered in the future. Assessments for these clients will
continue to be done by existing stakeholders.
WHY IS THIS BEING PROPOSED?
With introduction of the revised Home and Community Support Sector
Standards 8158:2012 (which will be mandatory with the new national service
specifications) HCSS providers will all be required to develop an individual
service plan that describes client’s goals, support needs, and requirements
based on an individual assessment they have undertaken, and through the
identification and management of any risks.
By asking Clinical Coordinators working in HCSS providers to use the InterRAI
Contact Assessment tool, it would eliminate duplication of assessment
processes in the system instead of non complex clients having to be assessed
by both Clinical Needs Assessors working as part of the CCC, and then again
by Clinical Coordinators in the HCSS provider.
This would also decrease ‘handoffs’ and minimise the involvement of different
practitioners with client care. This would be a more efficient process and
reduce potential client confusion with less people to deal with.
InterRAI Contact assessments could be undertaken face to face with clients
as HCSS Clinical Coordinators would be based locally to where clients live,
and would be visiting them regularly in their home as part of the support and
25
supervision provided to Support Workers. This is preferable to telephone based
assessments, which have been a necessary part of the Care Coordination
Centre service. Locally based HCSS Clinical Coordinators would be able to
develop the local service knowledge and connections required for good
care management for non-complex clients.
After having completed the InterRAI contact assessment the Clinical
Coordinators can develop and oversee implementation of a goals based
care plan, through the direct supervision of support workers and regular client
reviews, and through appropriate liaison with other services including primary
care.
With introduction of a bulk funding model and case mix approach discussed
in proposal 3, HCSS Clinical Coordinators would have the funding flexibility to
involve other service providers as appropriate, to help achieve the goals
identified in the care plan.
With responsibility for assessment and care/case management of non
complex clients passed to the HCSS providers, Clinical Needs Assessors
working as part of the Care Coordination Centre will then have the scope to
be able to develop enhanced Care/Case Management roles for Older
People with complex needs, who require a more responsive service than is
currently possible, and more intensive support.
Clients with complex needs are likely to be high users of many different
services such as specialist hospital services, primary care, pharmacy, allied
health and non-governmental support services. Relationships, connections
and good channels of communication between the proposed Care/Case
Management roles and the interdisciplinary team will be crucial for success. It
is therefore proposed that each Care/Case Manager will be assigned a
specific group of General Practices to work with, and other services within a
defined geographical area, which will support these relationships to develop.
This process will support the potential future development of ‘Care Clusters’ 4
to evolve.
It is proposed that the concept of the enhanced Care/Case Management
roles should be developed through a steering group which will include
representatives from:
4 Please refer to the Auckland Uniservices Report which can be accessed at:
http://www.southerndhb.govt.nz/hopplanning
26
The Care Coordination Centre
HCSS providers
Primary Care
Specialist Services
Community Pharmacists
Community Stakeholders
The steering group will be asked to lead the process of agreeing a clear
definition of the care/case management role; to define appropriate key skills
and competencies required; develop training programmes, mentorship and
peer review/support processes; and to lead and facilitate the development
of relationships and connections with primary care and community support
services.
It is proposed that this steering group includes representation from the Year on
Year project being managed by Southern PHO, to ensure developments are
done in tandem and developed cohesively.
It should be noted that through this proposal for change we are consulting on
the concept of developing an enhanced care/case manager role for older
clients, and the proposal to establish the steering group to ascertain the
detail of what that role may involve.
Once the Care/Case Manager role has been defined and scoped, further
consultation will occur with affected parties.
IMPACT OF PROPOSAL
The Care Coordination Centre will continue receiving referrals for all
Health of Older People Services, which would then be triaged as either
non complex and allocated to HCSS Clinical Coordinators, or complex
and allocated to Clinical Needs Assessors as happens currently, while
the proposed care/case management function is further defined and
scoped. Please refer to appendix 3. The Care Coordination Centre will
continue to provide a seven day service to enable responsive service
provision.
Clinical Coordinators, who will be registered health professionals based
in HCSS providers, will be expected to undertake InterRAI Contact
Assessments and provide Care Management for clients with non-
complex needs.
27
Clinical Needs Assessors, working as part of the Care Coordination
Centre, will be expected to continue undertaking InterRAI MDS-HC
Assessments for older clients with complex needs.
The concept of an enhanced Care/Case Management role will be
developed through a steering group involving Clinical Needs Assessors,
Clinical Coordinators, primary care and specialist service clinical
leaders, professional leaders and key stakeholders from community
services.
Once the Care/Case Manager role has been defined and scoped
further consultation will be undertaken.
A support unit function will be developed to provide appropriate
InterRAI assessment training, Goals Based Care Plan training, facilitate
peer review processes and quality assurance monitoring mechanisms
(see proposal 4).
Assessments of Personal Health and LTS-CHC clients will continue to be
done by existing staff groups, but consistency of assessment tools used
will be supported by proposal 4.
PROPOSED PROCESS FOR AFFECTED STAFF AND CONTRACTORS
The proposed RFP evaluation criteria will ensure Clinical Coordinators in
HCSS providers are capable of undertaking InterRAI Contact
assessments and Care Management for older clients with non complex
needs
InterRAI assessment training will be provided for Clinical Coordinators
based in HCSS providers
Goals based care plan training will be provided for Clinical
Coordinators based in HCSS providers and Clinical Needs Assessors
working as part of the Care Coordination Centre.
While the Care/Case Management function is being defined and
scoped, current Clinical Needs Assessors will be asked to work with
specific general practices/services provided within a defined
geographical area to develop enhanced relationships and knowledge
of available support services.
The concept of an enhanced Care/Case management role will be
developed through a steering group which will include representatives
from the Care Coordination Centre, HCSS providers, Primary Care and
Specialist Services. The Steering Group will define the Care/Case
management role; key skills/competencies; and develop proposals for
training, mentorship and peer support functions. Any changes required
in order to implement the identified Care/Case Management function
will involve further consultation.
28
Demand/capacity planning for any additional work created by
enhanced Care/Case Management duties will be undertaken with the
CCC and funding amended accordingly.
The seven day referral triage service by the Care Coordination Centre
will continue, and a process will be developed to access the
assessment function seven days per week.
PROPOSAL 3: ENABLE THE INTRODUCTION OF THE NEW HCSS SERVICE AND CARE/CASE
MANAGEMENT MODEL WITH A REVISED FUNDING AND CONTRACTING APPROACH FOR
HEALTH OF OLDER PEOPLE SERVICES
Southern DHB proposes to:
a) Develop an alliance contract with successful HCSS providers
b) Introduce a case mix funding model to Home and Community Support
Services for Health of Older People Clients
c) Introduce bulk funding for Health of Older People clients that provides
appropriate incentives to HCSS providers to help maximise client
independence and improve quality.
These changes will help support effective partnerships between contracted
providers and Southern DHB; and fair and consistent funding structures which
support the flexible, innovative and efficient use of resources to meet the
needs and goals of clients.
These changes will ensure equitable access to quality services, improve the
experience of care for clients and ensure best value is achieved from health
system resources.
WHY IS THIS BEING PROPOSED?
Contractual relationships in an alliance are based on agreement of shared
goals, risks and desired outcomes. Alliance relationships are based on mutual
respect, trust, increased dialogue and team work.
Development of an Alliance partnership between successful HCSS providers
and Southern DHB will form the basis for improved service provision through
the joint development of innovative practice and quality improvements.
29
An alliance contract developed with providers will support improved quality
assurance, with streamlined and more meaningful monitoring and auditing
processes based on client outcomes.
To achieve this approach Southern DHB will give preference in the proposed
RFP process to organisations that can provide complete district wide service
coverage, without having to rely on subcontracting arrangements, unless it
will demonstrably support enhanced client care, for example a partnership
with Māori Health providers.
Service developments will be supported through the introduction of Case mix
and bulk funding for Health of Older People service clients. This approach is
currently being introduced into Home and Community Support Services in
several districts across New Zealand.
Home and Community Support Services for LTS-CHC and Personal Health
clients will continue to be funded using the existing fee for service model,
although this could be an area for potential future development.
Casemix categories for Health of Older People service clients have been
developed to group together clients who have similar needs and identify
what resources they require. Better understanding and agreement between
professionals of what services different clients require can lead to better
planning, budgeting, reporting and equity of service provision. Please refer to
appendix 4 for more information.
The case mix model Southern DHB intends to introduce includes 39 categories
of need; which includes six non complex levels and thirty three complex
levels. The category which a client’s needs most appropriately fit into is
identified from an InterRAI assessment (contact or MDS-HC).
The high number of case mix categories reflects the potential of Health of
Older People clients to have varying levels of disability needs, plus brittle
social supports, cognitive impairments, social isolation and potential for
rehabilitation.
Introducing case mix will enable greater understanding of the appropriate
level of support that should be offered to clients, based on an assessment of
their needs, and ensure equitable service provision. It will also provide an
improved basis for quality assurance in service provision and benchmarking
between service providers.
30
Equitable service provision for all client groups also needs to be supported by
a fair and consistent funding model that supports innovation and quality
improvement. By developing a bulk funding model with HCSS providers for
health of older people clients, it is proposed that innovative service
developments, and the flexible and efficient use of resources to meet the
needs of the Southern population, will be supported.
The funding model will be developed through the alliance partnership to
support quality improvement initiatives such as goals based care plans, staff
training, clinical supervision, peer review, staff development and improved
staff working conditions.
IMPACT OF PROPOSAL
Developing an alliance contract with HCSS providers and introducing
Bulk Funding for Health of Older People clients will support quality
improvement initiatives, which will help improve service outcomes for
the people of the Southern district.
Introducing a Case Mix approach to funding for older clients will
support quality assurance mechanisms and equity of service provision.
PROPOSED PROCESS FOR AFFECTED STAFF AND CONTRACTORS
A service transition period will be determined with successful HCSS
providers following the proposed RFP to ensure staff and clients are
supported through the change process. Training for Clinical
Coordinators to undertake InterRAI assessments will be provided, and
Clinical Coordinators and Clinical Needs Assessors will undertake Goals
Based Care Plan training together. The steering group will be
established to support the development of enhanced Care/Case
Management roles.
During this transition period Southern DHB will work with successful HCSS
providers to develop the alliance contract. This will involve agreeing
shared values, goals and risks. Once the alliance contract is
established the alliance partnership will develop the bulk funding
model, and quality assurance mechanisms for Health of Older People
clients.
Equitable funding will be agreed for LTS-CHC and Personal Health
clients based on traditional funding and contracting mechanisms.
PROPOSAL 4: DEVELOP SOUTHERN DISTRICT SUPPORT UNIT FUNCTIONS TO FACILITATE
THE NEW MODEL OF CARE
31
Southern DHB proposes to:
a) Develop a single referral form that can be used across the district
where required for Home and Community Support Services for all
clients
b) Standardize eligibility criteria and assessment tools for Home and
Community Support Services that can be used across the district to
ensure equity of access for clients with Personal Health needs (eligibility
criteria for LTS-CHC is already standardised nationally and InterRAI is
already the agreed assessment tool for Health of Older People clients
and case mix will ensure equity of access for this group).
c) Ensure there continues to be a centralized resource for InterRAI training
(InterRAI Lead Practitioners) to support clinicians equitably who are
based in the Care Coordination Centre, HCSS providers and residential
care services. This will ensure consistent application of InterRAI
assessment tools across the district.
d) Provide ongoing goal based care plan training and facilitation of peer
review processes for HCSS Clinical Coordinators and Care
Coordination Centre Clinical Needs Assessors.
e) Develop quality assurance and monitoring functions which includes
InterRAI data analysis, participation in national bench marking of
service provision, complaint management and audit processes.
These proposals will help ensure equitable access to quality services is
provided across the Southern district.
WHY IS THIS BEING PROPOSED?
It is not clear that access to Home based support services (particularly
personal health services for palliative clients and those with long term
conditions) is being provided equitably across the district due to local
variations in service provision.
All HCSS Services should be accessed through a simple referral process and
consistently applied, evidence based eligibility criteria, to ensure
transparency of service provision and equity of access. This would help all
health professionals to know what services are available and how to access
them, so that clients can be referred and supported in a timely fashion,
regardless of age, funding stream or place of residence.
32
To ensure consistent application of InterRAI assessment tools for Health of
Older People service clients, ongoing training will be required for all clinical
assessors based in multiple providers. Current InterRAI Lead Practitioners
already provide training to Clinical Needs Assessors working as part of the
Care Coordination Centre, it would be appropriate to expand their coverage
over time to include new providers using InterRAI assessment tools, so that
everyone in the district accesses the same training, provided in the same
way.
To support the development of Care/Case Management and goals based
care planning for Health of Older People service clients, appropriate training
and ongoing peer review between Clinical Needs Assessors of clients with
complex needs, and Clinical Coordinators of clients with non complex needs
would be beneficial. This should be supported within the alliance framework.
Following recommendations by the Office of the Auditor General to improve
quality management in HCSS, the MOH is developing a quality framework
which will likely involve increased monitoring, reporting and benchmarking of
services, which the Southern district will participate in.
Southern DHB also has responsibilities for undertaking quality assurance and
promoting quality improvement, it is proposed that this is developed through
the alliance framework with HCSS providers.
IMPACT OF PROPOSAL
The Southern DHB InterRAI Lead Practitioners will be asked to provide
InterRAI Contact Assessment training to new Clinical Coordinators
based in HCSS providers. Additional workload generated by this
request will need to be monitored, funded and managed accordingly.
The Southern DHB InterRAI Systems Clinician will be asked to support
development of monitoring reports using InterRAI data from all
providers (Care Coordination Centre, HCSS providers, residential care),
to ensure equity of access to services based on assessed need.
Development of these reports will depend on the outcome of the MOH
work to develop a quality framework for HCSS. Any additional
workload generated by this request will need to be monitored, funded
and managed accordingly.
PROPOSED PROCESS FOR AFFECTED STAFF AND CONTRACTORS
33
Southern DHB will work with stakeholders to map current assessment
and referral processes across the district for all Home Based Support
Services. A standardised referral form, assessment tool and referral
processes will be agreed with stakeholders for all personal health
clients across the district (InterRAI has already been agreed as the
standardised assessment tool for older clients and the CCC provides a
standardised referral process for older clients).
Planning and Funding will work with the CCC to ensure access to
InterRAI training is available equitably to all providers undertaking
InterRAI assessments.
Planning and Funding will work with HCSS providers and CCC Clinical
Needs Assessors to ensure goal based care plan training is available.
Any additional workload generated by these proposals for the InterRAI
Lead Practitioners and Systems Clinicians will need to be monitored,
funded and managed accordingly through discussion with service
managers.
FEEDBACK AND CONSULTATION
The purpose of this document is to consult with the Southern district
community on whether the outcomes proposed are supported, and whether
the suggested changes are the best way to achieve them.
Southern District Health Board is seeking feedback to: ensure that the
proposed changes enhance service provision; help inform any subsequent
implementation plans; and minimise unintended consequences.
To help facilitate some specific feedback being sought, some questions are
included in a survey at appendix 5.
This survey can be completed online at:
www.southerndhb.govt.nz/hopplanning
Or please complete the questions in appendix 5 and mark any written
feedback confidential and return to:
Health of Older People
Planning and Funding
Private Bag 1921, Dunedin
Or by email to: [email protected]
The deadline for submissions is Wednesday 18th July, 1pm.
34
Genuine consideration will be given to all submissions received.
PROPOSED TIMEFRAMES
Objective Indicative Timeframe
Public Announcement of Consultation Wednesday 20th June
2012
Consultation phase Four Weeks
Written Feedback Closes Wednesday 18th July
2012
Recommendations to Southern DHB Board Thursday 2nd August 2012
Notification of decision to affected staff and
contract exit notices issued where appropriate
Monday 6th August 2012
Final Decision publicly announced Wednesday 8th August
2012
Commencement of proposed RFP Process Monday 13th August
2012
New HCSS Contracts Commence 1st February 2013
Transfer of any affected staff and clients to
successful HCSS providers
One Month
Existing HBSS contracts to end 1st March 2013
InterRAI Contact Assessment Training for HCSS
Clinical Coordinators
One Month from 1st
March 2013
Goal Based Care Plan Training for Clinical
Needs Assessors (CCC) and Clinical
Coordinators (HCSS)
From 1st April 2013
Phased introduction of new model of care TBC (following training
period)
SUPPORT
35
Planning and Funding at Southern DHB recognises that proposals such at this
can cause anxiety or stress for people. We will ensure a fair, transparent
process is undertaken that treats people with respect.
Please feel free to contact Planning and Funding at Southern DHB if you have
any queries on this proposal.
Managers of contracted services will be expected to support their staff
through this consultation process and the implementation of any proposed
changes.
36
APPENDIX 1: GLOSSARY
CCC: Care Coordination Service (combines previous NASC and CSCC
functions and includes Clinical Needs Assessors working for the Southern
District Health Board and Rural Hospitals)
CNA: Clinical Needs Assessor working as part of the CCC. A qualified Health
Professional with a current Annual Practising Certificate (APC). Undertakes the
assessment and planning of care process for older people using InterRAI
assessment tools.
Clinical Coordinator: Registered Health professional working for a HCSS
provider
HBSS: Home Based Support Service (current service name)
HCSS: Home and Community Support Service (proposed new service name)
InterRAI: Is an electronic assessment tool which includes the Minimum Data
Set Home Care (“HC”) and Contact Assessment (“CA”) tools for the
assessment of the needs of older people in hospital, the community or in
residential care who may need to receive long-term publicly funded support.
LTS-CHC: Long Term Support – Chronic Health Conditions (previously called
Interim Funding)
RFP: Request for Proposal
37
APPENDIX 2: EXAMPLE GOAL LADDER
Agnes Foster is an 87 year old lady who lives alone in her three bedroomed house.
Her husband Bill died four years ago from cancer. Agnes remained fit and well
throughout the time that she cared for Bill. She thinks that her years farming made
her strong enough to help Bill get around as he got sicker. She still hates to think how
thin her lovely big strong man was by the time he died.
Agnes has three sons and a daughter. Her sons live on the family farm. Agnes and Bill
moved up to live near their daughter Liz six years ago when they retired from the
farm due to Bills ill health. Liz is married with three grown up children and four
grandchildren. She works fulltime at a local pharmacy. Liz visits Agnes every day and
brings her dinner each night.
Since Bill’s death Agnes has become a lot less active. She never had a drivers
licence as Bill would drive them both around. Liz tries to take Agnes out in the car
when she can but they both find this difficult now. Three months ago Liz took Agnes
for dinner at a local restaurant to celebrate Liz’s 60th birthday. Agnes needed the
help of one of Liz’s sons to get her in and out of the car.
After Bill’s death Agnes feels she gave up for a while. She got weaker and weaker
and lost her appetite. She lost a considerable amount of weight. One night she got
up to go to the toilet and fell in the bathroom. She was taken by ambulance to the
local hospital and she has spent three weeks recovering from a broken hip.
Agnes developed a delirium post op and she still is confused at times. She
had a (L) hemiarthroplasty two weeks ago and now is walking with a frame to the
toilet. She requires assistance transferring on and off the toilet and in and out of bed.
On her discharge from the hospital Liz wants Agnes to come and live with her;
however Agnes refuses to go anywhere but back to her own home. Liz has noticed
that over the past year Agnes has become more and more frail. She has had four
falls in the last six months. Two months ago Agnes fell while she was walking to the
toilet, she fell and was not able to get up until Liz arrived that evening. Liz had to call
her grandson to help get Agnes back into her chair. When she fell Agnes cut her shin
badly. The District Nurses had to come to dress the wound. Since then she has the
dressing changed weekly. Liz also has noticed that her mum is often constipated
and this causes her pain and discomfort. This has been a lot worse since she was
admitted to hospital.
Liz was cooking her mum a meal each day and brining it round. However Agnes’
appetite is so poor nowadays that she never finished the meals.
Liz thinks that the time is coming where her mum will need to come to live with her.
Agnes has always been extremely house proud but now Liz finds that she is having to
do all the housework which is becoming more and more difficult. Liz does not know
38
how she will cope as she has a bad back. She is scared she will hurt herself and then
her mother would be in a worse situation.
Another reason that Agnes says that she is not as active as she used to be is due to
her urinary incontinence. She feels embarrassed when going out in public and thinks
that she is too much of a burden on Liz.
Agnes is identifed as a client with complex needs at initial screening and is
subsequently assessed using the interRAI MDS-HC. The assessor identifies the
appropriate casemix category for Agnes. Following this assessment goals are
identified by Agnes in collaboration with the assessor. This goal and the resultant
goal ladder form the basis for the content of services to support Agnes in the home.
SORT is then used to develop the support plan for Agnes – excerpts are shown
below.
Primary Goal:
To sit in the front row of her grandsons wedding on 15th September 2012
Future Possible Goals:
To visit great grandson in Nelson in January 2013
Risk Profile:
At high risk of falling
Recurrent UTIs
Fragile skin
Carer stress
Goal Ladder:
Goal Time Frame
1. To be able to walk 15 metres with her stick and one person helping
9 weeks
2. To be able to manage her continence for four hours 10 weeks
3. To manage own personal cares 7 weeks
4. To make my lunch independently 6 weeks
5. To shower myself independently 6 weeks
6. To get into my daughters car with assistance 4 weeks
7. To have pain 3/10 when i get up in the morning 2 weeks
Example Excerpts from the Support Plan:
Week One
39
Mar 5th - Mar 11th Date Started Date Achieved Comments
1. Hands on assistance to walk to dining room with walking frame
2. Hands on assistance to walk to shops without walking aids
3. Stand behind client in kitchen by bench - knee bends 10 repetitions. Hold support
4. Assist client to put on continence pads
5. Prompt client to use continence pads
6. Supervise client when putting on continence pads
7. Assist client to dress lower half in sitting
8. Assist client to dress top half in sitting
9. Assist client to put on shoes and socks in sitting
10. Assist client to put on underwear in sitting
11. Client to make hot drink in sitting
12. Client to sit in kitchen while support worker prepares meal
13. Fill the kettle for client and they can complete making the hot drink
14. Assist client to wash bottom half while they wash top half independently
15. Assist client to transfer in / out of car (three times with five minutes rest between)
16. Hands on assistance to walk to car with walking frame
17. Prompt client to take analgeisa as prescribed by GP
Week Five
Apr 2nd - Apr 8th Date Started Date Achieved Comments
1. Hands on assistance to walk to the lounge with walking stick
2. Hands on assistance to walk to shops without walking aids
3. Hands on assistance while walking to
40
letterbox with walking stick (3 times with a rest of 5 minutes between)
4. Stand behind client in kitchen by bench - knee bends 10 repetitions. Hold support
5. Assist client to put on continence pads
6. Prompt client to use continence pads
7. Supervise client when putting on continence pads
8. Prompt client to dress top half in sitting
9. Prompt client to dress top half while standing
10. Prompt client to put on shoes and socks in sitting
11. Prompt client to put on underwear in sitting
12. Client to prepare meal. Support worker to prompt steps get all ingredients ready, sit and take frequent rests, use perching stool
13. Client to sit and prepare vegetables
14. Client to stand in 3 minute blocks and rest in between while preparing meal
15. Supervise client while they shower.
Week Ten
May 7th - May 13th Date Started Date Achieved Comments
1. Hands on assistance to walk to the lounge with walking stick
2. Hands on assistance to walk to shops without walking aids
3. Hands on assistance while walking to letterbox with walking stick (3 times with a rest of 5 minutes between)
4. Stand behind client in kitchen by bench - knee bends 10 repetitions. Hold support
5. Assist client to put on continence pads
6. Prompt client to use continence pads
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APPENDIX 3: PROPOSED CARE REFERRAL AND ASSESSMENT PROCESS FOR HEALTH OF OLDER
PEOPLE SERVICE CLIENTS
Multiple Referral
Sources e.g.:
Referral Screening
and Triage:
InterRAI Assessment
Tool:
Plan of Care:
Key Contact:
Primary
Care Hospital
Staff
District
Nurses
Self
Referrals
Care
Coordination
Centre
Contact Assessment
undertaken by Clinical
Coordinator working for
a HCSS provider
MDS-HC Assessment
undertaken by Clinical
Needs Assessor working
as part of the CCC
Client driven Goals Based
Care Plan to support Health,
Wellbeing and
Independence
Client driven Goals Based
Care Plan to support
Health, Wellbeing and
Independence
Older Clients with
‘non complex needs’
Older Clients with
‘complex needs’
HCSS Clinical Coordinator CCC Clinical Needs Assessor
42
APPENDIX 4: DEVELOPM ENT OF CASE MIX FUNDING
Casemix has been in place for a number of years across multiple countries as a way
to help organise funding to hospitals. As a person presents to hospital, they receive
a diagnosis, such as a broken hip, heart attack or stroke. Over many years and
following discussion with clinicians and managers, the ideal inputs to maximise the
recovery of a patient with a particular diagnosis has been described and priced.
Casemix for home care is a similar process, except instead of using a diagnosis we
use needs to describe what services a client may need. Needs are separated into
either non-complex or complex. Non-complex needs are assessed using a brief
assessment tool (Contact Assessment) and complex needs are assessed using a
comprehensive assessment tool (Home Care Assessment). Both assessment tools
group clients together with similar sets of needs. There are six groups for non-
complex and 33 for complex. Each group requires a particular approach to
delivering care and services. The case study below is of Mrs Phillips who has been
assessed with non-complex needs within the group ‘2b’.
Case study: Mrs Phillips is 81 years old; she lives with her husband in Wellington who is
of a similar age. Both were extremely well and healthy up until recently and
although Mr Phillips continues to undertake the shopping and housework and aside
from mild respiratory disease is extremely well, Mrs Phillips has had a recent decline in
her health. Three months ago, she was admitted for a prolapsed uterus and came
straight home after a week in hospital for a hysterectomy. Shortly after coming
home, she developed a pneumonia and was so breathless was admitted for IV AB
therapy for two days.
After coming home from this admission, she has failed to return to her previous level
of fitness. Over a six month period, she has progressed from a fit and well older lady
who could drive, undertake her own shopping, and visit her family and friends each
week independently to now being someone who relies on her husband to
undertake housework, complains of fatigue, rarely goes outside and is beginning to
feel despondent and exhausted with life.
The GP refers for an assessment; she is screened as non-complex and is assessed at
home by the RN HBSS coordinator. During the assessment, Mrs Phillips undergoes a
goal facilitation process as well as the contact assessment. She is classed as
category 2b and identifies that she wants to return to cooking meals again as well as
being fit enough to go shopping with her daughters. A goal ladder is developed
and a referral is placed with the physiotherapist to support the development of the
goals.
A support plan is developed that initially provides a higher input from Support
Workers with a graduated reduction over three months. Support Workers feed back
to the RN coordinator on a two weekly basis against the goal ladder. After one
43
month, the inputs were reduced and after two months reduced further. At three
months, Mrs Phillips was discharged from the service being able to undertake
shopping with her husband and daughters and being able to make all meals during
the day.
Screening: Screening would indicate that this client is non-complex and appropriate
for DHB funded services. Ideally, the screening process should form part of the
primary care referral pathway.
Assessment: Initial assessment by RN coordinator (or equivalent registered health
professional) using interRAI contact assessment as well as a goal facilitation process.
Weekly inputs: 4 hours (4 visits) per week from Support Worker for one month; 2 hours
(2 visits) per week from Support Worker for one month; 1 hour per week from Support
Worker for one month. Four hours of physiotherapy – including assessment,
development of plan that is incorporated into goal ladder and review with
coordinators. Hours input per week is variable, though should be reduced over time.
Reviews: At three months, Face-to-face, RN coordinator (or equivalent registered
health professional), Use of goal facilitation toolkit and goal ladder
Reassessment: In the case of this client, no further assessment was required.
However it is anticipated that should clients remain as 2b, assessments will be
undertaken annually (or as indicated by reviews or feedback from Support Workers),
face-to-face by a RN coordinator (or equivalent registered health professional).
Should a change in need be identified by reviews or support worker feedback, the
contact assessment should be undertaken to inform decision making process as well
as casemix category.
Outcomes: Reduction in inputs to no service or casemix category 2a within three to
six months
44
Client referral to CCC
CLIENT FLOW: CASE-MIX CATEGORY (NON-COMPLEX 2B)
Client screened as ‘non-complex’
and eligible for services
Provider identified through case-
weight and referred
Contact assessment by Provider
Health Professional (RN, OT, PT)
Use of Case mix algorithm to
determine category
Establishment of package using goal
facilitation tool and development of
independence focussed support
ladder. Use of allied health as
required to maximise recovery
Category 2b
THREE monthly reviews by health
professional coordinator (RN, OT, PT)
using ongoing goal facilitation
approach as well as the case mix tool
and complex/non-complex screening
questions
No change in
casemix category
identified
See other
relevant
flow
charts
Category 2a
Category 3a
Category 3b
Client identified as
complex
Referral to CCC for
Assessment and
care management
as indicated
Discharge
(inform client, GP
and CCC of
decision to
discharge)
Change in need
identified
Category 2a
Category 3a
Category 3b
Establish package
and refer to
appropriate client flow
to inform reviews
45
APPENDIX 5: FEEDBACK SURVEY
The purpose of this document is to consult with the Southern district community on
whether the outcomes proposed are supported, and whether the suggested
changes are the best way to achieve them.
Southern District Health Board is seeking feedback to: ensure that the proposed
changes enhance service provision; help inform any subsequent implementation
plans; and minimise unintended consequences.
To help facilitate some specific feedback being sought, some questions are outlined
below.
This survey can be completed online at: www.southerndhb.govt.nz/hopplanning
Or please complete the questions below and mark any written feedback
confidential and return to:
Health of Older People
Planning and Funding
Private Bag 1921, Dunedin
Or by email to: [email protected]
The deadline for submissions is Wednesday 18th July, 1pm.
Genuine consideration will be given to all submissions received.
46
1. How many people does this submission represent?
2. Do you support the six main outcomes proposed, as important aspects of helping
more older people to live safely and independently in the community?:
Outcome Fully
Support
Partially
Support
Don’t
support
a) More equitable access to, and
provision of services
b) More people maintain functional
independence
c) More people maintain psychosocial
wellbeing
d) Improved quality, safety and
experience of care
e) The right care is delivered in the right
place at the right time
f) Best value from public health system
resources
Please provide comments to explain why any of the outcomes are not fully
supported:
Comments:
Proposal 1:
Introduction of the revised National Service Specifications and sector standards NZS
8158:2012 will become mandatory once finalised by the Ministry of Health. This will
form the basis for introducing a ‘restorative’ model of care and enhanced quality
standards into the Southern district.
47
3. Do you support the principle that Home and Community Support Services should
be delivered equitably across the whole Southern district?
Fully
Support
Partially
Support
Don’t
support
Please provide comments to explain if this principle is not fully supported:
Comments:
4. Do you support the proposal that each Home and Community Support Service
provider will be able to deliver equitable services to all eligible clients regardless
of age or funding stream, i.e. Health of Older People Service clients, Long Term
Support – Chronic Health Care clients and Personal Health clients?
Fully
Support
Partially
Support
Don’t
support
Please provide comments to explain if this proposal is not fully supported:
Comments:
Proposal 2:
48
5. Do you support the proposal for HCSS providers to undertake InterRAI contact
assessments and care management for Older People with non complex needs?
Fully
Support
Partially
Support
Don’t
support
Please provide comments to explain if this proposal is not fully supported:
Comments:
6. Do you support the concept of developing enhanced care/case management
roles for Older People with complex needs?
Fully
Support
Partially
Support
Don’t
support
Please provide comments to explain if this concept is not fully supported:
Comments:
Proposal 3:
7. Do you support the proposal that Southern DHB should work collaboratively with
all HCSS providers to achieve shared goals, risks and outcomes through an
alliance partnership?
49
Fully
Support
Partially
Support
Don’t
support
Please provide comments to explain if this proposal is not fully supported:
Comments:
General:
8. It is the intention of this proposal for change to ensure equitable access to, and
provision of, Home and Community Support Services for the whole of the
Southern Community. How can we ensure equitable access to these services for
the Māori community?
Comments:
9. Do you have any alternative proposals for helping more older people to live
safely and independently in the community?
Comments:
10. Do you think there is anything else we should consider as part of this proposal?
50
Comments: