Improving Falls and Fracture Service Outcomes for Older People: Prevention and

Rehabilitation

Opportunities for Home Based Support

Lisa Gestro

National Programme Lead

What we will cover

• Setting the scene

• The programme framework

• Our Implementation Approach

• Key Learning's

• The opportunity for Home Based Support Providers

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Setting the Scene

A new way of working for ACC

Our Commitment

Building partnerships through innovation, and a shared commitment to service development with DHB’s and other health system partners to improve services for older people

Creating Alliances across key stakeholders to collectively design, develop and monitor new models of care

Working with willing partners to innovate across current service boundaries in a way that allows for innovation and best practice

Creating and testing new funding approaches for the purpose of redesigning pathways for older people that are reflective of the whole patient journey, rather than individual episodes of care

The Health of Older Persons Programme ($30.5m) is a flagship programme to test this new way of working

Moving to a population approach

83%

Needs

Based

Proactive

Care

15% 2%

low risk medium risk high risk

83% - Keeping the ‘well old’ well at home

15% - Identifying and targeting those at risk (<65 if appropriate)

2% - Modernisation of services to ensure effectiveness –rehab and prevention

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The Programme Framework

Wellness: Meet Muriel

Independent

Lives in her own home

Wants to stay that way for as long as possible

Needs services that are responsive, individualised and local

One size will NOT fit all

Wellness: Key Themes

Self-defined and includes all aspects of life (the Te WhareTapawha model of wellbeing includes physical wellbeing, spiritual wellbeing, family and social wellbeing, psychological and mental wellbeing)

Independence; making choices and taking responsibility for own choices

Being respected and valued

Relies on having the support available/financial resources to be able to access what you need when you need it: a supportive environment, affordable good nutrition; emotional support, medical care.

Needs services that align around the individual, not that the individual needs to align themselves around

These themes are not different across health and ACC!

Wellness

The Programme Framework

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Wellness – The Role of Screening

General Practice Teams are increasingly focused on Risk

Stratification

Largely focussed on Chronic Conditions

Screening now being extended to include falls risk as part of

frailty and LTC

Models vary between Pro active Screening of targetted

populations to opportunistic screening of all older people as they

present to primary care

Data sharing a key part of this initiative

The provision of services in the community for identified at risk

also a key part of the programme

Māori or Pacifica aged 65-74, with ACC fall-related claim in previous 12 months

Lives at home

Eligible

Ask following three screening questions by telephone (anyone can administer):1. Have you slipped, tripped or fallen in the last year?2. Can you get out of a chair without using your hands?3. Are there some activities you’ve stopped doing because you are afraid

you might lose your balance? Do you worry about falling

No to all questions

Administer two, timed, functional assessments:1. Timed Up and Go (TUG) Test AND2. Tandem stand

Timed Up and Go (TUG) Test ≥12 seconds ANDInability to hold tandem stand for 10 seconds…

And meets the following: Cognitively intact Not receiving a personal care

package Not utilising a walker

internal/external

And meets the following: Cognitively intact or mild

cognitive impairment Receiving a personal care

package Utilising a walker

internal/external

Electronic referral to ACC Lead Provider

Consider multifactorial falls risk assessment as per HQSC

Person aged 75+ - enrolled with CM Health GP

Age Residential Care Client Dementia?

NOT eligible

Consider multifactorial falls risk assessment as per HQSC

Timed Up and Go (TUG) Test ≤12 seconds ORAbility to hold tandem stand for 10 seconds Electronic referral to Community

Central

First best responder will do home visit and complete assessment.In addition to strength and balance programme may be referral to other specialists as required.

No further follow up.Recall for 12 months.

Yes to any question

Make a time for the patient to come in or check when they are next due in (within 3 months or earlier if clinically indicated

General Practice Pathways

The Programme Framework

Strong evidence that strength and balance programmes successfully reduce falls and fractures by up to 29%

ACC previously funded the provision of Tai Chi in the community, but the model was unsustainable because it was disconnected to other parts of service pathways

Crucial this time that a broader approach is taken, and that Community Strength and Balance fits within the broader health pathway

Commissioned the work of a Technical Advisory Group to develop baseline criteria, allowing freedom and flexibility in the design of programmes

Community Strength and Balance

1. Improve balance and leg strength to reduce the risk of falling

2. Include baseline and on-going assessment

3. Include exercises that provide individual challenges

4. Balance exercises one third of the total exercises

5. Include minimum of one hour weekly group + 10 weeks home-based exercise

6. Strategy to support on-going regular activity

7. Trained instructors

8. Enrolled through a health professional or self/community referrals

9. Available to people at increased risk of falling

Nine programme criteria (group based)

Procurement of Community S&B

Class

Class

Class

Class

Class

ClassClass

Class

Class

Class

Class

Class

Class

Lead AgencyKey functions:

• Coordination of community programmes

• Grow access

• Meet local need (as part of LFWG)

• Reporting

• Budget management

• Support programme approval

Local Falls Working Group (LFWG)

Establishing local service pathways

Identify falls risk &

refer to strength & balance as per

locally agreed pathway

Provider

A

Provider

C

Provider

B

Provider

D

Lead Agency ensures

programmes are:

• Sustainable

• Accessible

• Affordable

• Targeted

• Available

• Tailored

• Meets 9 criteria

Contribution may cover:

• Support programmes to

become ‘approved’

• Class/programme promotion

• Administration

• Travel for coordination

• Information resources

• Train class instructors

The Programme Framework

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The current Inpatient Journey

• The journey for injured older people is different that the

journey for older people who are funded by health

• There is an additional level of bureaucracy for ACC patients

for hospital staff

• The ACC journey is driven by entitlement rather than by need

• Liaison with ACC Case Management teams can be

problematic

• For the older person, the discharge and home care event can

be problematic:

• Change of HBSS Carer

• Duplication of assessments

• No continuity from hospital community team

• Discussion between funders on return to pre-injury state

The Current Inpatient Journey

ED Gen Med

PHAS

Surgery

Rehabilitation:

ATR Ward+/- NWB period

The Modernisation of Non Acute Rehab

• Looking to ‘group’ the whole rehab journey into one costed

event

• Removing pain points around permissions for ward and

clinical staff

• Removing barriers such as the current non funding of the

NWB event – all will be costed into one overall episode of care

• Rehab ‘setting’ no longer relevant– can start in the acute

phase

• This has significant value to hospitals that are currently

providing Early Supported Discharge

• A single agent will eventually be seen as the ‘broker’ of ACC

funding

• Imperative that we co-design the pathway

• Model based on high trust

• Vital in the development and pricing of packages of care for the inpatient journey

• Marries nicely with the casemix work already undertaken in home care

• Allows for robust clinical pathways to be co-designed for each casemix cluster

• Gives the provider more flexibility to develop service plans

• Gives the provider far greater visibility over a large group of patients

• Gives the provider transparency over annual budgets allowing for better planning

• Enables the process of Risk and Gain sharing to be discussed between funder and providers

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The Role of Casemix

The Case Mix Algorithm

• The profiling tool firstly considers the client’s living arrangements

• The remainder of the tool has three major components:

• The client’s contextual environment and the impact of these on length of stay and subsequent pathway development.

• Assessment of function (including non-weight bearing / restricted weight bearing ).

• The Diagnostic Related Groups (DRG), which have been organised around: (i) Head, Neck, Shoulders, Arms, Trunk, Knees and Toes; (ii) Common Injury DRGs; (iii) Injury DRGs; and (iv) all other DRGs.

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Support Need Vs Diagnosis

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The Role of InterRAI

• Currently looking at the role of InterRAI Acute and/or Sub Acute tool for NAR

• During the pilot phase we will be using the InterRAIdata to inform AROC data requirements as well

• Agreement to pilot the suite in Waikato and Canterbury

• Significant benefit for HBSS as more comprehensive data will be prepopulated on discharge from hospital

• Looking eventually to offer InterRAI ED screener as well

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The Programme Framework

There is strong evidence that specific multicomponent balance and strength exercise programmes delivered in the home can reduce the rate of falls by 32%.

Like Community group programmes, ACC has previously dabbled in the provision and financial support of these programmes (OEP)

A Technical Advisory Group (TAG) was set up by ACC building on previous work done by the Health Quality and Safety Commission Reducing Harm from Falls Expert Advisory Group

The TAG was asked to develop an independent report making recommendations to ACC.

Draft criteria now available

Models are now being developed locally that include the provision of home care, exercise physiologist’s and community allied health teams

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In-home Strength and Balance

The exercise programme must be specifically designed to prevent falls, and consist of progressive leg muscle strengthening and standing balance training exercises

The exercise programme must be individually prescribed and supervised by an appropriately qualified registered health professional, who actively monitors the exercise programme.

Exercises should have clear instructions and illustrations with advice to perform them at least three times a week.

Individual, conventional measures of strength and balance should be monitored at intervals and the exercise programme progressed to maintain improvement.

Exercise programme should be an integral part of the integrated falls and fracture system.

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Five Programme Criteria (Home Based)

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So, how?

How we get there is important

Joined up governance and delivery teams

Supported by cross sector advisory groups

A new approach: Collaboration, not competition

As ACC, we are looking to contribute to the achievement of shared benefit, not just our own benefits

Recognising that each district’s start point or platform is different

Not interested in a ‘cookie cutter’ approach

On-going, local relationships

Welcome an increased role for Home care, through local service design and governance.

Learning from the past

Programmes funded in isolation from the rest of the health system are:

- Not sustainable

- Not targeted to need

- Difficult to attribute benefits

Local variation and design needs to form the start point for service delivery

High trust relationships are key to the success and longevity of programmes

Where are we at currently?

Primary Prevention pathways being developed across 20 systems –first group is at or near contracting stages

Casemix being trialled in 5 DHB areas – currently at data validation phase

Inclusive process involving all parts of system, consumer focus and clinically led

Community Strength and Balance about to be tendered nationally

InterRAI acute being trialled in Waikato and Canterbury

National Advisory Group in place that includes NZHHA

Opportunities for HBSS

• Opportunities for HBSS to play an increased role across the whole pathway

• Delivery of In Home Strength and Balance should be intrinsic to any system that delivers ‘restorative’ home care

• Key opportunity for HBSS to begin to feature more strongly in integrated Early Supported Discharge Teams

• Excellent opportunity for funders to align groups of older people according to need, rather than maintain separate pathways

• HBSS providers needs to be engaging locally in working group design discussions

• HBSS governance needs to stay linked in to national discussions to inform new policy as it is developed

• Pilot opportunities likely to be made available in the next 12-18 months, but this shouldn’t prevent local discussions being pursued 3

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Questions, Comments, Discussion….

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