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PresCare Alexandra Gardens

Sub-acute care program
PresCare Alexandra Gardens
North Rockhampton, QLD

Residential - Regional, 30-79 Beds

Award descriptors:
Leadership and culture, Workforce, Clinical care / medication management

About the program
Care recipient satisfaction, choices, preferences and involvement in decision making are of paramount importance to the team at Alexandra Gardens, a 94-bed residential-aged-care facility in Rockhampton. This was the catalyst for developing and implementing a sustainable, integrated Sub-Acute care model. 

During 2014, a pilot program was funded by the Australian Government through a Better Health Care Connections grant. The program focused on proactive care through a simple Green-Yellow-Red traffic light system to detect, assess, report and respond early to deteriorating care recipients. Consultation and involvement of care recipients, families and all levels of staff is critical to the model. The aim was to prevent and better manage clinical deterioration and avoid unnecessary hospitalisation, without reducing the quality of care, and to improve care recipient satisfaction.

To achieve this, the team wanted five key outcomes:

  • A simple way to identify and respond quickly to changes in care recipients' conditions
  • A skilled nursing service
  • A suite of tools to guide the decision making process when a care recipient deteriorated
  • Clear reporting lines for escalation
  • Early and ongoing timely involvement of the care recipient, family and relevant clinicians

Aligning with the Australian Aged Care Accreditation Standards, this model enhances the provision of specialised nursing care with skilled qualified staff, confident to work to their full scope of practice to meet the needs of care recipients. It also promotes participation of care recipients and representatives in choice and decision-making while remaining at ‘home’ to receive the treatment they require, rather than being transferred to hospital.

What we did
The aim of providing Sub-Acute Care was to develop a model of care to better manage clinical deterioration in care recipients, to avoid unnecessary hospitalisation and to improve care recipient satisfaction while meeting their needs, choices and preferences, without reducing quality of care. To achieve this, the team wanted four key outcomes:

  • A  simple way to identify early and respond quickly to changes in a care recipient’s condition
  • A  skilled nursing service
  • A suite of tools to guide the decision making process when a care recipient deteriorated
  • Clear reporting lines for escalation.

This involved up-skilling staff to provide more advanced clinical care and improved clinical communication, equipment to assist clinical assessment, and robust partnerships across the Rockhampton health sector.

A governance committee was established to oversee and drive implementation, with representation from the acute hospital, Medicare Local, Central Queensland University (CQU), a geriatrician and another local residential aged care provider.

The team coordinated information sessions, internally educating staff about the processes; and then consulted widely in the community, engaging with care recipients and families, GPs, Queensland Health medical officers and nursing staff, specialists and Medicare Local to gain support and commitment.

A Sub-Acute Toolkit was developed and comprised a suite of tools and resources to guide the early identification and management of clinical deterioration in the care recipients, including:

  • A simple traffic light system of green (continue as current) to amber (Sub-Acute) to red (Acute), promoting early identification and management of symptoms for the eight common clinical conditions (UTI’s, chest pain, dyspnoea, dehydration, falls, constipation, delirium and end-of-life care) that had resulted in hospitalisations for care recipients
  • Residential Acute Deterioration Detection Chart (RADD Observation Chart) and Residential Aged Care End of Life Care Pathway
  • Suite of Clinical Management Guidelines for the eight conditions
  • Purchase  of diagnostic equipment (ECG Machine, Bladder Scanner and Vital Signs      Monitors)
  • Clinical handover using the SBAR clinical communication tool
  • Policies and procedures
  • An educational DVD.

Workforce development and a clear clinical governance structure were crucial in enabling staff to identify early and deliver the clinical care encompassed by the model.

Along with staff training in the eight targeted areas, and practical competency assessments, the staff roles and responsibilities matrix now includes clinical leads and nurse practitioner roles for escalation and management of clinical deterioration. The facility now has a Nurse Practitioner on staff.

Formal engagement with CQU delivered the qualitative and quantitative analysis of the project outcomes. Pre and post implementation focus groups were held with staff, and surveys were conducted to ascertain knowledge improvement, levels of confidence and behaviour changes. Quantitative data measurements covered pre and post transfers to hospital, total and average hospital lengths of stay, and the number of Sub-Acute care episodes provided in the facility.

Why we did it
The growth of the ageing Australian population is characterised by escalating multiple comorbidities, with 10% of RACF care recipients transferred to emergency departments each year (ABS 2013). These transfers are costly, stressful and often unnecessary or avoidable. Research has shown that RACF nursing staff confidence, clinical skills and access to resources, influences the delivery of quality of care and potentially reduces unnecessary transfers to the emergency department. 

Care recipients at Alexandra Gardens expressed a strong desire not to go to hospital, as it was a very unpleasant experience for them. When transferred, they felt lost and forgotten and often enduring many tests and diagnostic procedures. Importantly, care recipients and their families prefer they remain at ‘home’ for their treatment and care.

Prior to implementation of the Sub-Acute model of care, staff identified trends in care recipients being transported to hospital when their condition changed. Analysis of hospital admission data confirmed the reasons for transfer were due to eight common and often avoidable clinical conditions: UTIs, chest pain, dyspnoea, dehydration, falls, constipation, delirium and end-of-life care.

Who worked with us
The initiative was driven locally using a collaborative project management framework. A governance committee was established to oversee and drive implementation with representation across the acute and primary health sectors: Rockhampton hospital, Medicare Local, CQU, a local geriatrician and another local RACF provider.

Prior to commencement in March 2014, the team coordinated a number of information sessions internally, speaking to all staff (no matter their role) about the process and benefits of providing Sub-Acute care at the facility as well as dispelling misconceptions. From there, the team and committee consulted widely in the community, engaging with care recipients, families, GPs, Queensland Health medical officers and geriatrician to gain support and commitment to the Sub-Acute model of care.

Formal engagement with CQU ensured in-depth qualitative and quantitative analysis of the project outcomes. Pre and post focus groups were held with staff, and surveys conducted to ascertain knowledge improvement, confidence levels and behaviour changes. Quantitative data measurements covered pre and post hospital transfers, total and average hospital lengths of stay, and Sub-Acute care episodes provided in the facility.

Ongoing feedback from collaborating organisations was positive as commitment was maintained throughout the project from the Medicare Local, geriatrician, Residential Acute Care Services (RACs), GP’s and CQU. Working relationships were developed and fostered: Relationships with GPs strengthened, with 75% of care recipients signing clinical management guidelines for the selected Sub-Acute conditions; with the ED with 50% reduction of care recipients transferred to hospital; and existing relationships with RACS strengthened as evidenced by increased referrals.

What we learned
Aligning with the Australian Aged Care Accreditation Standards, the Sub-Acute model has enhanced the provision of specialised nursing care by qualified staff to meet needs, choices and preferences of care recipients and families, and promoted their participation in decision-making while they remain at ‘home’ to receive the treatment they require, rather than being transferred to hospital.

Within the project’s first 12 months:

  • The number of care recipients transferred to hospital decreased 50%
  • The total number of days they were in hospital decreased 57% (average LOS from 8.1 days to 4.9).  In 2015, hospital admissions decreased a further 5%.
  • Admission reasons have changed, from potentially preventable conditions in 2013 (UTI’s, chest pain, dyspnoea, dehydration, falls, constipation, delirium and end-of-life care) to acute conditions in 2015 (hematemesis, acute respiratory distress, intracranial haemorrhage, atrial fibrillation and heart failure).

Since 2014:

  • There have been no UTI admissions to hospital
  • Falls for care recipients living with dementia have decreased 14%
  • Falls with injury decreased 40%
  • Better bowel management has resulted in a significant reduction in the use of aperients.

Subsequently, care recipient satisfaction has increased from 90% to 96.7%.

Workforce development and a clear clinical governance structure were crucial in enabling staff to identify early and deliver care encompassed by the model. Successful implementation relied on up-skilling staff to provide more advanced clinical care and improved clinical communication, and strengthened partnerships across the Rockhampton health sector. Nursing staff are now confidently working to their full scope of practice. The program has also made a positive impact on staff satisfaction, with post-project survey results finding increased staff satisfaction and motivation to 92%, above industry average in Australia (Roy Morgan Research).

A positive unexpected outcome was the boost in clinical placements. Recruiting younger clinical staff to the aged care industry is challenging, but seeing the innovative work being delivered within this facility was beneficial. Placements at the facility are now more rewarding, with nursing students observing firsthand the significance of early detection of deterioration, prompt assessment and intervention, teamwork and family involvement.

The evaluation also identified:

  • More precise assessment and reporting tools and equipment facilitated identification of the deteriorating care recipient
  • Clinical training and support empowered and improved staff confidence and skills in detecting and managing deterioration earlier
  • Communication and relationships within the local health sector have improved, enabling      treatment to commence earlier, preventing further deterioration.

The program’s value was highlighted in February 2015 when Cyclone Marcia hit Rockhampton area. In the aftermath, all local hospitals and emergency services were struggling at full capacity. For five days, the facility did not have power and staff continued caring for care recipients in 38-40 degree tropical heat, with high humidity and no air-conditioning. Generators and industrial fans could not provide a comfortable temperature and despite constant fluid rounds, staff identified early signs of dehydration in care recipients. The Sub-Acute management guidelines were immediately activated, resulting in 12 care recipients receiving subcutaneous fluid infusions with positive benefits, including improved vital signs, increased urine output and improved appetite. As a result of this care provided by facility staff, no care recipients required transfer to hospital and there was no loss of life.

Key contributing factors to success of the model have been:

  • Effective and committed leadership
  • Close working relationships built with nurse practitioners from RACS
  • Commitment and continual involvement from all levels of facility staff
  • Ongoing staff training
  • Establishment of Clinical Lead Nurse positions with clear roles and responsibilities for day-to-day clinical leadership
  • GP support with sign-off of the Clinical Management Guidelines.

Given the success, the model is now being taken to the next level, with the Early Detection of Deterioration in Elderly (EDDIE) initiative, which will translate original research knowledge into practice at a second facility. The provider and CQU have again entered into a formal research agreement to develop a robust protocol including economic information, in preparation for future development of the EDDIE program as an app for the aged care industry. 

Both partners have also continued to contribute in-kind funding to present and promote the model locally, interstate and internationally at aged care industry and health conferences and leadership forums.

Importantly, this successful and well-received Sub-Acute model is now part of normal practice at Alexandra Gardens. Staff have the skills, tools and knowledge to better manage a deteriorating care recipient and provide Sub-Acute care; relationships between the aged care, primary health and acute hospital sectors have improved; and care recipient and family satisfaction has improved with increased involvement and choice in their care.

More information on this program:
Dee Jeffrey, djeffrey@prescare.org.au or phone (07) 3223 4444.

 

Changed
Friday, 21 December 2018 - 6:56am