Transcript CREST (Community Rehabilitation Enablement & Support Team)

CREST
(Community Rehabilitation
Enablement & Support Team)
Community, Rehabilitation,
Enablement, Support Team
Dr Anne Roche
Paulina Baird
April 2013
CREST
How
it started
Demographics
• 13.5% of the Canterbury population
is over 65
• Estimated to rise to 20% in 2020
• Number of 85+ will double
• 85+ year olds utilise 3x health care
resources of other age groups
Pressure on aged care and hospital beds
• Prior to the earthquake plans were in place to plan and
implement a support discharge programme in Canterbury.
• The earthquake resulted in a loss of 106 medical beds and
635 ARC beds
• We needed to progress the supported discharge initiative
rapidly to reduce facility constraints
What is CREST?
• CREST is a community based rehabilitative supported discharge
and admission avoidance service for older people.
• It works with an interdisciplinary team
– a liaison team (covering both hospital and primary care)
– a case manager (physiotherapist, OT, RN) that establish
rehabilitation plans
– a coordinator (community provider RN) who supervise
teams of well-trained Key Support Workers.
• CREST provides clients with up to 4 visits a day, 7 days a week
Why CREST?
• Hospital is not the best location to rehabilitate and
care for older people
• 25-50% older people lose some function in hospital,
and 66% have not regained function 3 months later
• CREST improves client function and independence and
increases the time the client spends at home
• Designed to reduce:
– length of stay in hospital
– residential care placement
– need for long-term home care
Eligibility Criteria
•
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•
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Age > 65 years
Medically stable – ready for discharge from hospital
At risk of readmission, or entering ARC
Potential for partial or complete recovery with suitable home
rehabilitation within six weeks.
• The client is able to stand and transfer with one person (with or
without the help of a resident carer).
• The client consents to being treated at home by the team and aware of
the objectives set by the IDT
• The client has had a recent acute illness or injury or is at a borderline
level of function with an associated reduction in ADL and/or EADL
Making disability worse
worse
• Physical inactivity and disuse aggravate
medical conditions such as diabetes, heart
disease and causes deconditioning
• Hospitalisation induces inactivity and
dependence, “ wrapping older people in
cotton wool”. Risk of adverse events 10 x
higher > 65y
• Preclinical disability can be recognised and
averted with health promoting interventions,
e.g. activity, nutrition
•
Ageing, Health Risks and Cumulative Disability NEJM 1998.338:103541
Transition to home to home
• Discontinuity in clinical responsibility
• Uncertainty about changes to medication, what
medications already at home, whether prescription
will be filled etc
• Uncertainty about physical environment, resilience of
family, perceived risk
• Little consideration of what is important for the person
Referral
Process
for
CREST
Client
Pathway
CREST Liaison
identifies appropriate
CREST Client
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CREST Liaison
Chapter 3 CR
CCMS User G
Completes Liaison
Assessments &
determines complexity
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·
CREST Liaison
RAT
CREST Administrator
completes admin
procedures
·
CREST Admin
Client
transferred to
CREST
·
Case Manager
OPHSS
(Complex)
Coordinator
Comm Provider
(Non- Complex)
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Complex CRE
Process Map
Non-Comple
Process Map
EuroQol
Nottingham
Goal Ladder
Chapter 5 - 7
Client managed as per
CREST requirements
Client transferred
from CREST
·
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Chapter 8 C
Completion
Process Map
Completion
Map (CREST
CREST
Goals is growing…
SMART
S pecific
M easurable (meaningful to pt)
A ttainable
R ealistic
T ime oriented
Goal Ladder- client identifies “distal goal”where they want to be, proximal goals are
the steps required, how they get there.
Grocery shopping (& coffee) with Liz by x
Attending church with friend by x
CREST discharge
Commenced HBSS x
2hrs week
Preparing breakfast and snacks by x
Walking to dairy (450 metres) by x
Walking to car and getting in with help by x
One 2 hour visit x3
week
For pain to be 3/10 - getting in/out bed by x
To be able to defrost and heat MoW by xxx
Dressing independently at home by xxx
Withdraw weekend
visits
Washing independently at home by xxx
Withdraw AM visits
Walking to letter box independently by xxx
CREST x3 a day x7
Dressing independently within 5 days
Drawing curtains independently by x
Getting in / out of bed independently by x
Hosp. discharge
Walking to toilet independently day or night
by 3 days
Walking to ward doors within 2 days
Withdraw night
visits
Week 3
Long term goal:
To walk to fish and chip shop
once a week to buy meal
Week 2
To have a robust plan to manage
COPD and CHF symptoms
-weekly weigh
-Respiratory OR education,
domicilary O2
-prompt breathing exercises
Week 2
To walk to his letter box each day,
increasing distance by 1 power
pole each time
Goal ladder continued
Week 1
To take medication each day at the correct
times
KSW to check daily for 3 days, then observe
Week 1
To eat 3 meals a day
KSW to check he has eaten each time they
visit
Week 1
To wash and dress independently each day
Patient examples
• Mr CG age 93,lives with wife.
– Admitted May 2 with abdominal pain due to
constipation
– Previous admission April 20 with NSTEMI and
exacerbation heart failure. Urinary retention- D/C
with IDC and plan for trail of void at home (DN)
– Presented to ED May 1 with abdo pain
• Mr GC
– Constipation resolved, recatheterised with flip flow
valve, LRTI and UTI treated
– Apprehensive about discharge
– CREST- CM present when he got home, helped to
settle, distal goal- get out into garden, twice daily
KSW- showering, walks, Physio- chair raiser,
frame, exercise programme.
– Became independent w shower, D/C 30/5
Primary Care CREST
• Gradual extension into Primary Care since Dec 2011
• Initial pilot, 4 General Practices, Referral to OPH
Clinical Nurse Specialist who screened potential
candidates
• Patients need to be well enough for GP management
at home, but would benefit from increased support,
with rehabilitation focus to enhance recovery.
• OPH triage team redirected some referrals for respite
care etc to CREST
Primary Care CREST
• October 2012: 8 referrals from General Practice, 13
internal referrals from Older Persons Health
Community Teams- triage, Clinical Assessors,
patients seen on visits by Geriatrician and/ or
Community Gerontology Nurses
• Steady increase in numbers
• March 2013: 18 referrals from GP, 19 referrals
internal referrals
Primary Care CREST- patient
example Care CREST
• 75 yr old woman, referred for respite care
• Morbid obesity, exacerbation of back pain, had
pushed personal alarm 3 times in 10 days
• Supportive daughter away on holiday
• Bipolar Affective Disorder, currently depressed
• Had been incontinent in bed, unable to get up to the
toilet because of back pain. Sleeping in Lazy Boy
chair
• Seen by CREST Liaison, increased supports at
home, practical assistance to get mattress and
bedding cleaned
Patient example continued
• Seen by Physiotherapist and Occupational therapist
• Goals identified
• Care plan around encouraging independence in
shower, frequent supervised walks, sleeping in bed
• Referred to Medication Management Service ,
Dietitian and Psychiatric Services for the Elderly
• Back pain resolved, able to return to baseline
package of care at home, more confident about
ability to stay at home in medium term
CREST (tip) of an iceberg
• Intervention and close observation at home can
unmask previously unidentified problems
• Cognitive impairment
• Anxiety, made worse by social isolation
• Shortness of breath, made worse by anxiety.
• Co-ordinators inform Primary Care Team. CREST
can assist in appropriate response/ referrals/
discussion with family etc.
Quality and Improvement
• Group structure
o Operational Group to discuss day to day issues
o Data collection, monitoring through Quality Group
o Sign off from Steering group
• Case Managers / Providers
o Monthly educational training sessions and peer reviews
• On-going improvement
o Continual Process improvement Process – what's working well
o Tool development – how do we do it better
o Training and development – do we have the right skill mix
CREST Clients Average Length of Stay
35
30
25
20
15
10
5
0
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Admissions to ARC
• During the 2011/12 Year
2011/12
Crest Discharges Entering ARC
General 65+ Discharges Entering ARC
Difference
28 days 90 days
3%
7%
11%
13%
-8%
-6%
• During the 2012 Year
2012
Crest Discharges Entering ARC
General 65+ Discharges Entering ARC
Difference
28 days 90 days
2%
5%
11%
13%
-9%
-8%
Client Survey
• Approximately 1500 surveys were sent out in January 2013
• 80% surveys returned
• 90% clients satisfied or very satisfied with the overall CREST
service
• 84% believed they set obtainable goals
• 73% of clients received between 1 – 6 hours of care per week
while on CREST
• 78% of clients believe that CREST works well with other health
services in the home
• 76.5% of clients believed they were able to do what they wanted
with the assistance of their support worker