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(Community Rehabilitation Enablement & Support Team) CRES T Dr Anne Roche Paulina Baird April 2013 Community, Rehabilitation, Enablement, Support Team

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CREST (Community Rehabilitation

Enablement & Support Team)

CREST

Dr Anne RochePaulina Baird

April 2013

Community, Rehabilitation, Enablement, Support Team

How it started

• 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

Demographics

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

anner2
add comment about duration of intervention, up to 6 weeks, with focus on early identification of ongoing care needs and transfer to long term supports

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• 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 1998.338:1035-41

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

CREST Client Pathway & Supporting Documentation

Documentation & SupportClient Pathway

CREST Liaison identifies appropriate

CREST Client

Completes Liaison Assessments &

determines complexity

CREST Administrator completes admin

procedures

Client transferred to

CREST

Client managed as per CREST requirements

· CREST Liaison Process Map· Chapter 3 CREST Handbook· CCMS User Guide

· CREST Liaison Assessment Form· RAT

· CREST Administration Process Map

Case Manager OPHSS

(Complex)

Coordinator Comm Provider (Non- Complex)

· Complex CREST Client Management Process Map

· Non-Complex CREST Client Management Process Map

· EuroQol· Nottingham EADL· Goal Ladder (CCMS)· Chapter 5 - 7 CREST Handbook

· Chapter 8 CREST Handbook· Completion of CREST Non-Complex Client

Process Map (CREST Coordinator)· Completion of CREST Complex Client Process

Map (CREST Case Manager)

Client transferred from CREST

Client Pathway

CREST is growing…

SMARTS pecificM easurable (meaningful to pt)A ttainableR ealisticT ime orientedGoal Ladder- client identifies “distal goal”- where they want to be, proximal goals are the steps required, how they get there.

Goals

Grocery shopping (& coffee) with Liz by x

Walking to car and getting in with help by x

Walking to dairy (450 metres) by x

Walking to letter box independently by xxx

Walking to ward doors within 2 days

Dressing independently within 5 days

Walking to toilet independently day or night by 3 days

Washing independently at home by xxx

Dressing independently at home by xxx

To be able to defrost and heat MoW by xxx

For pain to be 3/10 - getting in/out bed by x

Getting in / out of bed independently by x

Drawing curtains independently by x

Preparing breakfast and snacks by x

Attending church with friend by x

Hosp. discharge

CREST discharge

Withdraw night visits

Withdraw AM visits

Withdraw weekend visits

CREST x3 a day x7

One 2 hour visit x3 week

Commenced HBSS x 2hrs week

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 timesKSW to check daily for 3 days, then observe

Week 1 To eat 3 meals a dayKSW 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 structureo Operational Group to discuss day to day issueso Data collection, monitoring through Quality Groupo Sign off from Steering group

• Case Managers / Providerso Monthly educational training sessions and peer reviews

• On-going improvemento Continual Process improvement Process – what's working wello Tool development – how do we do it bettero Training and development – do we have the right skill mix

Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-130

5

10

15

20

25

30

35

CREST Clients Average Length of Stay

Admissions to ARC

• During the 2011/12 Year

• During the 2012 Year

2011/12 28 days 90 daysCrest Discharges Entering ARC 3% 7%General 65+ Discharges Entering ARC 11% 13%Difference -8% -6%

2012 28 days 90 daysCrest Discharges Entering ARC 2% 5%General 65+ Discharges Entering ARC 11% 13%Difference -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