home and community support services proposal for … · 3 introduction southern dhb is committed to...

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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




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




Proposal 4: Develop Southern District Support Unit functions to Facilitate the New Model of Care 30


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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

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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:

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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.

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HCSS PROPOSAL FOR CHANGE OUTCOMES FRAMEWORK:

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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

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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

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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”


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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”

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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

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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.

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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):

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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:

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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

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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

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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’

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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

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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:

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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.

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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

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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.


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:


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.


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.


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.


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.


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.


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:






34


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


3. Hands on assistance while walking to

40

letterbox with walking stick (3 times with a rest of 5 minutes between)




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


3. Hands on assistance while walking to letterbox with walking stick (3 times with a rest of 5 minutes between)




41

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:







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


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


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:

home and community support services proposal for … · 3 introduction southern dhb is committed to...

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