Aged Care & Rehabilitation Clinical Services Plan 2007 Ã¢Â€Â“ 2012

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Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012Future Model of CareResearch is necessary to determine whether or not a “facility based” service is required in the southwest, complementing a smaller number of community packages than the 56 which is currentlyplanned. The Australian Government funded Pathways Home Research Project will inform thisdecision by mid 2008.Recommendation – Transitional Aged Care ProgramMonitor Transitional Aged Care Program activity to determine the most appropriate client mixand service structures for ongoing program management6.1.9 Community Dementia TeamsCommunity Dementia Teams (CDT) are a service not yet established in SSWAHS, although theservice is successfully operating in South Eastern Illawarra and Hunter New England Area HealthServices. The teams generally comprise registered nurses and clinical psychologists.These teams can provide specialist support in community and residential settings, including thecommunity/acute interface, to support people with dementia and their carers. The focus of CDTs isin providing assistance to manage the behavioural and psychological symptoms of dementia. Thereis strong evidence that early intervention/appropriate assessment and planning, around the time ofdiagnosis or onset of severe behavioural disturbance, can prevent escalation of behaviour problems,reduce carer stress, and reduce inappropriate admissions to either hospital or a residential agedcare facility (Brodaty, Draper & Low, 2003). At present, SSWAHS has a limited capacity to respondto this area of need, beyond the initial assessment phase.The service model does not involve long term case management, but rather assessment, initial casecoordination, development of behaviour management and modification strategies, referral for longterm services, and carer education and support. The service should be developed jointly betweenAged Care and Mental Health, with staff ideally located within each ACAT and linking closely withthe Specialist Mental Health Service for Older People (SMHSOP), including the BASIS teams.Funding for a Community Dementia Clinical Nurse Consultant (CNC) for SSWAHS was announcedin early 2007. This position may focus on development of Community Dementia Teams.The HACC program is a possible source of funding for the development of Community DementiaTeams. To date, DADHC has not funded such a service in SSWAHS, despite SSWAHS identifyingthis as a priority for new funding.Recommendation – Community Dementia TeamsPilot two Community Dementia Teams in SSWAHS (at Concord and Liverpool) staffed byRegistered Nurses and Clinical Psychologists, linked with ACAT and the Specialist MentalHealth Service for Older People.6.1.10 Centre Based Day CareCentre Based Day Care (CBDC) provides socialisation and monitoring opportunities for frail olderpeople and respite for carers.SSWAHS operates 20 dementia specific, frail aged, multicultural, ethno-specific and AboriginalCBDC services, funded by SSWAHS, the HACC Program, and the National Respite for CarersProgram (NRCP), or a combination of programs. Each service uses a slightly different model tomeet local needs and funding requirements. There are different opening hours, days of operation,activities and staffing. All provide transport to and from the service, greatly facilitating access. CBDCprograms operate from a variety of venues such as stand alone buildings on hospital sites,Community Health Centres, and Council premises. Some services share facilities to createeconomies of scale.2005/06 ActivityCBDC data is collected and reported differently across the Area due to the variability in fundingsources. As such, it is not possible to compare this data.Page 46
Aged Care & Rehabilitation Clinical Service Plan 2007 - 2012Current and Emerging Issues• Increasing prevalence of dementia - the prevalence of dementia is expected to double by2016. Particular expertise is required to assist clients with dementia;• Model of Care – models of CBDC differ due to local circumstances. Operational policies alsodiffer. There is a need for consistency and equity across SSWAHS;• Increasing frailty of clients – services note that clients are becoming increasingly complex andfrail, requiring greater assistance to attend and participate in activities;• Continuum of care/service integration – it is essential for recipients of CBDC services to beappropriately linked with other acute and community aged care services;• Service access – waiting lists exist to access some services. Growth allocations for CBDChave been forthcoming through the HACC program in recent years, although there is often atime delay to access this funding and develop additional services;• Service flexibility– CBDC is often provided in purpose designed facilities. To maximise useand improve service to the community, out of hours and weekend services are required;• Workforce – equitable staffing profiles should be established across all services and staffshould receive appropriate training, especially in the early identification and management ofclient deterioration;• Cultural diversity – attention needs to be given to the needs of people from culturally diversecommunities. This could occur through the employment of bilingual staff for people withdementia from CALD communities, or Aboriginal staff for older Aboriginal people, and use ofclustering or ethno-specific days;• Corporate governance – arrangements are being made to streamline CBDC governance tocreate consistent Area wide structures;• Funding – some CBDC services are funded by SSWAHS and others through HACC and/orNational Respite for Carers Programs. Funding amounts and expectations vary betweencentres; and• Staffing – staffing levels and numbers vary across centres, as do the type of staff employed toprovide the service.Projected ActivityFuture CBDC activity will be determined subject to availability of external funding, and a review ofCBDC operations in SSWAHS. Demand for this service will increase, although new services may beprovided by non-government organisations in the future rather than by SSWAHS, as a result ofinfrastructure constraints and increasing service costs.Future Model of CareAs recurrent funding for new CBDC services is now provided through the HACC Program, it is notproposed to establish new centres using SSWAHS resources.To enhance the service provided to the community and maximise the use of available infrastructure,existing services could be expanded to provide after hours and weekend support, using funding fromexternal programs. Opportunities to develop new dementia specific services may also beconsidered, which take into account language and cultural needs of local residents. Opportunities toutilise CBDC centres for the provision of outreach assessment and therapy services, and carersupport services, should also be considered.Recommendation – Centre Based Day CareUndertake a comprehensive review of Centre Based Day Care in SSWAHS, includinggovernance, operations, funding, staffing, policies, procedures, client mix, opportunities forexpansion and clinical service delivery6.1.11 Dementia Advisory ServicesDementia Advisory Services (DAS) are a recently developed service model, established to providestrategic support for people with dementia and their carers in acute, community and residentialsettings (subject to the funding source). The roles of DAS include: the coordination of servicesavailable for people with dementia and their carers; providing individual, group and communityhealth promotion, education and support; undertaking service development initiatives with a range ofproviders; and assisting with dementia planning and service development. Recent DAS projectsinclude education associated with Carers Week and Dementia Awareness Week, and coordinationof carer support groups.Page 47
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