Older Person Chronic Disease Model of Care

Chronic disease currently accounts for almost 80 per cent of the total disease burden in Australia and this is expected to continue to rise. Chronic diseases include diabetes, cardiovascular disease (including stroke and heart failure), cancer, asthma, chronic obstructive pulmonary disease, arthritis and musculoskeletal disease, dementia and mental health problems and disorders.

These diseases share the following characteristics as outlined in the National Chronic Disease Strategy and the NSW Chronic Disease Strategy 2006-09 (NSW Health, 2006). Chronic diseases are the most common and leading cause of premature mortality. They have the following features:

• complex and multiple causes;
• gradual or sudden onset with acute stages;
• occur across the life cycle, becoming more prevalent with older age;
• compromise quality of life through physical limitations and disability;
• long-term and persistent, and may lead to gradual deterioration of health.

Chronic Disease impacts on each individual in different ways over their lives.  In order to understand the kind of Models of Care that can assist an individual in maintaining their health and well being, the idea of a 'suitcase' was developed.  The 'suitcase' represents the kinds of resources an individual requires to assist them in their journey.  Seven journeys have been developed to date representing work in progress.  Please e-mail your comments to suzanne.samuels@doh.health.nsw.gov.au .

Journey 1 - Primary Prevention

Resources to assist with prevention of chronic disease. All individuals can take action to deter the development of chronic disease.

• Smoking, Nutrition, Alcohol, Physical Activity, Psycho - social.
• Aged Care: Annual Care Plan (Medical, Psycho-Social), Vaccination, Cognitive Screening, Falls Prevention.

Journey 2 - Secondary Prevention

• Self-Management: Medication, Monitor clinical indicators, Escalation plan in care plan.
• Rehabilitation: Rehabilitation for Chronic Disease services assist people with a chronic disease to achieve optimal physical and psychological function, to self manage their disease and to be active partners with their medical team in decisions about their health care.

Journey 3 - Acute Event

• CAPAC: The essential functions of CAPAC services are to provide the most appropriate care setting, avoid hospital admissions or reduce patient length of stay through the immediate provision of multidisciplinary care.
• Healthy at Home: This Model aims to provide an effective model of care that provides a better alternative to inpatient care and supports older people in their home environment.  It is an interagency model that provides integrated community care for people aged over 65 years (over 45 years for Aboriginal and Torres Strait Islander people) with emerging acute care needs.
• ED ASET: Emergency Department Aged Care Services in Emergency Teams are multi-disciplinary teams that are skilled in accessing and facilitating care for older people.
• ComPacks: ComPacks is a joint discharge program between multidisciplinary health teams and non health community case managers.  It is designed to assist patients to leave hospital and return to functionality in a timely manner.  The focus is on maximising patient independence and capacity in line with their preferences and goals while helping to manage demand across the health system.
• Rehabilitation: Rehabilitation for Chronic Disease services assist people with a chronic disease to achieve optimal physical and psychological function, to self manage their disease and to be active partners with their medical team in decisions about their health care.
• Comprehensive Geriatric Assessment: a holistic assessment process that is appropriate for an older person - it uncovers underlying disease processes as well as identifying the current acute event.

Journey 4 - Multi-system Failure

• Care Coordination and Case Management: Case Managers are now being charged with the responsibility to implement Case Management programs by ensuring collaboration between various disciplinary groups and coordination in the provision of services.
• Advance Care Planning: The Advance Care Planning (ACP) model works to improve the journey of patients, particularly older people, through the health system.  ACP takes into account the patient’s wishes, values and beliefs about medical treatment in order to prepare for end-of-life situations. 
• Community Care, Health and NGO Interventions and Support: A range of community services are available to assist older people and people with chronic disease to maintain their health and well being by supporting socialisation, activities of daily living, transport to access a range of health and community services as well as providing psycho-social care and support to the individual and their family/carer/s.

Journey 5 - Changed Function / Capacity

• Healthy at Home: This Model aims to provide an effective model of care that provides a better alternative to inpatient care and supports older people in their home environment.  It is an interagency model that provides integrated community care for people aged over 65 years (over 45 years for Aboriginal and Torres Strait Islander people) with emerging acute care needs.
• ACAT: Aged Care Assessment Teams approve care recipients for residential, community or flexible care. ACATs provide comprehensive aged care assessments.
• Respite: Respite means different things to different people and a number of service models are available from in-house care to facility based care centres.
• Residential Aged Care / Community Care: Residential Aged Care Facilities provide accommodation to older people ranging from semi-independent living to high level care.  Community Care organisations provide a range of services ranging from intensive case coordination services and therapy to in-house support such as domestic assistance, personal care and transport assistance. 
• ComPacks Care Coordination: ComPacks is a joint discharge program between multidisciplinary health teams and non health community case managers.  It is designed to assist patients to leave hospital and return to functionality in a timely manner.  The focus is on maximising patient independence and capacity in line with their preferences and goals while helping to manage demand across the health system.

Journey 6 - Acute Event for Aged Person

• CAPAC: The essential functions of CAPAC services are to provide the most appropriate care setting, avoid hospital admissions or reduce patient length of stay through the immediate provision of multidisciplinary care.
• ED ASET: Emergency Department Aged Care Services in Emergency Teams are multi-disciplinary teams that are skilled in accessing and facilitating care for older people.
• ComPacks: ComPacks is a joint discharge program between multidisciplinary health teams and non health community case managers.  It is designed to assist patients to leave hospital and return to functionality in a timely manner.  The focus is on maximising patient independence and capacity in line with their preferences and goals while helping to manage demand across the health system.
• Rehabilitation /Self-Management: (INPT/Community) Rehabilitation for Chronic Disease services assist people with a chronic disease to achieve optimal physical and psychological function, to self manage their disease and to be active partners with their medical team in decisions about their health care.
• Comprehensive Geriatric Assessment: a holistic assessment process that is appropriate for an older person - it uncovers underlying disease processes as well as identifying the current acute event.
• Transitional Aged Care: a program to address the needs of older people who, in the absence of the program, would require residential aged care.  It is a time-limited (12 weeks) period of support and low intensity therapy in a residential or community setting.
• ACAT: Aged Care Assessment Teams approve care recipients for residential, community or flexible care. ACATs provide comprehensive aged care assessments.

Journey 7 - Ageing with a life-long disease or disability

• Joint Clinical Care Coordination and Holistic Case Management: Case Managers are now being charged with the responsibility to implement Case Management programs by ensuring collaboration between various disciplinary groups and coordination in the provision of services.
• Community Service: (incl. Brokered Services), GP, ACAT, Specialist Service eg; Mental Health. Community Care organisations provide a range of services ranging from intensive case coordination services and therapy to in-house support such as domestic assistance, personal care and transport assistance. 

Feedback

These journeys are in draft format and we welcome your feedback.   Please send your comments to the office of the Clinical Services Redesign Program to suzanne.samuels@doh.health.nsw.gov.au for processing.