The ageing population poses many challenges for health care planners. These challenges are exacerbated by imperatives to contain costs, meet the increasing community expectations for quality health care, address the negative attitudes of health care staff towards older people and community stereotyping of ageing.

To help overcome these challenges this project team set out to re-conceptualise our philosophy of care to develop a new model of care.

The Older Person Acute Care Model (OPAC) is based on international best practice and underpinned by the principles of person centredness, multidisciplinary teamwork and practice development. The model aims to improve patient experiences and health outcomes whilst developing a workplace culture that values and embraces the care of older people.

The aim was to improve patient experiences and health outcomes whilst developing a workplace culture that values and embraces the care of older people.

Increasing adverse events (eg falls, pressure areas and the staff’s perceived need for physical restraints) were a significant concern in addition to ageist attitudes of staff and lack of involvement of older people in planning their care. In 2001, research revealed major deficits in the standard of care given to older people in hospitals (SNMAC 2001). There have been no studies in an Australian context, however, reports in the media suggest less than standard care. Research also shows that negative attitudes of health care staff to older people contributed to problems relating to their care. (Higgins et al 2007).

A significant driving force for the need for change in health care is the ageing population. By 2016 the population of people over 65years will have increased by 16% (Nay 2004) It is widely recognized that the largest users of heath care today are older people with chronic complex diseases and disability. The number of people with dementia is a major concern for health planners. Hospitalization for older people is often traumatic and frequently associated with functional decline (SNMC 2001; Street 2004). It is for this reason that we advocated the need for a more effective continuum of care for older people by developing a model of care that acknowledges the older person and the need for change and focus on the principles and standards of practice for care of the older person.

The development and implementation of the OPAC Model aligns with the NSW Health's Goals:

• Improving experiences for patients
• Preventive focus
• Partnership

In particular the model focuses on the essentials of care for the older people and aligns with the NSW Health and Hunter New England Health's Older Person Journey project work for the improved care of the aged and chronically ill person.

The model focuses on the older person with complex needs, based on principles of best practice multidisciplinary care. Principles and standards of care (SNMAC 2001) are respect, dignity, involvement, communication, choice and individualized care in areas such as continence, dementia and confusion, mental health needs, mobility, nutrition and hydration, pain, palliation, and pressure damage. Staff members engage in critical reflection to identify practice issues. Initiatives are evidenced based.

During implementation we:

1. identified indicators of change - improved patient experiences and outcomes, a workplace culture that values older people through positive attitudes, dynamic teams, empowered staff and clinical leadership.
2. realigned nursing positions to focus on older person care.
3. promoted the model through multidisciplinary in-service.
4. formed a leadership group for support, critical reflection and action on OPAC issues.
5. supported nurses to take a leadership role when implementing the OPAC model, using practice development, change and education.
6. sponsored nurses to attend practice development workshops and stewardship programs for research.
7. enhanced links with the University of Newcastle for clinical research.
8. published and presented project work locally, nationally and internationally (Peek et al. 2007; Higgins et al. 2007ab; Day et al. in press).
9. undertook OPAC projects:
   • developed a delirium alert protocol (DAP) and evaluated its effectiveness.
   • improved assessment and management of pain.
   • developed clinical guidelines for assessing pain in older people.
   • researched the needs of the relatives in the acute care setting.
   • developed a problem based, person centered approach to the management of older people with respiratory diseases.
   • developed and implemented bowel management guidelines for older people in acute care.
   • conducted a study of the attitudes and behaviours of health care workers towards older people (Higgins et al 2007).
   • designed promotional media depicting the model.

The OPAC Model was developed within a practice development framework. Our most outstanding achievements to date include:

• 14% reduction in hospital acquired pressure areas.
• Design and implementation of bowel management guidelines.
• Delirium detection and early management.
  • Development of prevention and early detection protocol.
  • Improved staff knowledge of delirium.
  • 25% improvement in the detection of delirium.
• Assessment and pain management.
  • Pain guidelines for older people in acute care setting.
  • Improved knowledge of pain assessment and management of older people.
• Reduced reliance by staff on the use of physical restraints.
• Improved workplace valuing of older people. Staff encouraged to undertake practice development and research involving older person care as evidenced in the 13 project areas and researchable topics undertaken to date.
• Grant submission to NHMRC for $500,000 for practice redesign project in 2009 looking at improved length of stay, readmissions and adverse events for all patients over 70years admitted to four emergency departments within Hunter New England Health.
• Three journal articles published.

Model currently being implemented throughout Hunter New England Health as a component of the Older Person Journey project.

The model has provided a platform for service wide change in treament approaches and care management of older people. It includes:

• a shared vision and focus for all care and treatment approaches.
• a platform that focuses on personhood.
• a focus for discussing and resolving patient issues and concerns.
• a mechanism and a focus for critical reflection and to bring about change.
• a platform for interdisciplinary dialogue.
• a guiding framework for evaluation and research.

This model is strategially aligned to NSW Health's goals for person centred care and for a focus on the esssentials of care.

The OPAC model has applicability in all acute care settings where there are older people. With the provision of education using the OPAC information package as a guide, this model has the potential to be transferred across NSW Health.

This Model will continue to:

• guide standards of care.
• guide the development, review, implementation and evaluation of policies and procedures for practice.
• support staff to use the best available evidence for care and treatment.

• Day, J, Higgins, I, Koch, T, in press, Delirium and older people: What are the constraints to best practice delirium care. Journal of Older People Nursing.
• Higgins, I, Vanderreit, P, Slater, L & Peek, C, 2007a, The negative attitudes of nurses towards older patients in the acute hospital setting: A qualitative descriptive study. Contemporary Nurse Journal. 26(2): 225-237.
• Higgins, I, Joyce, T, Parker, V, McMillan, M, Fitzgerald, M, 2007b The immediate needs of relatives during hospitalisation of acutely ill older relatives. Contemporary Nurse Journal. 26(2): 208-220.
• McCormack, B, Manley, K, Garbett, R, 2004, Practice Development in Nursing. Blackwell Publishing, Oxford.
• Peek, C, Higgins, I, Milson-Hawke, S. Harper, D, McMillan, M, 2007, Towards innovation:  the development of a person-centred model of care for older people in acute care Contemporary Nurse Journal. 26(2): 164-176.
• Caring for older people: A nursing priority: Integrating knowledge, practice and values. Report by the Standing Nursing and Midwifery Advisory Committee (SNMAC), March 2001, Department of Health, United Kingdom.
• Practice Guidance: Principles standards and indicators: A resource tool: caring for older people: A nursing priority. Standing Nursing and Advisory Committee, March 2001, Department of Health, United Kingdom.

Carmel Peek, Sally Milson Hawke, Isabel Higgins, Debbie Harper, Debbie Bruce, Pui (Iris) Li, Nursing staff of JHH Wards J3, H3, F2 and G2, Glody Mabbot, Leanne Bashford, Fran Dumont, Michelle Giles, Kristy Barnes, Jo Sillitoe, Fiona Hodson, Caroline Phelan, Jeanene Douglas, Linda Ritchard, Pauline Dobson, Vanessa McDonald.

Project Partners
Lynne Slater, Pamela Vanderreit, Terry Joyce, Margaret McMillan, Jenny Day, Tina Koch.

Acting Area Quality Manager, Clinical Governance
Hunter New England Area Health Service
Phone: 02 6767 7233