DHB’s health strategy for elderly

Out for public consultation now is the DHB’s proposed health strategy for Hawke’s Bay’s elderly. Improving Health Services For Older People in Hawke’s Bay is a well-done, provocative report (if you have a certain tolerance of jargon).

If you plan on getting old in Hawke’s Bay, BayBuzz suggests you give it a read! It’s online at the DHB website, and available at local libraries. Even better, think about these issues and comment to the official consultation process, which ends May 23. You can email comments to Julie.Charlton@hbdhb.govt.nz. Or mail to: Julie Charlton, HBDHB, Private Bag 9014, Hastings.

I reported on the strategy in the recent BayBuzz Digest article reproduced below (or you can print out this version).

On another health matter, have you taken the BayBuzz Fluoride Survey?

Seniors Push Health System to Crisis
By Tom Belford

A new report prepared by the DHB, Improving Health Services For Older People in Hawke’s Bay, voices this warning: “To do nothing will see existing services both in the community and secondary sectors pushed to crisis by the increasing workload, and growth in demand-driven expenditure rapidly outstripping the expected increases in funding.”

The facts and implications in this report, which is now out for public consultation, are daunting. As the Bay’s senior citizen population expands dramatically, beginning in earnest in 2013-14, their demands on the entire health system, and especially the regional hospital, will skyrocket.

The raw numbers
Today there are about 22,900 people in Hawke’s Bay who are over 65 years old. Of those, around 2,860 are over 85 years, and it is this group that is the most intensive user of health and disability support services. Patients over age 65 – today about 15% of the Bay’s population – already account for 24% of all emergency department attendances and 45% of bed utilization in the hospital. These two charts display current service usage by people over age 65 in 2009 … and the expected growth in demand.

In fifteen years, Hawke’s Bay will be home to approximately 35,940 people aged 65+ and 4,780 people aged 85+ … that’s a 67% increase in 85+ residents by 2026.

And while the sheer numbers are rising, so are expectations regarding the extent of medical treatment to be delivered. One practitioner BayBuzz spoke with observed that the demand for more, longer and more expensive treatment was often driven more by families of patients than by patients themselves. The study notes that: “… expectations of services are increasing and this is likely to accelerate as the baby boomers reach older age.”

In short we face a ‘perfect storm’ of rising numbers, rising expectations, and finite resources. Something’s got to give … or change.

The report concludes: “Hawke’s Bay DHB needs to act now to meet the increasing needs of its older population. Clinical and financial sustainability of services for the elderly will not be achieved simply by trying to do what is currently done more cheaply or efficiently.”

The illness
According to the report, the following are issues commonly raised by service providers, advocates, and service users alike. All of these will be exacerbated as numbers of seniors rise:

• Patients and their families find navigating the multiplicity of providers and funding streams confusing and frustrating.
• Lack of service coordination can lead to patients falling between the gaps.
• Too often older people are struggling in isolation and don’t get services until they have a crisis.
• The acute, episodic care model does not adequately meet the needs of older people who have long term health and disability issues.
• Instead of a ‘patient-centred’ approach, older people report feeling talked down to and patronized by some health professionals and not feeling like they have a voice.
• Inconsistent follow-up in primary care for people discharged from hospital.
• Concerns about the quality of care provided by Home Based Support Services and oversight of in-home workers.

These are mainly concerns about how care is managed, who does what, access to care, what the cracks in the system are.

But beyond all this, it would appear the physical ‘problem’ is that sicker people are living longer! As one doctor commented to BayBuzz, people used to die not just younger, but faster. A critical medical incident like a stroke or heart attack was more often followed by … death! The term ‘compressed morbidity’ was used to describe this scenario.

But now, new drugs, treatment advances and medical technology now stretch life out, adding about 2.5 years of life expectancy every ten years. Unfortunately, after an acute incident, it’s not necessarily a particularly healthy life.

As the study notes: “…we do know that nearly 40% of people aged over 65 years in Hawke’s Bay today have one chronic condition such as diabetes, cardiovascular disease, renal disease or cancer. 34% of those aged 75+ have two or more chronic conditions. Therefore we can be certain that the nature of the services will need to shift toward an emphasis on long-term conditions and toward increased complexity as patients with multiple co-morbidities will require longer stays in hospital and more complex procedures.”

The treatment
Fortunately, Improving Health Services does more than sound alarm bells. It proposes for public consideration a transformation of how health services should be delivered to our elderly population, phased in over 2-3 years.

Essentially, DHB’s proposed strategy seeks to spread care of the elderly down through the health system, including moving patients, whenever clinically feasible, to greater degrees of at-home self-care. The basic premise is to minimize the most expensive medical care – that provided in the hospital itself – relieving both financial and personnel pressure, and have more patients treated out in the community … in so-called intermediate care.

Without changing the delivery model, says the report, “The DHB will need to purchase new bed capacity to meet demand. The question for the DHB is whether to invest in more beds at the hospital, or purchase capacity in the community. We need a stronger focus on making sure that older people are admitted to hospital because it is the right option, not because it is the only option – and to do that we need to resource alternative methods of service delivery.”

So, how is this community-based ‘intermediate care’ supposed to be provided? A combination of more ‘sub-acute beds’ purchased from the aged residential care facilities that already provide hospital-level care services, backed up by a system of ‘hospital-at-home’ arrangements “for those well enough to remain safely at home but who require an enhanced level of medical and nursing oversight for a period until they regain their health.” This system envisions intermediate care that would typically last no longer than six weeks and frequently as little as 1-2 weeks or less.

Access to the beds and hospital-at-home services would be agreed between Community Geriatricians (the report suggests DHB’s current 2.8 FTEs are over-burdened at present and that this requires further review) and the patient’s GP.

Other changes are envisioned to support care in the community for elderly patients. For example, seven ‘Care Clusters’ would be aligned with groups of General Practices to help provide an array of services – e.g., physio, nursing, dietician – to higher needs patients. And 7-8 ‘Care Managers’ would coordinate the care needed by elderly persons requiring intensive care and multiple services. Each would have a case load of around 250 patients. Used in Canterbury, this approach reduced entry to residential care by 43% compared to usual practices. Home-based support services working closely with the Care Managers would emphasize restorative services, with a focus on ‘doing with’ the client rather than ‘doing for’ – i.e., encouraging independence.

These changes, and others detailed in the report, would involve an additional spend of nearly $1 million per year on health care for HB’s elderly. DHB Board members, when receiving the recommendations at the last DHB Board meeting, were not exactly thrilled to hear the budget estimates. They cautioned that the public, upon reading the report, should not assume that additional monies were readily available. Similarly, while a variety of new roles are envisioned, it is not clear where all this skilled community-based health personnel is to come from.

Which brings us back to the admonition in the report expressed earlier: “Clinical and financial sustainability of services for the elderly will not be achieved simply by trying to do what is currently done more cheaply or efficiently.” Can a new delivery model save the day? Here, from the study, is the alternative:

“Without a significant increase in service provision the threshold for intervention will need to increase and people will need to be more sick or functionally impaired to receive services. This will have significant implications for the quality of life of older people and their families, for health agencies and professionals, for the funder and for the Government.”

Not an appealing prospect!