CREST (Community Rehabilitation Enablement & Support Team)

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CREST (Community Rehabilitation Enablement & Support Team) . CREST. Community, Rehabilitation, Enablement, Support Team. Dr Anne Roche Paulina Baird April 2013. How it started. Demographics. 13.5% of the Canterbury population is over 65 Estimated to rise to 20% in 2020 - PowerPoint PPT Presentation

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CREST (Community Rehabilitation Enablement & Support Team)

CREST (Community Rehabilitation Enablement & Support Team)

CRESTDr Anne RochePaulina BairdApril 2013

Community, Rehabilitation, Enablement, Support Team

1How it started13.5% of the Canterbury population is over 65Estimated to rise to 20% in 2020Number of 85+ will double85+ year olds utilise 3x health care resources of other age groups

Demographics

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Pressure on aged care and hospital bedsPrior to the earthquake plans were in place to plan and implement a support discharge programme in Canterbury.The earthquake resulted in a loss of 106 medical beds and 635 ARC beds We needed to progress the supported discharge initiative rapidly to reduce facility constraints3What is CREST?CREST is a community based rehabilitative supported discharge and admission avoidance service for older people.It works with an interdisciplinary team a liaison team (covering both hospital and primary care)a case manager (physiotherapist, OT, RN) that establish rehabilitation plansa coordinator (community provider RN) who supervise teams of well-trained Key Support Workers.CREST provides clients with up to 4 visits a day, 7 days a week

4add comment about duration of intervention, up to 6 weeks, with focus on early identification of ongoing care needs and transfer to long term supportsWhy CREST?Hospital is not the best location to rehabilitate and care for older people25-50% older people lose some function in hospital, and 66% have not regained function 3 months laterCREST improves client function and independence and increases the time the client spends at homeDesigned to reduce:length of stay in hospitalresidential care placementneed for long-term home care5

Eligibility CriteriaAge > 65 years Medically stable ready for discharge from hospitalAt risk of readmission, or entering ARCPotential for partial or complete recovery with suitable home rehabilitation within six weeks.The client is able to stand and transfer with one person (with or without the help of a resident carer).The client consents to being treated at home by the team and aware of the objectives set by the IDT The client has had a recent acute illness or injury or is at a borderline level of function with an associated reduction in ADL and/or EADL

6Making disability worse worsePhysical inactivity and disuse aggravate medical conditions such as diabetes, heart disease and causes deconditioningHospitalisation induces inactivity and dependence, wrapping older people in cotton wool. Risk of adverse events 10 x higher > 65yPreclinical disability can be recognised and averted with health promoting interventions, e.g. activity, nutritionAgeing, Health Risks and Cumulative Disability NEJM 1998.338:1035-41Transition to home to homeDiscontinuity in clinical responsibilityUncertainty about changes to medication, what medications already at home, whether prescription will be filled etcUncertainty about physical environment, resilience of family, perceived riskLittle consideration of what is important for the person

Referral Process for CREST 9

Client Pathway

10CREST is growingSMARTS pecificM easurable (meaningful to pt)A ttainableR ealisticT ime orientedGoal Ladder- client identifies distal goal- where they want to be, proximal goals are the steps required, how they get there.Goals11

Grocery shopping (& coffee) with Liz by xWalking to car and getting in with help by xWalking to dairy (450 metres) by xWalking to letter box independently by xxxWalking to ward doors within 2 daysDressing independently within 5 daysWalking to toilet independently day or night by 3 daysWashing independently at home by xxxDressing independently at home by xxxTo be able to defrost and heat MoW by xxxFor pain to be 3/10 - getting in/out bed by xGetting in / out of bed independently by xDrawing curtains independently by xPreparing breakfast and snacks by xAttending church with friend by xHosp. dischargeCREST dischargeWithdraw night visitsWithdraw AM visitsWithdraw weekend visitsCREST x3 a day x7 One 2 hour visit x3 weekCommenced HBSS x 2hrs week12Week 3

Long term goal:To walk to fish and chip shop once a week to buy meal

Week 2

To have a robust plan to manage COPD and CHF symptoms -weekly weigh -Respiratory OR education, domicilary O2 -prompt breathing exercisesWeek 2

To walk to his letter box each day, increasing distance by 1 power pole each time

Goal ladder continuedWeek 1To take medication each day at the correct timesKSW to check daily for 3 days, then observeWeek 1To eat 3 meals a dayKSW to check he has eaten each time they visitWeek 1To wash and dress independently each dayPatient examplesMr CG age 93,lives with wife.Admitted May 2 with abdominal pain due to constipationPrevious admission April 20 with NSTEMI and exacerbation heart failure. Urinary retention- D/C with IDC and plan for trail of void at home (DN)Presented to ED May 1 with abdo painMr GCConstipation resolved, recatheterised with flip flow valve, LRTI and UTI treatedApprehensive about dischargeCREST- CM present when he got home, helped to settle, distal goal- get out into garden, twice daily KSW- showering, walks, Physio- chair raiser, frame, exercise programme.Became independent w shower, D/C 30/5Primary Care CRESTGradual extension into Primary Care since Dec 2011Initial pilot, 4 General Practices, Referral to OPH Clinical Nurse Specialist who screened potential candidatesPatients need to be well enough for GP management at home, but would benefit from increased support, with rehabilitation focus to enhance recovery.OPH triage team redirected some referrals for respite care etc to CRESTPrimary Care CRESTOctober 2012: 8 referrals from General Practice, 13 internal referrals from Older Persons Health Community Teams- triage, Clinical Assessors, patients seen on visits by Geriatrician and/ or Community Gerontology Nurses

Steady increase in numbers

March 2013: 18 referrals from GP, 19 referrals internal referralsPrimary Care CREST- patient example Care CREST75 yr old woman, referred for respite careMorbid obesity, exacerbation of back pain, had pushed personal alarm 3 times in 10 daysSupportive daughter away on holidayBipolar Affective Disorder, currently depressedHad been incontinent in bed, unable to get up to the toilet because of back pain. Sleeping in Lazy Boy chairSeen by CREST Liaison, increased supports at home, practical assistance to get mattress and bedding cleanedPatient example continuedSeen by Physiotherapist and Occupational therapistGoals identifiedCare plan around encouraging independence in shower, frequent supervised walks, sleeping in bedReferred to Medication Management Service , Dietitian and Psychiatric Services for the ElderlyBack pain resolved, able to return to baseline package of care at home, more confident about ability to stay at home in medium termCREST (tip) of an icebergIntervention and close observation at home can unmask previously unidentified problemsCognitive impairmentAnxiety, made worse by social isolationShortness of breath, made worse by anxiety.

Co-ordinators inform Primary Care Team. CREST can assist in appropriate response/ referrals/ discussion with family etc.Quality and ImprovementGroup structureOperational Group to discuss day to day issuesData collection, monitoring through Quality GroupSign off from Steering group

Case Managers / ProvidersMonthly educational training sessions and peer reviews

On-going improvementContinual Process improvement Process what's working wellTool development how do we do it betterTraining and development do we have the right skill mix

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Based on CREST clients discharged during that month24

Admissions to ARCDuring the 2011/12 Year

During the 2012 Year

2011/1228 days90 daysCrest Discharges Entering ARC3%7%General 65+ Discharges Entering ARC11%13%Difference-8%-6%201228 days90 daysCrest Discharges Entering ARC2%5%General 65+ Discharges Entering ARC11%13%Difference-9%-8%General 65+ Discharges are limited to 65+ on discharge, acute and arranged admissions only, and discharge type of discharge routinely.

Note this is based on all CREST discharges28Client SurveyApproximately 1500 surveys were sent out in January 201380% surveys returned90% clients satisfied or very satisfied with the overall CREST service84% believed they set obtainable goals73% of clients received between 1 6 hours of care per week while on CREST 78% of clients believe that CREST works well with other health services in the home76.5% of clients believed they were able to do what they wanted with the assistance of their support worker

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Function

Phase