Department of Health Hume Region
Integrated Aged Care Plan 2010 – 2015
Final Report
August 2010
Hume Region Integrated Aged Care Plan: Final Report
Foreword
The development of a Hume Integrated Aged Care Plan signals the commitment of the Hume Region Department of Health, service providers, and other stakeholders to achieve integrated aged care services across the Hume Region. Key to reaching this goal is the recommendation that aged care providers collaborate to further develop the Region‟s partnership approaches, planning structures and processes. With a well developed aged care service planning structure in operation, critical aged care issues can be better informed, understood and addressed jointly to meet the challenges associated with the growing number and of older people in Hume and their increasing support and care needs.
Through the implementation of the Integrated Plan, the Region will be able to gain greater clarity of the issues affecting the provision of aged care services for older people and continue the process of addressing these issues together.
The project consultants, LIME Management Group, wish to acknowledge and thank the many individuals and organisations who generously gave of their time and provided valuable contributions during the development of the Plan. It is important to note that the Plan relied upon the input and work of many stakeholders particularly service providers, carers and consumers who participated in Region-wide consultations, a workshop and the Integrated Aged Care Plan Steering Committee. In addition the Hume Region Department of Health provided support and leadership for the Plan and the Steering Committee was chaired by the Hume Health Services Partnership representative.
The next steps for the Hume Integrated Aged Care Plan are acceptance by the Department of Health and endorsement by the Hume Health Services Partnership. The Integrated Aged Care Plan Steering Committee will provide carriage for the Plan through the acceptance and endorsement process and remain actively involved while the Aged Care Collaborative is established to take the Plan forward.
On behalf of the Integrated Aged Care Plan Steering Committee and the Department of Health we are pleased to commend the Hume Region Integrated Aged Care Plan 2010 - 2015.
“signature” “signature”
Nick Bush CEO Cobram District Hospital Janet Chapman Hume Health Services Partnership Manager Population Health and Service Representative Planning Chair Integrated Aged Care Plan Steering Department of Health Committee Hume Region
Hume Region Integrated Aged Care Plan: Final Report
Table of Contents
Summary, Model and Recommendations ...... i 1 Introduction ...... 1 1.1 Aim ...... 1 1.2 Background ...... 1 1.3 Project Methodology ...... 2 2 Project Context...... 3 2.1 Key Policy Drivers...... 3 2.2 Aged Care Service System Overview ...... 8 2.3 Related Sector Developments ...... 9 3 The Hume Region and Aged Care ...... 11 3.1 Hume Region Overview ...... 11 3.2 Population and Health Demographics ...... 13 3.2.1 Population characteristics ...... 13 3.2.2 Socioeconomic factors ...... 15 3.2.3 Health and Disability ...... 17 3.2.4 Service Usage ...... 19
3.3 Hume Region Aged Care Service System ...... 22 4 Major Findings and Themes ...... 23 4.1 Introduction to Findings and Themes ...... 23 4.2 Key Population and Health Factors ...... 23 4.3 Stakeholder Consultation Findings Summary ...... 24 4.4 Consumer and Carer Consultation Findings Summary ...... 26 5 Hume Integrated Aged Care Plan ...... 27 5.1 Integrated Planning Principles ...... 27 5.2 Recommendations ...... 28 5.3 Action Plan ...... 29 Appendix 1: Package Providers by LGA ...... 34 Appendix 2: Survey Findings Summary ...... 35 Appendix 3: Stakeholder Consultation List ...... 41 Appendix 4: Stakeholder Consultation Data ...... 44 Appendix 5: Findings linked to Policy Messages ...... 53 Appendix 6: Project Steering Committee and Stakeholder Workshop ...... 55 Appendix 7: Workshop Issues ...... 56 Appendix 8: The KeyRing Model ...... 57
Hume Region Integrated Aged Care Plan: Final Report
Summary, Model and Recommendations
The Hume Integrated Aged Care Plan outlined in Section 4, reflects the new aged care paradigm which promotes positive and healthy aging, independence, and early intervention for consumers. For service providers the focus is on innovative and flexible service models and a person centred approach. Two other areas, easily accessible service information for providers and consumers, and building workforce capacity and capability were found to be very significant issues and are addressed in the recommendations.
Identification of key issues and development of the Hume Integrated Aged Care Plan were informed by many sources: . Policy information . Demographic, health and service information . Consumer, carer and service provider consultations . Service provider survey data . Regional contextual information . Gap Analysis Report . Project Steering Group and Stakeholder workshop and . Project Steering Group information, discussion and guidance.
The Plan identifies five Recommendations, as well as Strategies and Actions for each recommendation. These are expanded upon in Section 4. A Hume Region Integrated Aged Care Service System Components, Model and Planning Structure have been developed and are described below.
Hume Region: Integrated Aged Care Service System Components, Model and Planning Structure
Figures 1 and 2 provide a Hume Integrated Aged Care Service System Components, Model and Planning Structure. The Service System Components figure highlights the range of services that need to work together on aged care service planning, development and delivery. The Model has, at its centre, the goal of providing „person centred‟ services and concentrates on the five elements that are covered in the recommendations: collaboration and partnerships; service information provision and sharing; innovative and flexible service models; workforce capacity and capability; health and wellbeing for older people.
An overview of the planning structure is provided on page iii. The structure identifies the Hume Health Services Partnership (HHSP) as the authorising environment with an Aged Care Collaborative as a working group of the HHSP, involving representation from key stakeholders. At the sub-regional level, Primary Care Partnership (PCP) members form four sub regional groups for sub regional service planning, development and coordination; Local government area meetings are identified for networking and coordination and multi agency meetings for individual consumer care planning where agencies have shared and complex clients. These different structural levels need to link and communicate with each other to ensure an integrated approach to aged care.
i Hume Region Integrated Aged Care Plan: Final Report
Figure 1: Hume Integrated Aged Care Service System Components and Model
Model Elements Residential Care 1: Collaboration & 5: Health & wellbeing . Low Care . High Care Partnerships . Public and Acute & Sub Acute Promote Health & Private . Hospitals Structure to support Wellbeing for older collaboration people . MPS . Rehabilitation Engagement of all Health Promotion – . Transition care . Multi Purpose stakeholders planned and Services (MPS) Develop shared Person centred coordinated . Mental health vision, values, services Engage with . Palliative care approach communities & Housing consumers Promote aged care . Living independently planning structure Expand/promote Collaboration, . Retirement Villages social connections . Independent Living Networking and Units (ILU) Coordination . Supported Residential Services Spirit of . Caravan parks cooperation across 2: Service Information stakeholders provision & sharing 4: Innovative & Flexible working on service models solutions together Develop Advocate for flexible, mechanisms to Community innovative models promote service Care 3: Workforce capacity information & & capability Promote and share . HACC best practice . CACP referral at all service Primary Care locations Develop Workforce Support new services . EACH . Community Health . ACAS Support new Strategy to meet identified . MPS . Local service gaps approaches to Invest in existing . GPs government information workforce . Mental health . Disability dissemination . Transport Increase access to Improve technology Specialist staff in aged care sector
ii Hume Region Integrated Aged Care Plan: Final Report
Figure 2: Hume Integrated Aged Care Service Planning Structure
HUME HEALTH SERVICES PARTNERSHIP (HHSP)
Authorising Body
Aged Care Collaborative - Working Group of HHSP Representatives from key stakeholders across the aged care sector
PCP Sub-regional Aged Care planning and service development group inclusive of aged care stakeholders including input from carers and consumers; build on strengths of existing planning approaches.
LH Primary Care Partnership GV Primary Care Partnership UH Primary Care Partnership CH Primary Care Partnership Aged Care Planning and Aged Care Planning and Aged Care Planning and Aged Care Planning and Service Development Group Service Development Group Service Development Group Service Development Group
Local Government Area - Networking and Coordination meetings Information sharing, service access, workforce and care planning - Feedback to PCP Aged Care Group/Aged Care Collaborative Currently operating in some areas of Hume Region
Multi-agency meetings - based on local referral pathways, could be by LGA or community of interest Practitioner level, open to regional /sub regional services if involved with the consumer Focus on individual consumer care planning and complex consumer needs
iii Hume Region Integrated Aged Care Plan: Final Report
Recommendations
To achieve integrated and person centred aged care services in the Hume Region the following five recommendations are provided:
Recommendation 1: Promote effective collaboration between aged care providers through further development of Hume Region‟s partnership approaches, planning structures and processes.
Recommendation 2: Improve mechanisms to provide and share information among providers and ensure service information is accessible to consumers.
Recommendation 3: Facilitate innovative approaches to building and maintaining capacity and capability in the aged care workforce to meet current and projected demand.
Recommendation 4: Promote innovative and flexible service models to enable service providers to better respond to the needs of older people and their carers.
Recommendation 5: Promote health and well being for older people.
iv Hume Region Integrated Aged Care Plan: Final Report
Action Plan The Action Plan (outlined in detail in Section 4.8) provides a series of strategies and associated actions designed to achieve integrated and person centred aged care services in Hume, as related to each of the five recommendations. Strategies are summarised in the following table.
Recommendation Strategies
1. Promote effective collaboration between aged o Establish a structure to support collaboration (refer Figure 2) care providers through o Promote active engagement of stakeholders further development of o Develop a shared vision, values and approach Hume Region‟s partnership o Promote a Hume aged care planning structure approaches, planning
structures and processes.
2. Improve mechanisms to provide and share o Promote service information and referral at all service locations information among providers o Support new approaches to promote aged care information and ensure service dissemination information is accessible to o Improve ICT strategies consumers.
3. Facilitate innovative approaches to building and maintaining capacity and o Develop a Hume Aged Care Workforce Strategy capability in the aged care o Invest in the existing workforce workforce to meet current o Increase access to Specialist Aged Care Services and projected demand.
4. Promote innovative and flexible service models to enable service providers to o Advocate for and trial innovative and flexible service models and funding better respond to the needs o Promote best practice of older people and their o Support new services to meet identified gaps carers.
5. Promote health and well o Develop a Hume Older Persons‟ Health and Wellbeing Plan being for older people. o Link HP planning and localised approaches o Engage with local community groups and consumers o Invest in social connections for older people
v Hume Region Integrated Aged Care Plan: Final Report
1 Introduction
1.1 Aim
The purpose of developing the Hume Integrated Aged Care Plan is to achieve the following:
. Facilitate the development of client centred services responsive to the needs of older people . The development of an integrated seamless service system that will improve consumer navigation of aged care services . Develop a proposal for a service mix based on client need and population projections . Develop a responsive remote/rural service model . Develop an integrated approach to prevention and health promotion for older people across the region, particularly in relation to disadvantaged population groups . Identify priorities for integrated health promotion activity and . Identify workforce issues and priorities to support an Integrated Aged Care Plan.
1.2 Background
This Final Report on a Hume Integrated Aged Care Plan (HIACP) brings together collated and analysed: o Policy information o Demographic, health and service information o Consumer, carer and service provider consultation findings o Service provider survey data o Regional contextual information o Project Steering Group and Stakeholder workshop input and o Project Steering Group information and discussions.
Based on the above, and drawing from the Gap Analysis Report produced in Phase 3 of the project, the Final Report outlines a Hume Region Aged Care Service System Components, Model, and Planning Structure, as well as Recommendations, Strategies and Actions to achieve integrated and person centred aged care services in Hume Region.
1 Hume Region Integrated Aged Care Plan: Final Report
1.3 Project Methodology
LIME Management Group was engaged by the Project Steering Committee to develop the HIACP. The following methodology and project phases were employed:
Project Phase Methodology . Devised stakeholder consultation sample and strategy including process for Phase 1: stakeholder engagement Project Scoping and . Project Workplan - project tasks, timing and responsibilities Planning . Source/gather relevant policy, data and other information
. Data Analysis: Collation and analysis of relevant policy, data, information Phase 2: Data . Survey of public and private aged care service providers to identify issues and Analysis and gaps in service system Stakeholder . Stakeholder Consultations. Consultation Scope: service system strengths, Consultation issues, gaps and needs, workforce capacity and issues, service coordination practice, early intervention, positive ageing, health promotion practice, service integration/ requirements, future priorities . Triangulation/analysis of data & survey & consultation findings . Gap Analysis‟ Report: - Demographic profile and overview Phase 3: Gap - Service delivery profile, service uptake Analysis - Identified service systems strengths, gaps, needs, issues and recognised
priorities - Overview of factors which impact on service delivery – supply & demand - Stakeholder views and preferences re future directions and strategies
. Identify and source additional information/consultation as required Phase 4: . Workshop Gap Analysis and Points for Discussion re an integrated aged care Hume service model including service planning, coordination, promotion of access; Integrated health promotion priorities tailored to ageing people, workforce priorities and Aged Care development opportunities Plan . Hume Region Integrated Aged Care Plan including recommendations, actions
and suggested strategies.
2 Hume Region Integrated Aged Care Plan: Final Report
2 Project Context
2.1 Key Policy Drivers
` The following state and commonwealth policies are relevant to the development of the HIACP. It is vital to note the key messages these policies are delivering as they flag what is important, what needs to change, and how services should operate.
Repeatedly, the factors related to the purpose of developing an HIACP are reinforced in these policies, such as access, information, consistent intake and assessment, integration of services, special needs groups including rural and remote, a person centred approach, health promotion, facilitating consumer independence and self management, transition planning, coordinated care, workforce development and information technology.
Policy Key Points and Strategies Relevance to the Hume IACP Caring for Older Inquiry into aged care system re meeting the Special needs groups also include Australians financial and other challenges in providing people who live in rural and Productivity Commission more and diverse aged care services. The remote areas. Issues Paper Commission‟s task is to: Also looking at workforce issues – May 2010 . Examine social, clinical and institutional how to ensure a large enough and aspects of aged care in Australia appropriately skilled workforce . Develop options for the reform of funding Re carers/volunteers – how to and regulation (includes analysis of meet info needs; access to whether retirement living options should respite, training and education and be more closely aligned to aged care) support . Address interests of special needs
groups . Examine future workforce requirements Issues Paper asks for responses . Assess medium/long term implications of by July 2010 changes in aged care role/responsibilities
ST Towards a 21 Key recent and relevant Federal Government Outlines the Building Blocks for Century Primary policy document which outlines Key Directions Reform - Regional Integration, IT Health Care System – A for Change in the primary care sector: and ehealth, Skilled Workforce, Snapshot 2010 . Improving Access and Reducing Inequity Infrastructure and Financing and (After hours primary care, primary care & System Performance – highly GP access for older people, mental relevant to underpin future service health, Indigenous) sector developments and . Better Management of Chronic approaches. Conditions (diabetes via GP practices) . Increasing the Focus on Prevention „Medicare locals‟ – consideration (Medicare locals – primary health orgs, of what this means, existing PCP health communities reports and building structure in Vic, plus these entities workforce capacity, tobacco control, will have access to flexible funding conduct Aust health survey to target service gaps . Improving Quality, Safety, Performance and Accountability (new framework, national authority, COAG)
3 Hume Region Integrated Aged Care Plan: Final Report
Policy Key Points and Strategies Relevance to the Hume IACP Building a national National aged care system building on aged High relevance Aged Care care reforms: . HACC status quo in Victoria System . National HACC program (bar WA & Vic) . Information/assessment Budget release May 2010 . $37 million for info/assessment „one stop centralisation (one stop shops‟ shops) – impact on existing . Funding 31,000 aged care training places practice plus incentives to upgrade qualifications . Potential for more staff, . More nursing places/scholarships opportunities for training . Up to 25 projects to identify nurse . Potential access to more practitioner models and practice MPS sub acute beds . Increase Zero Real Interest Loans – . Medicare locals – see above investment in aged care facilities . 280 sub acute beds for MPS . Financial incentives for GP home visits . Medicare locals flexible funding pools . Benchmarking tool and business advisory services – improve aged care practice . Govt to conduct study on staffing levels, skills mix and resident care needs in resi care facilities
A Healthier Future The reform agenda urges action to: Recommendations and actions: For All Australians . Tackle the major access and equity . Support for people living in – Final Report of issues that affect people now; remote and rural areas the National . Redesign our health system to meet . Improving health outcomes Health and emerging challenges; and of Indigenous people Hospitals Reform . Create an agile, responsive and self- Commission – . Timely access to quality care June 2009 improving health system for future in public hospitals generations. . Consumer The report presents over 100 recommendations engagement/voice to transform the Australian health system. . Prevention/early intervention . Connect and integrate health and aged care services . Use of data, information and communication . A learning/supported workforce . Implementing/funding reform . Reforming governance
CiYC: A planning Care in Your Community (CiYC) is a Highly relevant framework that: framework for comprehensive framework underpinning the . Provides a set of service integrated development of integrated health care in area planning principles ambulatory health care (DH 2006) and community based settings – with the overall . Promotes person and family aim of reducing the need for inpatient care. centred care
Primary health Outlines the directions for primary health care Integrated care is available to all care in Victoria: a for the next three years The future primary people regardless of: discussion paper health care system in Vic is underpinned by a . place of residence (DH April 2009) wellness and person-centred care approach . socioeconomic status enabling people with chronic and complex . cultural and social conditions to have well-planned, integrated background care. . Indigenous status . complexity of health care need
4 Hume Region Integrated Aged Care Plan: Final Report
Policy Key Points and Strategies Relevance to the Hume IACP DH Hume Region Covers the focus for the DH Health and Aged The eight priorities are: Health and Aged Care Team in Hume which builds on the work . Better service coordination Care Priorities done in 2008-09 and addresses the state and re chronic conditions and 2009-2012 regional priorities plus implementation complex care strategies. . Indigenous health . Increased prevention and EI . Support partnerships in service delivery . Support for the most disadvantaged and vulnerable people . Increased emphasis on community based care . Develop new service models to meet changing needs . Focus on quality approach to service performance and budget management
The Victorian The HACC ASM is aimed at increasing the Central implications re the role HACC Active effectiveness in maximising client and provision of HACC allied Service Model independence through supporting the health services particularly in the (ASM) development of person centred and capacity development of more coordinated building approaches to service delivery. It is and integrated practice between seeking to reshape HACC services through HACC services plus promoting innovative, active service models which adopt ways for consumers to retain or a restorative care and capacity building improve independence and self- approach to clients and their needs, and efficacy. maximising client independence.
Victorian HACC Developed for HACC funded service providers Highly relevant plan noting that Active Service the Plan has a two year timeframe for the “putting the ASM into practice Model implementation of the HACC ASM. The Plan is Implementation requires significant change Plan 2009-2011 arranged around six key themes each with a management”. Key role for DH in (Jan 2010) series of objectives, strategies and actions. enabling sharing of practice The six themes are: learnings; building evidence base 1. Communication, consultation & planning and ensuring a partnership 2. Providing organisations with practical approach. Objectives include: support for change . Share good practice/learnings 3. Supporting broader systemic change . Improve INI, assessment and care planning in ASM 4. Strengthening assessment & care planning . Support agencies to assess 5. Strategic use of funds readiness for ASM 6. Action research & development. . Build on related program initiatives like integrated care . Embed ASM into quality frameworks
A New Strategy This Commonwealth strategy sets out The four actions are: for Community proposals for greater integration of the HACC . Improving consistency in Care Program and other Commonwealth community intake to services The Way Forward care programs. Working within a framework of . Comprehensive assessment 2009 tiers of care, the document proposes four for packaged care . Identifying entry points to actions to enhance access to services. community care which provide information, consistent assessment, supported referral . An electronic client record.
5 Hume Region Integrated Aged Care Plan: Final Report
Policy Key Points and Strategies Relevance to the Hume IACP Improving Care Three key considerations are outlined to Twelve principles of note: for Older People: improve and integrate timely care for older . Care issues for older people a policy for Health people across community settings. To: . Clinical governance Services 2005 . adopt a strong person-centred approach responsibility to the provision of care and services . Involving older people & . better understand the complexity of older carers people‟s health care needs . Identifying people with . improve integration within Health additional care needs Service‟s community-based programs . Assessing care needs and between health and ongoing support . Planning care services . Transition planning and coordination of care Twelve core principles underpin the policy. . Hospital inpatient care . Health Service community- based programs . Relationships between Health
Services and ongoing community support services . Older people awaiting long- term care options . Promoting health independence
Better Access To Key policy and framework that outlines the Via PCPs and allowing for local Services (BATS) principles and process surrounding the focus, the framework requires 2001 implementation of service coordination in services to coordinate activities, Victoria through PCP‟s and implementation of develop consistent practices and the Victorian Service Coordination Manual. define roles and responsibilities regarding common consumers.
Victorian Outlines strategies to improve overall access Provides a focus on improving the Government to residential aged care: quality and supply of residential Residential Aged . advocating to the Commonwealth aged care across the State Care Policy 2009 . streamlining the planning system . facilitating improved supply of residential aged care places . promoting innovation and leadership in Victorian residential aged care . developing the aged care workforce . strong commitment to residential aged care
Count us In! Count us in is a Victorian Government initiative A focus on achieving greater Social inclusion which aims to promote and facilitate social inclusion of people in for people living in community inclusion, good health and quality residential care. Projects included: residential care of life for older people living at public sector . Developing a 2006 residential aged care services. multifunctional community
and Dementia garden Over Phases 1 and 2 a series of pilot projects . A facilitated playgroup were funded across metro and rural Victoria. connecting parents, Community based organisations in partnership with resi care services developed strategies to babies, toddlers and break down barriers to inclusion, to improve residents social inclusion for residents and support the . Training volunteers and move towards a more inclusive life for older school to improve people in resi care. visitor/resident interaction.
Further projects are to be funded.
6 Hume Region Integrated Aged Care Plan: Final Report
Policy Key Points and Strategies Relevance to the Hume IACP Early Intervention The EICD Initiative aims to demonstrate Ensuring peoples‟ health and in Chronic improved health outcomes and quality of life wellbeing with a focus on chronic Disease (EIiCDI) for consumers with chronic disease with conditions Initiative (DHS) community health services and PCPs seeking to provide a multi-disciplinary and coordinated response to consumers with chronic conditions with a strong emphasis on self management.
Australian Closing the Gap1highlights the Australian Within this context, the Hume Government: Government‟s priorities for improving the regional implementation plan2 Closing the Gap health, well being and life expectancy of details the following priority areas on Indigenous Indigenous people and has committed funds “to and actions of note: Disadvantage: The Challenge for improve chronic disease management and . Tackling Smoking Australia 2009 expand the capacity of the health workforce to . Primary health care services tackle chronic disease in the Indigenous that can deliver population.” This strategy includes the location . Fixing the gaps and of extra health professionals in Indigenous improving the patient journey services. . Making Indigenous health everyone‟s business
Doing it with us Consumer participation is seen as an essential Makes reference to the community not for us – principle of: participation of carers and people participation in . Health development your health with dementia. service system . Community capacity building and the, 2006 –09 . Development of social capital.
1 Australian Government: Closing the Gap on Indigenous Disadvantage: The Challenge for Australia 2009 2 National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Hume Regional Implementation Plan (Draft)
7 Hume Region Integrated Aged Care Plan: Final Report
2.2 Aged Care Service System Overview
High Dependence High
Care
Acute,
sub acute,
palliative
In-home Low
Care -
packages
n the community the n
Hostels
o
s
co are
Assessment ent
f care f
illages/
Indepen resident
Respite Care 3. Hostels
Increasing le Increasing
Supported U dent Living
Retirement villages/ Retirement
ndent Living Units Living ndent Residential
rovis In-home services ngoing
to supplement/ Services Units Living Independent Intervention & Health Promotion Promotion Health & Intervention
Group housing Promotion Health & Intervention Information, Active Ageing, Early Early Ageing, Active Information, substitute for Early Ageing, Active Information,
carer support Retirement villages/
Living independently in the community the in independently Living i independently Living
Increasing intensity of community care care community of intensity Increasing
e i
Independent Living Units
7. Group housing/Retirement housing/Retirement 7. Group
p
Assessment and Information and Assessment
9. Information, Active Ageing, Early Early Ageing, Active 9. Information,
Intervention & Health Promotion Promotion Health & Intervention
villages/Indepe
n o n
Carer not Living with carer Living alone co-resident co-resident without carer
5.4. Assessment Living independently in the community
5. Respite Care Information, Active Ageing, Early Intervention & Health R espitePromotion Care rer High Independence
Source: LIME Consultants: City of Monash Community Care Workshop Presentation 2004, adapted from A. Howe.
The diagram above provides an overview guide to the range of services that operate across a more comprehensive view of the aged care service system. The base of the triangle is where high independence is represented and as the triangle rises there are increasing levels of dependency. The triangle is widest at the base as the majority of older people are living independently at home and in the community. At the peak of the triangle there are fewer older people but with very high levels of dependency who are supported in high care residential care.
In between these two contrasting dependency levels is a range of different aged care services to provide a variety of support to consumers, carers and families depending on their particular needs and situation. Throughout the triangle, the role of information provision and assessment is ongoing. Diagrammatically, assessment is central to the triangle as it plays a vital role in the surrounding services. The involvement of acute hospital care (including sub acute care) is placed close to the peak of the triangle, as hospital admissions increase in frequency and intensity as consumers experience higher levels of frailty and age related illness, however it is recognised that hospital admissions may occur at any time for a range of reasons. A final point notes that, as the triangle rises to a peak, there is a trend overall to an increasing intensity of care and supports required including for those older people living in the community.
8 Hume Region Integrated Aged Care Plan: Final Report
2.3 Related Sector Developments
Important to the development of the HIACP and adopting an integrated approach to service planning, development and delivery, is awareness of parallel developments in the service system and taking them into account to effectively and efficiently build service system capacity and connections. The following are significant developments that have come to attention; most but not all are taking place in the Hume Region however they are all relevant to a Hume Region Integrated Aged Care Plan.
Access Points Commonwealth funded Access Point Demonstration Projects are being implemented across Australia to improve the navigation of the service system for those frail older people, their carers, families and friends who do not already know where to go. Victoria has two Access Point Demonstration Projects - one at Uniting Care Community Options, in Knox servicing the Eastern Metro Region and the other in Grampians Region at Ballarat Health Services. In Victoria the Access Points are being promoted under the name Direct2Care. The Projects are designed primarily to service consumers via telephone, e-mail or fax with capacity for a face-to-face consultation when needed. The public contact telephone number is 1300 121 121. The Access Points model is built on the service coordination framework, will complement PCP work and the implementation of the Victorian HACC assessment framework.
Active Service Model – Home and Community Care Program (HACC) The Hume Region Department of Health has engaged a Project Officer to support the development and implementation of the HACC Active Service Model (ASM)
Allied Health An Allied Health Review project will commence in Hume region in the second half of 2010. Its aim will be to develop a framework and a model for HACC Allied Health service delivery and ensure these services are best placed to meet the demands of a growing aged Hume Region population. Included in the Review will be HACC funded allied health services and HACC Continence services.
Closing the Health Gap The Hume Region's Closing the Health Gap plan was developed in 2010 and identifies five priority projects that aim to improve the health of Aboriginal and Torres Strait Islander people in the Region. These include: improving the client's journey through the health system, especially from hospital to primary care services; increasing the cultural competence of all health services to support greater use by Aboriginal and Torres Strait Islander people; investigating the health needs of the Aboriginal and Torres Strait Islander people in the Lower Hume and Central Hume sub-regions to identify how to best provide new services; developing a program that focuses on young women's sexual and reproductive health needs; and reducing tobacco use.
Consumer Directed Care The commonwealth government has introduced funding for consumer directed care in community care programs. Consumer Directed Care (CDC) will initially focus on respite care provided under the National Respite for Carers Program (NRCP), and services provided under the government‟s packaged care programs. Through a competitive application process Commonwealth Respite and Carelink Centres across Australia will each be funded to provide up to 20 carers with their own individualised CDRC package. In total there will be 200 CDRC packages allocated. In addition, the government will also fund 500 Consumer Directed Care places under the Innovative Pool Program. The 500 places will broadly align with existing Community Aged Care Packages (CACP), Extended Care at Home (EACH) and EACH Dementia packages.
9 Hume Region Integrated Aged Care Plan: Final Report
Cross Border The DH Hume Region is to undertake a project into Cross Border service issues.
HACC, CACP and Planned Activity Groups (PAGS) It has recently been reported that PAGS are not a service described for purchase through a CACP. This policy interpretation will therefore enable consumers on a CACP to be eligible to participate in HACC funded PAGS for the same cost as HACC consumers and the PAG fee will be met personally by the CACP consumer and not through their package. The change does not apply to EACH as these are more comprehensive packages.
Medicare Locals or Primary Health Care Organisations As part of its health reforms, the commonwealth government will establish a network of Primary Health Care Organisations or Medicare Locals across Australia. They are referred to by government as „one-stop shops‟ for access to aged care information, assessment and services. Medicare Locals will support health professionals to provide more co-ordinated care, improve access to services, and drive integration across the primary health care, hospital and aged care sectors. It is understood the first group of Medicare Locals will commence in July 2011. Alignment of Medicare Locals with Primary Care Partnerships (PCP) catchments is one option under consideration.
Mental Health A project is in progress which is examining and addressing governance issues and arrangements for Mental Health Services in the Hume Region.
Nursing A Review of HACC District Nursing Services is currently under way in the Hume Region with the outcome to be reported in the second half of 2010.
Oral Health The recently developed Hume Region Integrated Oral Health Plan (2010-2013) provides a proposed service mix based on current need and population projections for community oral health services in Hume and a series of actions to guide the implementation of responsive remote/rural oral health service model. Strategies include: workforce development: promoting access for disadvantaged population groups; developing service coordination practice and; creating an integrated approach to prevention and oral health promotion.
Rumbalara Aboriginal Cooperative The Indigenous Land Council has handed over 20 ha of land in Shepparton to Rumbalara where a range of services, including aged care services will be developed ($40 million complex to be built in stages). Services and facilities will include: 30 bed aged care facility, 36 assisted living and housing units, a community centre, student respite housing, student housing, a training facility for aged carers and case management, a men‟s shed and a women‟s centre.
Rural Aged Care Research The John Richards Initiative (JRI) established at LaTrobe University Albury-Wodonga campus, will lead research and innovation in rural aged care, with an emphasis on research into rural aged care that improves well being by informing innovative rural ageing policy; exploring models of service provision for older people in rural communities that enhance their capacity to be resilient and self determining; and developing and testing effective rural workforce planning strategies and informing education.
Sub- Acute Services Review A Review of Sub-Acute Services is currently taking place in the Hume Region with the outcome to be reported in the second half of 2010.
10 Hume Region Integrated Aged Care Plan: Final Report
3 The Hume Region and Aged Care 3.1 Hume Region Overview
11 Hume Region Integrated Aged Care Plan: Final Report
The Hume Region in northeast Victoria covers twelve local government areas which are Alpine, Benalla, Mansfield and Wangaratta (Central Hume); Indigo, Towong and Wodonga (Upper Hume); Mitchell and Murrindindi (Lower Hume); and Greater Shepparton, Moira and Strathbogie (Goulburn Valley). It is a vast and varied region of much natural beauty covering over 40,000 square kilometres stretching in the south from areas that are on the urban fringe of Melbourne to mountainous areas in Alpine in the north east to locations along the Murray River with cross border links to NSW. There are few major centres in the Region relative to its size and they are not evenly distributed throughout the Region. The major centres are Wodonga, Wangaratta and Shepparton. Overall the Region is sparsely populated, involves considerable distances to traverse, includes isolated mountainous locations, National Parks and farms plus challenging climatic conditions in some locations such as snow, ice and fog as well as summer heat and bush fires.
Other notable and relevant features include: to the north, Indigo Shire is divided by the Hume Highway; Strathbogie and Towong have a small and scattered population; a movement of retirees from other areas outside of Hume particularly to Moira and Indigo; plus retirees attracted by low cost retirement type living in caravan parks near the Murray River; plus affordable housing is now less available in towns if people wish to move in from more rural/remote areas.
In the very recent past the Region has faced the dual environmental challenges of prolonged drought and serious bushfires and it is likely that the legacy of this will remain in the Region for some time. It can be anticipated that the effect of the drought will add to the socio-economic disadvantage in pockets of the Region and the impact of the bushfires on residents in the Mitchell and Murrindindi Shires particularly will be significant with many people losing their homes and livelihoods.
In terms of aged care services, there are multiple service providers. The Region has almost 100 organisations providing aged care services and they include HACC providers, Aged Care Assessment Service (ACAS), Psycho Geriatric Assessment Team (PGAT), Package providers, Residential Aged Care, Carer Respite services and Supported Residential Services. In addition there are the services that older people also use such as Community Health Services, Hospitals, Rehabilitation, General Practitioners (GPs), Vision, and Hearing. While the number of service providers is high overall there are areas with significant service gaps, service overlaps, waiting times and access issues due to various factors such as distance, transport, workforce capacity and service capacity.
12 Hume Region Integrated Aged Care Plan: Final Report
3.2 Population and Health Demographics
3.2.1 Population characteristics
Table 1: LGA Population Projections to 2016 and Number and Percentage of people 50+ and 70 + IAP LGA 2011 2016 50+ % total 70+ % total 2016 pop 2016 2016 pop 2016 Central Alpine 13,048 13,405 6632 49% 2445 18% Hume Benalla 14,419 14,750 7162 49% 2639 18%
Mansfield 8,257 9,080 4276 47% 1258 14% Wangaratta 28,199 28,912 12254 42% 4283 15% Goulburn Gt Shepparton 63,101 66,243 23711 36% 7930 12% Valley Moira 29,477 30,686 13764 45% 5072 17%
Strathbogie 9,844 10,069 5285 52% 1976 20% Lower Mitchell 37,065 42,523 13190 31% 3641 9% Hume Murrindindi 14,318 14,670 6841 47% 1928 13% Upper Indigo 16,214 16,768 7463 45% 2110 13% Hume Towong 6,270 6,193 3195 52% 1777 19% Wodonga 37,352 39,713 12495 42% 3736 9% HUME 277,565 293,011 116,269 40% 38,206 13% Vic 5,549,810 5,942,912 1,885,365 32% 649,236 11% Source: Dept Planning and Community Development
Table 1 shows the population projections for 2011 and 2016 for Hume by Local Government Area (LGA), and Victoria. By 2016 more than 116,000 people aged over 50 years and 38,000 people aged over 70 years will reside in Hume. In addition Strathbogie, Towong, Alpine and Benalla will have around 50% of their population aged over 50 and almost 20% of their populations aged 70 and over (well over the Hume average of 13 percent and Victorian average of 11 percent).
Chart 1: Hume Region Population Projections by age group, 2006 to 2036
Source: Hume Region LGA Profiles DHS 2009
Chart 1 above shows population projections for the Hume Region for a 30 year period from 2006 to 2036. Of note is the 65 to 84 age group marked increase for the whole period, along with a steady increase for the 85+ age group. All other age groups remain flat. The projection is for an extensive period so many variables may impact on the actual population outcomes however even in the short and medium term, from 2011 to 2016 and 2021, the increase in the 65 to 85 age group is very significant.
13 Hume Region Integrated Aged Care Plan: Final Report
Municipalities that abut the border with New South Wales (NSW); Moira, Indigo, Wodonga and Towong are impacted by the preferences of the NSW population for whom it may be more expedient to use services in Victoria. An example of this is Upper Murray Health and Community Services at Corryong which has an agreement to provide services to people from parts of three local government areas, (two being in NSW) south eastern area of Greater Hume Shire, southern border area of the Tumbarumba Shire and the eastern part of Towong Shire (Part B) which includes Khancoban, Walwa\Jingellic and Cudgewa.
Table 2: Persons aged 75+ living alone in Hume Number aged 75+ Additional Comment re 85+ living alone Benalla houses the largest percentage of people living Central Hume 1,683 alone who are aged over 85 in Central Hume Strathbogie houses the largest percentage of people Goulburn Valley 2,201 living alone who are aged over 85 in Goulburn Valley Lower Hume 653 Towong houses the largest percentage of people living Upper Hume 1,065 alone who are aged over 85 in Upper Hume Source ABS 2006
Table 2 identifies the number of people aged 75 plus living alone in Central Hume, Goulburn Valley, Lower Hume and Upper Hume. The largest number of people aged 75 plus living alone reside in Goulburn Valley followed by Central Hume with Strathbogie (4.3%) Towong (3.6%) and Benalla (3.4%) having the highest percentage of people aged 75+ living alone. Benalla, Strathbogie and Towong also house the largest percentage (of overall population) of people aged 85 plus who live alone.
Table 3: Indigenous Population by LGA and IAP IAP LGA No. Indigenous % of No aged % aged 50+ People Population 50+ Central Alpine 61 0.5 6 10 Hume Benalla 133 1.0 20 15 Mansfield 37 0.5 10 27 Wangaratta 208 0.8 24 12 Total : 439 0.7 60 14 Goulburn Greater 1819 3.2 226 12 Valley Shepparton Moira 308 1.1 57 19 Strathbogie 77 0.8 19 25 Total: 2204 2.3 302 14 Lower Mitchell 344 1.1 34 10 Hume Murrindindi 102 0.7 18 18 Total: 446 1.0 52 12 Upper Indigo 94 0.6 24 26 Hume Towong 45 0.7 12 27 Wodonga 455 1.4 51 11 Total: 594 1.1 87 15 HUME Total: 3683 1.4 501 14 Source ABS census 2006
Table 3 provides an overview of the Indigenous population in Hume. Most Indigenous people reside in the Goulburn Valley and over 300 of these people are aged 50+.
14 Hume Region Integrated Aged Care Plan: Final Report
Table 4: Percentage of overseas born and NESB by LGA and IAP IAP Cultural Diversity Catchment % born overseas % CALD Top 5 Languages /LGA Central Hume Alpine 14.8 13.4 Italian, German, Dutch, Arabic, Croatian Benalla 7.6 5.8 German, Italian, Polish, Dutch, Hindi Mansfield 11.0 8.4 German, Italian, Spanish, French, Dutch Wangaratta 8.1 7.9 Italian, German, Greek, Dutch, Filipino Goulburn Valley Gr 10.9 14.7 Italian, Arabic, Turkish, Albanian, Greek Shepparton Moira 8.2 8.3 Italian, Arabic, Dutch, German, Cantonese Strathbogie 8.0 6.6 Italian, German, Greek, Hakka, Tagalog Lower Hume 10.6 9.6 Italian, Mandarin, Macedonian, Greek, Mitchell Maltese 11.2 9.2 German, Italian, Greek, Dutch, Murrindindi Arabic Upper Hume Indigo 7.8 6.5 German, Italian, Dutch, Croatian, French Towong 7.8 5.1 German, Dutch, Italian, Croatian, Yugoslavian/ Serbo-Croatian (as described) Wodonga 9.2 6.9 German, Croatian, Italian, Serbian, Mandarin Source ABS census 2006
As identified in Table 4 more people born overseas and those from a Non-English Speaking background (NESB) reside in Goulburn Valley and Central Hume than in Lower and Upper Hume.
3.2.2 Socioeconomic factors
SEIFA The SEIFA (Socio-Economic Index for Areas) data can identify areas of low socio economic status, which can correlate with poorer health outcomes for people in those areas. The average SEIFA for Victoria is approximately 1,000.3 The following table lists SEIFA per Hume LGA with Benalla, Greater Shepparton and Strathbogie having the lowest SEIFA in Hume. Note, the Benalla township alone has a SEIFA of 937. In Euroa it is 958 and Mooroopna 932.
Table 5: Hume Region: SEIFA Alpine 989 Benalla 967 Central Hume Mansfield 1008 Wangaratta 987 Greater Shepparton 968 Goulburn Valley Moira 971 Strathbogie 968 Mitchell 1000 Lower Hume Murrindindi 1006 Indigo 1016 Upper Hume Towong 1000 Wodonga 993 Victoria 1,000 Source ABS 2006
3 DHSV Hume Oral Health Needs Profile (May 2009)
15 Hume Region Integrated Aged Care Plan: Final Report
Community Wellbeing Indicators – Food Security Food Security was measured in the 2007 Community Indicators Victoria Survey. Respondents were asked if there had been any times in the previous 12 months when they had run out of food and could not afford to buy more. Chart 2 lists findings from the survey in relation to the Hume Region, which reports an overall greater percentage than Victoria. The proportion of those affected in Lower Hume and Benalla is significantly higher than both the Hume and Victorian figures.
Chart 2: % of population experiencing food insecurity in past year
14 11.5 12
10 8.7 8.3 7.6 7.3 8 7.1 6.9 6.8 7 6 6 6
6 4.7 4.8 Percentage Percentage 4
2
0
Vic
Moria
Indigo Hume
Alpine Alpine Gr
Mitchell
Benalla Benalla
Towong
Wodonga
Mansfeild
Wangaratta Strathbogie
Shepparton Murrundindi
Central Hume Goulburn Valley Low er Hume Upper Hume *
Source Community Wellbeing Indicators 2007
DVA As noted in Table 6, older people (veterans) holding either Gold or White cards comprise over 15% of the 70 and over population in Moira, Towong, Wodonga, Benalla and Strathbogie.
Table 6: Hume Region DVA Gold & White card holders 70 + years IAP LGA DVA client pop 70+ % of 70+ Population Central Alpine 197 11 Hume Benalla 332 16 Mansfield 102 11 Wangaratta 470 13 Total : 1101 Goulburn Gt Shepparton 750 12 Valley Moira 706 17 Strathbogie 242 15 Total: 1698 Lower Hume Mitchell 315 13 Murrindindi 199 12 Total: 514 Upper Indigo 193 12 Hume Towong 142 16 Wodonga 438 16 Total: 773 Source DVA: 2009 Aged Care Approvals Round Veteran Information
16 Hume Region Integrated Aged Care Plan: Final Report
3.2.3 Health and Disability
Dementia
Table 7: Dementia Prevalence rates by Age and Gender and Projected Estimates Age group Female Male Age group Estimate of people with Prevalence % Prevalence % dementia in Hume by 2016 <60 0.01 0.01 <60 21 60-64 0.6 1.2 60-64 172 65-69 1.3 1.7 65-69 261 70-74 3.3 3.5 70-74 443 75-79 6.3 5.8 75-79 578 80-84 12.6 11.8 80-84 817 85-89 21.5 18.6 85+ 1811 90-94 33.3 31.1 Total 4103 95+ 40.3 38.1 % of total pop 1.4% Sources: ABS (2004), Jorm et al (1987), Hofman et al (1991), Ritchie and Kildea (1995), Lobo etal (2000).
The estimate of people with Dementia was done by Access Economics for Alzheimer‟s Australia and is based on age specific prevalence rates from the Australian Bureau of Statistics Disability, Ageing and Carers Survey released in 2004, together with international epidemiological data then applied to ABS population projections.
Over 4000 people in Hume are estimated to have dementia by 2016 and 2628 (64%) of these people will be aged over 80 years. By 2020 this will increase to over 4500, a higher number than Gippsland and Grampians but lower than Loddon Mallee, and Barwon S/West.
Dementia will rapidly become one of the major sources of burden of disease over the next decade. It is estimated by 2023 dementia will have gone to 4th place (from 11) for men and 3rd (from 4t) for women.4
Community Wellbeing Indicators – Self reported health Self-Reported Health was measured in the 2007 Community Indicators Survey. Respondents were asked to rate their health as excellent, very good, good, fair or poor. Chart 3 lists the percentage of people who reported their health as very good or excellent. Those residing in Lower Hume and Greater Shepparton were less likely to report their health this way than the whole of Hume and Victoria.
Chart 3: Percentage of people reporting health as very good or excellent
63.2 70 60.4 57.1 59 55.9 54.3 55.6 54.3 54.3 60 51.6 52.1 53.6 51.2 48.9 50 40 30
percentage 20
10
0
Vic
Moria
Indigo Hume
Alpine Alpine Gr
Mitchell
Benalla Benalla
Towong
Wodonga
Mansfeild
Wangaratta Strathbogie
Shepparton Murrundindi
Central Hume Goulburn Valley Low er Hume Upper Hume *
Source Community Wellbeing Indicators 2007
4 Alzheimer‟s Australia: Dementia Prevalence: Victoria and its Regions Information Sheet January 2010 17 Hume Region Integrated Aged Care Plan: Final Report
Ambulatory Care Sensitive Conditions (ACSC) People with chronic health conditions are significantly represented in numbers of people requiring hospitalisation. The ACSC study collates the numbers of people hospitalised with conditions thought to be avoidable if preventative care and early disease management were applied.
The whole Hume Region has higher admission rates for diabetes complications than Victoria; with Lower Hume having the highest rate of all. Admission rates for Chronic Obstructive Pulmonary Disease (COPD*) are higher than Victoria in all areas of Hume. Goulburn Valley has slightly higher admission rates than Hume overall and Victoria for congestive cardiac failure.
Chart 4: ACSC admission rates per 1,000 people
35 Lower Hume , 32.88
30
Goulburn Goulburn Valley , 27.78
Hume , 26.42 Central Hume , 24.05
25 Vic , 23.87 Upper Hume , 22.44
20
15
10
rate 1,000per people Lower Hume , 3.89
5 Goulburn Valley , 3.56
Central Hume , 3.44 Hume , 3.45
Upper Hume , 3.24
Vic , 2.75 Goulburn Valley , 2.78
Upper Hume , 2.42 Hume , 2.52 Vic , 2.4
Central Hume , 2.33 Lower Hume , 2.33
0 Diabetes complications COPD* Congestive Cardiac Failure ACSC condition
Source DH Hume Region Planning Unit
As an indicator of need the 2006 Census asked about the need for “help or assistance in one or more of the three core activity areas of self-care, mobility and communication because of a long term health condition, disability or old age”. Hume region overall reported an indicator of 4.8% of the population with the highest levels reported for Strathbogie (5.8%), Moira (5.7%), Alpine and Wangaratta (5.5%) and Benalla (5.4%).
The table below shows the estimated number of people eligible for HACC services aged over 70 years who are not eligible for DVA Homecare or reside in residential care settings. These estimates are then weighted for socioeconomic status, health status, remoteness, indigenous status and cultural and linguistic diversity. Over 40% of the HACC eligible population reside in the Goulburn Valley area with a further 10% in each of Wangaratta and Wodonga municipalities.
Table 8: Hume Region HACC Eligible Population IAP LGA RREF Pop at June 09 based on RREF percentage 2006 census projection June 2009 Central Hume Alpine 2,728 6.00% Benalla 2,904 6.39% Mansfield 1,393 3.06% Wangaratta 4,940 10.86% Total : 11965 26.3% Goulburn Gt Shepparton 10,297 22.64% Valley Moira 6,223 13.68% Strathbogie 2,210 4.86% Total: 18730 41.18% Lower Hume Mitchell 4,048 8.90% Murrindindi 2,303 5.06% Total: 6351 13.96% Upper Hume Indigo 2,535 5.57% Towong 1,353 2.97% Wodonga 4,546 10.00% Total: 8434 18.54% Hume Total: 45480 100.00% Source; DH Hume region HACC Annual Supplement 2009-10
18 Hume Region Integrated Aged Care Plan: Final Report
3.2.4 Service Usage
Service Information The Commonwealth Carelink Centre receives calls from the public and service providers to the offices at Shepparton and Wangaratta. The number of calls each week is low. Data relating to the number of calls is confidential to the commonwealth government.
HACC The number of people receiving services funded by the Home and Community Care (HACC) program in 2008-2009 per 1000 target population over 70 years across Hume is 385.6 which compares with a statewide range of 282.4 in Eastern Metropolitan region to a high of 418.3 in Loddon Mallee. Within Hume the range of people using HACC services per 1000 of the target population is from 323.1 in Greater Shepparton to 427 in Benalla.5
Packages People with more complex needs who require case management are assessed by the ACAS for a Community Aged Care Package. The table below shows the number and type of packages allocated by the Commonwealth to Hume Region. Appendix 1 provides an overview of funded package providers in Hume.
Table 9: Hume Region Package Allocation 2009 CACP CACP (Rural DEM/ CACP (DVA) R) CALD EACH EACHD FSD FSD FHCP RRA HLNK HLNK2 488 5 5 10 88 36 5 15 13 14 10 9
TOTAL NUMBER OF PACKAGES 698
The table below shows the distribution of CACPs and EACH and EACH D packages across each LGA in Hume Region. The areas with the highest level of HACC eligible population tend to have the highest distribution of packages with the exception of Alpine.
Table 10: Number of People on Packages 2009 IAP LGA CACPs EACH EACH D Central Hume Alpine 52 2 2 Benalla 49 3 - Mansfield 14 1 - Wangaratta 63 14 7 Goulburn Valley Gt Shepparton 96 12 7 Moira 66 21 6 Strathbogie 20 3 1 Lower Hume Mitchell 41 14 3 Murrindindi 21 9 4 Upper Hume Indigo 29 1 2 Towong 12 1 1 Wodonga 43 6 2 Hume Total: 506 87 35
Reports across the region of demand for packages outstripping supply are backed up by the number of people on the electronic wait list; see Table 11 below. However the allocation of packages aligns with the commonwealth formula.
5 DH prepared by Planning and Development January 2010
19 Hume Region Integrated Aged Care Plan: Final Report
Table 11: Number of People on Package Wait List June 2010 IAP LGA CACPs EACH EACH D Central Hume Alpine 48 0 0 Benalla 23 4 1 Mansfield 6 1 0 Wangaratta 48 4 3 Total : 125 9 4 Goulburn Valley Gt Shepparton 61 5 11 Moira 19 6 3 Strathbogie 3 1 1 Total: 83 12 15 Lower Hume Mitchell 9 1 0 Murrindindi 10 3 2 Total: 19 4 2 Upper Hume Indigo 19 0 0 Towong 8 1 4 Wodonga 31 10 6 Total: 58 11 10 Hume Total: 285 36 31
ACAS Clients The Aged Care Assessment Services eligible population is all people aged 70 or over plus Aboriginal and Torres Strait Islanders aged 50 – 69. The number of clients assessed by the ACAS per 1000 eligible population in Hume ranged from 72.5 in Indigo to 116.1 in Wangaratta for the period 2007 - 2008. The regional indicator for Hume is 97.7 which is the second highest in the state; Loddon Mallee Region has the highest indicator at 111. The lowest regional indicator is Gippsland with a rate of 70.4.6
The above data is based on individuals assessed (i.e. not the number of assessments) and on referrals (i.e. not completed assessments). In Hume and particularly Wangaratta, the numbers are high because there is a relatively high rate of referral in comparison to the size of the target group (e.g. Wangaratta had the 6th highest referral rate in the state in 2007-08 and it was higher than the state average). This suggests the ACAS in the area has a high community profile and people know to access the ACAS service. Also the Hume ACAS does not tend to assess people more than once in a year (they had the lowest rate of reassessment of any ACAS in the state in 2007-08) and there is a low rate of non-target-group referrals (e.g. the proportion of referrals of people aged < 70 was lower than the state average) which means the referrals are appropriate.7
It should be noted that Indigo is also being serviced by Greater Southern ACAS in NSW, so these assessments are not reflected in the above table.
Aged Care Planning Framework The published national planning benchmark for aged care is to achieve 113 aged care places per 1000 people aged 70 years and over. These places should be made up of 88 residential places (44 low care and 44 high care) and 25 community care places (21 low care {CACPS} and 4 high care {EACH and EACH D}.
6 DH Prepared by Planning and Analysis January 2010 7 LaTrobe University August 2010
20 Hume Region Integrated Aged Care Plan: Final Report
Table 12: Aged Care Residential Places at June 2009 High Care Low Care IAP LGA 2011 Bench Allo- Oper’ Oper’ Allo- Oper’ Oper’ Under/Over 70 + mark cated nal BM cated nal BM BM. Oper Pop. (BM) status status High/Low care Central Alpine 2,009 88 95 95 7 60 60 -28 -21 Hume Benalla 2,253 99 73 73 -26 95 95 -4 -30 Mansfield 1,009 44 30 30 -14 42 42 -2 -16 Wang. 3,729 164 160 152 -12 174 174 10 -2 Goulburn Gt Shep. 6,832 301 339 282 -19 387 357 56 37 Valley Moira 4,379 193 150 150 -43 233 233 40 -3 Strathbogie 1,670 73 71 62 -11 99 95 22 11 Lower Mitchell 2,742 121 145 90 -31 174 116 -5 -36 Hume Murrindindi 1,539 68 50 50 -18 75 65 -3 -21 Upper Indigo 1,747 77 106 100 23 94 82 5 28 Hume Towong 1,012 45 39 39 -6 64 64 19 13 Wodonga 3,073 135 155 115 -20 125 125 -10 -30 HUME 31,994 1,408 1,413 1,238 -170 1622 1508 100 70 Department of Health – Aged Care Branch
As shown in Table 12, many areas within Hume including Benalla, Mansfield, Moira, Murrindindi and Towong are below the ratio for allocation of high care places. In Wangaratta, Gt Shepparton, Strathbogie, Mitchell and Wodonga allocated places are not yet operational so these areas are also below the benchmark with an overall shortfall of 170 operational high care places in Hume although the allocation is slightly above the benchmark. With the trend for older people to remain at home as long as possible, combined with population projections in the 65-84 and 85 plus age cohorts (Chart 1 page 13) for Hume, the pressure on access to high care residential places will increase significantly and the need to make operational all allocated high care places is urgent.
For operational low care places Alpine and to a lesser extent Benalla, Mansfield, Mitchell, Murrindindi and Wodonga are below the benchmark but overall there are 100 operational low care places over the benchmark in Hume although the allocation of low care places is 214 over the benchmark. When operational high and low care residential places are combined Alpine, Benalla, Mansfield. Mitchell, Murrindindi and Wodonga are below the benchmark.
The policy of “ageing in place” (i.e. enabling a resident who enters a place for low care, to remain in that place if their needs become high care) further changes the actual operational use of the allocated place. It was reported that it is not always possible to follow this policy because of the inability to address the needs of high care clients and maintain occupational health and safety standards due to the fabric of some low care facilities in Hume.
During consultations for the Plan there was discussion about vacancies in some residential care facilities and interest in converting some residential care places to community care packages as this was the community preference. In general there is state government support for this strategy.
Of the 147,000 people in permanent residential care across Australia at June 2009, 76 percent received high care and 59 percent were aged over 85 years. The proportion of permanent residents receiving high care has increased significantly over the last decade e.g. it was 58 percent in 1998.8The appropriateness of using the 70+ age cohort for the benchmark for planning purposes has been raised and it has been suggested that 85 years plus may be a more appropriate age cohort for the benchmark for planning allocation of aged care places.
The percentage of Public Sector aged care residential places across Hume region is 44 percent for high care and 20 percent for low care with 100 percent of high care places in Alpine, Mansfield, Murrindindi and Towong being in the Public Sector. There are no Public Sector high or low care residential care places in Strathbogie and Wodonga.
8 AIHW 2008 21 Hume Region Integrated Aged Care Plan: Final Report
3.3 Hume Region Aged Care Service System The following diagram represents an overview of the numerous organizations that provide a range of aged care programs in Hume Region. These include: Fifty–two HACC providers of which 13 are designated HACC assessment services (HAS), thirteen- aged care package providers, Four carer respite services; Two ACAS and two psycho- geriatric assessment services and: Fifty-five residential aged care services and two pension only Supported Residential services. Sub and regional services tend to have their main office in Shepparton or Wangaratta and staff travel across the region to provide services. The grid shows a larger number of services in the Goulburn Valley (3 LGA) and Central Hume (4 LGA) catchments.
Lower Hume Central Hume 1. Darlingford NH, Blue Cross Willowmeade; Kilmore DH; Seymour DH; Seymour EC; High Dependence 1. St Johns; Rangeview; Alkoomi; Cooinda; Alpine Health; Benalla DH; Yea DH; Calendula Mansfield DH; NE Health 2. Seymour Hospital; Kilmore DH; Alexandra DH; Yea DH 2. NE Health Wangaratta, Benalla HS, Alpine Health; NE Health Kerford Unit, Mansfield DH 3. GV Health; NE Health; Rumbalara; City of Gt Shepparton. Murrindindi Shire; Villa 3. Alpine Health; NE Health; GV Health; Rumbalara; RCOW; Villa Maria; Maria; Benetas; Baptcare Uniting Care 1. High 4. Darlingford NH, Blue Cross Willowmeade, Kellock Lodge; Kilmore DH; Yea DH; Care St Catherine‟s; St Johns; Rangeview; Alkoomi; Cooinda; Alpine Health; Calendula Mansfield DH; Bentley Wood 5. GV ACAS, HAS, Aged Psychiatric Assessment & Treatment Team 2. 4. NE ACAS, HAS, NE Health Aged Psychiatric Assessment & Treatment Acute Team 6. Villa Maria- Carer Respite Centre and Carelink 5. Villa Maria- Carer Respite Centre and Carelink, Uniting Care Flexible 3. Packages Respite Neil Stuart House, Upper Murray Family Care 7. Nil pension only SRS 6. Nil pension only SRS 8. The Elms Village, Currie Park 4. Low care 7. Homestead Life 9. Murrindindi Shire, Mitchell CHS, Seymour Hospital CRC; RAHT 8. City of Wangaratta; Shires of Alpine, Mansfield & Benalla; Wangaratta RSL DVA Day Club, NE Health CRC; RAHT 10..Mitchell CHS; Murrindindi Shire; Carelink; Deaf Access; Vision Australia 5. Assessment 10 Benalla HS; Ovens & King CHS; Carelink; Deaf Access; Vision Australia; Alzheimer‟s Australia Alzheimers Australia; City of Wangaratta; Shires: Alpine, Mansfield, Benalla Goulburn Valley 6. Respite Care, Upper Hume 1. Mercy Place; Ave Maria; Cobram DH;GV Health; Numurkah HS; Violet Town BN; Carer Support 1. Indigo Nth Health; Bupa, The Grange;; Beechworth HS; Nagambie Hosp; Nathalia DH; Yarrawonga HS; Bentley Wood; Euroa Health; Tallangatta HS; Upper Murray H&CS; Westmont Homestead; Shepparton Multicultural ACF; Shepparton Retirement Villages Yackandandah BN 2. Goulburn Valley Health; Numurkah District HS; Nathalia DH; Cobram District 7. Supported 2. Albury Wodonga Health; Upper Murray H&CS; Walwa BN; Hospital; Shepparton Private, Violet Town BN, Euroa Health, Nagambie Hosp Residential Services Tallangatta HS; Murray Valley Private; Yackandandah BN; MH Inpatient GV Health Wanyarra Unit Beechworth HS; Yarrawonga HS 3.Cobram DH; GV Health; NE Health; Rumbalara;; City of Gt Shepparton, RCOW; 8. Group housing/Retirement 3. NE Health; GV Health; Rumbalara; RCOW; Villa Maria; UMH&CS, Villa Maria; Benetas villages/Independent Living Units Baptcare 4.Ottrey Lodge;; Mercy Place; Ave Maria; Maloga; GV Health; Numurkah HS; Violet 4. Westmont Homestead; The Grange; Beechworth HS; Indigo Nth Town BN, Nagambie Hosp; Nathalia DH; Yarrawonga HS; Bentley Wood; Euroa Health; Tallangatta HS; Upper Murray H&CS; Yarrawonga HS; 9. In-home services & Health; Shepparton Multicultural ACF; Shepparton Retirement Villages Yackandandah BN AH & CRC 5.GV ACAS, HAS, GV Health Aged Psychiatric Assessment & Treatment Team 5. NE ACAS, HAS; NE Health Aged Psychiatric Assessment & Treatment Team 6.Villa Maria- Carer Respite Centre and Carelink, GV Health-Una House, Southern 10. Information, Active Ageing, Early 6. Villa Maria- Carer Respite Centre and Carelink, Upper Murray Cross Ave Maria Village Respite, Rumbalara Respite, GV Family Care Intervention & Health Promotion Family Care 7. Moira Shire Lodge Cobram 7. Delaney Manor Bright 8.Oasis Village Cobram, Ave Maria Village, Harmony Village, Masonic Court 8. UMH&CS, Indigo North Health 9.Gt Shep CC, Moira HC Alliance, Strathbogie Shire, Shepparton RSL DVA Day Club, 9. Tallangatta HS, UMH&CS, Indigo Shire and City of Wodonga, High Independence Day Therapy Centre Euroa and Violet Town, GV Health CRC, RAHT Albury Wodonga Health CRC, Indigo Nth Health; RAHT 10.Carelink; Deaf Access; Vision Australia Alzheimer‟s Australia; GV CHS; RIAC; Gt 10.UMH&CS; Tallangatta HS, Indigo North Health, Indigo Shire and Shep CC, Moira HC Alliance, Strathbogie Shire City of Wodonga; DAIS Gateway CHS; Carelink; Deaf Access; Vision Aust Alzheimer‟s Aust Region wide services are in Italics
22 Hume Region Integrated Aged Care Plan: Final Report
4 Major Findings and Themes
4.1 Introduction to Findings and Themes
A summary of key gap analysis findings and theses is provided in this section which comprises: 1. An overview of key population and health factors which require consideration in the development of the Plan (3.2) 2. A summary of the service provider Survey (Appendix 2) 3. A summary of stakeholder input regarding gaps, issues and priorities for the Hume Region (4.3). 132 service providers were consulted via a series of forums* in twelve locations. The full list of stakeholders is provided in Appendix 3 with the detailed consultation findings provided in Appendix 4. 4. A summary grid of stakeholder consultation findings in relation to key policy directions (Appendix 5) 5. A summary of findings from two consultation forums with consumers held in Corryong and Shepparton (4.4)
*Forums were held in twelve locations (Alexandra, Benalla, Bright, Cobram, Corryong, Euroa, Kilmore, Mansfield, Rutherglen, Shepparton, Wangaratta and Wodonga).
4.2 Key Population and Health Factors
Population Hume averages 13 percent (and Victoria 11 percent) of people aged over
Higher % of 70+ pop 70. In Alpine, Benalla, Strathbogie and Towong this figure is closer to 20 and 85+ who live percent. Benalla, Strathbogie and Towong also house the largest alone in some areas percentages (of overall population) of people aged 85 plus who live alone.
Socio economic Veterans holding Gold/White cards comprise over 15% of the 70 and over
Areas of low SEIFA. population in Moira, Towong, Wodonga, Benalla and Strathbogie Benalla, Greater Shepparton & Strathbogie have the lowest SEIFA (Hume) Lower Hume ^reported issue of More people reported issues of food security (2007) in Hume (7.3% of the food security population) than Victoria (6%). In Hume the areas most affected are all of Lower Hume (Murrindindi 11.5% and Mitchell 8.7%) and Benalla (7.6%). Health & Disability People residing in Lower Hume and Greater Shepparton were less likely to
Increasing dementia report their health as very good or excellent than the whole of Hume & Vic. Increasing rates of dementia (over 4,000 in Hume by 2016) Significant ACSC for Higher ACSC rates for diabetes complications (Lower Hume significantly diabetes in Lower Hume higher); COPD and congestive cardiac failure.
Strathbogie and Benalla in particular house significant percentages of older people and older people who live alone and when this is combined with the issues of low SEIFA for both areas and the challenging geography in Strathbogie, the two areas can be seen to have strong elements of disadvantage.
Lower Hume and Greater Shepparton are significant in that they show financial disadvantage using food security measures plus report a perception of poorer health. This highlights a need here for greater emphasis on early intervention (EI) and health promotion (HP) among other things.
Health wise, the increasing rates of dementia in Hume combined with lack of access to mental health assessment, services and support is a major issue and requires urgent resource planning to increase capacity, especially in light of burden of disease projections where dementia will rapidly become one of the major diseases in the next ten years.
High rates of complications from diabetes and COPD in the Region, especially Lower Hume, points to the immediate need to develop, coordinate and target early intervention and health promotion approaches addressing these health concerns.
23 Hume Region Integrated Aged Care Plan: Final Report
4.3 Stakeholder Consultation Findings Summary
Policy and background information was presented in each of the stakeholder forums with findings from the service provider survey used as a basis to discuss participant views on the key gaps, issues and
priorities for the Hume Region, in the development of integrated aged care services. A summary of findings and themes from the forums are grouped below. (Note a full detailed version of consultation information is available in Appendix 4).
It is noted that many of the service provider issues relate not only to local areas but right across the Region. This suggests key uniform mechanisms need to be developed and bedded down as a strong foundation to facilitate a collaborative working approach locally and regionally, to support integrated
aged care service planning, development and delivery right across the Region.
A key issue cited by stakeholders is the current lack of joint service system planning. What
Lack of joint occurs is largely uncoordinated and often not inclusive of all stakeholders, which is a particular service system issue where services will be directly impacted by service system changes or developments and planning, service may not fully reflect community needs. fragmentation and multiple This lack of partnership and uniform approach to service planning and development is, in part, providers responsible for another key issue, that of service fragmentation and a lack of service not integrated coordination. Similarly expressed by carers in the following section, there is a view that there are too many different services which are not well linked and have different criteria for access (even if Lack of they are the same service type). Workers reported that it is difficult to „keep up with what services service/care coordination are available‟.
Many staff are time poor and unable to engage in processes to support better linkage and communication between agencies. Service provider network and case conference meetings continue in some locations but many that did exist have ceased over the past ten years, often
triggered by client information privacy concerns. There is broad support from stakeholders to develop better partnerships and communication across services to achieve greater service
coordination.
Of particular concern to most stakeholders are the large number of providers and fragmentation of packages (CACP and EACH). Access can be inequitable, some areas have an overlap of case
Package Issues managers while others have longer waiting lists for a package. There is an opportunity to explore various models and to better coordinate with HACC in home service providers. Concern was also widespread about the lack of funds per CACP to adequately support consumers at home; in some
instances consumers were better supported by HACC services. This aspect simply added to the frustration with the CACP model and commonwealth application/allocation process.
System Service fragmentation is exacerbated by a number of ‘disconnects’, for example „GP‟s are not disconnects well linked into health service system and are only minimally involved in care coordination;
hospital discharge planning continues to be an issue in a few areas. Poor IT operating A number of system issues impact on the capacity of organisations to improve communication systems and support better client transitions. For example: IT operating systems which do not connect,
have limited or no capacity for e referral, and limited understanding and uptake of the SCTT. Issues re consumer This all impacts significantly on the capacity of consumers to access, navigate and transition access, across services. navigation and transitions Service system disconnects and differing criteria also impact on the capacity of consumers to
Maintaining maintain social connections with past friendship groups when they are allocated a package or social relocate to residential care. Some services are attempting to keep consumers in contact with connections - significant need friendship groups and provide a person centred approach, post relocation, however this is challenging.
24 Hume Region Integrated Aged Care Plan: Final Report
Limited EI & Maintaining and promoting a good quality of health is well understood to have a key role in HP, not successful and positive ageing. To date there is limited development of Early Intervention practice integrated, impact on and Active Service Model approaches targeted to older people in Hume. Some stakeholders ASM stated there is a need for a coordinated approach with opportunities for service providers to work approach together and collaborate on developing and implementing strategies.
Despite the best intentions of most stakeholders, the issues and complexities noted above impact Lack of person on the capacity and focus of service providers to deliver person centred approaches, the centeredness development of which requires supportive systems, resources and practices.
The low profile and impact of Primary Care Partnerships (PCP) emerged as part of the dilemma Low PCP regarding some of the above issues. Future potential roles and action by PCP member agencies profile and impact that were identified included promotion and understanding of Service Coordination, the SCTT, e referral, intake assessment practice, bringing people together, promoting EI and HP.
Similar to many other regional areas, client access to (appropriate and sometimes assisted) Transport – transport is a key issue in the delivery of aged care services. A few new projects and approaches some projects, cost are currently attempting to address some transport gaps; however it remains a significant issue, significant particularly cost related.
Stakeholders frequently commented on gaps in mental health services. These included a long Gaps in mental wait for dementia assessment (CADMS have adopted an early intervention approach – as a result health, there is the issue of where to refer older people who may have more established disease) and dementia assessment, gaps in residential care for people with dementia (including younger people) and managing care and behavioural issues. This issue is severely compounded by a lack of geriatricians and psycho- support geriatricians working in the Region.
Ageing There is an issue regarding lack of appropriate services now and into the future, especially carers; accommodation, for adults with a disability who are still being supported and cared for by their younger people with ageing parents and younger adults with dementia. These stressful consumer and carer disabilities/d predicaments were raised by service providers and carers on numerous occasions. ementia
Limited local service provision and a low level of service outreach to Strathbogie, is an issue as this is a location without a publicly funded health service, and has a sparse and scattered Strathbogie population with a high percentage of older people aged 70 years and over, and a high percentage of its population aged 85 years plus lives alone. Plus Strathbogie has a low SEIFA score,
indicating an area of low socio economic status which can correlate with poorer health outcomes for people in this part of the Region.
The need for access to public Oral Health services in Lower Hume and more remote areas such as Corryong was identified in consultations.
Significant The complexities of providing aged care services in the Hume Region are compounded by workforce significant workforce issues which include: issues – . An ageing workforce and a lack of younger workers to fill positions across the service system. ageing, allied health, GPs, The physical nature of some home care roles is also increasingly difficult for ageing workers medical . An ageing volunteer pool – with limited numbers of younger people to step into these roles specialists, reliance on . Large gaps in allied health particularly occupational therapy and physiotherapy and in some ageing areas social work. This can translate to significant waiting times for community based volunteers services and impacts on the capacity to deliver early intervention and active service
approaches. Rehabilitation services are being asked to fill the gap in some areas. . A lack of GPs is a critical issue. This leads to significant impacts on: the capacity to
medically staff hospital emergency departments; access to GPs by residential care facilities; clients being able to access a local trusted GP who understands their medical history and; compounds the issue of GP service system disconnects . Lack of Specialists such as geriatricians, psycho-geriatricians, vision, and stoma therapy.
25 Hume Region Integrated Aged Care Plan: Final Report
4.4 Consumer and Carer Consultation Findings Summary
The consumers and carers consulted showed meaningful links to their local communities and were well able to articulate their views on the current aged care service system, what worked well and the key issues and complexities they faced in their lives and in dealing with services. These are grouped according to six broad themes.
Support Most wished they could remain independent and not require help or services. As independence such being in a situation where they are forced to ask for help is difficult for many.
Both consumers and carers stressed the importance of social support services (for Social example PAG programs attended by the person they are caring for) as making a connectedness significant difference in both their lives. Being part of a Carer‟s Group provides them with much needed support, contacts and access to service information.
Information A common issue is one of access to up to date information regarding available and access services. Use of acronyms by agencies makes understanding the system more complex. Carers provided a view of how access to information could be improved: . „Information points‟ in GP Practices, local pharmacies, local notice boards . Telephone access – a single phone number . Advocacy service dedicated to older people . Clear language without acronyms . A user friendly community services guide.
Service Similar to service providers, consumers and carers were of the view that there are fragmentation „too many services and they are not well integrated‟. This resulted in poor communication across services (an issue not helped by frequent staff turnover). One carer commented „I need to keep repeating my story.‟
Transport Accessing public transport is complex when trying to match available services with barriers medical appointment times. One commented that „the local bus is unable to get me to the first appointment of the day.‟ Service system Consumers and carers commented on four other service system issues issues - lack . A perceived inflexibility in the delivery of home maintenance and it not being of person tailored to the range of consumer needs to support them living at home centred . A „conservative approach to risk management‟ taken by some services. For approach example group outings were cancelled by a new manager who decided there were too many walking frames to safely transport by bus . Case management: some cited the impact of frequent staff turnover and infrequent contact by the case manager as (negatively) affecting the value of the service to them while others were not clear of the role (do I have one?) or I am „still waiting for one‟ . In some areas, the only option for younger people with a disability who require residential care was inappropriate nursing homes.
Community Corryong consumers and carers were pleased to be involved in community groups engagement and projects which were working towards building services: . The Community Liaison Group – community development and projects . Working with the NE transport group to get more local transport.
26 Hume Region Integrated Aged Care Plan: Final Report
5 Hume Integrated Aged Care Plan
5.1 Integrated Planning Principles
Adapted planning principles from „Care in Your Community‟9 provide a guide to an integrated planning approach for the development of this Plan and underpin the following Recommendations and Action Plan. The principles are:
The best place to provide support – community based where safe and cost effective, services integrated to improve accessibility, availability and quality of care (mechanism could be collocation or clustering).
Together we do better – promotes partnerships, and a population health approach which recognises social determinants of health and prioritises health promotion and illness prevention. Service users, carers, families will be empowered and supported to take more responsibility, increase self-management and independence where possible.
A better service support experience – person or family centred, focusing on needs of the whole person; equitable, timely and appropriate access to support and services regardless of where they live; based on evidence, planned for an area based on needs of a defined population; service users information will be consistently managed and coordinated across services to protect privacy, support integrated services and continuity of care; funding and accountability for delivery of quality services will support the provision of the right support at the right time in the right place.
A better place to work – workforce will be configured to deliver integrated aged care services and support; workforce will be flexible and multi skilled for a variety of settings including community and home based; consolidation of service delivery in community based settings will support improved working conditions, efficient use of workforce and better quality systems.
Technology to benefit people – consistent planned approach to developing the infrastructure of integrated aged care support, including ICT, standard tools, protocols, facilities and equipment; ICT will be used to better inform people about available services, how to access these services, plus positive ageing and how to contribute to their own health and well being.
The following Recommendations, Strategies and Actions have been reached through consideration and analysis of all sources of data and information documented in this Report, the Project Steering Group and Key Stakeholders workshop, and discussion and guidance from the Project Steering Committee. Appendix 6 provides a list of workshop participants and Appendix 7 outlines the key issues addressed at the workshop.
9 Care in Your Community: A planning framework for integrated ambulatory health care DH 2006
27 Hume Region Integrated Aged Care Plan: Final Report
5.2 Recommendations
To achieve integrated and person centred aged care services in Hume Region the following five recommendations are provided:
Recommendation 1: Promote effective collaboration between aged care providers through further development of Hume Region‟s partnership approaches, planning structures and processes.
Recommendation 2: Improve mechanisms to provide and share information among providers and ensure service information is accessible to consumers.
Recommendation 3: Facilitate innovative approaches to building and maintaining capacity and capability in the aged care workforce to meet current and projected demand.
Recommendation 4: Promote innovative and flexible service models to enable service providers to better respond to the needs of older people and their carers.
Recommendation 5: Promote health and well being for older people.
28 Hume Region Integrated Aged Care Plan: Final Report
5.3 Action Plan
Recommendation 1: Promote effective collaboration between aged care providers through further development of Hume Region‟s partnership approaches, planning structures and processes. Rationale: Limited, collaborative aged care service planning; cultural divide between the aged care sectors and need to build a shared vision of person-centred care; low profile and impact of PCPs in aged care; limited local networking and service coordination meetings; over past decade decrease in case conferencing due to perceived „privacy‟ issues; no structure for integrated aged care service planning involving stakeholders across the region; government policy tensions for providers with „partnerships‟ versus „competition‟ policy frameworks. Key Strategies Actions Responsibility Timing Establish a . Establish a Hume aged care planning structure including: IACP Steering 2010 structure to o Hume Health Services Partnership (HHSP) as the authorising environment Committee and support o Establishment of an Aged Care Collaborative as a working group of the HHSP with representation from HHSP collaboration key stakeholders (see Figure 2, o PCP members to form 4 sub regional groups for sub regional planning, development & coordination page iii) o Local government area networking and coordination meetings for information sharing, service coordination and care planning o Multi agency meetings for individual consumer care planning where several agencies involved and complex consumer issues . Build links across the structure to support information sharing, build common philosophies, understanding, knowledge and collaboration within and between agencies
Promote active . Target key aged care providers e.g. residential care (public and private), community and primary care, HHSP 2010 engagement of GPs/Divisions, health services/hospitals, Local government and NGOs, to become members of the Aged Care stakeholders Collaborative and/or PCP sub-regional groups . Identify opportunities to develop/support existing local community aged care reference groups to inform service planning and development
Develop a shared . Agree on a vision for Hume Region aged care HHSP and Aged 2010 vision, values . Agree the values that underpin the vision including a person centred approach Care and approach . Adopt a population health approach with a focus on health and wellbeing, evidence and needs, innovation and Collaborative best practice
Promote a Hume . The Aged Care Collaborative to identify opportunities for shared strategic planning Aged Care 2010 - aged care . PCP aged care groups to focus on shared service planning, local networking and service coordination Collaborative; ongoing planning structure . Local government and multi agency groups to focus on a shared approach to care planning, information sharing PCPs; LGAs; and service coordination. Agencies
29
Hume Region Integrated Aged Care Plan: Final Report
Recommendation 2. Improve mechanisms to provide and share information among providers and ensure service information is accessible to consumers. Rationale: Consumers and service providers expressed strong concern about access to information and referral; consumers unaware of where and how to get aged care service information and services; service providers less aware than used to be of the range of services and service providers; current service information and referral processes generally inconsistent; poor IT connectivity. Key Strategies Actions Responsibility Timing Promote service . PCP aged care groups to develop mechanisms to support agencies to provide: PCPs; 2010 - information and o Service information to consumers and service providers and Aged Care ongoing referral at all o Referral support for consumers to other services Collaborative service locations . Promote and support e - referral and expansion of IT connectivity . Promote and support agencies to using and updating the Human Services Directory as the main information tool
Support new . Pilot potential options e.g. Older Persons Information Hub/s model which would provide information to Aged Care 2011 - approaches to consumers and service providers; Integrate and promote locally, the Carelink one telephone number and Collaborative; ongoing promote aged service; Aged Care Expos across Hume in locations such as Seymour, Shepparton, Wangaratta and Wodonga; PCPs; LGAs; care information Local government area provider networking and coordination meetings for information sharing, service Agencies dissemination coordination and care planning – as per Recommendation 1 . Hume key stakeholders proactively engage with the new commonwealth initiative Primary Health Care Organisations or Medicare Locals
Improve ICT . Identify and support initiatives to increase and improve the use of technology in the aged care sector to Aged Care 2011 strategies enhance communication and access to information e.g. increased use of SCTT tool, records management; care Collaborative; planning. PCPs
30
Hume Region Integrated Aged Care Plan: Final Report
Recommendation 3. Facilitate innovative approaches to building and maintaining capacity and capability in the aged care workforce to meet current and projected demand. Rationale: Complexities of providing aged care services in the Region is compounded by an ageing workforce; an ageing volunteer pool; lack of Specialists; and the lack of GPs and allied health staff. Key Strategies Actions Responsibility Timing Develop a Hume . The Aged Care Collaborative to lead the development of a Workforce Strategy as a priority. Aged Care 2011 Aged Care . Identify the priority areas to be addressed in a Workforce Strategy e.g. specialist aged care services; culture & Collaborative Workforce practice; recruitment & retention; training & development; innovative alternatives; support & supervision; service Strategy models & models of care . Identify and evaluate the merits of other workforce initiatives (e.g. Wodonga and Wangaratta workforce projects; John Richards Rural Aged Care Research LaTrobe University Wodonga work on the ageing workforce; Hume ICDM Workforce Plan
Invest in the . The Workforce Strategy will inform training and development opportunities and investment across the aged care Aged Care 2011- existing sector e.g. HACC Training Calendar ; EIiCDM Workforce Calendar; annual funding rounds; agency T&D priorities; Collaborative; ongoing workforce TAFE courses; agency initiatives Agencies . Explore a range of mechanisms to support access to staff training and development e.g. traineeships, scholarships, paid fees, books; sponsorship; agencies pool/share resources to expand opportunities; commonwealth government funding/scholarship initiatives and opportunities for RNs to train as Nurse Practitioners . Promote investment and participation at all levels in changing the cultural/philosophical paradigm in aged care e.g. the continued roll out of the „Health Coaching‟ course; engagement with the Active Service Model industry project officer; support of the Aged Care Collaborative
Increase access . Develop options to recruit and/or train specialist aged care service providers e.g. gerontology; neuropsychiatry; Aged Care 2011 - to Specialist CNP; continence; wound management; dementia and delirium Collaborative; ongoing Aged Care . Consider innovative approaches to meeting specialist care needs e.g. Nurse Practitioners, use of medical Agencies Services technology (telemedicine/telehealth) . Develop options to better invest in clinical expertise and leadership.
31
Hume Region Integrated Aged Care Plan: Final Report
Recommendation 4. Promote innovative and flexible service models to enable service providers to better respond to the needs of older people and their carers. Rationale: Current funding and policy approaches can work against the delivery of person-centred care e.g. there is lack of flexibility in service delivery; there are multiple providers funded by different government agencies resulting in confusion for consumers, carers and other providers. There are gaps in access to specialist services and in provision of services to some communities. Key Strategies Actions Responsibility Timing Advocate for and . Support opportunities for: DH; Aged Care 2011 - trial innovative o Innovative and flexible funding models that enable a more person centred approach and focus on Collaborative; ongoing and flexible consumer outcomes HHSP; service models o An expansion of the MPS model to other small rural health services Agencies and funding o Containment/reduction of package care providers for Hume and promotion of best practice models that facilitate consumer service transitions (e.g. through allocations to Health Services and Local government) o Innovative disability accommodation options in support of ageing parents/carers with a disabled adult (e.g. KeyRing model as described in Appendix 8)
Promote best . Support opportunities to pilot innovative and flexible service transition models that address the interface DH; Aged Care 2011 - practice between different services such as acute, sub-acute, rehabilitation, packaged care, home care, residential care, Collaborative; ongoing and palliative care HHSP; Agencies . Investigate innovative GP access models (e.g. multiple residential care organisations engaging a GP/clinic; Nurse Practitioner employed across public/private residential care; GP Practice Nurse involvement with care plan) . Support opportunities to increase the emphasis on service quality and innovation in residential care based on a person centred approach and consumer outcomes . Explore options such as centre based, at home, and private allied health to develop flexible, innovative allied health service models, including support for the ASM and outreach to remote areas of Hume and use of Allied Health Assistants under supervision of the clinician . Consider the development of a framework for understanding Early Intervention (EI) approaches and develop EI models (e.g. community based, home based, and workplace) . Encourage mechanisms for sharing and showcasing Hume best practice and innovative & flexible service models
Support new . Identify and promote opportunities and incentives for the involvement of GPs and other clinicians in service DH; Aged Care 2011 – services to meet planning and development Collaborative; ongoing identified gaps . Improve access to CADMS, ACAS and other identified specialist aged cares services across Hume HHSP . Identify opportunities to improve access to integrated aged care services in Strathbogie Shire . Support the implementation of the recommendations of the HACC DNS and Allied Health Reviews.
32
Hume Region Integrated Aged Care Plan: Final Report
Recommendation 5: Promote health and well being for older people. Rationale: Health Promotion (HP) for older people generally underdeveloped across the region and usually not coordinated; desire by service providers to work together on this area; low profile and impact of PCPs in aged care HP; consumers and carers stressed the importance of social support and connections in their lives. Key Strategies Actions Responsibility Timing Develop a Hume . Develop a Health and Wellbeing Plan focussed on older people (e.g. promote health and wellbeing for older PCPs; Aged Care 2010 - 2011 Older Persons‟ people regardless of where they live –the community or residential care; guide and inform decision making; Collaborative; Health and support a social model of health including aspects such as transport and housing; support innovative Agencies Wellbeing Plan approaches and pilots such as Cooinda Health and Wellbeing program, Well for Life)
Link HP planning . Promote a collaborative agency approach to HP for older people (e.g. building on the existing PCP HP Plans PCPs; Agencies 2010 - and localised and Local government Positive Ageing Plans; involving key service providers to coordinate locally focussed ongoing approaches plans, funding and activities within a PCP area; working with John Richards Rural Aged Care Research LaTrobe University Wodonga, to support an evidence base and evaluation of coordinated HP approaches)
Engage with local . Include older people, carers and relevant organisations in HP planning and delivery (e.g. through local PCPs; Agencies 2010 - community organisations such as Probus, U3A, Rotary, Senior Citizens Clubs, CWA, RSL, Churches, Carer Groups; ongoing groups and involvement of older people in HP community events, planning forums and meetings such as Corryong consumers Community Needs Study; Aged Care Expos; Community Reference Groups)
Invest in social . Promote and expand social connections through provision of affordable, accessible, and flexible opportunities for Aged Care 2010 - connections for socialisation Collaborative; DH; ongoing older people . Seek opportunities to improve infrastructure and service flexibility to support social connectedness (e.g. CACPs Agencies consumers attending PAGS; transport pilots) . Undertake research into and pilot new and innovative service models for social connections both in the community and in residential aged care.
33
Hume Region Integrated Aged Care Plan: Final Report
Appendix 1: Package Providers by LGA
Cobram
UMH&CS
Baptcare GV Health
34
Hume Region Integrated Aged Care Plan: Final Report
Appendix 2: Survey Findings Summary
Service providers were invited to complete a survey which was used as a basis to discuss participant views on the key gaps, issues and priorities for the Hume Region. 209 surveys were distributed and 96 responses were received, including some from residential care services both public and private. Of the survey respondents: . 69% provided community services, 49% health services, 47% residential care (NB some organisations provided more than one service) . 62% provided HACC, 44% provided residential care, 36% included health promotion in their service suite . 68% are involved in partnerships/joint projects . Referrals (to theses organisations) came mainly from hospitals and family, followed GP‟s and ACAS . The Service Coordination Tool templates (SCTT) were always used by 53% of the survey respondents, with only 6% always using e- referral
Surveys asked respondents to rate (scale of 1-8 with 8 being strongly agree and 1 being strongly disagree) their agreement with the following statements in relation to the area in which their agency provides services. Charts 4 to 10 summarise these responses. . Older people, their families and service providers are well informed about aged care services. . Early intervention/Health promotion practice is well developed. . Aged care services are available when people need to use them. . Aged care services work well together to meet clients/carers needs. . Older peoples‟ needs are well met in our community. . It is difficult to provide service in/to some parts of our catchment. . It is difficult to attract and retain suitably qualified staff.
Survey Charts
Chart4: Older people, their families and service providers are well informed about aged care services.
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
2.5 3 3.5 4 4.5 5 5.5 6
35 Hume Region Integrated Aged Care Plan: Final Report
Chart 5: Early Intervention/health promotion practice is well developed
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
2.5 3 3.5 4 4.5 5 5.5 6
Chart 6: Aged care services are available when people need to use them
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
2.5 3 3.5 4 4.5 5 5.5 6
36 Hume Region Integrated Aged Care Plan: Final Report
Chart 7: Aged care services work well together to meet clients/carers needs
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
2.5 3 3.5 4 4.5 5 5.5 6
Chart 8: Older peoples needs are well met in our community
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
2.5 3 3.5 4 4.5 5 5.5 6
37 Hume Region Integrated Aged Care Plan: Final Report
Chart 9: It is difficult to provide services in /to some parts of our catchment
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
3 3.5 4 4.5 5 5.5 6 6.5 7
Chart 10: It is difficult to attract and retain suitably qualified staff
Benalla
Wang
Alpine
Mansfield
Tow ong
Wodonga
Indigo
Moira
Gt Shep
Strathbogie
Murrindindi
Mitchell
3 3.5 4 4.5 5 5.5 6 6.5 7
38 Hume Region Integrated Aged Care Plan: Final Report
Written Responses
Surveys also asked respondents to provide written comments re the key issues and gaps facing aged care services in their area. These are grouped below:
. Workforce recruitment and retention plus an ageing workforce (all), Div 1 Nurses (Benalla), Workforce coordination (Wang) . Lack of capital funding . Need for flexible service funding to fill service gaps . Affordable fee for services for CACPs plus access to package care and issues of numerous providers . Access to: ˉ GPs for residential care services Central Hume ˉ GEM beds Alpine ˉ Low level psychogeriatric facilities Benalla ˉ Dementia care Mansfield ˉ Flexible respite (Benalla) Wangaratta ˉ Medical specialists ˉ Diversional therapy ˉ ACAS (Alpine) . Gaps in early intervention programs including assessment for dementia . Transport to access services/distance to travel to clients and cost in staff time . Limited Health promotion . Need for advocacy to support client access of complex service system.
. Capital and service funding including ACAS which recognises that services are required 365 days (all) . Workforce recruitment and retention especially allied health and outreach Goulburn Valley (GS), Nursing, Medical, Geriatrician, Dental, Optician, PCA, Exercise Greater instructors (Moira), Case Management (Strathbogie) Shepparton . Lack of bilingual workers (GS, Moira) Moria . Gaps in aged mental health including Psychogeriatricians, Geriatrician (GS) Strathbogie . Lack of early intervention programs and HP including those for CALD (GS, Moira).
. Workforce recruitment and retention particularly Allied Health . Shortage of bilingual workers (Murrindindi) . Lack of early intervention and Health Promotion programs (including those for CALD communities) . Lack of capital for building community/shared facilities . Issues of service funding, financial sustainability Lower Hume . Funding for consumables (for example wound dressings) Mitchell . Transport gaps including community transport for clients to access services Murrindindi . Significant distances for staff to travel to some clients . Access to Allied health services - community OT, Podiatry, Social Work . Access to GPs limited in some areas . Aged community understanding of service changes related to the ASM . Need to build knowledge of service system and how to navigate it – consumers and services plus clearly defined referral pathways.
39 Hume Region Integrated Aged Care Plan: Final Report
. Workforce recruitment and retention especially Allied Health (all), Certificate 3 ready applicants (Indigo), staff backup (Towong) . Gaps in Dementia care, Packaged care . Access to: ˉ Specialist services Doctors, ACAS, Oral Health, GEM beds, low level Psychogeriatric services (Towong) ˉ GEM beds, Slow Stream Rehab, low level Psychogeriatric facilities and care models and Dementia acute care, Packaged care (Wodonga) Upper Hume ˉ GPs for residential care services (all) Indigo . Service outreach . Gaps in early intervention programs including assessment for dementia Towing . Transport to access services/distance to travel to clients and cost in staff time Wodonga . Limited Health Promotion . Need for advocacy to support access to complex service system . Capital (including for MPS) plus flexible service funding . Impact of fee for services on value of CACPs, CACPs not keeping up with cost increases . Promoting client centered care including for Dementia clients . Transport to access services/distance to travel to clients & cost in time & $ . Assistance to navigate the complex service system . Communication between services including GPs.
40 Hume Region Integrated Aged Care Plan: Final Report
Appendix 3: Stakeholder Consultation List
132 Service providers and 27 Carers/consumers were consulted, plus government officers and management consultant
Euroa 25 March Lesley Fowler Strathbogie Shire Council Mary Bourke Strathbogie Shire Council Anne Egan Strathbogie Shire Council Kym Durance CEO Euroa Health Wendy Birch NUM Euroa Health Kilmore 25 March Tony Vivian EO Lower Hume PCP Felipe Rodriguez CEO Violet Town Bush Nursing Centre Toni Crowe GV Health ACAS Tracey Webster Mitchell CHS Sarah Every Mitchell CHS Barbara Moss Mitchell CHS Mel Markey Dianella Hostel Amanda Edwards Kilmore District Hospital Shepparton 13 April Maureen Flynn Uniting Care Goulburn NE Kerrie Reardon Villa Maria Leah Kateiva Villa Maria John Morris Ambulance Vic West Hume Carmel Smith Goulburn Valley Hospice Debbie Gook Hume Region ACAS – Shepparton Corey Mark Hume Region ACAS – Shepparton Teri Bennet-Meyer Gt Shepparton City Council Jason Watts Gt Shepparton City Council Sally Wright Outside Partners – consultant Julyan Howard GV Health District Nursing Service Sally Arthur GV Health Rehabilitation Unit Kate Fagan Vision Australia Rochelle Chandler Vision Australia Gayle Sammut GV Health Mg Allied Health Judy Dahlke Karingal Hostel CEO Julie Russell Numurkah District HS Nicole Gray Goulburn Valley PCP Kerry Rees OCP Pathways- Salvation Army Cobram 13 April Shirley Bourke Baptcare Hume Packages Sheridan Hicks Moira Healthcare Alliance Terry Welch Yarrawonga Dist Health Service Fiona Stevens Yarrawonga Dist Health Service Leigh Giffard Nathalia District Hospital Kris Andrews Nathalia District Hospital Pat West Cobram District Health Janet Shankland Cobram District Health Rutherglen 14 April Jenny Donnelly Integrated Health Services Project Officer Julie Kiroluch Deaf Access Vic Judith Barber NE Health Wangaratta Jane O’Bryne ACAS Ovens & King CHS
41 Hume Region Integrated Aged Care Plan: Final Report
Jen White ACAS Ovens & King CHS Ann-Marie Ellis Indigo North Health Inc Judy Dhosi Indigo North Health Inc Jenny Templeton Indigo North Health Inc Tammie Long Indigo North Health Inc Jo Kelly Indigo North Health Inc Pam Tobias Indigo North Health Inc Shirley Bourke Baptcare Hume Packages Carmel Ardern Baptcare Care Manager Wodonga 14 April Mick Crothers Ambulance Vic Upper Hume Lenore Rhodes Wodonga Hospital Kerry Strauch Vision Australia Vision Australia Glenn MacKinnon Disability Advocacy & Info Service (DAIS) Sheri Brooks Upper Murray Family Care Ruth Harris Upper Murray Family Care Susan Thomas Albury Wodonga Health Jacinta Flood Albury Wodonga Health Glenys Clark Indigo Shire Melissa Johnson Indigo Shire Elizabeth Mitchell Indigo Shire Belinda Johan City of Wodonga Karen City of Wodonga Jan Kowarzik Upper Murray Family Care Karyn O’Loughlin Albury Base Hospital Anne Duncan Albury Wodonga Health – Wodonga Hospital Maureen Maw ACAS OKCHS Grace Langmead ACAS OKCHS Lorraine MacDonald Albury Wodonga Regional GP Network Shirley Bourke Baptcare Hume Packages Corryong 15 April Mary-Anne Grunow Tallangatta Health Service Denise Gigliotti Tallangatta Health Service Sharon Nicholas Upper Hume Health and Community Services Maxine Brockfield Upper Hume Health and Community Services Mary Hoodless Upper Hume Health and Community Services Nic Martin Upper Hume Health and Community Services Martin Butcher Disability Access and Information Service Consumer /Carer Consultation Shepparton 12 April 21 Carers / Consumers Consumer /Carer Consultation Corryong 15 April 6 Consumers/carers Alexandra 20 April Sue McLaurin Murrindindi Shire Council Ann Hunter Murrindindi Shire Council Corrienne Nichols Murrindindi Shire Council Maurice Woodbarn Ambulance Vic S Hume Sue Sawyer Kellock Lodge Alexandra Inc Donna Walsh Kellock Lodge Alexandra Inc Fiona Mackey Darlingford Upper Goulburn Nursing Home Lorina Gray Yea Hospital Tanya McHugh Baptcare Mansfield 20 April Kerryn Brakels Mansfield District Hospital Peter Wiseman ACAS OKCHS
42 Hume Region Integrated Aged Care Plan: Final Report
Gayle Dougall Mansfield Shire Council Michelle Harmer Moira Healthcare Alliance Bright 21 April Colleen O’Connor Alpine Shire Council Karen Keat Alpine Shire Council Susan Pack Barwidgee Lodge Alpine Health Trevor Marshall Alpine Health Carolyn Prowse Alpine Health Gill Graves Alpine Health Annie Wilson ACAS OKCHS Fiona MacPhee ACAS OKCHS Tracey Corsini ACAS OKCHS Wangaratta 22 April Marie Marottta Department of Health Neil Duggan Department of Health Brian Fitzpatrick BentleyWood Aged care Narelle Woodall BentleyWood Aged care Colleen Sinclair Beechworth HS Margaret Turner Beechworth HS Jeanine Aughey Upper Murray Family Care Faye Flanigan Upper Murray Family Care Sandra Davidson Aged Mental Health Services NE Health Wangaratta Bobbie Titcher Moira HC Alliance Helen Johnson ACAS OKCHS Darren Morvell Rural City of Wangaratta Wendy Ross Rural City of Wangaratta Pam Ewert Goulburn Valley Health - GV Area MH Service Adele Lavis Goulburn Valley Health - GV Area MH Service Mandy Flynn Northeast Health Wangaratta Cathy Larkings Northeast Health Wangaratta Rhonda Lea Northeast Health Wangaratta Karen Gunner Northeast Health Wangaratta Emma Parsons Northeast Health Wangaratta Naomi McDonald Northeast Health Wangaratta Deb Eason Northeast Health Wangaratta Jenny Tobe CS NE Leanne Christie CS NE Neroli Raff O&K CHS Kaye Pink O&K CHS Benalla 22 April Janet Chapman Department of Health Jill Gaffney Benalla Rural City Council Dianne Martin Benalla Rural City Council Helen McDonald Benalla Rural City Council Anne Ryan Alzheimers Aust Vic Benalla Phillip Allen ACAS OKCHS Margaret Aldous Cooinda Village Kelli Williams Benalla & District Hospital Nathan Willoughby Benalla & District Hospital Laurel Eddy Benalla & District Hospital Liz Kerrins Regional Info & Advocacy Council
Other Stakeholders Frank Carlus Department of Health Central Office Judy Beaumont Department of Health Central Office Harvey Ballantyne Hume Region Department of Health Peter Axten aspex consulting Commtram Ballarat
43 Hume Region Integrated Aged Care Plan: Final Report
Appendix 4: Stakeholder Consultation Data Lower Hume Consultation
Mitchell Key issues, . Planning and service development poorly communicated and uncoordinated – leads to gaps, other service fragmentation and poor service awareness, poor relationships (e.g. Transition Care considerations developed with minimal local service input) . Workforce issues Ageing workforce ˉ Significant ageing workforce across rural areas ˉ Allied health staff, particularly occupational therapy and physiotherapy and home based services, long wait for CHS allied health. Insufficient private allied health providers compounds issue Access to GPs ˉ Lack of General Practitioners and other services . HACC services struggling to meet service demand/ service targets – many provide CACP at a lower cost than FCR as CACP unable to afford full cost and HACC (PAG, nursing) services want to ensure clients are able to receive required services . Disconnected service system IT systems and ˉ GP‟s not well linked into health service system, limited care coordination supports ˉ Discharge planning from acute to community and from outside Region to Hume, poor ˉ Large number of retirement facilities, issue of sustainability and access to services ˉ Poor consistency re availability of services e.g. access to transition care Population and . IT solutions and workforce not readily available to support better connections e.g. e-referral CALD increases . Demographics
ˉ Projected large increases in population in Wallan and surrounds
ˉ Growing number of people from the Middle East moving into the area – needing to work with this CALD community Best practice, Internal (Seymour) discharge planning meetings – includes range of stakeholders, a „good other start to better care planning‟ developments Prior work with GPs and GP aged care planing processes were effective/good model to consider
Previously had Lower Hume (HACC) best practice meetings which were a valuable mechanism for information sharing, creating service awareness and links. Current residential/aged care sector meeting could potentially be reconfigured and broadened to have a similar focus
Suggested . Significant need for overarching localised planning processes priorities and ˉ Involving existing stakeholders and service providers – reduce duplication and strategies fragmentation and improve coordination ˉ Which can (for example): consider options such as decentralised services e.g. District Nurses working from local sites; lead the development of local service provision agreements; consider IT requirements and options; be informed via other processes (e.g. outcome of HACC Nursing review) . Build Early Intervention practice via ˉ New service partnerships and agreements ˉ Working with existing community networks e.g. Probus for screening ˉ Training of service sector e.g. emphasis on self management, active health participation ˉ Consideration of mental health model in early psychosis – learnings/application . Improve transitions between services – opportunity to create and use technology to support better client flow (consider a project to develop coordinated approach) . Build access to information for consumers ˉ All staff have information provision responsibilities ˉ Look at existing functions/events – how could these be used? . Promote access to transport ˉ Build on/extend existing public transport ˉ Consider how existing transport could be made more efficient ˉ Consider findings from Lower Hume Transport Project.
44 Hume Region Integrated Aged Care Plan: Final Report
Murrindindi
Key issues, . Early Intervention and Health Promotion practice variable – tend to focus more on a gaps, other wellness approach linked to Active Service Model. Community Health services tend to considerations have more of a role in this. Perception that PCPs could have a greater role in driving HP practice PCP – could . Workforce recruitment and retention is a key issue and particularly significant for Allied drive EI HP Health. This can translate to significant waiting times for these services. Mitchell CHS practice receives HACC finding for allied health across both Mitchell and Murrindindi. Perception that Murrindindi is less well covered, however an occupational therapist is based locally
which is efficient as older people need to be assessed at home Allied health gap . Access to low –cost housing an issue in some areas . The ageing parents of younger people with disabilities – issue that accommodation for the Ageing parents & younger person not available and they re-locate, sometimes followed by the parents who social then need to give up their connection to a community they have lived in for a long time connections . Travel – highly resource intensive component of home based service delivery, not funded as a specific item GPs – access, no choice, limited . General Practitioners significant issue – long wait times, no choice or continuity of GP coordination (older people need to recount their history over and over again), no GP in Eildon at present. GPs provide limited cover in hospital emergency departments (Yea and
Alexandra), not well coordinated or linked to community services („getting the GPs to work as a team is our biggest challenge‟). The prosed redevelopment of Alexandra hospital may attract new doctors to the area . Access to Emergency Departments for local ambulance services variable, transporting patients to Melbourne is often the only option . Poor access to: vision services (Vision Australia staff person no longer based at Murrindindi Shire); stoma specialist; haemodialysis . Service system navigation an issue for services and clients, multiple agencies some with similar roles, service criteria varies . Poor discharge planning (from hospitals) an issue – PCP are working with services to collate discharge plans and impact on discharge process
Best practice, Services coordinated in the delivery of water exercise and other programs, supported through other access to a bus developments The Murrindindi Community Services Group networking meetings are rotated between sites in Alexandra and Kinglake. These are attended by a range of service providers including housing, disability, community health, acute, residential care, Centrelink, and provide a valuable means of sharing information
Community Connections transport project has led to improvements in transport – better use of idle buses, more flexibility (NB, issue re ongoing sustainability of approach)
Access to locally based specialists has increased with some from Melbourne providing sessional services at the local hospitals. These include gastroenterology, orthopaedics, cardiology („it‟s easier to access these services than a GP‟)
Yea hospital – District Nurse and CH staff are trained in health coaching, works well in developing client agreements around managing health issues
Murrindindi Shire – 6 week ASM program that works with clients in reviewing their care plans and adopting an ASM approach. Generally worked well, some clients joined the gym as a result Suggested . Promote use of e-referral as more efficient and less resource intensive priorities and . Re streamlined approach to service delivery and navigation supported via clear pathways. strategies Flexibility required also - „need a system where we respond to clients rather than them conforming to what‟s available‟‟ . Bolster transport/access through funding a flexible, small bus route . Promote social connectedness through provision of affordable and accessible opportunities for socialisation – build infrastructure and improve service flexibility to assist in this area
45 Hume Region Integrated Aged Care Plan: Final Report
Central Hume
Alpine
Key issues, . Service boundaries not uniform which creates confusion and gaps gaps, other . Lack of Allied Health – occupational therapy and physiotherapy – impact on capacity to considerations promote „active service model‟. Allied health services are stretched to meet direct care needs. Much of the existing allied health resources are centre based in rehabilitation services with no capacity for outreach . Also a general issue of workforce recruitment and an ageing workforce – similar situation to other parts of Hume Region ˉ Access to psychogeriatric/mental health services/supports & geriatrician limited: ˉ (Current approach where geriatrician provides „training‟ for GPs and nurse practitioners good in theory but not assisting access to this level of service). ˉ Six month wait for CADMS plus focus of CADMS now on early intervention. More difficult to have older later stage clients assessed plus gaps in psychogeriatric supports ˉ Access to neuropsychology an issue as clients need to travel to Melbourne ˉ People with challenging behaviours not able to be managed in dementia specific services. Issue of the interface between HACC and disability services . Access to GPs in Myrtleford area problematic – two week wait in some instances. Clients are also required to „be seen by any GP, whoever they can get which means the GP they see may not be familiar with their history‟ . Travel – highly resource intensive component of home based service delivery, not funded as a specific item . Funding shortfall for aids, equipment and home modifications a continuing challenge which can translate to clients „sitting in acute beds waiting for modifications before they can go home‟ . Community Health funding is provided through hospital not Community Health Service, impact on targeting of resources . CACP – long wait list and issue of balancing costs, for example CACP are required to pay full cost for PAG
Best practice, Aged care services work well together (also reflected in survey results). For example other ˉ Council HACC staff have developed an (Informal) system where package care waiting developments lists are updated every 3 months ˉ „Extended care‟ meetings (Council, District nursing, Case managers) serve as an effective communication mechanism ˉ Council, ACAS and CHS also try to coordinate client assessments ˉ Services also attempt to keep clients in contact with friendships groups after they relocate to residential care
GP Practice Nurse in Bright – starts the process of assessment (aged care plan) including home visits, GP becomes involved later (effective use of limited resources)
MPS funding flexibility allows for flexible care plans to be developed – person centred and targeted to client needs
Suggested . Explore mechanisms to gain greater access to allied health, home based services including priorities and discussion with rehab services – support early intervention and active service model (ASM) strategies . Promotion of ASM (and rationale) more broadly across services and community . Promote service/funding flexibility similar to MPS approach, for example Alpine Health able to fund care coordination position . Explore options to create a seamless „continuum‟ across rehabilitation services, transition care and ASM, potentially supported through same workforce . Support seamlessness through better usage of SCTT across services, potentially led through PCP
46 Hume Region Integrated Aged Care Plan: Final Report
Benalla
Key issues, . Staff recruitment and retention significant issue – „it works against building good service gaps, other coordination practice‟. Particularly difficult to recruit Division 1 nurses and Allied Health considerations staff, plus to provide attractive career paths . Ageing workforce an issue, difficult to retain younger workforce . Staff need to work with clients who have challenging or difficult behaviour – need adequate supports in place for this . Care coordination takes a significant proportion of HACC assessment time . Equitable access to packages e.g. CACP waiting lists greater in some areas than others . GPs not well linked into service system, poor referral processes . Early intervention programs numerous but very fragmented e.g. GVGP 8 week diabetes education, Delatite CHS programs, HARP etc . Fragmentation issue extends to broader service system – „there is confusion about what is there and what is provided‟- could benefit from rationalisation . Transport time unfunded – significant issue for respite services . (At times) limited access to assessments and services means older people with „lower level‟ behaviour issues do not benefit from an early intervention approach
Best practice, Some have „recruitment‟ links to TAFE courses for Div 2 nurses and personal care workers other developments CACP efficiencies at Cooinda Village where residents on CACP benefit from in-house services and economies of scale regarding cost
HACC assessment officers attend hospital discharge planning meetings – very positive
Transport connections 2 current trials: GV connections bus – can be booked by individuals with 24 hours notice; Mansfield to Benalla CHS trial
Benalla Council – some HACC funds for transport to hospitals 1 day per week
Suggested . Addressing workforce issues priorities and ˉ Option to explore (as a group) skilled migration programs, plus look at supports across strategies the community not just workplaces and what level of migration support is provided ˉ Consider „floating‟ staff to cover gaps e.g. assessment or nursing roles ˉ Systems to support staff working with clients who demonstrate challenging behaviour (could be a shared approach) . Build IT systems to support better discharge, care coordination (noted as a state wide issue) . Develop integrated approaches to early intervention and service delivery – based around one care plan, centralised locally . Have applied for funding to develop a universal care plan template across Council, CHS and hospital . Support Active Service Model with greater input by Allied health staff . Consider mechanisms for rationalisation of services e.g. tiered approach . Build networking and communication via PCP is one option.
Mansfield
Key issues, . Issue of service access for older people who live in geographically challenging areas. Hard gaps, other to deliver home care, and ambulance access compromised, in some areas. Difficult also for considerations older people to relocate to town area as housing is getting more expensive . Workforce Issues ˉ Staff recruitment and retention an issue as per other areas. This is compounded by a lack of rental properties and facilities such as child care ˉ Ageing workforce, also need to support older people working in physical home care roles ˉ Allied Health gap . Supports for ageing parents who have children with disabilities such as autism
47 Hume Region Integrated Aged Care Plan: Final Report
. Psychogeriatric services: wait list for dementia assessment . Transport of older people ˉ NB have Council community bus on Thursdays which circuits, picks people up and transports to Mansfield ˉ Volunteers also provide some transport to appointments – volunteer coordinator at Council – many volunteers which is positive ˉ Are also considering ways to utilise school bus during school hours . The relocation of clients from community living to residential care can impact on their social connectedness and their capacity to maintain friendship groups e.g. those from a PAG
Best practice, All services represented at hospital discharge planning meetings, These agencies work other collaboratively to ensure clients are provided with some service/s on their return home developments Service provider meetings provide an opportunity to network and share information and resources (e.g. joint training) - „communication and relationships are essential, if relationships are poor care coordination doesn‟t work‟
Suggested . Regional workforce development strategy required. Could include options to promote priorities and workforce flexibility plus consider a shared approach to housing, providing child care etc, strategies and promoting the benefits of working in the aged care sector . Promoting the uptake and use of SCTT by addressing technology issues.
Wangaratta
Key issues, . Staff recruitment and retention significant issue gaps, other ˉ Particularly difficult to recruit Div 1 nurses to mental health services and resi care considerations ˉ Limited career path for personal care attendants ˉ Unit price for some services does not cover more highly skilled staff with degrees . Care coordination – often multiple services involved with limited awareness and coordination (not an issue so much for clients who have an allocated case manager) . Level of funding for CACPs insufficient to cover all needs – some clients are better off continuing with existing HACC services . Travel component of service delivery not funded as a stand alone item, transport gaps . Service gaps/long wait for services ˉ CADMS 4 month wait (issue as more people with dementia living alone), CDAMS shift to more of an early intervention approach ˉ „Low level‟ psychogeriatric care ˉ GPs – most GP „books closed‟, long wait for appointments, issue also for people in residential care ˉ Very limited access to geriatrician . Services such as PAG and CACP working with increasingly complex clients – „people are coming to these services at a later stage, often more complex‟
Best practice, Building case management skills in the sector - NE Health provide on the job training linked to other TAFE Case management course developments Suggested . Facilitating service transitions priorities and ˉ HACC ASM has enabled shared vision strategies ˉ Access to CACP could be assisted by regulation of costs, flexible funding ˉ Electronic (packages) wait list with organisation (e.g. ACAS) funded to manage . Developing health promotion ˉ Requires reliable, localised data to underpin effective HP planning ˉ Coordinated approach to broad gaols rather than scattergun, PCP driven, link HP plans across organisations ˉ Staff development – understanding EI, HP, social determinants of health ˉ Need robust evaluation process . Access to dementia services/assessment ˉ „Memory clinic‟ model – coordinated across Alzheimer‟s Assoc, CDAMS, GPs ˉ Identify/source funding options, re configuration of existing resources ˉ Requires skilled workforce, quality framework.
48 Hume Region Integrated Aged Care Plan: Final Report
Goulburn Valley
Greater Shepparton
Key issues, . Distance, travel and transport gaps, other ˉ Similar to other areas – older people in outlying areas and service access considerations ˉ Difficult to sell properties plus relocation often impacts on social connections ˉ Distances travelled by care workers significant cost ˉ Transporting clients to appointments problematic . Workforce ˉ Minimal access to Geriatrician ˉ „Shrinking pool‟ of skilled staff due to ageing workforce ˉ Salary inequities, relatively low level of pay if working in aged care ˉ Recruitment of aged care staff, not „sold‟ well as an occupation to students . Service coordination, connections ˉ Information sharing from mental health and specialist services like oncology limited when clients return to residential care ˉ E-referral „slow‟ uptake plus part of the Region prevented from using e referral due to Server and information privacy issue ˉ Misinformation re how to use SCTT, misuse of these tools . Packages ˉ Large number of package providers, very fragmented ˉ Differences in what is provided and costs across different providers ˉ Long wait list . HACC funding - does not cover travel, after hours, some admin/management plus social work and allied health assistant not funded under HACC
Best practice, Regional meetings and service provider meetings assist to understand the range of services other developments Strength - services work collaboratively and „around barriers‟ Suggested . Promoting Early Intervention priorities and ˉ Define EI and framework for understanding/development of approaches strategies ˉ Consider social model of health, broader considerations e.g. housing ˉ Who does EI? Define roles and minimise duplication of effort ˉ Promote balance between EI aspects of roles and other components ˉ Link to ASM ˉ PCP could provide structure to coordinate effort . Service transitions ˉ How to support clients move across services – central to promote client choice ˉ Protocols to underpin client transition ˉ Best use of SCTT/tools ˉ Broad sector involvement/commitment required . Supporting service integration ˉ IT solutions e.g. „auto populate‟ function in completing client e-record ˉ Use of common tools e.g. SCTT ˉ Reduce multiple assessments – share information, develop trust across services, would require agency specific questions
Moira
Key issues, . Mental Health Services gaps, other ˉ Access to mental health services (including dementia specific) limited considerations ˉ Coordination and feedback from mental health services is poor . Gaps ˉ Delivered meals are only available to people who are deemed at nutritional risk ˉ Lack of specialist medical services ˉ Hard to access transitional care beds ˉ Concerns that residential respite may be discontinued due to high level of administration required for a short stay . Younger people cared for by ageing parents - lack of suitable accommodation, nursing home in area inappropriate
49 Hume Region Integrated Aged Care Plan: Final Report
. Care/service options for younger people with dementia limited . Packages ˉ Communication gaps across packages & resi care services re people on waiting lists ˉ Full cost recovery required for PAG – hard to fund in a package ˉ People can become excluded from their previous social networks at PAG when transitioning to package or residential care . Growth in Oasis Village (a low cost caravan park) – people on low incomes, health care cards, potential growth in service demand . Complexity of cross border clients and relationships with other services, etc Best practice, Health coaching – 2 day course delivered via Moira Health Alliance – highly valuable and other assists in development of ASM approaches developments Suggested . Improve communication/liaison over packages & resi care re waiting lists and client needs priorities and . Oasis Village –planned and coordinated approach required before issues arise. strategies
Strathbogie
Key issues, . No public beds in Strathbogie – residents required to go to Shepparton or Benalla gaps, other . Spread of population – very scattered, shape of Shire makes access to some people considerations difficult and resource intensive . A more fragmented service system than in other Shires due to no central base of services, workers come from all areas. Issues include: ˉ Numerous CACP providers but limited turnover. Waiting lists not reflective as services not referring to CACP ˉ No GP cover on weekends ˉ No dental services ˉ Lack of social work ˉ Delays in access to District nursing . Increased number of lone person households, no carer and combined with geography can be time/resource intensive. Also difficult to support people who live alone with dementia . DALY relatively high numbers of cardiovascular issues, diabetes, cancers . Heavily reliant on volunteer drivers (aging volunteer pool). Some trips are as far as Melbourne. Difficult to fit appointments around infrequent public transport services. Many older people require 1:1 support to access transport Best practice, (Limited) out posting from GVH in Shepparton assists with access to some services e.g. other counselling, mental health developments GP aged care panels supported an effective relationship between GPs and residential care (no longer exist) Suggested . Addressing fragmentation – PCP undertake service mapping priorities and . Promoting Early Intervention strategies ˉ Address issue of EI and HP funding to promote sustainability, requires recurrent $ ˉ Need capacity to develop and deliver local activities within a broader „Hume corridor‟ service model, define responsibilities via formalised agreements, potentially via PCP ˉ Create opportunities for services to work together and collaborate on strategies . Service Transitions ˉ Transition from community to residential care could be assisted through timely information provision on „what to expect‟ ˉ Promote awareness of services more broadly so clients are aware of home care, nursing services etc . Addressing service/staffing gaps ˉ District nursing - develop sub-contracting, out posting relationships with Benalla ˉ Services come together – problem solving approach to address social work gap ˉ Explore option of common staff bank to fill gaps - Opportunity to pool resources in areas such as staff training - Volunteer strategy – target workplaces, source grants to support development activities . Consider service brokerage/other arrangements to address issue of „clients who live close to service boundaries‟
50 Hume Region Integrated Aged Care Plan: Final Report
Upper Hume
Indigo
Key issues, . Workforce gaps, other ˉ Ageing considerations ˉ Volunteer reliant ˉ Lack of Geriatrician . Service inflexibility – large proportion of part time staff, clients are required to fit with what is available and provided rather than what truly meets their needs, not very person centred . Transport limitations ˉ Highly reliant on volunteers, only a few available cars, require 48 hours notice ˉ Transport costs „eat into package dollars‟ ˉ Issue for people whose spouses have been placed in residential care some distance away ˉ Limited public transport options . Volunteers ˉ Highly reliant on volunteers for transport ˉ Difficult to recruit enough volunteers to undertake delivered meals . Mental health ˉ 8 months wait for CADMS ˉ Lack of case management for 65+ people with mental health issues
Best practice, Indigo North Health Service has developed a central intake role to provide information and other direct people to appropriate services. Works on the principle of assisting clients to develop developments their own knowledge base. Also uses e-referral. Referrals have increased as a result - person centred approach
Benalla hospital practice effective and linked discharge planning
Continuum of care meetings in Indigo are highly valued by those who attend – good mechanism for care planning and sharing of information
Suggested . Explore options to have Allied health staff trained to work with older people with mental priorities and health issues – build a case management role strategies . Consider ways to promote and develop person centred care approaches as opposed to staff/service generated.
Towong
Key issues, . Younger people cared for by ageing parents gaps, other ˉ Younger people in residential care - need to move to Wodonga and family (older considerations carers) unable to visit ˉ Younger people with disabilities –limited range of services and activities, care burden on ageing parents . Built infrastructure – poor footpaths/ lack of footpaths in some areas, low level street lighting, poor access to local supermarket . Workforce ˉ Turnover of staff providing specialist outreach services (e.g. rural allied health team) – each time a new staff member requires orientation, etc and this is time consuming ˉ Staff require training in ASM to embed this approach and practice . Oral heath service gap – significant across public and private
51 Hume Region Integrated Aged Care Plan: Final Report
Best practice, Flexible approach to HACC provision promotes access other developments Upper Murray H&CS have developed AIFL on line training certificate 3 and 4 in aged care - local access to training
Gym for older people – created normalising of active lifestyle for past decade Suggested . DAIS (Disability, Advocacy and Information Service) explore option to work with DIAS/ priorities and DIAS web page for staff training strategies . Explore options to support better access to specialist services e.g. Geriatrician . Explore options to increase available transport for people to get into Wodonga for appointments (current access limited – hospital car infrequent).
Wodonga
Key issues, . Complexity of cross border clients and relationships with other services, etc gaps, other . Medical Services considerations ˉ Good access to GPs (high number across Albury Wodonga) however GP visits to residential care an issue as they are only funded $25 for this. Some residential care services are forced to send residential clients to hospital emergency departments for medical care ˉ Difficult to attract and retain Registrar level doctors . Barriers to e-referral, data bases not connected. SCTT not suited to adaptive technology (e.g. that used by Vision Australia staff) . Shortage of psychologists (Medicare item related) . Multiple services, fragmentation, staff not aware of full range of service available . Workforce recruitment and retention an issue in some areas
Best practice, Creating access to local training – the „Tallangatta model‟ where one staff employed by other Wodonga TAFE (previously a Tallangatta staff member) delivers aged care training developments (certificates) on-site to Tallangatta Health HACC staff
Suggested . Service fragmentation, poor service awareness – option to develop an electronic service priorities and directory like Infoxchange strategies . Workforce development ˉ Mechanisms to support new graduates to encourage them to stay working in the area ˉ Targeted communication/activities with schools, TAFE to encourage study in aged care, invite student placements ˉ Use „Tallangatta model‟ as practice example . Early Intervention: identify the range of areas which may benefit from EI approaches (e.g. dementia falls). Develop EI models – community based, home based, workplace, shared and coordinated approaches . Improve transitions/service navigation: ˉ Better use of SCTT ˉ Improved electronic communication and electronic client records ˉ Supported through electronic service directory, updated service information ˉ Identified case manager ˉ Good communication and planning – network meetings, etc ˉ Active involvement in discharge planning.
52 Hume Region Integrated Aged Care Plan: Gap Analysis Report
Appendix 5: Findings linked to Policy Messages Government policy is seeking service providers to work in partnership, integrate their service planning, improve service coordination and communication between stakeholders, share information to create consumer and carer friendly access to services, focus on healthy lifestyles, social connectedness and positive ageing.
The following grid summarises the identified gaps and issues for aged care in the Hume Region and cross tabulates this with current policy directions; stakeholder consultations; consumer and carer consultations; the service provider survey; other particular areas of note and relevant developments in the aged care service system. By bringing the information and data together in this way, it highlights the consistency and strength of the issues and gaps and the localities where they impact the most.
Consumer/ Other Identified Gaps and Stakeholder Policy Carer Survey Of note: processes or Issues consults Consults developments Lack of joint service Low PCP profile system planning Particularly with multiple package Service fragmentation providers; lack of & service engagement by ‘disconnects’ – plus GPs; decrease in packages & resi care service provider meetings MPS have Service inflexibility – flexible funding to limited person centred respond to approaches individual consumer needs Change to Retaining social Some informal HACC PAG connectedness as but effective eligibility for people relocate practices in place CACP consumers No funded public Limitations to service health service in
access Strathbogie
Good access in „Access Points‟ Limitations to small community demonstration information e.g. Corryong projects Works well in small community Improving service e.g. Corryong „Access Points‟ navigation and and demonstration transitions Intake model projects Indigo Nth using SCTT Issues re Server & information Poor IT & connectivity security in part of region Hume Region – HACC Allied Gaps in Allied Health Health review to commence 2010
53 Hume Region Integrated Aged Care Plan: Gap Analysis Report
Consumer/ Other Identified Gaps and Stakeholder Policy Carer Survey Of note: processes or Issues consults Consults developments EI approach Early planning Gaps in Mental Health adopted at re Memory CADMS Clinic CACP, EACH and EACH D, High demand for high wait list packages numbers. NB in line with Comm‟ formula No lack of GPs in Employment of Lack of GPs & limited Wodonga c/f GP Practice service system links books closed in Nurses can Wangaratta assist GPs Numerous Limited transport projects & some options and access gains Better in some Limited role of PCPs areas than others Engagement of Underdeveloped ASM DH Hume practice Region ASM project officer „Normalisation‟ Where of gym and Underdeveloped early developed not exercise with intervention & health always Corryong promotion practice coordinated consumers/car ers Low PCP profile; Building service low use SCTT & coordination practice e referral Hume’s geography, Strathbogie remoteness and Towong distance GV – Mooroopna, Euroa, Low SEIFA Shepparton Central Hume – Benalla Lower Hume – all Food Insecurity issues Central Hume – Benalla Areas where self Lower Hume – all reported health is Central Hume – poor Benalla Central Hume – Benalla Older people who live GV – Strathbogie alone Upper Hume - Towong High ACSC for Lower Hume in diabetes particular complications
54 Hume Region Integrated Aged Care Plan: Final Report
Appendix 6: Project Steering Committee and Stakeholder Workshop
Name Agency Janet Chapman DH Natasha Kukanja DH - HACC Donna Richards Moira Healthcare Alliance Sandra Davidson NE Health Wangaratta Aged Psychiatry Deb Gook ACAS West Hume Wendy Ross Rural City Of Wangaratta Leigh Giffard Nathalia Hospital Tammie Long Indigo North Health Service Leigh Rhode Goulburn Valley Health Jacque Phillip Numurkah Hospital Chris Symons Cobram Hospital Fiona MacPhee ACAS East Hume Trevor Marshall Alpine Health Greg Pearl Upper Hume PCP Beth Dawson DH - HACC ASM Industry Consultant Kerrie Reardon Villa Maria Society Jacinta Flood Albury Wodonga Health Jason Watts City Of Greater Shepparton Amanda Edwards Kilmore Hospital Ann Wearne Central Hume PCP Steve Pitman Border GPs Cameron Butler Indigo North Health Service Stephen Carroll DH
Apologies Julie Russell Numurkah Hospital Margaret Aldous Cooinda Aged Care, Benalla Nick Bush Cobram Hospital Louise Pearce Rural City of Wangaratta Neil Duggan DH Louise Sharkey Seymour Hospital
55 Hume Region Integrated Aged Care Plan: Final Report
Appendix 7: Workshop Issues
Participants worked in small groups to address the following areas identified throughout the Project:
a. Collaborative service planning – local and regional
b. Critical service gaps e.g. Strathbogie, Dementia assessment and support, Specialist services
c. Staff recruitment, retention and training
d. Special needs groups – Indigenous, CALD, homeless, ageing carers, rural and remote
e. Accessible service information – consumers, carers and service providers
f. Coordination and transition planning for consumers e.g. packages and multiple providers
g. Transport – consumers and service providers
h. Coordinated Health Promotion
i. Involving GPs more, the role of GP Practice Nurses and GP Divisions.
56 Hume Region Integrated Aged Care Plan: Final Report
Appendix 8: The KeyRing Model
The KeyRing model, developed in the UK, is based on the idea of „living support networks‟. Small networks of up to nine people with learning difficulties are established in a particular neighbourhood, using ordinary social housing. Each individual has his or her own flat, all within walking distance of each other. The model development commences with the appointment of a „community living worker‟ whose role is to help people settle into the network, and to provide continuing support. In return for free accommodation (plus the payment of some household bills) the community living workers commit an average of ten to twelve hours a week to assisting members of the network. The community living worker lives as part of the network, in the same neighbourhood as the KeyRing tenants. Each person in the network knows where everyone else lives and will have their phone number. The community living workers are themselves supervised and supported by network managers, who also work directly with tenants. Mutual support by tenants is encouraged and facilitated through a tenants' group in each network.
KeyRing is primarily targeted at people with learning difficulties who have basic self-care skills, but who still need continuing support. Just over a third of KeyRing tenants (36 per cent) had lived in some form of shared housing (staffed houses of group homes) prior to joining KeyRing. Forty-two per cent had previously lived with family. Most of the remaining tenants had formerly struggled without formal support, including some who had become homeless.
Access to housing is typically provided by a three-way agreement between the purchasers of the service (usually the relevant government department), the local housing department and KeyRing. Once people are accepted as potential KeyRing tenants, they are then treated as a priority for suitable accommodation in the area where a network is being developed. A key aim of KeyRing is to ensure that people with learning difficulties get their own home. This was something that many tenants had long aspired to, and for many it represented a significant achievement in the face of scepticism from families and professionals.
57