Plan for General, Geriatric and Rehabilitation Medicine in · CNC Clinical Nurse Consultant ... a...

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Plan for General, Geriatric and Rehabilitation Medicine in CSAHS, 2002-2007 _________________________________

August 2003

GGRM Strategic Plan 2002 - 2007 __________________________________________________________________________________________

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This report was commissioned by: GGRM Central Sydney Area Health Service This report was written by Jill Hardwick, in-conjunction with many GGRM and CSAHS staff. Jill can be contacted as follows: Jill Hardwick Hardwick Consulting 6 Toxteth Road Glebe NSW 2037 Tel: 02 9660 5668 Fax: 02 9660 0406 email: [email protected] © Central Sydney Area Health Service 2003 The data in this report are, to the best of the authors’ knowledge, up-to-date and accurate. The author accepts no responsibility for any errors resulting from unforeseen inaccuracies or for damage or loss suffered by any individual or agency as a result. Any representation, statement, opinion or advice expressed or implied in this report is made in good faith and on the basis that Hardwick Consulting is not liable to any person for any damage or loss that has occurred or might occur, in relation to that person taking or not taking action in respect of any such representation, statement, opinion or advice.

mailto:[email protected]�


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Abbreviations ACSA Aged and Community Services Australia

ADD Ageing and Disability Department

ADL Activities of Daily Living

AHS Area Health Service

ACE Aged Care Evaluation

ACCR Aged Care Client Record

ACAT Aged Care Assessment Team

ASET Aged care Services Emergency Team

CACP Community Aged Care Package

CADE Confused and Disturbed Elderly

CALD Culturally and Linguistically Diverse

CAS Comprehensive Assessment Services

CERA Centre for Education and Research on Aging

CIARR Client Information and Referral Record

CLASP Concord Living After Stroke Program

CNC Clinical Nurse Consultant

COPD Chronic Obstructive Pulmonary Disease

CRGH Concord Repatriation General Hospital

CSAHS Central Sydney Area Health Service

CRC Carer Respite Centre

CSW Community support worker

DADHC Department of Ageing, Disability and Home Care

DAHC Department of Health and Aged Care

DEED Discharge of the Elderly from the Emergency Department

DSP Disability Services Program

DVA Department of Veterans’ Affairs

FTE Full time equivalent

GGRM General, Geriatric and Rehabilitation Medicine

GPC General Practice Casualty

HACC Home and Community Care

ISD Information Services Department

IT Information Technology

IWLAHP Inner West Live At Home Program

MOU Memorandum of Understanding

NDEMS Neurodegenerative Education and Management Service


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NHTP Nursing Home Type Patients

NRCP National Respite for Carers Program

NUM Nurse Unit Manager

OOS Occasions of service

PADP Program of Appliances for Disabled People

PACS Picture Archiving Communication System

RIS Residential Information Service

RMO Resident Medical Officer

RTP Resource Transition Plan

RPAH Royal Prince Alfred Hospital

SAS Service Access System

SEH South East Health Service

SGRACF State Government Residential Aged Care Facility

STRONG Strength, Training, Rehabilitation and Outreach to unidentified Needs in

Geriatric Medicine

TACS Transcultural Aged Care Services

TCH The Canterbury Hospital


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Table of Contents 1. GGRM Mission Statement ........................................................................................... 7

Target Group............................................................................................................................................... 7 Mission ......................................................................................................................................................... 7 Guarantee of service: ................................................................................................................................ 8 Commitment of Service: ............................................................................................................................ 8

2. Executive Summary of Recommendations ............................................................... 9 3. Introduction ................................................................................................................ 16

BROAD OBJECTIVE ......................................................................................................................................16 KEY TASKS..................................................................................................................................................16 PLANNING PROCESS...................................................................................................................................16 REVIEW OF THE PREVIOUS PLAN ................................................................................................................17

4. Context........................................................................................................................ 19 COMMONWEALTH GOVERNMENT ................................................................................................................19 National Ageing Strategy......................................................................................................................... 19 Review of Aged Care Reforms ............................................................................................................... 20 HACC Reforms ......................................................................................................................................... 21 NSW STATE GOVERNMENT .......................................................................................................................22 NSW Healthy Ageing Framework .......................................................................................................... 22 Improving the Aged Care Interface........................................................................................................ 22 NSW Government Action Plan ............................................................................................................... 23 CSAHS.......................................................................................................................................................24 Clinical Strategic Plan .............................................................................................................................. 24 Resource Transition Program................................................................................................................. 24

5. CSAHS – the number, distribution, projections, mortality and morbidity of older people........................................................................................................................... 26 HEALTH OF OLDER PEOPLE .......................................................................................................................30 ACUTE HOSPITAL CARE...............................................................................................................................32 MORTALITY AND LIFE EXPECTANCY ...........................................................................................................33

6. GGRM services, organisational structure, utilisation and resources................... 34 WESTERN SECTOR......................................................................................................................................34 Inpatient services...................................................................................................................................... 34 Non inpatient services ............................................................................................................................. 35

Aged Community Services Team........................................................................................................................... 35 Inner West Live at Home Program......................................................................................................................... 36 Community Respite Team .......................................................................................................................................36 Carer Respite Centre................................................................................................................................................36 Residential Information Service.............................................................................................................................. 37 Carer Education Project ...........................................................................................................................................37 Home Based Therapy ..............................................................................................................................................37 Aged care Services Emergency Team.................................................................................................................. 37 Outpatients Clinics ....................................................................................................................................................37 CLASP.........................................................................................................................................................................37 Day Hospital ...............................................................................................................................................................38 Neurodegenerative Education and Management Service .................................................................................38

EASTERN SECTOR.......................................................................................................................................38 Inpatient services...................................................................................................................................... 38 Non inpatient services ............................................................................................................................. 38

Outpatients .................................................................................................................................................................38 STRONG.....................................................................................................................................................................39 Program of Appliances for Disabled People ........................................................................................................39 Day Hospital ...............................................................................................................................................................39 CNC Continence .......................................................................................................................................................39 Community Aged Care Team .................................................................................................................................40 Inner City Live At Home ...........................................................................................................................................40 Day Centres ...............................................................................................................................................................40 Community Visitors Scheme ...................................................................................................................................40 Multicultural Aged Care Advisor (MACA)..............................................................................................................41 NSW Transcultural Aged Care Service (TACS) ..................................................................................................41


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CANTERBURY SECTOR ................................................................................................................................41 Inpatient services...................................................................................................................................... 41 Non inpatient services ............................................................................................................................. 42

ACAT ........................................................................................................................................................................... 42 Day Centre .................................................................................................................................................................42

CSAHS PODIATRY .....................................................................................................................................42 RESEARCH AND EDUCATION.......................................................................................................................43 CERA .........................................................................................................................................................43 INTERFACE WITH OTHER CLINICAL GROUPINGS..........................................................................................44 UTILISATION ................................................................................................................................................44 RESOURCES................................................................................................................................................46 Staffing ....................................................................................................................................................... 46 Funding ...................................................................................................................................................... 49 NURSING HOMES AND HOSTELS .................................................................................................................50

7. Future service requirements..................................................................................... 51 8. Issues affecting future service delivery................................................................... 52

8.1 POPULATION DEMOGRAPHICS ...........................................................................................................52 8.2 RESOURCES ......................................................................................................................................52 8.2.1 Staffing issues ............................................................................................................................ 52

Staff Education Issues ..........................................................................................................................................53 8.2.2 Funding........................................................................................................................................ 54 8.2.3 Physical facilities ........................................................................................................................ 54 8.2.4 Information Technology support .............................................................................................. 55 8.3 NEED FOR NEW MODELS OF CARE ....................................................................................................56

Specific service development issues ............................................................................................................... 57 8.3.1 Transitional care/slow stream rehabilitation ........................................................................... 57 8.3.2 Discharge planning .................................................................................................................... 58 8.3.3 People from CALD backgrounds ............................................................................................. 58 8.3.4 Aboriginal and Torres Strait Islander Peoples ....................................................................... 59 8.3.5 Carers .......................................................................................................................................... 59 8.3.6 Services for younger people with disabilities ......................................................................... 59 8.3.7 Canterbury sector....................................................................................................................... 59 8.3.8 Customer Focus ......................................................................................................................... 60 8.3.9 Burns Rehabilitation................................................................................................................... 60 8.3.10 Non-Traumatic Acquired Brain Injury ....................................................................................... 61 8.3.11 Rehabilitation of “Out of Area” elective patients ...................................................................... 61 8.4 GGRM ORGANISATIONAL ISSUES .....................................................................................................61 8.4.1 GGRM management infrastructure ......................................................................................... 61 8.4.2 Quality.......................................................................................................................................... 62 8.4.3 Risk management ...................................................................................................................... 62 8.5 PARTNERSHIPS.................................................................................................................................63 8.5.1 General Practitioners ................................................................................................................... 63 8.5.2 GPC................................................................................................................................................ 63 8.5.3 Residential Aged Care Facilities................................................................................................ 64 8.5.4 Homoeopathic Clinic.................................................................................................................... 64 8.5.5 Psychogeriatric services ............................................................................................................. 64 8.5.6 Podiatry ......................................................................................................................................... 64 8.5.7 Others ............................................................................................................................................. 65

9. Recommendations, Supporting Strategies, Timeframes and Responsibilities. .. 66 10. References.................................................................................................................. 80

APPENDIX A: LIST OF PEOPLE CONSULTED ........................................................................................82 APPENDIX B: RECOMMENDATIONS FROM THE PREVIOUS PLAN ..........................................................83 APPENDIX C ORGANISATIONAL CHARTS ............................................................................................88 APPENDIX D: CASEMIX REPORTS..........................................................................................................94 APPENDIX E: GGRM CLINICAL INDICATORS......................................................................................95


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1. GGRM Mission Statement Target Group

GGRM offers services to a range of people, with differing needs.

Clients to be offered geriatric or aged care services are usually older people, and their carers, who present with high level needs due to one or more of the following problems. These problems may be acute or chronic.

Physical disability

Mental disability

Care, accommodation and support issues

Multiple, medical problems/polypharmacy

Some younger adults with disability and high level needs.

(Working Group on Care of the Older People in NSW Health Care System, August 2002)

Some GGRM Community teams may also service children and younger adults with disabilities, who require case management, respite or socialisation.

Clients to be offered rehabilitation services are people who have suffered significant loss of function and/or ability due to an accident, illness or injury, including those with chronic pain. People with impairment of a permanent or potentially permanent nature, in whom identifiable and reasonably achievable management goals can be identified, will be offered care. People with congenital conditions will be seen if there is a new loss of function.

This service will generally be delivered in the context of the precipitating pathology having been previously treated or continuing to be treated by the most appropriate clinical specialty group.

Patients to be offered general medicine services are people with new or chronic disease presentation requiring inpatient acute or elective internal medicine services. Comprehensive internal medicine services are required to be available and delivered across all medical disciplines at a level appropriate to an acute metropolitan hospital setting (TCH).

Carers of all of these groups will also be supported in their caring role.

Mission GGRM is committed to:

working with the people of Central Sydney Area Health Service to promote, protect, restore and maintain their level of well-being

working with general practitioners, other health care professionals and other service providers to promote, protect, restore and maintain the health of their clients and patients

fulfilling Area, State and National responsibilities to provide a high level of quality general medical, geriatric and rehabilitation services


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providing, in conjunction with the tertiary education sector and professional colleges, professional health education and training

encouraging and undertaking research examining the processes and outcomes of services delivery within the structure of

the CSAHS Quality Framework providing a satisfying, safe place of work for employees.

Guarantee of service: GGRM aims to provide the best quality services to its patients and clients, and their carers, and internal customers, by providing:

high quality, diagnostic, therapeutic, maintenance and restorative services accurate assessment provision, coordination or referral to continuing care information about their health and the service available access to hospital and community-based services a friendly and cooperative approach to service delivery by appropriately skilled staff access to a range of hospital and community-based health services staff who care training for future generations of healthcare professionals a sound research base to extend our knowledge of illness, its treatment and

prevention Commitment of Service: GGRM’s commitment is to:

provide professional, multidisciplinary, coordinated health care to all clients and patients

respect cultures, beliefs and conscientious convictions recognise individual’s needs and include where appropriate family, friends and carers

in planning programs for each client/patient’s care include patients/clients in all aspects of their care by ensuring ongoing

communication discuss with patients/clients options for treatment, indicating benefits and risks,

enabling informed decisions involve consumers in service development and planning provide services in a non-discriminatory manner, regardless of race, ages, gender,

sexual preference, marital status, intellectual or physical impairment respect patient/client privacy and maintain all information as confidential arrange interpreter services to assist if needed.


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2. Executive Summary of Recommendations The strategic direction of GGRM for 2002-2007 is summarised into the following recommendations. Some recommendations refer to GGRM as a whole, while others refer specifically to either General Medicine, Geriatric or Rehabilitation Medicine. See section 9 for a complete action plan. 2.1 Population demographics

• Ensure collection and analysis of relevant population demographic data (including disability data) to identify changing needs.

• Test the claim that increasing patient/client acuity, in both hospital and community services, makes current staffing ratios and funding inadequate (see section 8.1 & 8.2.1).

• Monitor the needs and subsequent demands of the ‘old old’ population on the service.

• Investigate trends in waiting times in ACATs (see section 8.1).

2.2 Resources 2.2.1Staffing (see section 8.2.1)

• Develop a comprehensive GGRM Human Resource Plan , to aid staff recruitment and retention, including:

- providing opportunities for staff to develop their expertise by working within a variety of work teams and experiences (in line with NSW Health Ageing Framework),

- developing staff development programs,

- developing professional support structures and programs.

• Identify gaps in CNC service delivery via benchmarking the number of CNCs and nurse educators with numbers for other clinical groups. Identify means of correcting deficiencies.

• Identify opportunities to enhance nurse education support.

• Review the adequacy of the number and distribution of allied health resources, for both inpatient and non inpatient services, including the cost and feasibility - of their availability on the weekends, - of having a pool of allied health staff to provide cover for staff on leave and

vacancies.

• Benchmark the numbers of junior medical staff, staff specialists, registrars and resident medical officers allocated to GGRM departments and other medical subspecialties, against clinical loads.


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• Continue the educational experiences available to medical students/staff via rotations into medical teams at TCH.

• Reconfigure existing Education Committee to reflect the needs of all GGRM staff.

• Review the impact of the Risk Management Strategy on Day Centre staffing ratios.

• Review adequacy of staffing of PADP and ensure policies are standardised across the Area.

• Develop distribution systems to communicate with all GGRM staff.

• Develop and offer regularly a GGRM Staff Orientation Program.

• Review roles and perceived inequities between Community Service Manager positions.

2.2.2 Funding (see section 8.2.2)

• Identify service needs in a systematic way and be aware of government initiatives that potentially fund service gaps.

• Address funding inequities across the three sectors.

• Ensure that adequate administrative support is built into submissions for future service enhancement.

• Pursue options for services whose current funding is short term – CLASP, TACS, Carer Education Project, NDEMS.

• Refine and consolidate strategies to address issues raised by the growth in the service delivery model using private agencies.

• Seek funding for the enhancement of TCH General Medicine services including ECHO, EST etc.

2.2.3 Physical Facilities (see section8.2.3)

Commissioning and resourcing of Magnolia Cottage (the new premises for Kalparrin Day Centre), including establishment of new work practices.

Commissioning and resourcing of the new ward at RPAH.

Commissioning and resourcing of the KGV area for the Eastern Sector Community

teams.

Commissioning and resourcing of the refurbished wards at CRGH including the establishment of new work practices with the co-location of inpatient and ambulatory services.

Commissioning and resourcing of the new Rehabilitation Medicine ward at CRGH.

Re-establishment and resourcing of the geriatric and rehabilitation ward at TCH when

palliative care vacates Cassia ward.


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Clarification of the role of GGRM and the psychogeriatric service in the proposed development of the Croydon site i.e. services GGRM and the psychogeriatric service will provide in the slow stream rehabilitation unit (if established), the dementia nursing home and the delivery of podiatry services.

Explore accommodation options for Canterbury Aged Community Services and General Medicine Services at TCH.

New premises for Sita Carter day centre to be found. Facilities at Balmain Hospital need to be reappraised in the context of the provision of

suitable accommodation that meets contemporary standards, to meet the needs of both the ageing patient and staff.

2.2.4 Information Technology (see section 8.2.4)

• Document GGRM’s current and future IT needs and determine the funding options for having these needs met.

• Negotiate IT support from ISD.

• Identify areas of work practice where IT may contribute to GGRM effectiveness and efficiency in relation to patient care, general communication and service reporting.

• Identify and support GGRM ‘Super Users’ on sites to assist staff with basic IT issues.

• Identify and train all GGRM staff to a minimum computer literacy level.

• In conjunction with ISD, develop a workplan to further the development of CERNER to meet the varying IT needs of GGRM.

• Develop new models of service delivery using existing technologies ie. teleconferencing and telehealth pilot projects.

• Standardise data collection systems to enable accurate benchmarking between like community services ie. ACAT waiting times.

• Reconfigure existing Information Technology Committee to reflect the needs of all GGRM staff.

2.3 Models of Care Review current service delivery models and develop new models of care, to ensure

GGRM provides the most effective method of service delivery, in the most appropriate setting of care, to meet the population’s changing needs (see section 8.3).

• Develop strategies to preserve and enhance effective domiciliary and ambulatory services, including service delivery models of ACAT, dementia specific teams.

• Further the development of the newly funded Aged care Services Emergency Teams (ASET).


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• Consolidate GGRM target groups, identifying future areas of possible growth eg. children with disabilities, young adults with disabilities, and communicate final decision to staff and relevant external stakeholders.

• Explore the feasibility of innovative care options including:

- transitional care (see section 8.3.1),

- slow stream rehabilitation in the domiciliary setting (see section 8.3.1),

- the incorporation of successful aspects of the Priority Health Care Programmes into aged care services,

- enhanced Hospital in the Home services (i.e. provides personal care and allied health services) to fulfil an effective post acute care role.

• Clarify the need for and balance between general and specialised outpatient services in Geriatric Medicine, including STRONG, falls clinics, cognitive disorders clinics, continence clinics (see section 8.3).

• Determine role of and need for community education/health promotion programs to be offered by GGRM (as outlined in National Strategy for an Ageing Australia, 2002).

• Define and benchmark GGRM’s service delivery role in relation to identified target groups outlined below, with a view to develop appropriate models of care for:

- carers (see section 8.3.5),

- people from CALD backgrounds (see section 8.3.3),

- Aboriginal and Torres Strait Islander people (see section 8.3.4),

- younger people with disabilities (see section 8.3.6).

• Determine how best to respond to the needs of the population groups identified above.

• Ensure staff training is available to meet the needs of the above groups.

• Ensure the development and review of all services, policies and procedures considers the NSW Health Aboriginal Health Impact Statement.

• Review inpatient multidisciplinary discharge planning processes to ensure they are safe and timely (see section 8.3.2), including the feasibility, staffing implications and cost of increasing the number of weekend discharges.

• Refine entry and exit processes for community services and develop a common Area-wide protocol (see section 8.4.1).

• Develop procedures to allow and encourage client participation in decision making regarding their care (see section 8.3.8).

• Develop procedures for informed consent for all intervention procedures, data collection and data transmission (see section 8.3.8).


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• Participate in any State-wide program to develop services and facilities for people with challenging behaviours as a result of non-traumatic acquired brain injury.

• Develop partnerships with other Clinical Directorates to address issues of rehabilitation for ‘out of Area’ elective patients.

• Determine extent of rehabilitation services required by the tertiary burns unit at CRGH.

Examine specific issues in the Canterbury sector (see section 8.3.7):

- Endorse the General Medicine model of service provision for medical services at Canterbury Hospital,

- Continue to strengthen the Department of General Medicine at TCH through appointment of physicians with general and subspecialty expertise, who have links with other facilities and subspecialty services within CSAHS,

- Strengthen links between the Department of General Medicine at TCH and tertiary units at CRGH and RPAH to facilitate access of patients requiring that level of expertise,

- Monitor the relationship between General Medicine and Geriatric Medicine at Canterbury Hospital including the admission protocols in the Emergency Department,

- Recruit to the vacant staff specialist geriatrician positions,

- Develop strategies to counter the professional isolation of Geriatric Medicine medical, nursing and allied health staff at TCH,

- Compare the level and range of geriatric medicine and rehabilitation services in both the hospital and community in Canterbury with the level and range of services in other sectors, especially the numbers of allied health staff,

- Seek funding to expand the range of services in the Canterbury sector, including post acute and community care, diabetes management, chronic pain clinics, pulmonary rehabilitation and cardiac rehabilitation,

- Seek expanded access to Drug and Alcohol services at TCH.

2.4 Organisational Issues 2.4.1 GGRM Infrastructure

Maintain the sector organisation and delivery of services and strengthen the Area focus of GGRM.

Create and seek funding for a senior position with no line management

responsibilities to ‘drive’ the service development issues on an Area wide basis - quality, education, hospital based policies and procedures etc. using the approach taken in the risk management portfolio (see section 8.4.1).

Develop standard operating procedures across Area for community teams. Standardise like service names across the area eg. ACAT’s.


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Present budget and expenditure information in a format that enables:

- comparisons of resource levels to be made between sectors

- the monitoring of the balance of resources between inpatient and non inpatient services

Ensure area-wide representation on all committees. Attract new funding to support equitable services in all sectors, particularly

Canterbury, rather than expand/develop new services in the other two sectors.

• Assess the feasibility of managing some waiting lists on an Area (as opposed to sector) basis eg. OT waiting times in ACAT vs. HBT.

• Implement the proposed change from July 1 2002 of the reporting of Canterbury sector aged care community services from Canterbury hospital management to Balmain Hospital/GGRM management and ensure the full transfer of the budget (see section 8.4.1).

• Clarify the future of General Medicine at Balmain Hospital (see section 8.4.1).

• Develop strategies to increase customer focus within GGRM.

2.4.2 Quality (see section 8.4.2)

• Develop staff expertise and collect area wide clinical indicators for benchmarking and quality purposes.

• Consolidate GGRM Quality Committee to address needs of all GGRM staff.

2.4.3 Risk Management (see section 8.4.3)

• Continue to implement risk management strategies emanating from the GGRM risk management planning process currently underway.

• Integrate risk management principles into standard GGRM work practices.

• Evaluate risk management strategies introduced during the Risk Management project.

2.5 Partnerships (see section 8.5)

Review and if required formalise GGRM’s relationship with other key clinical groups/stakeholders. These stakeholders can be divided into two groups: internal stakeholders (including Mental Health, Population Health, Neurosciences, Bone and Joint, Palliative Care, Allied Health) and external stakeholders (the Divisions of GP, Guardianship Tribunal, Office of the Protective Commissioner, Department of Housing, other government departments, non government organisations, Councils).

Consolidate and establish new partnerships with non-government agencies and private practitioners, including GP’s.

Continue to strengthen relationships with GPs regarding discharge planning.

Ensure consumers continue to be represented on relevant GGRM committees.


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• Negotiate with Mental Health to maximise the effectiveness of the provision of psychogeriatric services, including at the new Croydon site (see section 8.5.5).

• Develop management/supervisory plans with Mental Health to aid with staff management of joint GGRM/Mental Health staff (see section 8.2.1).

• In conjunction with Allied Health Services identify options for providing podiatry services and ensure consultation with HACC providers in the planning process (section 8.5.6).

• Investigate the interface between Geriatric and Rehabilitation Medicine and nursing homes to identify problems and options (CERA has specifically expressed an interest in undertaking research and education in this area) (section 8.5.3).

• Follow Clinical Council decision as to governance of GPC and Homeopathic Clinic, as they relate to GGRM.

• Develop strong partnerships with CSAHS Human Resource Departments to aid staff recruitment processes (see section 8.2.1).


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3. Introduction The General, Geriatric and Rehabilitation Clinical Directorate is comprised of three departments – General Medicine, Geriatric Medicine and Rehabilitation Medicine. Geriatric and Rehabilitation medicine inpatient, ambulatory care and community services are offered in the three sectors of CSAHS (Eastern, Western and Canterbury). General Medicine offers inpatient services only, with different models of delivery, in both Canterbury Hospital and Balmain Hospital. In 1996 the General, Geriatric and Rehabilitation Medicine (GGRM) clinical directorate developed a plan for the 5-year period from 1996 to 2000. It was a positive process and much was achieved over the timeframe of the plan. In order to maintain continuity, GGRM management decided another strategic plan was needed to set goals and provide direction over the next 5 years from 2002 to 2007. In 2005 a mid-plan review will be conducted. The terms of reference for the plan were as follows:

Broad objective

To develop a strategic service plan for the provision of general medicine, geriatric and rehabilitation services to meet the needs of the population of CSAHS for a 5-year period, 2002 to 2007. The plan will consider services provided by CSAHS as well as those provided by Non Government Organisations and private practitioners and agencies.

Key Tasks

A number of key tasks have been undertaken to develop this plan:

1. A review of the previous plan (1996) to determine progress.

2. Review of current policy on aged care at the Commonwealth and State level.

3. Assessment of the aged population of CSAHS and future projections.

4. A description of existing services, government and non government, including, where possible, the current and projected activity of these services.

5. Consideration of appropriate models of care.

6. Identification of any service gaps and deficiencies, overlaps, need for change, opportunities for improvement and priorities for action.

7. Development of strategies, resource implications, time frame and responsibilities.

8. Review the administrative relationship between the General Practice casualty (GPC) management and GGRM.

Planning Process

Planning has occurred in consultation with key stakeholders - hospital and community managers, Department heads, nursing and allied health staff (inpatient and community), Non Government Organisations, community representatives, Division of General Practice - to


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define key issues affecting future service delivery. Most consultations were on an individual basis; others were in groups. A list of the people/groups consulted is given in Attachment A.

A committee comprising the following members oversaw the planning process: • Dr John Cullen, Director, GGRM (chair) • Mr Peter Clout, General Manager, Balmain Hospital • Ms Ann Kelly, DON, Balmain Hospital • Ms Anne Frisby, Manager, Speech Pathology, Balmain Hospital • Ms Julie-Ann O’Keeffe, A/Service Manager, Eastern sector, GGRM • Ms Rhonda Stiller, Service Manager, Western sector, GGRM • Mr Richard Gilbert, Director of Planning • Ms Norah McGuire, Consumer Representative • Ms Jill Hardwick, Consultant

The role of this committee was:

• To provide advice, guidance and support to the consultant in the development of the service plan and consultation process.

• To ensure that consultation occurs with key service providers within CSAHS and with other government and non-government organisations.

• To monitor progress and to ensure relevant documentation is available to assist the consultant in the preparation of the service plan.

• To debate key issues and assist with the development of options and the determination of priorities.

• To provide comments on the draft plan.

Review of the previous plan

The previous plan had a number of recommendations, which are reproduced in appendix B. Some of these recommendations have been achieved: • The consolidation of GGRM beds will occur as part of the current capital redevelopment

(Resource Transition Program) in CSAHS: - Geriatric Medicine will have a designated ward at RPA – to be established 2003

(8.1.1.1); - a designated 20-bed rehabilitation ward will be established at CRGH and co-located

with the Aged and Extended Care Department (AECD) (8.2.1.1) and the Aged Care Community Services (8.1.3.2);

- the Aged Care Community Services in the Eastern sector will be located in the re-furbished KGV building although they will not be with the community nurses (8.1.3.1).

• Most community services have adopted a case management approach (8.1.6.1). • The position of Head of Department of Rehabilitation Medicine Services in the Western

sector has been filled. • A General Medicine department at CRGH no longer exists and specialists who used to

be part of that department have been incorporated into other sub-specialities (8.3.1.1). • Since the last plan Canterbury Hospital redevelopment has been completed. There have

been major changes in the organisation and staffing of the General Medicine department of TCH so that there is organ specific sub-specialty expertise across a range of disciplines – cardiology, respiratory medicine, endocrinology, infectious diseases and neurology.


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• Clinical indicators are collected by GGRM as part of the Area-wide quality program (8.4.2.3).

• Specific programs and services exist for people from culturally and linguistically diverse (CALD) backgrounds (8.4.6.1).

• GP and consumer representatives have been included in management committees (8.4.7.1).

There are a number of recommendations that are no longer relevant: “8.2.2.3 Negotiations continue with the Department of Veteran Affairs to see if CRGH can continue to provide rehabilitation services to Veterans on a funder-provider basis.” “8.2.3.2 The feasibility of providing Industrial Rehabilitation services on a for-profit basis be examined.” “8.5.1.1 Ward 17 at CRGH …………….be increased from 15 to 25 beds. “ There are a number of recommendations that have not been achieved or have only been partially completed. • transitional care / slow stream rehabilitation is a service gap for GGRM and CSAHS

(8.1.2.1). • there is a sense that there is a disparity of resources between sectors and there has not

been a review of staffing levels and caseload to determine whether this is the case (8.1.4.1).

• there has not been a monitoring of the focus of care – inpatient vs. non-inpatient (8.1.4.3).

• liaison and communication between GGRM and the Emergency Departments to ensure appropriate referral, is variable (8.1.5.2)

• there is no outpatient rehabilitation / day hospital service for TCH (8.2.3.3) • the casemix strategy for the GGRM directorate has not been fully implemented (8.4.1.2) • the health promotion philosophy and strategy has not been fully implemented (8.4.4.1) • podiatry is still a major issue for GGRM (8.4.10.1) • PADP remains an issue (8.4.11.1) • a comprehensive community data collection system still does not exist (8.4.13.1) Many of these issues are addressed again in this plan – transitional care, resource disparity, communication with the Emergency Department, podiatry, PADP, data and information. Some issues such as a strategy for casemix have not been implemented, as they are dependent on the future direction adopted by the Area. The purpose of this current plan is to build, consolidate and extend the work done over the previous five years.


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4. Context All levels of government have a role in funding, administering and/or providing policy direction for general medicine services, aged care services and rehabilitation services for people with disabilities. Below is a discussion of some of the government impacts on some GGRM services.

Commonwealth government

Residential aged care is primarily financed and regulated by the Federal Government and provided primarily by the non government sector. The Federal Government also funds and administers community care for older people with the States and Territories, with State, Territory or Local Governments directly providing some services. HACC is a joint Federal/State program for the frail aged, people with disabilities and their carers. Nationally the Federal Government contributes approximately 60% of program funds and maintains a broad strategic role. The States/Territories match the remaining 40%, which in some states include contributions from Local Government. The Commonwealth also funds community care directly, for example through Community Aged Care Packages (CACPs) and Extended Aged Care at Home (EACH). It also provides annual funding to each State and Territory Government to manage and administer the Aged Care Assessment Program through which Aged Care Assessment Teams (ACATs) are funded. In planning residential and community care services, the Commonwealth sets standards based on the number of people aged over 70. As the ageing population is remaining disability-free for longer, there is a growing argument that says the more relevant group for whom these services should be planned is the population over 80 years.

National Ageing Strategy

The National Strategy for an Ageing Australia (Commonwealth of Australia, 2002) is “a framework for our national response to the challenges and opportunities that an older Australia will present." It focuses on four themes: • independence and self provision (includes employment for mature aged workers); • attitude, lifestyle and community support; • healthy ageing; and • world class care The two themes that have most relevance to GGRM are healthy ageing and world class care. The healthy ageing goals are: • the opportunity for all Australians to maximise their physical, social and mental health; • population health strategies that promote and support healthy ageing; • the availability of information, research and health care infrastructure to support the

healthy ageing of the Australian population. The world class care goals are: • a care system that has an appropriate focus on the health and care needs of older

Australians and adequate infrastructure to meet these needs; • a care system that provides services to older people that are affordable, accessible,

appropriate and of high quality; • a care system that provides integrated and coordinated access, assistance and

information for older Australians with multiple and significant and diverse care needs; • a sustainable care system that has a balance between public and private funding and

provides choice of care for older people.


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Review of Aged Care Reforms

The Two Year Review of Aged Care Reforms undertaken by Professor Len Gray, (Gray 2000) examined the impact of a major reform package introduced by the Coalition Government in 1997. This reform of Commonwealth-funded residential aged care – nursing homes and hostels – was deemed necessary for a number of reasons: • the sustainability of the primarily Commonwealth funded two tiered nursing home and

hostel system; • the poor quality of much of the existing building stock; • the changing roles of nursing homes and hostels; • the growing overlap between the higher levels of hostel dependency and the lower levels

of nursing home dependency resulting in a meaningless nursing home/hostel distinction; • higher levels of recurrent funding received by nursing home residents compared to

hostel residents of equivalent or even higher dependency; • the distinction between the nursing home and hostel sectors meant that residents had to

face disruptive moves when their care needs increased; • the tool for classification of residents to nursing home or hostel was different; • the different standards for hostels and nursing homes. The major elements of the reform package were: • the funding and administration of hostels and nursing homes under the one system; • a single classification tool was introduced to cover the full spectrum of residential care

needs which enabled appropriate funding to be directed to all residents, regardless of their location. In other words funding is now tied to resident need, rather than aged care home ‘type’ thereby enabling ‘ageing in place’;

• nursing home and hostel respite were included in the new funding structure; • all residents (hostel and nursing home) pay the same daily fees (determined by pension

status); • people entering after March 1998 are income tested; • new arrangements for accommodation payments were introduced; • new residential care standards and accreditation standards were introduced with a

primary focus on care as well as on continuous improvement, education and staff development;

• certification was introduced, which focuses on the improving the physical standards of residential aged care buildings.

The terms of reference of the review were to assess and report on the impact of these reforms in relation to access, affordability, quality, efficiency industry viability, State and Territory programs, choice and appropriateness and other considerations. The review looked at the effect of the reforms on Aged Care Assessment Teams (ACATs) and concluded that the reforms have not changed their role. However, many ACATs considered that the new system increased the complexity and duration of assessments. Some ACATs reported that they now assumed a greater role in advising people about their options for care and other issues such as the financial implications of care choices (Gray 2000:176). The review also concluded that there had been a decline in the number of low dependency individuals in residential care. There has been a substantial growth in the provision of Community and Aged Care Packages (CACPs) which seem to have been substituted for residential care (Gray 2000:187). This change in policy has resulted in individuals in the community having increased levels of dependency. The review also attempted to assess whether the reforms have created an increased incentive for people to stay in hospital rather than enter residential care. It concluded,


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despite the limitations of the data, that most people classified as Nursing Home Type Patients (NHTP) are not discharged to residential care and that the length of stay for all NHTP appears to be relatively stable (Gray 2000:191). The government (DHAC 2001) has accepted the main recommendation made in relation to this area of the review, namely: “It is recommended that the Commonwealth and the States and Territories (a) jointly undertake a critical analysis of current measures of need for care, type of care required and appropriate care delivery setting for older people with care needs, and (b) work cooperatively to ensure that appropriate acute, sub-acute and non-acute care options are available across the full range of settings, including hospitals, hospices, rehabilitation services, aged care homes in the community, to ensure client focussed transitions between levels of care across Commonwealth and State programs.”

HACC Reforms

The Home and Community Care (HACC) Program was established in 1985 in recognition of the serious weakness in the organisation and delivery of health and welfare services to aged and disabled people. As mentioned previously, it is a joint Commonwealth/State funded initiative, with the Commonwealth providing 60% and the State and Territories providing 40% of funds. There has been a number of reviews (House of Representatives Standing Committee 1994; Commonwealth Department of Human Services and Health 1995; National Ageing Research Institute 1999) of the program over the last 15 years and all of them have consistently pointed to the need for the development of a standardised assessment system that would be used and understood by all services. Comprehensive assessment (Lincoln Gerontology Centre 1998) together with the introduction of a HACC Minimum Data Set (MDS), are the two major developments in the current HACC Reform Project. The first stage is the implementation of a comprehensive assessment framework in NSW (ADD 1998) is the development, trialing and formal ratification of the Client Information and Referral Record (CIARR) as the referral tool between HACC services. The consultation, development and implementation process at the local level will be steered by a representative network of community care providers and users whose role will be: • to ensure all community care services link into the CIARR based referral system • to recommend comprehensive assessment services (CASs) for the area i.e. locally

endorsed agencies with recognised knowledge and skills to do a holistic or comprehensive assessment

• develop and/or refine an area protocol for the comprehensive assessment of people with complex, multiple or high needs

• ensure all agencies in the network use the protocol • monitor the implementation process GGRM is currently involved in this implementation together with the other major activity of the HACC Reform Project, the implementation of the HACC MDS. GGRM managed HACC projects have successfully completed ACHS accreditation. Recently additional accreditation requirements for HACC projects have been mandated by DADHC.


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NSW State Government

NSW Healthy Ageing Framework

The NSW Healthy Ageing Framework, 1998–2003 sets out the directions for NSW Government policies and programs for older people over the next five years which is managed and coordinated by the Ageing Issues Directorate within the Department of Ageing, Disability and Home Care (DADHC), previously known as Ageing and Disability Department (ADD). Six key areas for action over the next five years are outlined: 1. Attitudes to ageing and older people 2. Participation in community life 3. Making your own decisions 4. Supportive neighbourhoods and communities 5. Health, accommodation, care and support 6. Making the best use of resources Specific actions to be undertaken in the five year period of the plan, which are the responsibility of the Minister for Health and are of relevance to GGRM, are: • Ensure that health services are focused on healthy ageing outcomes by supporting the

appropriate training of professionals working with older people, for example, ACATs (Key action area 1).

• Develop health, accommodation care and support services responsive to the needs of people with dementia and their carers by implementing initiatives under the NSW Action Plan on Dementia (Key action area 5).

• Improve the care and rehabilitation of people following a stroke by developing evidence based standards of care for acute stroke and early rehabilitation, guidelines for the management of risk factors and guidelines for patient and carer education (Key action area 5).

• Improve the coordination of support for people with complex needs through an integrated work plan of the relevant government agencies and implementing a pilot project (Key action area 5).

• Improve health system information about older people by including ageing indicators in health surveys, such as the statewide health survey (Key action area 6).

Improving the Aged Care Interface

NSW Health has also produced a discussion paper, Improving the Aged Care Interface (NSW Health 2001) which puts forward a number of proposals that are intended to clarify the role of the Commonwealth and NSW Governments and non government sector in residential aged care services and to reform the interface between aged and acute care services. It contains proposals regarding: • the expansion of transitional care • residential care charging of certain patients; • the transfer of State Government Residential Aged Care Facilities (SGRACF) and

Confused and Disturbed Elderly (CADE) Units to the non government sector; • the potential for co-location of public hospitals and residential care facilities in limited

situations. There remains a lack of consensus between State and Commonwealth regarding these issues.


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NSW Government Action Plan

In March 2000 the NSW Minister for Health announced the Government Action Plan for Health. The Plan guaranteed for the first time three-year recurrent budgets, a $2 billion cash injection to health services and a fairer distribution of health dollars across NSW. The Plan is being implemented by a number of implementation groups. The lead group is the Clinical Council. The Chronic Care Implementation Group is focusing initially on three priority health care programs – to implement service improvements for people with cardio-vascular disease and its risk factors (including diabetes), respiratory illness and cancer. This single disease focus does not address the needs of older people who tend to have multiple diseases. In 2002 NSW Health established two working groups to address these issues relating to the care of older people within the public health system - The Care of Older People Working Group, and a Greater Metropolitan Transition Taskforce (GMT2) subcommittee on the Acute Care of the Elderly.

The report from the Working Group on the Care of Older People in the NSW Health Care System was released in December 2002. This committee endorsed a model of care and identified four key demand areas

management of older people in emergency departments – strategies to be developed via the newly funded ASETeams

discharge planning and post-acute care – including access to post acute services seven days per week, needs analysis of nursing and allied health staff required to provide home-based services, involvement of GP’s, provision of a range of multi-disciplinary outpatient, community, rehabilitation and transitional care services

management of the confused elderly in hospitals – including ‘expert’ dementia/delirium teams

systems and models of care – including the need for specialist workforce training and education and standard evaluation/performance indicator systems.

The GMT2 subcommittee report is not available at this time. However, the subcommittee has identified workforce deficiencies across all key disciplines. The Report of the Greater Metropolitan Services Implementation Group was released in 2001. (http://internal.health.nsw.gov.au/policy/gap/metro/GMSIGmetro.pdf) This final report makes recommendations relevant to GGRM including the specific areas of cardiac disease, brain injury and stroke. The GMT2 process has implications specific to General Medicine at TCH. It has recognised and enhanced the role of metropolitan hospitals in the provision of health services, providing for better linkages and easier access, with cross-accreditation of senior medical staff, to tertiary referral facilities. Whilst the funding implications for TCH are small, the organisational and strategic focus enhances health care provision across the Area. GMT2 reinforces the need for metropolitan general medical services to continue to develop and respond to the provision of health services across the broad spectrum of presentations. Other wide reaching recommendations to changes in service delivery from GMT2 include the need to develop network type services, with a range of clinical cross appointments to cover regions, with common referral protocols and clinical pathways, common data collection and analysis systems. While not specifically addressing primary or community-based care, GMT2

did acknowledge the need to further develop general discharge planning systems, with transitional or outreach/community programs.

http://internal.health.nsw.gov.au/policy/gap/metro/GMSIGmetro.pdf�


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The report of the Consumer and Community Participation Implementation Group (NSW Health 2001) also makes some recommendations that are relevant for GGRM:

• that feedback from patients, carers and staff is regularly collected and used to improve policy, planning and service delivery and is available to the public

• that participation in decision-making and access to information are recognised as an important part of achieving equity in health outcomes, particularly for members of disadvantaged communities

CSAHS

Clinical Strategic Plan

Following the integration of CRGH into the State health system on July 1 1993, CSAHS reorganised clinical services on an Area basis (CSAHS 1993) to form eleven clinical groupings – GGRM, Cardiovascular Services, Bone and Joint Diseases, Cancer Services, Women’s and Children’s Health, Neurosciences, Respiratory and Critical Care Services, Gastroenterology and Liver Services, Population and Drug Health Services, Mental Health Services and Oral Health Services. Each clinical grouping comprises all the relevant hospital and community services in the Area. A clinical director and clinical manager head each clinical grouping. The GGRM General Medicine services are unique, in that whilst being part of the GGRM directorate, it is required to deliver services which are across directorates, in terms of disease presentations and definitions. The metropolitan hospital model is such that most other directorates are not represented specifically, although physicians holding appointments are part of a directorate depending on vocational interests and expertise.

Resource Transition Program

The Resource Transition Program (RTP) is a rebuilding program worth $375 million that is enabling the redevelopment of services and hospital infrastructure to accommodate technological changes in health care in all the major facilities in the Area including community health centres. This major re-configuration of services is also increasing the overall efficiency of services, allowing the Area to meet NSW Health targets in terms resources, beds and activity levels and ‘freeing up’ some resources so they can be shifted to areas of more significant population growth ie. Resource Distribution Formula Clinical groups were required to develop Service Delivery Plans on an Area-wide (rather than facility) basis including projected numbers of inpatients to 2006. These projections were then matched to asset requirements. The required asset stock was matched, in turn, to the current capacity and asset plan options developed. The Service Delivery Plan for GGRM (CSAHS 1996) proposed the following developments: • a 20-bed designated Geriatric Medicine ward at RPAH; • a 20-bed designated rehabilitation unit at CRGH; • the establishment of a day hospital at the new Canterbury Hospital; • acute psychogeriatric beds to be provided at CRGH; • consolidation and co-location of community services in the Eastern sector; The Plan also predicts significant increases in the number of people using ambulatory care (outpatient) services in both geriatric and rehabilitation medicine.


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The geriatric ward at RPAH and the rehabilitation ward at CRGH are currently under construction and it is expected they will be available for use by GGRM in 2003/04. The proposed day hospital was not established at TCH, despite the major re-building of the hospital. Since the completion of the GGRM Service Delivery Plan, details of the redevelopment of the old Western Suburbs Hospital site at Croydon have been finalised. A mix of health and residential aged care facilities are planned for this inner west health centre site. These include: • a comprehensive community health centre • 40 bed dementia specific nursing home (reduced from the original brief of 60 beds) • aged hostel accommodation and aged self care apartments The multi-service centre will be accommodated within a purpose-built facility replacing a number of outmoded buildings in different locations in the inner west. Included among the community health centres will be post acute care including domiciliary outreach, community nursing, and podiatry services. The nursing home will specialise in dementia care: some of the 40 beds will be respite care places. The initial plan for this facility included 10 transitional care / slow stream rehabilitation beds. This function is not explicit in the current plan. A decision has been made to accommodate the consolidated community services from the Eastern sector in the planned refurbished KGV building.


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5. CSAHS – the number, distribution, projections, mortality and morbidity of older people

At the time of the Census in 2001 the population of CSAHS was 500,778 and is expected to be over 509,000 by 2006. The proportion of the population over 65 years in 2001 was 12.08% and 5.53% were over 75 years. The population over 65 is expected to increase between 1996 and 2006 by 5.5% from 59,000 to 62,000 but as a proportion of the total population it will decrease slightly to 12.1% - lower than the proportion of 13.3% predicted for NSW as a whole (Table 1). The characteristics of new residents into the major foreshore developments along the northern border of the Area (Parramatta River) are likely to have further impacts on these population figures. In 2006, the over 65 years population in the Eastern sector is expected to be around 20,000; in the Western sector it will be almost 25,000 and it will remain around 17,000 in the Canterbury sector. Although aged care service planning is based on the population over 65 or 70 years, the average age of the population who use Geriatric Medicine services is over 80 years. CSAHS 75years+ population is expected to increase by more than 3,000 people between 1996 and 2006, an increase from 5.3% of the population to 5.6%. GGRM services are divided into three sectors – the Eastern sector includes the LGAs of Sydney (part), South Sydney (part), Leichhardt and Marrickville; the Western sector covers Ashfield, Burwood, Canada Bay, Strathfield; the Canterbury sector is the municipality of Canterbury. Although the Eastern sector has the largest total population, the number of older people is greatest in the Western sector with over 23,000 people over 65 years representing 14.6% of the population (2001 figures). There are 18,000 people over the age of 65 in the Eastern sector (10.1%) and 17,000 (12.3%) in this age group in Canterbury (1996 figures). The Western sector has the largest ‘old old’ population (75years+). No figures relating to the numbers of people with disabilities are available for the whole CSAHS area.


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Table 1: Population over 65 years and 75 years in CSAHS in 1996, 2001 and projected population in 2006

1996 2001 2006*

Pop’tion 65+

Pop’tion 75+

Total Pop’tion

Pop’tion 65+

Pop’tion75+

Total Pop’tion

Pop’tion65+

Pop’tion 75+

Total Pop’tion

E sector Sydney/South Sydney (part)

4065 1698 39186 4620 2030 56080

Leichhardt 6379 2830 60720 6 072 62 452 6200 2710 62750 Marrickville 7776 3150 79717 7 496 73 431 9110 3730 81760 Total 18220 7678 179623 19930 8470 200590 % of total population

10.1% 4.3% 9.9% 4.2%

W sector Ashfield 5978 2881 41693 5 942 39 494 6340 3120 43770 Burwood 4465 2037 29630 4 297 29 960 4950 2550 31440 Canada Bay 8696 3866 56456 8 953 59 845 9330 4550 62850 Strathfield 4195 1983 27128 3 891 28 206 3990 1980 28440 Total 23334 10767 154907 23 083 157 505 24610 12200 166500 % of total population

15.1% 7.0% 14.6% 14.8% 7.3%

Canterbury 17061 6765 138532 16 940 130 947 17320 7730 142790 % of total population

12.3% 4.9% 12.9 % 12.1% 5.4%

Total CSAHS 58615 25210 473062 60529 27737 500778* 61860 28400 509880 % of total population

12.4% 5.3% 12.08% 5.53% 12.1% 5.6%

NSW 762902 315770 6038696 833 419 6371745 897162 421694 6735592 % of total 12.6% 5.2% 13.07% 13.3% 6.3%

* estimated Source: Department of Health Population Projections, ABS Estimated Resident Population, 2001 Census Data NB. Limited 2001 census data is available at this time only.


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Map showing CSAHS in the relation to the other Area Health Services in NSW


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Key: 1. Concord Hospital 2. Thomas Walker (Rivendell) 3. Dame Eadith Walker (Yaralla) 4. Canterbury Hospital 5. Tresillian Family Care Centre 6. Rozelle Hospital 7. Balmain Hospital 8. Royal Prince Alfred Hospital 9. NSW Institute of Forensic Medicine 10. Health Quest 11. United Dental Hospital

Map of Central Sydney Area Health Service


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The proportion of the population over 65 years in CSAHS who do not speak English is around 40% compared to 19% for NSW as a whole. In the Western sector the main languages other than English are Italian, Chinese and Greek. In the Eastern sector Greek, Italian, Chinese are the biggest non-English language groups followed by Arabic and Vietnamese. In Canterbury, Italian and Greek speakers are the largest language groups after English followed by Arabic, Chinese and Vietnamese (Table 2). The major Canterbury groups for which an interpreter is needed are Arabic, Chinese, Vietnamese and Korean. Table 2: CSAHS population over 65 years showing the proportion whose main

language spoken at home is English/not English Sector % of population

over 65 whose language spoken at home is English

% of population over 65 whose language spoken at home is not English

Main languages (other than English) spoken

Western Sector 61.2 38.8 Italian, Chinese, Greek Eastern Sector 59.0 41.0 Greek, Italian,

Chinese, Arabic, Vietnamese

Canterbury Sector 58.9 41.1 Italian, Greek, Arabic, Chinese, Vietnamese

Total CSAHS 59.9 40.1 NSW 80.9 19.1 Source: 1996 Census At the 1996 Census, 4378 persons within CSAHS identified themselves as Aboriginal and/or Torres Strait Islander. This represents about 15% of the Sydney total and 0.4% of the State total population. Over two thirds of the CSAHS Aboriginal and Torres Strait Islander people live in the Eastern sector of the Area around Waterloo, Redfern, and Glebe (Table 3). The life expectancy of the Aboriginal population is much shorter than for the general population, with only 13% aged 45 years or older compared to 34% for the general population. Table 3: Aboriginal and Torres Strait Islander population in CSAHS by sector

Sector No. of Aboriginal

and Torres Strait Islander people

% of total CSAHS ATSI population

Western Sector 680 15.5Eastern Sector 2977 68.0Canterbury Sector 721 16.5Total CSAHS pop. 4378 1.0NSW 101485 1.7

Health of Older People

NSW Health conducted an Older People’s Health Survey in 1999. It was a telephone survey of randomly selected households in NSW involving over 9000 people over 65 years. The survey covered a range of health issues such as self rated health, use of health services, nutrition and food security, physical activity, physical functioning, falls, mental health and well being, diabetes, oral health, use of community services and the role of carers. A total of


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616 people responded from CSAHS, a response rate of 63.7% - the second lowest response rates of all AHSs. The results for NSW overall on the use of health services can be summarised as: • 96% of all older people interviewed had visited a GP in the last 12 months • 38.7% had visited a GP in the last 2 weeks • 22.7% had spent at least one night in hospital in the last 12 months • 6.8% reported a community nurse visit in the last 12 months and 2.7% in the last 2

weeks • 20.4% visited or were visited by a podiatrist • 15% consulted a chemist about a health problem • 14% visited or were visited by a physiotherapist Responses on a number of questions have been reported by AHSs. CSAHS residents’ responses are shown in Table 4 compared to the responses for NSW as a whole. CSAHS residents’ responses are less favourable than the NSW average on most indicators. Table 4: Responses by CSAHS residents in the Older People’s Health Survey

compared to the total for NSW, 1999

Survey item CSAHS %

NSW %

Self rated health as very good or excellent 30.6 37.6 Self rated health as fair or poor 59.2 54.3 Use of community services: - home duties in the last week - personal care in last week - meals delivered in the last week - home maintenance/gardening in last 4 weeks - attend day care centre in last 4 weeks

7.6 1.0 2.4 8.6 0.9

8.5 1.2 2.5 9.6 0.9

Reported need for more community services

11.1 8.1

Main responsibility in caring for someone with a long term illness, disability or other problem

7.8 9.2

Recommended quantities of vegetables eaten each day

27.9 36.0

Recommended quantities of fruit eaten each day

57.5 57.6

Adequate physical activity 46.8 39.2 Knowledge of Exercise Campaign 39.2 41.0 Activities of Daily Living - does home duties on own - prepares meals on own - does home maintenance/gardening on own - does not need help with personal care - does not need help with cutting toenails

84.2 92.5 62.8 94.7 67.7

87.5 94.1 70.5 97.2 72.6

Falls in the last 12 months - any fall - fall requiring medical treatment

26.7 10.9

26.8 8.6

Psychological distress - K6 score 60 or more

16.7

13.5


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- feeling depressed 4.5 3.0 Current doctor-diagnosed diabetes - foot check last 12 months - eye check last 12 months

14.5 34.1 53.7

12.2 47.3 61.9

Mouth/denture problems - edentulous people - dentate people

20.8 17.8

19.1 17.0

Source: NSW Older People’s Survey 1999 (HOIST), Epidemiology and Surveillance Branch, NSW Health

Acute Hospital Care

Older people admitted to acute hospitals are more likely to have significant co-morbidities, chronic and complex conditions, high dependency levels, vulnerability to adverse events, and needs for rehabilitation, discharge planning and post-hospital support, than are younger patients. A single illness model of care does not meet the medical or functional needs of this group. There is a developing recognition that a broad multidisciplinary approach that addresses the range of assessed needs is required. The average length of stay of older patients admitted via Emergency Departments has increased in the period 999/2000 – 2001/2002 for both CSAHS and NSW Public Hospitals. Table 5: Aged Patients in CSAHS Hospitals and Across the State - Admissions for

Overnight Stay through Emergency Department 1999/00 - 2001/02 Aged 65-74 years

Hospital 1999/00 200/01 2001/02 Seps Beddays ALOS Seps Beddays ALOS Seps Beddays ALOS CRGH 1701 14187 8.34 1710 14735 8.62 1648 12866 7.81 RPAH 2237 16350 7.31 2342 17757 7.58 2188 17708 8.09

TCH 881 5945 6.75 912 5382 5.90 901 5825 6.47 Balmain 29 219 7.55 27 163 6.04 16 130 8.13 CSAHS 4848 36701 7.57 4991 38037 7.62 4753 36529 7.69

NSW Public 55148 398258 7.22 55835 386887 6.93 55354 376797 6.81

Aged 75-84 Years



NSW Public 63005 508858 8.08 65859 518380 7.87 67479 528089 7.83

Aged 85+

Years



NSW Public 30357 269259 8.87 36360 333660 9.18 34481 294605 8.54

Source: CSAHS Planning Unit


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Mortality and Life Expectancy

Life expectancy at the age of 65 is an estimate of the average age of death for someone who has already reached the age of 65, assuming that current rates of death prevail for the remaining lifetime of that person. In NSW, between 1964 and 1998, the expected age at death for persons aged 65 increased for males from 77.3 to 82.0 years, and for females from 80.8 to 85.2 years. The World Health Report (World Health Organisation, 2001) reported Healthy Life Expectancy estimates (HALE), within the Australian population, as the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality. Table 6: Healthy Life Expectancy for the Australian Population (WHO, 2001) Males Females Average life expectancy at birth 77 82 Average healthy life expectancy 70 73 Lost healthy life years (time of ill-health/disability) 7 9 Between 1994 and 1998, the NSW average age-adjusted death rate was 814.0 per 100,000 person years for males and 499.9 for females. In CSAHS it was 6% higher than the NSW average for males and 4% higher for females.


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6. GGRM services, organisational structure, utilisation and resources

GGRM clinical services in CSAHS are organised into three sectors with linking of inpatient services and community services for the local population: the Western sector based at CRGH and providing services to the residents of Ashfield, Burwood, Canada Bay, Strathfield; the Eastern sector based at Balmain and Royal prince Alfred Hospitals, Glebe, Newtown and Marrickville and providing services to residents of Leichhardt, Marrickville and Sydney (part) and South Sydney (part); the Canterbury sector based at Canterbury Hospital and covering Canterbury municipality. Each sector has its own inpatient, ambulatory, and domiciliary services. Some services, which have an Area or State responsibility, are organisationally situated in one of the sectors. GGRM Organisational chart and Committee structure is included in Appendix C. The model of service delivery has the following core components: • acute inpatient beds in geriatrics and general medicine • beds for patients who are confused or behaviourally disturbed • sub acute beds (rehabilitation) • ambulatory clinics including day hospital • community and home based assessment, therapy and support (ACAT, home based

therapy) • frail aged day care • dementia specific day care • short and long term brokerage services • transport to and from some GGRM services • carer support and respite • nurse consultancy support – CNC positions in gerontology, continence and

amputation/rehabilitation • links with Emergency Departments including through the recently established Aged care

Services Emergency Teams (ASET) There are some key processes that are important aspects of the model of service delivery. They are: • admission direct from Emergency Department to acute geriatric and general medicine

beds • multidisciplinary management based on comprehensive assessment • the management of the patient’s transition between settings of care • multidisciplinary discharge planning where required • the involvement of consumers in Area and sector management committees The range of services in each sector is described in detail below.

Western sector

(Organisational chart is provided at Appendix C)

Inpatient services

There are four wards at CRGH for inpatients of the GGRM service – Wards 19 and 20 are the acute geriatric wards which also accommodate some general rehabilitation patients, and outlier patients from other units, Ward 35 provides geriatric rehabilitation. Ward 17 is for confused elderly patients from all of CSAHS (not just the Western sector). Currently these


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wards provide temporary accommodation while the ‘ramp’ wards are being re-developed, as part of the RTP, to form a GGRM precinct. Wards (including a purpose built 20-bed rehabilitation ward) and community services will be co-located as part of this redevelopment. Completion of the redevelopment is expected in March 2004. Table 7: CRGH: GGRM Inpatient Services

Ward No. of beds Type of patients

17 12 Psychogeriatric 19 24 Acute geriatric 20 24 Acute geriatric 35 23 Geriatric rehabilitation

Total 83

Non inpatient services

1. Community, domiciliary services are managed by a Service Manager who is responsible for a number of teams (including those in the Canterbury sector): • Aged Community Services Team which is the ACAT for the sector. • Inner West Live at Home – the Community Options program. • Community Respite Team – including respite day centres and in-home respite. • Carer Respite Centre, including the Residential Information Service – respite for carers • Home Based Therapy Team • Aged care Services Emergency Team The Community Respite Team, and the Carer Respite Centre and Residential Information Service, provide Area-wide services for GGRM.

2. Hospital based, non-inpatient services are managed by the Head of Department of Geriatric Medicine. These services (Aged and Extended Care Department) include: Day Hospital Outpatient Clinics Concord Living After Stroke Program (CLASP) Neurodegenerative Disorders Education and Management Service (NDEMS) Referrals to most non inpatient services are to a centralised intake phone number which is staffed during working hours from Monday to Friday. A detailed history about the client is taken at this point. Allocation to the appropriate service – outpatients, day hospital, the ACAT (known as the Aged Community Services Team), home based therapy - is made every morning at 8.30am at an allocation meeting which consists of 5 or 6 staff from all services. Aged Community Services Team The Aged Community Services Team is a multidisciplinary ACAT whose core function is to provide information, home based assessment (physical, medical, psychological and social aspects of the client), management and coordination of support services and monitoring for frail, confused and disabled older people and their carers. The staff undertake assessment for nursing home, hostel and residential centre placement, for the provision of Community Aged Care Packages (CACP). The team consists of nurses including psychogeriatric nurses, occupational therapists, social workers, nutritionist, administrative assistants and psychogeriatricians. The psychogeriatric sub team provides assessment, support and


36

monitoring of people with psychiatric disorders associated with old age. Waiting times are generally 8-10 weeks. Inner West Live at Home Program The IWLAHP is a Community Options program which provides individual case management and coordination for elderly and disabled people who are at risk of inappropriate or premature institutionalisation, who have complex health care needs which require ongoing monitoring and an integrated package of community care services. The program arranges a package of services through existing home and community care organisations, purchase services and equipment on behalf of the consumers if such services are not otherwise available and provides case management in consultation with the client/family. Staff consists of a full time manager and 1 full time worker, 1 part time worker and 1 administrative officer. Community Respite Team There are three components to this service: • Kalparrin Centre – a respite day centre for the confused and behaviourally disturbed

older people living in the community and their carers. The centre operates 7 days a week. Clients are provided with transport to the centre where they participate in a comprehensive activity program and are given lunch. The centre is staffed by a full time coordinator, drivers, diversional therapists and community support workers. The centre has the capacity for 16 clients a day and 8/10 at the weekend. There is a total of 50 clients. Most clients come twice a week with some coming three times (including the weekend). The average waiting time is about 2 months.

• Kindilan Centre – a respite day centre for the frail aged and physically disabled older people living in the community and their carers. The centre operates 5 days a week with one day specifically for Greek speaking people (Greek cluster). Clients are provided with transport to the centre where they participate in a comprehensive activity program and are given lunch. The centre is staffed by a driver, diversional therapist and community support worker and a coordinator. Clients attend once a week. There is a total client pool of between 60 and 70. The waiting time for the centre is about 4 months.

• Dementia Support Service is an Area wide service providing flexible and appropriate in-home respite and support for carers of people with dementia. The service includes individual or small group outings. Clients receiving in home respite are those who require a one to one care situation not available in day centres. Clients may come from culturally and linguistic diverse backgrounds, have physical disabilities as well as mild to severe dementia, who may or may not exhibit challenging behaviours. The service began in the Western sector and was extended to the Eastern/Canterbury sector in 2001. Each sector has a coordinator, with different models of service delivery. In the Eastern/Canterbury sector, all services are provided through a brokerage arrangement with selected agencies. In the Western sector there are four permanent part time workers as well as a casual pool of workers that provide about fifty percent of the services. The other fifty percent of services are provided through brokerage. The Western sector also operates a Meditrak (tracking) system to assist in the management of wandering.

Carer Respite Centre The Carer Respite Centre (CRC) is an Area-wide service and fulfils an information, advice and referral function for carers of people with any diagnosis and of any age. It provides short term respite to individuals and currently funds 10 community organisations to provide respite for groups. Staff consists of a manager, an administration officer and 2 coordinators. A total of 563 services were provided to carers between January and December 2001.


37

Residential Information Service The Residential Information Service (RIS) is also an Area-wide service and provides information, advice and details of vacancies in nursing homes and hostels in CSAHS. The service is staffed by a part time coordinator and administration officer. The service manages 11 respite beds in nursing homes and 2 respite beds in hostels. The Carer Respite Centre has limited funding to subsidize the patient contribution costs of residential respite care. The service updates and informs staff in GGRM three times a week of the status of available beds in nursing homes and hostels. The coordinator liaises with nursing homes and hostels and encourages the development of NESB clusters. Clusters exist for Arabic, Italian and Greek speaking people. There is a gap currently for Chinese speaking people. Carer Education Project This project is funded as a one-year demonstration program (2001/02) under the Care for Carers program of NSW Health Department. The project has 2 aims. The first is to provide education programs for the carers of frail aged people and people living with dementia. The second is to investigate the needs of ageing carers of adults with disabilities, with a view to developing appropriate educational courses for these carers. The project covers all municipalities of CSAHS and is staffed by a part-time coordinator who develops and coordinates the education groups. Home Based Therapy This HBT service provides allied health assessment and therapy at home. The team includes 2.0 FTE physiotherapists, 2.0 FTE occupational therapists and 0.1 FTE speech pathologist. The centralised intake service refers to home based therapy if the patient cannot access the day hospital. The waiting list is 4-6 weeks for physiotherapy and greater than 12 weeks for occupational therapy. Aged care Services Emergency Team The ASET team is an initiative of NSW Department of Health, funded in 2003. A single team covers both Concord and Canterbury Emergency Departments. There is screening of patients over 65 years at triage. ASET assessment identifies care needs and arranges community care to enable timely transfer out of ED. The team operates Monday – Friday business hours. Outpatients Clinics There is a range of specialist geriatric and rehabilitation clinics for aged and disabled people. There are general geriatric clinics (new patient and review), a bladder clinic (with a geriatrician, urologist and nurse continence advisor), a monthly amputee clinic, neuropsychology, general rehabilitation clinics, and a multidisciplinary chronic pain management service, (which includes an anaesthetist, rehabilitation specialist, registrar, and clinical psychologist). CLASP The Concord Living After Stroke Program (CLASP) grew out of recognition that people with stroke were not well supported after discharge. It is funded till June 2004 by the Department of Veterans’ Affairs (DVA). Staffing consists of 1.0 FTE project officer and 0.2 FTE physiotherapist. The service consists of: • a stroke review and education clinic • various support groups – a communications group, a young stroke group, a general

group, a carers group, an exercise group, an upper limb therapy group. The client population of the service is roughly half DVA and half non DVA clients. Ongoing funding for this program is not secure.


38

Day Hospital The Day Hospital is a day only centre for the assessment and rehabilitation of frail aged and people with a disability. Transport is available and people usually come in twice a week for a period of 3 – 4 weeks. The average waiting time is 10-12 days. A maximum of 10 patients are treated at any time and there may be 3 groups of patients a day. The staff includes 1.6 FTE physiotherapists, 0.6 FTE occupational therapists, 1.0 FTE social worker, 1.0 FTE nurse, 0.3 FTE speech therapists and 2.0 FTE drivers. Neurodegenerative Education and Management Service This service consists of two clinics – a Cognitive Disorders clinic and a Parkinson’s disease clinic. They are supra-Area, tertiary referral clinics that provide a coordinated team approach for the systematic evaluation and tertiary diagnosis of people suffering from the neurodegenerative disorders. The clinics also have a teaching role. The Parkinson’s clinic is run jointly with the Neurology Department. The service is staffed by geriatricians, neurologists, neuropsychologists, physiotherapist, occupational therapist, social worker and a research nurse in consultation with imaging physicians, molecular biologists and neuropathologists. Ongoing funding for elements of this program is not secure beyond June 2004.

Eastern sector

(See appendix C for organisational chart)

Inpatient services

There are three wards at Balmain Hospital, each with 26 beds, for acute and sub acute geriatric and rehabilitation inpatients. Limited general medicine services are available. There is no designated geriatric or rehabilitation ward at RPAH and currently patients are scattered throughout the hospital. A 20-bed ward is planned for Geriatric Medicine as part of the RTP. An interim 16-bed ward will be provided in 2003. Table 8: Eastern sector GGRM inpatient services

Ward No. of beds Type of patients Balmain – John Beasley 26 Rehabilitation Balmain – Lever 26 Geriatric medicine Balmain - Wakefield 26 Geriatric medicine RPAH between 20 and 30

patients are scattered throughout the hospital at

any one time

Geriatric medicine/rehabilitation

Total 98-108


1. The following non inpatient services in the Eastern sector are managed by Balmain Hospital’s General Manager. Outpatients Clinics at Balmain Hospital include general geriatric clinics, diabetic clinics and a continence clinic. A weekly Geriatric Registrar’s clinic is also held at Rozelle Hospital. Numerous rehabilitation clinics are held at the RPAH Day Hospital, including an Area amputee clinic, run by the rehabilitation specialist from CRGH.


39

General Practice Casualty operates in the grounds of Balmain Hospital. See section 8.14 for more details. STRONG The Strength Training, Rehabilitation and Outreach to unidentified Needs in Geriatric Medicine (STRONG) program commenced in 1999 with seeding funding from the DVA. This ambulatory program is unique in Australia and provides: • exercise as a treatment for disease, • education for health professionals in the identification of sarcopenia, its functional

implications and treatment, • ongoing research into exercise as a medicine. The exercise training offered includes progressive resistance training or weight lifting exercise, cardiovascular or aerobic or endurance training and balance training. Currently 180 people attend a week. In the report on its first 2 years of activity, the program has shown improvement in physiology, self reported and objective function, quality of life, depression and sleep for elderly patients with a wide variety of diseases – depression, diabetes, Parkinson’s Disease, stroke, osteoporosis, joint replacement and arthritis, corticosteriod or disease related muscle wasting, frailty and functional impairment. This exercise program is offered at Balmain Hospital by one of the staff specialist geriatricians together with an occupational therapist, an exercise physiologist and 2 hours per week of a dietician. The program also has two research grants from the NHMRC supporting 4 research officers and 2 students. Program of Appliances for Disabled People This is an Area-wide service providing aids and equipment to maintain aged and disabled clients of all ages in the home. The range of aids and equipment is vast including specialised wheelchairs, lifting hoists, shower chairs, walking aids, continence pads, suction catheters, voice and breast prostheses and oxygen. Some items may cost as much as $18,000. There are over 1000 active clients. The program’s budget is around $1.4m. There are 3.4 FTE staff. The PADP is managed by an Area committee who meet regularly to review budgets and products and decide priorities for clients requesting high cost items (over $800). There are other committees determining the allocation of continence pads and oxygen. There are Equipment Lending Pools in each sector for short term loan of aids, which complement PADP. Day Hospital Rehabilitation clinics are conducted primarily in the day hospital of the RPA Institute of Rheumatology and Orthopaedics. The staff of the day hospital includes 2.0 physiotherapists, 1.0 occupational therapist, 0.5 speech pathologist, a nurse unit manager, a bus driver and a receptionist. The rehabilitation medicine staff specialists hold clinics two days a week, plus an Area amputee clinic. There are 5 consulting rooms, a waiting room and access to a hydrotherapy pool. Transport is available. Aged care Services Emergency Team See Western Sector ASET description. CNC Continence The nurse who occupies this HACC funded position is based at Balmain Hospital. She conducts outpatient continence clinics, provides education, consults inpatients and visits people at home.

2. Community based, domiciliary services are managed by a Service Manager, who is responsible for a number of teams. They include:


40

Community Aged Care Team The Community Aged Care Team is a multidisciplinary ACAT whose core function is to provide information, assessment (physical, medical, psychological and social aspects of the client), management and coordination of support services and monitoring for frail, confused and disabled older people and their carers. The staff undertake assessment for nursing home, hostel and residential centre placement, and for the provision of Community Aged Care Packages (CACP). The team consists of occupational therapists, social workers, physiotherapists, nutritionist and 0.6 of a geriatrician and 1.0 FTE geriatric registrar. The psychogeriatric sub team of a psychogeriatrician, three psychogeriatric nurses and a psychogeriatric social worker (all funded by mental health) provides assessment, support and monitoring of people with psychiatric disorders associated with old age. Waiting times vary for different health professionals, with maximum wait approximately 12 weeks for occupational therapists. The average waiting time is about 2 months. About a quarter of the clients are under the age of 65 years. Inner City Live At Home Inner City Live At Home is a Community Options program which provides individual case management and coordination for elderly and disabled people who are at risk of inappropriate or premature institutionalisation, who have complex health care needs which require ongoing monitoring and an integrated package of community care services. The program arranges a package of services through existing home and community care organisations, purchase services and equipment on behalf of the consumers if such services are not otherwise available and provides case management in consultation with the client/family. Staff consist of 4 FTEs – a team leader, 2 case managers and an administration officer. Services are funded for around 80 clients who live in the Eastern sector. Over half of these clients are younger people with disabilities. The waiting time is up to 2 years. Day Centres Jane Evans Centre is a day centre for frail aged clients and those with dementia. The

centre is open 7 days a week and is attended by about 50 clients a week. Frail aged clients attend the centre on Mondays, Wednesdays, Thursdays and Saturday. The maximum number per day is 16 clients. People with dementia attend on Tuesday, Friday and Sunday. The maximum number per day is 12 clients. Some clients attend the centre 1 day a week, but most come 2 or 3 days a week. There is a small waiting list. Transport is provided to and from the centre.

Sita Carter Centre is a day centre for the frail aged, and operates 5 days a week from Monday to Friday. Between 18 and 20 clients attend each day and there is a large number from non English speaking backgrounds – Greek, Portuguese and Italian. Transport is provided to and from the centre. The team leader is responsible for both Jane Evans and Sita Carter Day Centres. The Centre is currently in interim premises, unsuitable for meeting the current and longer-term needs of the target group. Options for new premises are currently being canvassed.

Community Visitors Scheme Eastern Sector Aged Care Services manages a Community Visitors Scheme. The objective of the Scheme, funded by the Commonwealth government, is to improve the quality of life of residents of aged care facilities who have limited family and social contact and may be at risk of isolation from the general community for social or cultural reasons or through a disability. The Central Sydney Scheme has been funded since 1993/4 specifically to cater for isolated residents from Culturally and Linguistically Diverse (CALD) backgrounds. Every effort is made to recruit visitors who speak the same language and share similar cultural background as the residents. Community visitors are expected to visit the residents


41

at least once a fortnight. The Central Sydney Community Visitors Scheme is responsible for the entire Sydney metropolitan area. The Scheme is coordinated by 1.4 FTE staff. They have around 140 volunteers who visit some 150 residents of aged care facilities. There are 53 residents currently waiting to be matched with a volunteer. Multicultural Aged Care Advisor (MACA) The multicultural aged care advisor commenced working in the Eastern sector 14 years ago. She has pioneered a series of demonstration projects that have aimed to improve access for people from Culturally and Linguistically Diverse (CALD) backgrounds. Some of these projects have been taken up across NSW, and include the Clustering Program (creating the basis for the NSW Transcultural Aged Care Service), a ‘cultural diversity’ staff development program, and the Homereach Teleconferencing project, which provides information, education and support to CALD clients and carers. Two current projects are the development of competencies for aged care service staff on ‘best practice’ use of professional interpreters, and a transcultural recreational therapy training kit and workshops (for the residential and community aged care sectors). NSW Transcultural Aged Care Service (TACS) TACS promotes equitable access and quality of care in the residential aged sector for consumers from Culturally And Linguistically Diverse (CALD) backgrounds. The service works with interested mainstream residential aged facilities to implement care strategies based on the Aged Care Accreditation standards. Broadly, the service provides facilities with individualised advice, VETAB accredited cross-cultural staff training, practical resources and community support linkages. TACS also provides information and advice to ethnic community groups and organizations about current care options and opportunities for development of new services. Since 2001, when the Commonwealth Department of Health and Ageing (TACS’ funding body) called for TACS to provide ‘market research’ support to services applying for new residential or community care places targeting CALD consumers at the annual Aged Care Allocations Round (ACAR), the service has assisted many organizations and communities with service development. Two current projects include the re-mapping to the Certificate level III (Aged Care Work) of its VETAB accredited course A Home for All – Cross Cultural Awareness in Residential Aged Care Services, and a qualitative research projects on spouse-carers from CALD backgrounds. There are 4 staff including the manager

Canterbury sector

Inpatient services

Most medical services at TCH are provided by the Department of General Medicine, rather than a range of organ sub specialty medicine departments. The VMOs appointed to the Department of General Medicine all have other sub-specialty expertise including cardiology, respiratory medicine (2), endocrinology, infectious diseases, and neurology. Support in all other sub speciality disciplines is provided by the appointment of consultants from either RPAH or CRGH. Most VMOs in General Medicine have appointments at a tertiary hospital for referral of complex patients or for patients who need more sophisticated technology, and for continuing education and peer support. 2 VMO gastroenterologists provide procedural gastroenterology services from the Gastroenterology and Liver Services. General Medicine also has access to 10 beds in ICU and ICCU, supported by the Director of ICU. There is also a Department of Geriatric Medicine with 1.5 FTE staff specialists. The Palliative care ward from CRGH has displaced the Geriatric Medicine ward temporarily while the RTP is implemented. The purpose built geriatric and rehabilitation ward has an outside area, a small gym and an ADL area. At present, patients of the Geriatric Medicine service


42

are located primarily in an adjacent 22 bed ward, shared with General Medicine with outliers scattered throughout the hospital. Table 9: Canterbury Hospital GGRM Inpatient Services

Ward No. of beds Type of patients

Banksia Ward (short term while Cassia Ward is temporarily occupied by palliative care)

22 (will increase to 26 beds in

winter)

geriatric medicine, general medicine

Boronia Ward 30 general medical, geriatric medicine outliers


1. There are outpatient clinics for diabetes (diabetes complications assessment and management) and pulmonary rehabilitation (managed by the COPD Chronic Care Program).

2. Aged care Services Emergency Team (refer to Western Sector ASET description) 3. There are two community, domiciliary services for GGRM in the Canterbury sector – an

ACAT and a day centre for the frail aged and people with dementia. These teams are managed by the Service Manager based in the Western Sector.

ACAT The ACAT’s core function is to provide information, assessment (physical, medical, psychological and social aspects of the client), management and coordination of support services and monitoring for frail, confused and disabled older people and their carers. The staff undertake assessment for nursing home, hostel and residential centre placement, and for the provision of Community Aged Care Packages (CACP). The team consists of nurses, occupational therapists, social workers, physiotherapists, a psychologist, nutritionist, 0.5 FTE of a psychogeriatrician, psychogeriatric nurses. Waiting times vary between disciplines, with the longest wait approximately 8 weeks for occupational therapy. The team receives over 10 referrals a day. Day Centre Karinya Centre is a day centre for people with dementia and frail aged people, open 5 days a week from Monday to Friday. It opens occasionally on Saturday. Between 10 and 15 clients attend each day and there is a large number from CALD background. There are 2 full time staff – a coordinator and a driver and 5 part time community aides from a variety of backgrounds including Arabic, Vietnamese, Italian, and Chinese. Transport is provided to and from the centre.

CSAHS Podiatry

Podiatry services are provided to GGRM on the basis of a service agreement between the Division of Allied Health and GGRM. About 60% of all podiatry services in CSAHS are for GGRM clients. Podiatry for GGRM is provided at various sites across the Area - RPAH,


43

CRGH, TCH, Balmain, Rozelle, 9 residential centres, 3 Council premises, Sita Carter day centre, and a senior citizens club in Earlwood. Some home visits are made in the Eastern sector and the Canterbury sector. Sessional podiatrists provide most services. The total number of staff is between 4 and 5 FTE. They provide over 1000 occasions of service (OOS) a month. Negotiations with the CSAHS Allied Health directorate to resume control of podiatry services have concluded (August 2003).

Research and Education

CERA

The Centre for Education and Research on Ageing (CERA) is a joint Centre of the University of Sydney Department of Medicine and Concord Repatriation General Hospital (CRGH). CERA’s aim is to expand and share knowledge of human ageing through collaborative, multidisciplinary research and education with the purposes of: promoting healthy ageing; minimising the impact of disease and disability on older people; and improving the quality of life of our older population. CERA’s functions include: Conducting an integrated, collaborative and multidisciplinary program of epidemiological,

clinical, biological and health service research on ageing. Coordinating a structured program of education on ageing within the University of

Sydney medical curricula. Supervising and supporting a range of postgraduate research degrees in the area of

ageing. Providing educational input on ageing within a range of undergraduate and postgraduate

courses and within continuing education programs for health and allied workers and community organisations.

Provide an information and resource service on ageing issues for staff of CERA and GGRM.

CERA has a close working relationship with GGRM. A number of CERA staff hold joint appointments within the clinical services. The clinically oriented research undertaken at CERA often includes patients who have come through the clinical services. CERA and GGRM staff both provide input to the teaching of geriatric medicine and the continuing education of non-medical staff. CERA staff also provide support to clinical workers in education, research and evaluation projects which have a direct impact on client services and health outcomes. CERA has around 20 staff including medical, neuropsychology, scientific, nursing, educational, policy research and administrative staff as well as a number of postgraduate research students. Funding for the Centre comes from a range of sources – including CSAHS, University of Sydney, NHMRC grants, project tenders from government departments and the Ageing and Alzheimer’s Research Foundation. Professor David Le Couteur was appointed Director of CERA in 2001. CERA’s academic position was further strengthened in 2002 by the appointment of Professor Bob Cumming as the Professor of Epidemiology and Geriatric Medicine and the promotion of Dr Jillian Kril to Associate Professor. CERA has recently established the Biogerontology Laboratory within the ANZAC Research Institute to explore connections between the liver and problems in ageing. This complements the work being done in CERA’s Neuropathology Laboratory. A


44

separate development has been an increasing commitment to research into residential and community care in collaboration with industry and community organisations.

Interface with other clinical groupings

The CSAHS clinical groupings that GGRM has most interaction with include: • Population Heath • Mental Health • Neurosciences • Bone and Joint • Cardiovascular Services • Allied Health • Palliative Care The community nurses in Population Health work closely with the community teams in GGRM. In the western sector one community nurse centre is co-located with GGRM and have joint weekly meetings. In the Eastern and Canterbury sectors they are not co-located. Multicultural Health is located in Population Health. The director of Multicultural Health works closely with the Multicultural Aged Care Advisor. GGRM utilises the Health Interpreter Service. Health Promotion is also part of Population Health. They are an important resource for GGRM because of their work on nutrition, exercise and falls. Mental Health funds a number of psychogeriatric medical, nursing and social work positions in GGRM. These staff are integral members of the ACATs in each sector and some of the medical staff sit on the GGRM Clinical Management Committee. The medical staff also provide an important liaison role to GGRM. One of the aims of the CSAHS Mental Health Strategic Plan, 2000-2003 (2000:35) is to ensure there is continuity and coordination between mental health and aged care services in responding to the mental health needs of older people. Balmain Hospital provides allied health services to Rozelle Hospital – 32 hours a week of physiotherapy, 20 hours a week of dietetics, 28 hours a week of speech pathology. In each sector there are developing coordinated stroke services involving GGRM and Neurosciences, with GGRM being involved in the subacute and community phases of management, and variably in acute care. Service arrangements and management practices for patients presenting with stroke are not yet standardised. Funding for elements of stroke services has been available through the Priority Health Care Program, GMT2 and DVA (CLASP). The use of these funds is to be determined. Stroke services plan for the Canterbury sector is less advanced. There are ortho-geriatrics services in the Eastern and Western sectors where older patients are managed jointly by both the orthopaedic and geriatric medicine staff, with blanket referral to Geriatrics of patients presenting with proximal femoral fractures. Rehabilitation Medicine is involved in the consultation, assessment and rehabilitation of orthopaedic patients.

Utilisation

Table 10 shows the number of GGRM inpatients admitted to each hospital in 2000/01and 2001/02. The proportion of day only patients at CRGH compared to the other hospitals reflects differences in coding practices rather than different patient types. Differences in the average length of stay by site are, in part, a reflection of the way services are organised and of ED triage practices. In the Eastern sector acute services are provided at RPAH. Acute


45

and sub acute services are provided at Balmain Hospital. Patients transferred from RPAH to Balmain are recorded as two separations with two lengths of stay. At CRGH and Canterbury acute and sub-acute episodes occur on the same site and the length of stay reflects the both acute and sub acute episodes of the admission. See appendix D for Casemix reports. Table 10: GGRM separations and bed days by hospital, 2000/01 & 2001/02

Separations/ Episodes of care (excl. same day)

No. of same day

seps

Bed days (excl. same

day)

ALOS (excl. same

day)

% admitted through ED

00/01 01/02 00/01 01/02 00/01 01/02 00/01 01/02 00/01 01/02

RPAH Geriatric Medicine

1205 1155

98

120 8928

10077 7.41 8.72

95%

95%

Balmain** Acute

1639

1481

36

17

18006 15397 10.99 10.4

7%#

5%

Sub Acute 509 636 0 1 9006 10975 17.69 17.26 0% 0% CRGH General Medicine**

841

468

13

5 7308

4486

8.69 9.59

95%

94%

Geriatric Medicine Acute

1425

1500

2917*

17 19159 20781 13.44 13.85

88%

89%

Geriatric Medicine Sub Acute

415 473

0

3433 7356 8230 17.73 17.4

0%

0%

Rehabilitation Med

64 53 0 0 1470 2759 22.97 52.06 75% 60%

Canterbury All Medicine***

4234

4352

1477

1995

24967

24835 5.90 5.7

>95%

92%

Geriatric Medicine only

726 579 11 5 8242 8261 11.35 14.27 85%

* Coding practices vary between CRGH and RPAH/Balmain with CRGH coding all day only cases as inpatients while the same types of cases in the Eastern sector are coded as outpatient occasions .of service. ** General Medicine existed at CRGH until April 2002. When General Medicine was disbanded about half of the General Medicine patients were admitted under Geriatric Medicine *** includes all medical patients – general medicine, geriatric medicine as well as Emergency Department and ICU admissions. # the majority of Balmain Hospital admissions are direct transfers from RPAH Emergency Department. Source: CSAHS Casemix Unit


46

Table 11 shows the number of DVA patients as a percentage of the total number of GGRM patients. At CRGH only 11.5% of patients fall into this category compared to between 30 and 40 percent nine years ago before CRGH’s integration into the State system. Table 11: Percentage of DVA patients admitted to GGRM by hospital, 2000/01

Hospital % of total GGRM patients

CRGH 11.5RPAH n/aTCH 4.5Balmain Hospital 4.8

Source: CSAHS Casemix Unit ACAT waiting times are reported to have increased over the past two years. Different collection methods and reporting systems used by the three teams, discount any valuable comparisons or confidence in these figures being an accurate reflection of true waiting times. See Table 12. Table 12: Reported ACAT waiting times for 6 month periods in 1998, 1999, 2001

and 2002

Jul - Dec 1998

Jan – June 1999

Jan – June 2001

Jan-June 2002

Av. waiting time

Av. waiting time

Av waiting time

Av. waiting time #

E sector 7.1 days 7.9 days 17.6 days 30.6 W sector 10 days 13.6 days 11 days 22.0 Canterbury 10.34 days 6.6 days 10.40 days 22.6 Source: CSAHS Planning Unit

# NSW Evaluation Unit

Resources

Staffing

Recruitment and retention of experienced, competent staff within GGRM is an ongoing issue. These processes operate under the auspice of facility Human Resource Departments at both Concord and RPAH. Over recent years, recruitment into numerous positions has been extremely difficult, with some positions vacant in excess of 6 months. Tables 13 to 16 provide details of GGRM staffing by sector.


47

Table 13: GGRM Medical Staff Positions by sector 2002 Eastern Western Canterbury Geriatric medicine # Staff specialists Geriatricians

Psychogeriatricians

VMOs

3.6

2.0*

2.8+2.6 academic

1.4* 0.1

1.5 (vacant since

August 2002) 0.5*

Registrars Geriatric medicine

1.0 at RPA

2.0 at Balmain** 1.0 community

3.0

2.0**

1.0

Rehabilitation medicine

Staff specialists 1.8 2.0*** - Registrars 2.0 2.0 - General Medicine VMOs 0.1 8.0 Registrars 2.0** GPC 5.29 * Mostly mental health funding – 0.4 of the psychogeriatricians at CRGH is funded by GGRM. ** Basic trainees *** Up to 0.2 FTE Rehabilitation Staff Specialist time is spent in Eastern Sector. # A CSAHS Clinical Fellow position is also allocated to GGRM, who works across the sectors Table 14: GGRM Nursing Staff by hospital

Hospital FTE Balmain 85.06 RPAH 2.0 CRGH 102.80

Canterbury 49.74 Total 239.60

Table 15: GGRM hospital based Allied Health staff by sector

Eastern Western Canterbury Balmain RPAH CRGH TCH

Occupational/Diversional therapists

5.6 1.5 4.5 1.0

Physiotherapists 6.6 Rozelle

0.5

3 4 1.5

Social Workers 4 1 4.5 1.0 Speech pathologists 2.6 1 1 Nutritionist 2.32 0.75 1 Podiatrist 0 0 0.2 Psychologists 1.0

Please note hospital based domestic, food and some administrative services are not included in the above staffing figures.


48

Table 16: GGRM Community Staff by Sector Team Sector Funder Program East West C’bury

1.0 Coord

1.0 Coord

(covered by West)

C’wealth ACAP

1.0 TL 1.0 TL 1.0 TL C’wealth ACAP 2.4 SW 2.0 SW 2.8 SW C’wealth &

State ACAP & MH

4.9 OT 2.4 OT 1.8 OT C’wealth ACAP & HACC 2.0 RN 3.5 RN C’wealth &

State ACAP, HACC & General

3.0 PGN 3.0 PGN 1.7 PGN MH, HACC 2.5 PT 0.5 PT C’wealth &

State ACAP, General

2.0 Admin

1.4 Admin

1.0 Admin

C’wealth & State

ACAP, General

1.6 Med 1.4 Med *

C’wealth & State

ACAP, MH

0.4 Nutrition

0.4 Nutrition

0.4 Nutrition

C’wealth HACC

ACAT

0.5 Psych

C’wealth ACAP

1.0 Manager

1.0 Manager

C’wealth HACC

2.0 Coord

1.6 Coord

C’wealth HACC

COP

1.0 Admin

1.0 Admin

C’wealth HACC

1.0 Manager

1.0 Manager

1.0 Manager

C’wealth HACC

2.4 Driver

2.6 Driver

1.0 Driver

“ “

2.4 Div Ther

2.6 Div Ther

“ “

Day Centre

2.0 CSW 3.6 CSW 2.5 CSW “ “ (covered by West)

1.0 Manager

(covered by West)

“ NRCP

“ 3.0 Coord

“ “ “

“ 1.0 Admin

“ “ “

Carer Respite Centre

“ 0.6 Proj. Off

“ State Care for Carers

1.0 Coord

1.0 Coord

(covered by East))

C’wealth HACC & NRCP Dementia Support

3.0 CSW “ “ 1.0 Manager

(covered by East)

(covered by East)

“ PICAC T’cultural Aged Care

2.0 Coord

“ “ “ (Partners in culturally appropriate care)


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1.0 Admin

“

1.0 Advisor

“

Community Visitors

1.6 Coord

(covered by East)

(covered by East)

“ Comm. Visitors scheme

Continence 1.0 CNS “ HACC 1.0 Manager

(covered by East)

(covered by East)

State PADP PADP

3.4 Coord

“ “

1.0 EN State General 1.0 Admin

1.4 Admin

“ “

2.0 PT 4.0 PT C’wealth & State

HACC, DVA & General

1.0 OT 3.2 OT “ DVA & General 1.6 SW “ “ 0.5 SP 0.6 SP “ “ 1.0 Driver

2.0 Drivers

State General

1.0 Coord

C’wealth DVA

0.3 Psych

“ “

0.11 Dietician

“ “

Aged & Ext. Care

1.0 NUM

0.8 CNS “ “

Podiatry 1.3 2.6 2.8 TOTAL 52.4

FTE 56.21 FTE

20.5 FTE

* 1.0 FTE is MH funded shared between hospital and community.

Funding

The total budget of GGRM is estimated to be almost $34m. Table 17 shows the breakdown of expenditure for 2001/02 by sector. Contributions from HACC and the Commonwealth are also noted. It should be noted that a large proportion of funding for community services is from the Commonwealth not the State government.


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Table 17: GGRM Expenditure by Sector, 2001/02

Hospital

$

Com’nity

$

Total

$

HACC contributn

to com’nity services

$

C-wealth contributn to

ACAT funding

$

C-wealth NRCP funding

$ Eastern sector Balmain RPAH

11 240 3901 138 736*

1 784 319

14 163 445

320 889 319 064

Western sector 8 326 347 2 324 924 10 651 271 539 526 448 076 Canterbury sector 4 410 342 681 670 5 092 012 334 751 298 321 PADP 1 730 508 1 730 508 Special Purpose & Trust expenditure

2 116 669 1 366 971

Total 33 753 905 1 195 166 1 065 461 Total HACC budget for CSAHS (incl. Community Nursing Services)

6,149,821

Source: GGRM * does not include ward costs because beds are scattered over a number of wards throughout the hospital. ** shaded areas additional funding breakdown not additional funds to overall total.

Nursing homes and hostels

There are 56 nursing homes and 32 hostels in the Area with 3319 and 1581 beds respectively. Nursing home beds have decreased in CSAHS in the last 3 years by 681 and hostel beds have reduced by 32. Another two nursing homes are leaving CSAHS in the near future reducing the beds by a further 72.


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7. Future service requirements Future inpatient and non inpatient activity was estimated for GGRM in 1996 when the RTP was being developed. It is not possible to revisit these projections at this time using the Department of Health’s projection tool (APPI) because the data it uses does not identify GGRM patients specifically. It classifies patients into Service Related Groups (SRGs) only and there is no SRG into which all GGRM patients fall. An accurate method for projecting non inpatient activity does not exist. The GGRM Service Delivery Plan (CSAHS 1996) anticipated “significant increases” in non inpatient activity – outpatients, day hospital, community services.


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8. Issues affecting future service delivery Consultations were held with a range of people from within GGRM, from the CSAHS Area office and from other clinical groupings. A list of those consulted is provided in Appendix A. A number of issues emerged from these consultations. These issues, together with other developments at the Area, State and Commonwealth level, will impact on the future direction of GGRM.

8.1 Population demographics

Even though the older population of CSAHS is not expected to increase substantially as a proportion of the total population, it is growing in absolute terms. Between 1996 and 2006, the CSAHS population 65 years and over is expected to grow by 5.5%, while the population 75 years and over is expected to increase by 12.7%. There continues to be an ageing of the aged population. At the same time Commonwealth aged care policy is focused on avoiding admission to hostels or nursing homes for as long as possible with resulting increased demand on community support services. Together with competing demands from younger people with disabilities, community services report severe pressure on their services and growing waiting lists. This situation applies to all the GGRM community services – ACATs, Community Options, day centres. The ACATs are often faced with decisions regarding the extent to which they provide assessment only or also provide on-going monitoring and support, especially in the absence or unavailability of other community services – personal care, home help – because of the increasing pressure on these services. In the six years from 1996 there was a 6% reduction in Commonwealth ACAT funding. Table 12 shows the reported ACAT waiting times over the last two years. These average waiting times hide the variation between individual health professionals: the average waiting time between January and June 2001 for an occupational therapist in the Eastern sector was 22.8 days compared to 8.2 days for the psychogeriatric team. Since June 2001 there has been a further increase in the waiting times for the ACATs in the western and eastern sectors. The reasons for the long ACAT waiting lists need to be investigated. A number of suggestions have been made – the increasing need to provide case management/monitoring after the initial assessment, more dependent and complex people are being cared for in the community, an increasing amount of time spent assessing modifications for Department of Housing properties and the growing number of younger people with disabilities with complex needs. Further examination and monitoring of waiting lists is required to determine whether it is possible to improve the situation by introducing new policies or reviewing current practices such as entry and exit criteria to the service.

8.2 Resources

8.2.1 Staffing issues

In consultations, a number of specific staffing concerns were raised: the number of medical staff (staff specialists, registrars and resident medical officers

(RMOs) in both General and Geriatric Medicine seems less than for other clinical groups when measured in terms of average number of inpatients per specialist or team at any one time;

at TCH there are fewer registrars and RMOs for GGRM than in the other sectors;


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given the complexity of patients the current staffing ratios may be inadequate and may need increasing in some areas;

the existing CNC positions (there are three in total) are unable to cover all three sectors, including hospital and community services, for rehabilitation, continence, dementia/psychogeriatric and gerontology clients.

it was proposed that there is need for - more allied health staff in all disciplines on the wards and in the community; - therapy staff to be available at least 6 days a week; - psychology services at Balmain Hospital; - a pool of allied health staff who could cover staff vacancies and people on leave a review of day centre staffing levels, in the context of risk management strategy, has

resulted in a reduction of respite outings; higher client:staff ratios are required to permit the restoration of a full outing program

allied health staff are often seen as the most dispensable when staff cuts are needed to be made eg. health promotion officer was never re-appointed;

GGRM psychogeriatric staff across the Area are supervised by the mental health staff at Rozelle, making team management complex;

the medical, nursing and allied health staff of the Department of Geriatric Medicine at Canterbury Hospital feel professionally isolated from the rest of GGRM;

retaining competent PADP staff is an ongoing problem general recruitment and retention of experienced personnel is an on-going problem the Area recruitment process is slow and cumbersome, even when there is external

funding, approvals have been given and the appointment is straightforward. Staff Education Issues Geriatric Medicine in CSAHS has been successful in attracting registrar trainees largely because of its medical education program, which includes the Area wide rotation of staff in different clinical settings, weekly meetings and clinical education sessions. The educational experience of medical students, RMO’s and Registrars rotating to medical teams at Canterbury is improving through the leadership of the Department of General Medicine. The CERA Lecture series at Concord Hospital offers weekly presentations on issues relevant to the health care of older people. GGRM funds a program, organised by CERA, where a visiting professor (medical, nursing, allied health), often from overseas, is invited to give a series of seminars/presentations to staff of GGRM and to a wider relevant audience such as the residential care sector. The aim of the program is to promote best practice and is an example of true collaboration between the academic and clinical sectors. GGRM has an Education sub committee whose aims and objectives and membership are provided in Appendix F. The committee focussed originally on nurse education. It has since broadened its scope to include allied health and community staff. The committee is planning to distribute a GGRM education calendar. This calendar will be flexible with opportunities to factor in extra training that may arise. Issues that were raised during consultations include: a perception that the primary focus of the GGRM education committee is nurse

education; the need for an orientation course to GGRM broadly, not just to specific

services/facilities;


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the lack of a mechanism to ensure all possible courses are included in an overall GGRM education program eg. how does a specific course such as the use of interpreters get included in the GGRM education program?

the number of nurse educators appears inadequate, relative to number of GGRM beds, decreasing numbers of senior staff on the wards, the number of new graduates and the complex nursing needs of GGRM patients.

Support from the CSAHS Staff Development and Training Unit is required by GGRM committee

8.2.2 Funding

Funding for GGRM services comes from a number of sources – State, Commonwealth, shared Commonwealth/State, DVA. Each funding program has its own reporting requirements and acquittal procedures. These multiple processes add substantially to the workload of the community Service Managers, in particular. Some funding is short term; funding for the Carer Education Project ended in June 2002; CLASP and NDEMS funding ends in June 2004; TACS funding is renewed annually. The capacity to continue some core services is uncertain. The diversity of community programs (COPS, CACP, HACC, DSP, SAS) - for different target groups (older people, people with dementia, younger people with disabilities, carers), with funding from a number of sources and different providers (government, non government, private) - results in a number of problems, which have been listed by the National Community Care Advisory Committee (ACSA 2001): confusion for providers, referrers and clients poor integration between services leading to difficulties in accessing information and

navigating the system inconsistent program requirements in terms of accountability, quality assurance and

eligibility conflicting program boundaries resulting in both duplication and service gaps different planning cycles and processes duplication of effort between the Commonwealth and State governments. The trend to fund short term pilot programs results in on-going difficulties. The establishment of these projects takes time, acquittal of funds and evaluation of the project is resource-intensive. It is difficult to meet heightened consumer expectations after conclusion of the pilot. The funding for many programs fails to meet total expenditure, including funding of award increases and PADP funding with the widening of the eligibility criteria. The dramatic growth in service delivery via brokered agencies has meant increased and more demanding reporting systems, changes in service delivery models and communication strategies. It is estimated in 2001/02 GGRM community services spent over $1,080,000 on brokered services via private agencies. Strategies to address the range of issues created from this type of service delivery must be refined and consolidated.

8.2.3 Physical facilities

The RTP will result in major improvements in GGRM facilities across the Area including the: renovation and redevelopment of Balmain Hospital to provide designated geriatric and

rehabilitation wards – now complete.


55

establishment of a dedicated 20-bed geriatric medicine ward at RPAH is due for completion in March 2004. A 16 bed interim ward was occupied in mid 2003.

renovation of the ‘ramp’ wards at CRGH to establish a Geriatric and Rehabilitation Medicine precinct where the wards, aged care community services and CERA are co-located. Within this development a designated 20-bed rehabilitation ward will be established – due early 2004.

re-location of Kalparrin day centre to new premises on the Dame Eadith Walker estate – due late 2003.

re-location of the Eastern sector community aged services to renovated facilities at KGV – due early 2004.

opportunity to return Cassia ward (currently occupied by palliative care) at TCH to the geriatrics and rehabilitation service - date unclear.

Despite these major improvements, there are still some facilities’ issues that need to be addressed: the aged care community services at Canterbury Hospital are very cramped and require

more space. There is no room for further expansion of this service. any further expansion of General Medicine Services at TCH will require additional

accommodation. new premises need to be found to accommodate the Sita Carter day centre. The centre

is currently situated on the old Marrickville Hospital site but the current lease expires in June 2004 when the site will be re-developed for non-health purposes. Feasibility studies of co-location at Newtown, with Jane Evans Day Centre, are underway at time of this report.

within the timeframe of this plan the facilities at Balmain Hospital will need to be reviewed and upgraded to meet the standards of the new facilities at RPAH and CRGH.

8.2.4 Information Technology support

GGRM is a large organisation with around 400 FTE staff and a budget of $34m. Yet it has no dedicated Information Technology (IT) capacity to maintain hardware and software and to provide training. GGRM is reliant upon the Area Information Services Department (ISD) to provide all its needs. This often means long delays so some GGRM staff have become de facto computer resource people in the absence of regular, timely support. This situation is unsatisfactory because these staff do not have the depth of experience or the time to meet all the IT needs of GGRM staff, and have other roles to fulfil. GGRM has a range of IT needs, specifically for community services. These include: the various funding sources have different reporting requirements which GGRM is

required to adhere to, in addition the regular reporting of inpatients and outpatients. For example, specific reports are required for all HACC services; ACATs are required to provide six monthly reports to the Commonwealth; the Carer Respite Centre also has to make regular reports to the Commonwealth.

a number of new data systems are currently being implemented – the Aged Care Evaluation (ACE) system for all ACAT teams, including the electronic transmission of the Aged Care Client Record (ACCR) to the Commonwealth; HACC minimum data set which applies to all the HACC funded community services; SNAP, the inpatient classification of sub acute care which applies to the rehabilitation ward at Balmain Hospital and will need to be implemented on the new rehabilitation ward at CRGH. Balmain Hospital was the pilot site for the Picture Archiving Communication System (PACS) project.

the community services are also required to implement a new comprehensive assessment and referral tool – the CIARR – as the standard referral form between HACC services. The aim is to link specialist assessment, key workers, support, coordination and case management to the comprehensive assessment process. This system will have major IT requirements.


56

the application of CERNER to GGRM non inpatient services is anticipated. GGRM will need its own staff to work with ISD developing GGRM requirements and then implementing the system.

GGRM also needs IT support for other developments such as the development of the GGRM intranet site, the teleconferencing pilot project and telehealth projects with Far West and Northern Rivers Area Health Services. Communication in relation to quality and education activities could be greatly enhanced if GGRM was able to promote and inform GGRM staff of these activities via the intranet. Ongoing and regular maintenance, support and training of staff in current and future systems is vital to achieve maximum benefit from available technology.

8.3 Need for new models of care

Life expectancy is increasing and older people are physically healthier as a result of a number of factors – less smoking, better diets, more exercise etc. The incidence of physical diseases such as infectious diseases, circulatory diseases, respiratory diseases, gastro-intestinal diseases, cancer are decreasing. However the incidence of neurological conditions such as Parkinson’s disease, dementia, cognitive impairment is increasing as the population lives longer. These conditions are manifest in a variety of ways – motor slowing, falls, memory loss, dementia. These older people are presenting to the Emergency Departments of hospitals with a variety of symptoms – delirium and behaviour disturbance, motor slowing and immobility, pressure sores, gait and balance disorders, falls and fractures, brain-bladder disorders and incontinence. Staff in the Emergency Department may not have the specialist skills to identify the complex mix of physical and mental disorders. The ASET initiative is one response to these issues. Broe (2002) argues that a range of hospital-community interface programs need to be developed. Proven post acute care models need to continue to be funded – hospital in the home, discharge of the elderly from the Emergency Department (DEED)1, post surgical community nursing, ACAT dementia teams. New models need to be developed such as a Nursing Home Chronic and Complex Care Program – as in SEH. Broe sees the Chronic and Complex Care model that has been fostered by NSW Health as part of the Government Action Plan for Health as a ‘brilliant concept’ but that the disease specific model that was adopted is unsuitable for the “aged care client”. The model needs to be refashioned and incorporated into the core aged care services, such that there is a geriatric medicine chronic and complex care model involving geriatricians, ACAT, generalist community teams, the GP, non government organisations and HACC funded organisations. The output of the two committees recently formed by NSW Health, discussed in section 3, may begin to address this issue.

1 This service provides intensive outreach to patients aged 75 and over who presented to the hospital Emergency Department but were not admitted. Over 4000 patients aged 75 years and over presented to the Emergency Department at the Prince of Wales in a year but only 58% were admitted. A multidisciplinary team of medical, allied health and nursing staff treated the remainder at home. The services provided at home included parenteral administration of antibiotics and other medication, and blood transfusions. This program is similar to Hospital in the Home programs but differs because patients are diverted from the Emergency Department before admission. It also differs from CSAHS’ Hospital in the Home because it provides personal care and allied health services in the home in addition to technical nursing expertise.


57

The coordination and provision of services across the interface of hospital and community is required. The prevalence of neurological conditions and mental health disorders of older people requires that psychogeriatric services are well resourced and work cooperatively with aged care services, in the hospital and in the community setting. Improvements in therapeutic interventions for a range of conditions (osteoporosis, dementia, cardiac conditions) also mean some patients will no longer require admission to hospital, rather requiring regular monitoring in an ambulatory care setting. It is likely that an increase in the number and frequency of multi-disciplinary outpatient clinics will be required. Issues regarding the balance between general and specialised clinics and how should they be organised and funded are not resolved. Some outpatient Allied Health therapy is better delivered in a domiciliary, rather than an outpatient clinic or Day Hospital, setting. An expansion of domiciliary services is required to enable equitable and adequate access for residents of all sectors of CSAHS. The incorporation of exercise as a standard part of therapy for many chronic diseases in the next ten years is a prediction made by the advocates of the STRONG Medicine Unit (Singh, 2001). If this is the case, there will need to be an expansion of such programs to accommodate not only more referrals from GGRM but also from other specialities in the Area. Telehealth and teleconferencing pilot projects should be evaluated and adopted as methods of service delivery if proven successful. Specific service development issues

8.3.1 Transitional care/slow stream rehabilitation

Since the last GGRM plan, Eversleigh, Glebe Annexe and Our Lady of Loreto have closed resulting in the loss of transitional beds needed by patients: awaiting availability of an aged care residential bed requiring slow stream rehabilitation

A snapshot survey of CSAHS hospitals on 21 September 2001 revealed 26 patients (23 high care and 3 low care) were awaiting placement in a residential care facility. There are an additional number of patients in CSAHS acute beds who require slow stream rehabilitation. Patients requiring slow stream rehabilitation include: orthopaedic patients with prolonged restricted weight-bearing and other functional

problems; patients who are de-conditioned after surgery or long term hospitalisation; patients with a neurological diagnosis whose progress is slow; patients who no longer require acute medical or rehabilitation care but who are likely to

achieve worthwhile functional improvement over a long timeframe. These patients could potentially be cared for in a residential aged care facility with appropriate allied health, medical support and nursing care that fosters independence. It is considered that there would be 7-10 slow stream rehabilitation patients at CSAHS hospitals at any time who could benefit from such a model of care.


58

A model for transitional care is currently being piloted in the Hunter Area Health Service (NSW Health 2001). The 28-bed unit is on the grounds of the Royal Newcastle Hospital but is operated by a non government aged care residential provider. The Commonwealth government pays residential care subsidies at the level of high care respite (RCS-3) with all patients paying the standard pensioner contribution. The State government, via the Hunter Area Health Service, also provides funding for the pilot, covering some staffing costs and the costs of all fixed assets and capital works. The Area also meets the cost of unoccupied beds. Patients in the unit have been assessed by the ACAT and have been classified as either high care or low care. Maximum stay in the unit is eight weeks. A service of this nature was proposed for development on the Croydon (old Western Suburbs Hospital) site. The viability of this plan is uncertain. Other models of care are also being explored by CSAHS such as a joint GGRM - Lucan Care project, which has been funded for two years under the Commonwealth’s Innovative Care (Rehabilitation) Services Program. Under this proposal GGRM and Lucan Care will work collaboratively to provide finite-term (maximum 12 weeks) post hospitalisation support in the patient’s home. GGRM will provide medical, nursing and allied health support pre-discharge and Lucan Care will provide the case management and brokerage of a range of services such as short term flexible care packages (in-home services for daily living tasks), therapy services, transport, day respite, carer support, social, recreational and educational activities etc.

8.3.2 Discharge planning

While effective discharge planning is a priority for GGRM, there is scope to continually review discharge practices to ensure a smooth, coordinated, effective and timely process. CSAHS and NSW Health have been encouraging clinical departments to move towards discharging patients on a seven-day a week basis. Some clinical specialties, including Geriatric Medicine at RPAH, have rostered registrars to work on the weekend to facilitate this process, with a day in-lieu rostered off during the week. This is reported to result in improved continuity of care and facilitates the weekend discharge process. However, this medical staffing alone does not enable an increase in GGRM weekend discharges. The feasibility and cost implications of weekend discharges, including access to allied health services, community services and transport availability on weekends, would need to be explored for GGRM patients.

8.3.3 People from CALD backgrounds

Approximately 40% of the CSAHS population aged 65 years and over do not speak English at home. GGRM has pioneered the development of services to meet this need – the appointment of a Multicultural Aged Care Advisor over 14 years ago, the Community Visitors Scheme for people from Culturally and Linguistically Diverse backgrounds, the NSW Transcultural Aged Care Services. The latter two services were developed in CSAHS and were then extended to cover the whole metropolitan area in the case of the Community Visitors Scheme, and the whole of NSW in the case of the Transcultural Aged Care Services. It has been proposed that all GGRM staff should have cross cultural training and training in how to use interpreters, both of which can be provided by the multicultural aged care advisor in conjunction with the Central and South Eastern Sydney Health Interpreter Service.


59

8.3.4 Aboriginal and Torres Strait Islander Peoples

CSAHS has a significant Aboriginal and Torres Strait Islander population, especially the eastern sector, though this is not reflected in GGRM client numbers. This population has a much shorter life expectancy than the rest of the population and as such these people are considered by Government to be eligible to access the age care system by 45 years. Research needs to occur at a local level both to identify the particular needs of this and other special needs groups as well as those barriers encountered by them in accessing the service Research is also needed into the needs/expectations of older people from the various ethnic and cultural communities of CSAHS including the Aboriginal and Torres Strait Islander population. The NSW Health Aboriginal Health Impact Statement will be considered in the development and review of all services, policies and procedures.

8.3.5 Carers

Carers are fundamental to the provision of care to aged and disabled people. They are seen as a key target group of GGRM and carer support is a core service. As many carers are themselves aging, there are issues about who will carry on their role into the future. Similarly in an Area with such a large proportion of people from CALD backgrounds, more needs to be known about the needs of carers from different cultural backgrounds. The major service provided by GGRM specifically for carers is the CRC.

8.3.6 Services for younger people with disabilities

Many of the community services funded by HACC and the Commonwealth government are widening their eligibility to include clients of all ages. The result is many services that traditionally were for older people, are being required to provide for younger people with disabilities. These include younger people with physical disabilities as well as younger people with developmental disabilities and brain injuries. However, the boundary between Health and DADHC in relation to the responsibilities of each is unclear and further direction from Government is required. This trend has a number of implications: some staff are not familiar with the needs of younger people with disabilities younger people with disabilities will often require the services for a longer period so

waiting lists continue to grow the type of services that are needed by this group vary widely including recreation,

employment and supported accommodation. Demand for these services exceeds capacity.

8.3.7 Canterbury sector

The Canterbury sector demographics are vital to understanding specific issues within that sector. Australian Bureau of Statistics 1996 census data identifies: total population of 132,000 29% of the CSAHS population 49% overseas born 61% speak language other than English at home lowest average median income in CSAHS, making it one of the poorest populations in

NSW

Formatted: Bullets andNumbering


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highest absolute number and proportion of children aged 1-4 in CSAHS17% are 65 years+

Some older people in the sector (such as those in the Housing Commission development in Riverwood) have limited mobility and no access to transport. They may only be able to see a GP if he/she does house calls. In a unpublished document – The Canterbury Hospital Department of General Internal Medicine: Service Description and Plan (2002) - Dr. Paul Davis identifies areas requiring attention, due to these demographics, as diabetes, cardiovascular disease/stroke, smoking and chronic lung disease, obesity and hypertension. The need for a Chronic Pain Clinic to be developed and expanded access to Drug and Alcohol services, at TCH has been identified. TCH general physicians offer comprehensive care across most organ specific areas, with the capacity to treat most acute disease presentations adequately, even with the absence of some resources that would be expected as routine at other facilities (cardiological, investigative and others). There is a particular need to expand diabetes complications and risk factor management services for the Canterbury community. A role for geriatricians, including an outreach role, is also predicted based on the above figures. Currently there are substantially less geriatric and rehabilitation services in Canterbury, than in the other two sectors. Note that there is almost the same number of older people in Canterbury as there is in the Eastern sector. There is no outpatients clinic, no day hospital, no home based therapy and no dedicated transport. Consequently there is poor continuity of care and there may be no ambulatory follow-up. There is potential to improve management of the transition between the acute and sub-acute/rehabilitation phases of care for patients with proximal femoral fractures and stroke. The relative size of the Department of Geriatric Medicine compared to the other sectors results in a sense of professional isolation for medical, nursing and allied health staff. There are 1.5 staff specialists allocated to the service. At present these positions are vacant, with a CRGH Geriatrician providing cover. The nurses at TCH have limited experience with difficult and challenging behaviour and could benefit from education in this area and/or rotations through wards in other sectors eg. Ward 17 at CRGH.

8.3.8 Customer Focus

While there is some customer/carer involvement in some GGRM advisory committees, management structures, GGRM needs to further develop a customer focus. Methods for client participation in a range of processes should be developed, including clinical decision-making and consent processes to be developed on an Area wide basis.

8.3.9 Burns Rehabilitation

With the completion of the renovated burns unit at CRGH, making it the only tertiary burns service in NSW, the CRGH Rehabilitation Department will be required to provide rehabilitation to patients referred from anywhere in NSW.


61

8.3.10 Non-Traumatic Acquired Brain Injury

There is a lack of facilities for the management of people who have “difficult behaviours” as a consequence of non-traumatic acquired brain injury (such as those due to cerebral hypoxia). This deficiency requires a State-wide rather than an Area Health Service based solution.

8.3.11 Rehabilitation of “Out of Area” elective patients

GGRM is requested by Departments of other Clinical Directorates to provide rehabilitation to patients who are admitted electively for procedures, from other Area Health Services. There is often no prior consultation to establish a realistic rehabilitation plan, resulting in patients and families having raised expectations for the future. In addition, for best health outcomes rehabilitation and the transition to home is usually best provided locally to the patient’s home. Capacity to provide for these patients is also constrained as sub-acute services such as rehabilitation services are resourced on the basis of the local population, not taking these additional requests for service into account. Partnerships between GGRM and these other Clinical Directorates need to be developed to address this issue.

8.4 GGRM organisational issues

8.4.1 GGRM management infrastructure

The management infrastructure of GGRM is minimal. There is a clinical director, business manager and nurse coordinator. All these positions have other roles – the clinical director is the director of clinical services in the western sector and he also has a clinical load (which takes up at least half of his time); the business manager is the general manager of Balmain Hospital; the nurse coordinator is also the Director of Nursing at Balmain Hospital. Originally there were two nursing positions – nurse coordinator for GGRM and Director of Nursing for Balmain Hospital. These positions were amalgamated in the late nineties. Each sector has it own Service Manager for community services, although recently the Service Manager of the western sector has taken on the role for the Canterbury sector. With the community services section of GGRM being delegated expanding roles, these Service Manager positions are becoming untenable. The dual roles of many of the key GGRM management staff means that Area-wide coordination of the service is sometimes an issue. This situation is compounded by the fact that GGRM needs to provide services on a sector basis but it also needs to consolidate as an Area service. The approach that has been taken to date is to create Area wide portfolios for senior staff. The problem is that there are not enough senior staff to take on all the portfolios that have been identified. There is need for a senior position that has no line management responsibilities, to drive some of these Area-wide GGRM service development issues/portfolios. A number of organisational issues were identified in consultations: there was an anomalous situation in the Canterbury sector where the community

services are managed by Canterbury Hospital while the community services in the Eastern and Western sectors report to the GGRM management at Balmain Hospital – an agreement to transfer the management and budget of these services to Balmain Hospital occurred on July 1 2002;

entry and exit processes for community teams, and area wide protocols need to be developed

the future of General Medicine at Balmain Hospital


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8.4.2 Quality

CSAHS has a Clinical Quality Council which meets every two months. All clinical directors attend and provide reports on the following four quality activities: 1. Facilitated incident monitoring – a system for identifying, processing, analysing and

reporting incidents with a view to preventing their recurrence. 2. Sentinel event management. A sentinel event is an occurrence involving death, a ‘near

miss’ or serious physical or psychological injury. Reporting of these events is based on a proforma which includes a description of the event, the nature of the investigation and analysis, the action taken to plan to prevent further occurrences, possible action by the Clinical Quality Council (if appropriate) and the Area wide significance, details of who the event was reported to.

3. Clinical indicators – each clinical grouping is required to report at least one clinical indicator. Clinical indicators are measures that relate to specific clinical conditions, or measures of function that have particular significance for particular conditions (Boyce et al. 1997). Relevant GGRM Clinical Indicators are currently being developed and will be collected and reported regularly. See appendix E for these Indicators.

4. Ad hoc audit - the in depth analysis of a specific problem. A potential problem is identified and investigated and if necessary, changes in practice are implemented.

GGRM has a Quality of Care Committee whose aims and objectives and membership are provided in Appendix F. The focus of this Committee is on the quality activities for the Clinical Quality Council as indicated by the agenda format. The Committee needs to adopt a planned approach to quality for GGRM, considering the range of facilities, staff and service delivery models. The development of a wide range of appropriate clinical indicators for GGRM has proved problematic. Staff expertise and commitment to this process needs to be developed. A range of quality projects are underway or have been completed by individual services, especially in preparation for the ACHS Evaluation Quality Improvement Program. It should be noted that all GGRM community based services are accredited with their corresponding inpatient facility. The issues around quality of care in GGRM relate primarily to the dilemma between GGRM Area-wide activities vs. facility specific activities. Recently the membership of the quality committee has been broadened to begin to address this issue. GGRM also provides representatives to the Falls Roundtable – a national group that is part of a wider international consortium looking at strategies to prevent falls in hospital.

8.4.3 Risk management

A series of incidents in some of the community services prompted GGRM to review all its community services in terms of risk assessment and management. A Steering Committee has been established and there are five specific working parties – looking at ACATs, day centres, the Carer Respite Centre, brokerage and inpatient implications. Each working party is developing strategies for each of these services on the basis of ten principles. The initial phase of the project was completed by September 2002. Outcomes achieved thus far include:

• Development of standardised referral and assessment policies and tools.

• Increased staff awareness of patient/client and staff risks via training and education.

• Identification of community venues not suitable for some target groups and notification to local access committees.

• Development and implementation of an 'outing policy'.


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• Purchase of mobile phones for staff use when undertaking community visits.

• Increased risk awareness of private brokerage agencies.

• Implementation of staff peer review systems to assess risk.

• Positive feedback from staff about the effectiveness of ‘back-up systems’ during outings

• Extension of on-call system across all GGRM services 24 hours per day

• Development of a range of policies to maximise safety of staff and clients when in the community including minimisation and management of aggression.

Both hospital and community based teams continue to address these issues. Though some services have had to curtail their activities during this process, most people consulted saw it as a very positive and necessary step that will result in the standardisation of a range of policies and procedures across the whole of GGRM.

8.5 Partnerships

8.5.1 General Practitioners

There are approximately 700 general practitioners working in CSAHS and most of these belong to two organisations- the Central Sydney Division of General Practice and the Canterbury Division of General Practice. There are many informal links with GPs and the GGRM stream however more formal links with managed care need to be considered in the future. GP funding now includes Enhanced primary care items where activities such as teleconferences with geriatricians, hospital visits by GPs of their aged patients, creation of health plans etc can now be remunerated. Discharge planning within GGRM has been well regarded. This remains a priority area that requires increased GP /GGRM linkages to reduce return admissions to hospital and maximise quality of life for the older and disabled population in their community residences. There is potential to utilise teleconferencing as a method of involving GP’s in discharge and care planning.

8.5.2 GPC

General Practice Casualty (GPC) at Balmain Hospital is an innovative service providing high quality casualty care to the local population, 24 hours a day, 7 days a week. It is staffed by a pool of 30 GPs. The casualty offers GP-type services when a patient’s family doctor is not available. The GPC is currently not located with a clinical stream. It was previously part of the General Practice Clinical stream along with Central Sydney Division of General Practice and Canterbury Division and the University of Sydney Department of General Practice. However Central Sydney GP Division's decision to separate from CSAHS and become independent and the dissolution of the General Practice Clinical stream has left GPC without a clinical group affiliation. CSAHS Clinical Council is currently deliberating where it belongs. There are arguments for its inclusion into GGRM: it is located at Balmain Hospital – a wholly GGRM precinct; as a consequence of being

at Balmain Hospital it is funded as part of GGRM; between 10pm and 9 am, the GGRM resident medical officer (RMO) attends to people

who present at the GPC. The RMO is responsible to the Director of Clinical Services of the eastern sector of GGRM;


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it has clinical links with General Medicine and Geriatric Medicine and the GPC Director attends the weekly Geriatric Medicine clinical meetings at Balmain Hospital;

the NUM attends GGRM nurse management meetings.

8.5.3 Residential Aged Care Facilities

With greater focus on avoiding admission to hostels and nursing homes, the level of dependency of those actually admitted to residential care facilities has increased. Even though nursing homes are not the responsibility of State health services, the GGRM CNCs are being prevailed upon increasingly to provide support and advice to nursing homes. These requests present a dilemma for the CNC’s because they are aware it is not their responsibility but they recognise that by providing a response they may prevent an unnecessary hospital admission. This ‘grey area’ at the interface of Commonwealth and State responsibility needs to be acknowledged and both levels of government need to collaborate to determine and fund the most effective approaches to patient care and cost. Specialist consultancy support in geriatric medicine, wound care, management of challenging behaviours and continence management to nursing homes may be one solution. Nursing homes also need access to other education and expertise, assistance to develop protocols and to address issues such as advanced care directives. Currently there is no local capacity to meet these demands.

8.5.4 Homoeopathic Clinic

This clinic was established at Balmain Hospital with trust funding, after the closure of the Homoeopathic Hospital in Glebe. Consideration of its clinical governance is underway.

8.5.5 Psychogeriatric services

With the transfer and redevelopment of psychiatric services at Rozelle to CRGH, there will be a need for the psychogeriatricians in the western sector to be involved in the care and treatment of older people admitted to the ward replacing the current admission ward for older people at Rozelle (Ward 16). The development of the Croydon site (old Western Suburbs Hospital) is planned to include a dementia specific nursing home unit to replace ward 18 at Rozelle. This facility is to be run by a non government organisation (Catholic Health Care) and there will need to be protocols established to ensure the Area psychogeriatricians are responsible for admissions to and discharges from this unit and that the geriatricians are involved on a consultation-liaison basis.

8.5.6 Podiatry

Podiatry services are provided to GGRM on the basis of a service agreement between the Division of Allied Health and GGRM. A large proportion of the funding is from the HACC program. Podiatry services are in high demand but the public sector generally has great difficulty in recruiting and retaining staff. This difficulty relates to the discrepancy that exists between the award levels of pay for podiatrists in the public sector compared to what they can earn in the private sector. Difficulties in supervising podiatrists have been identified, as they are scattered across the Area in a number of sites. Even though there is only the equivalent of 4-5 FTE positions, there are many individuals who work on a part time sessional basis. A funded review of podiatry services has been contracted by DADHC. Management of the community podiatry services was transferred to Allied Health directorate in mid 2003.


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8.5.7 Others

The Department of Neurosurgery in the eastern sector is concerned about the timeliness of response to requests for consultations and rehabilitation assessments of neurosurgical patients.

• The relationship, in terms of roles and responsibilities, between the ACATs (GGRM) and

the community nurses (Population Health) could be strengthened. • Department of Housing policies and strategic direction has direct impact on community

based Occupational Therapy referral numbers and waiting times. Partnerships to address these impacts should be developed.

• Access to patient transport between facilities remains of concern, including both urgent

and non urgent transfers. There is also a lack of clarity on whether escorts should be provided while patients from Balmain or Canterbury Hospitals are undergoing investigations at RPAH or CRGH.

• Increasing requirements from external agencies, including Guardianship Tribunal,

Immigration Department, have had an impact on community team workloads. • There is a lack of clarity of the roles and responsibilities of GGRM staff in relation to the

management of affairs of clients who are under the care of the Office of the Public Guardian.

GGRM Strategic Plan 2002 - 2007 __________________________________________________________________________________

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9. Recommendations, Supporting Strategies, Timeframes and Responsibilities.

Based on the issues identified in the previous sections, the following action plan is proposed to direct GGRM 2002-2007.

Goals Recommendations/Strategies Person/s Res’sible

Time Frame

1. Population Demographics

1.1 Ensure collection & analysis of relevant population demographic data (including disability data) to identify changing needs

CSAHS Planning Unit

Annually

1.2 Monitor the needs and demands of ‘old old’ population on the service

1.3 Test the claim that increasing patient/client acuity makes current staffing ratios and funding inadequate (see section 8.1 & 8.2.1)

For planning decisions made by GGRM to be based on current, accurate data

1.4 Investigate trends in ACAT waiting times (see section 8.1) Community Service Managers, GGRM Project Manager, ACAT TL’s

Dec 2003


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Time Frame

2. Resources 2.1 Develop a comprehensive Human Resource Plan to aid staff recruitment

and retention, including opportunities for staff to develop expertise by working in a variety of teams, staff development and professional support structures

Working Party

2.2 Develop and offer regularly a GGRM Staff Orientation Program Community Service Managers

May 2003

2.3 Develop distribution systems to communicate with all GGRM staff – contact directory, email lists etc.

GGRM Project Manager

Dec 2003

2.4 Nursing - identify gaps in CNC service delivery via benchmarking the numbers of

CNC/CNE with other clinical groups - identify means of correcting deficiencies - identify opportunities to enhance nurse education

Area Nurse Coord’tor

2004

2.5 Allied Health - review the adequacy of the number and distribution of allied health

resources, for both inpatient and non inpatient services, including the cost and feasibility of weekend services, pool of staff to provide cover for leave

Allied Health Director

2004

Staffing GGRM to be sufficiently competent staffed, to enable delivery of high quality services (see section 8.2.1)

2.6 Medical Staff - Benchmark the numbers of medical staff against clinical loads and other

clinical groups - Continue the educational experience available to medical students/staff

via rotations into medical teams at TCH

2004


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Time Frame

2.7 Day Centre staff - Review impact of the Risk Management Strategy on day centre staffing

ratios

Team Leaders

Dec 2003

2.8 PADP - Review adequacy of PADP staffing against other AHS’s and ensure

policies are standardized across the Area

PADP committee, GM

Jun 2004

2.9 Community Service Managers - Review roles and perceived inequities between Service Manager

positions

GGRM Project Manager, GM

Feb 2004

2.10 Reconfigure existing Education Committee, including representation from all sectors, to reflect the needs of all GGRM staff

Education Committee

Dec 2003

2.11 Identify service needs in a systematic way and be aware of govt. initiatives that potentially fund service gaps

2.12 Address funding inequities across the sectors. See 3.18 for specific Canterbury issues

2.13 Ensure that adequate administrative support is built into future service enhancements

2.14 Pursue options for services whose funding is short-term – CLASP, TACS, NDEMS, Carer Education Project

Funding GGRM to maximise and distribute funding equitably across three sectors (see section 8.2.2)

2.15 Refine and consolidate strategies to address issues raised by growth in service delivery model of using private agencies

Brokerage Working Party

2004


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Time Frame

2.16 Seek funding for the enhancement of TCH General Medicine services including ECHO, EST etc.

2.17 Commissioning and resourcing of Magnolia Cottage (the new premises for Kalparrin Day Centre), including establishment of new work practices

Working Party

Oct 2003

2.18 Commissioning and resourcing of the new ward at RPAH

RTP User Group

2004

2.19 Commissioning and resourcing of the KGV area for the Eastern Sector Community teams

RTP User Group

March 2004

2.20 Commissioning and resourcing of the refurbished wards at CRGH including the establishment of new work practices with the co-location of inpatient and ambulatory services

RTP User Group

Dec 2003

2.21 Commissioning and resourcing of the new Rehabilitation Medicine ward at CRGH

RTP User Group

2004

2.22 Re-establishment & resourcing of the geriatric and rehabilitation ward at TCH when palliative care vacates Cassia ward

2.23 Clarification of the role of GGRM and the psychogeriatric service in the proposed development of the Croydon site

Clinical Director

Physical Facilities Ensure continuation of service delivery from facilities that meet staff and client needs (see section 8.2.3)

2.24 Explore accommodation options for Canterbury Aged Community Services and General Medicine at TCH

Site Business Manager


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Time Frame

2.25 New premises for Sita Carter day centre need to be found GM Dec 2003

2.26 Document GGRM’s current and future IT needs and determine the funding options for having these needs met. Negotiate IT support from ISD.

Working Party, ISD

2.27 Identify areas of work practice where IT may contribute to GGRM effectiveness and efficiency in relation to patient care, general communication and service reporting. Also see 2.3

2.28 Identify and support GGRM ‘Super Users’ on sites to assist staff with basic IT issues

2.29 Identify and train GGRM staff to a minimum computer literacy level

2.30 In conjunction with ISD, develop a work plan to further the development of CERNER to meet the varying IT needs of GGRM

ISD, GGRM Project Manager

Oct 2003

2.31 Develop new models of service delivery using existing technologies ie. teleconferencing and telehealth pilot projects

2.32 Standardise data collection systems to enable accurate benchmarking between like community services ie. ACAT waiting times


Dec 2003

Information Technology GGRM staff have access to, and skills to maximize, available technology to assist service delivery models (see section 8.2.4)

2.33 Reconfigure existing IT Committee to reflect needs of all GGRM staff


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Time Frame

Models of Care

3.1 Review current service delivery models and develop new models of care, where appropriate

3.2 Develop strategies to preserve and enhance effective domiciliary and ambulatory services, including service delivery models of ACAT, dementia specific teams

3.3 Further the development of the newly funded Aged care Services Emergency Teams

ASET Steering Committee

Ongoing

3.4 Consolidate GGRM target groups, identifying future areas of possible growth eg. children with disabilities, young adults with disabilities, and communicate decision to staff/relevant stakeholders

3.5 Explore the feasibility of innovative care options for - transitional care (see section 8.3.1), - slow stream rehabilitation in the domiciliary setting (see section 8.3.1), - the incorporation of successful aspects of the Priority Health Care

Programmes into aged care services, - enhanced Hospital in the Home services to provide an effective post

acute care role

Planning Unit; LUCAN; Executive

2003/04

3

GGRM to provide the most effective method of service delivery, to meet the changing needs of the population via appropriate models of care (see section 8.3)

3.6 Clarify the need for and balance between general and specialised outpatient services including STRONG, falls clinics, cognitive disorders clinics, continence clinics (see section 8.3),


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Time Frame

3.7 Determine role of and need for community education programs to be offered

3.8 Define and benchmark GGRM’s service delivery role in relation to identified target groups, with the view to develop appropriate models of care for:

- carers (see section 8.3.5) - people from CALD backgrounds (see section 8.3.3) - Aboriginal and Torres Strait Islander people (see section 8.3.4) - younger people with disabilities (see section 8.3.6)

3.9 Determine how best to respond to the needs of the above population groups

3.10 Ensure staff training is available to meet the needs of the above groups.

3.11 Ensure the development and review of all services, policies and procedures considers the NSW Health Aboriginal Health Impact Statement.

3.12 Review inpatient multidisciplinary discharge planning processes to ensure the outcomes are safe and timely – consistent with EQUIP standard (see section 8.3.2) including the feasibility, staff implications and cost of increasing the number of weekend discharges

3.13 Refine entry and exit processes for community services and develop a common Area-wide protocol (see section 8.4.1).

Community Service Managers; Project Manager

2004


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Time Frame

3.14 Develop procedures to allow and encourage client participation in decision making regarding their care (see section 8.3.8).

3.15 Develop procedures for informed consent for all intervention procedures, data collection and data transmission (see section 8.3.8)

2004

3.16 Determine extent of rehabilitation services required by the tertiary burns unit at CRGH

3.17 Develop partnerships with other Clinical Directorates to address issues of rehabilitation for ‘out of Area’ elective patients.

3.18 Identify and participate in any State-wide program to develop services and facilities for people with challenging behaviours as a result of non traumatic acquired brain injury.


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Time Frame

3.19 Examine specific issues in the Canterbury sector (see section 8.3.7) - Endorse the General Medicine model of service provision for medical

services at Canterbury Hospital.

- Continue to strengthen the Dept. of General Medicine at TCH through appointment of physicians with general and subspecialty expertise, who have links with other facilities and subspecialty services within CSAHS

- Strengthen links between Dept. General Medicine at TCH & tertiary units at RPAH & CRGH to facilitate access of patients requiring that level of expertise

- Monitor the relationship between General Medicine and Geriatric Medicine at Canterbury Hospital including the admission protocols in the Emergency Department

- Recruit to the vacant staff specialist geriatrician positions

- Develop strategies to counter the professional isolation of Geriatric Medicine medical, nursing and allied health staff at TCH


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Time Frame

- Compare the level and range of geriatric medicine and rehabilitation

services in both the hospital and community in Canterbury with the level and range of services in other sectors, especially the numbers of allied health staff.

- Seek funding to expand the range of services in the Canterbury sector, including post acute and community care, diabetes management, chronic pain clinics, pulmonary and cardiac rehabilitation.

- Seek expanded access to Drug and Alcohol Services at TCH.

4 Organisational Issues

4.1 Maintain the sector organisation and delivery of services and strengthen the Area focus of GGRM

Ongoing

4.2 Create and seek funding for a senior position with no line management responsibilities to ‘drive’ service development issues on an Area wide basis – quality, education, hospital based policies and procedures etc. using the approach taken in the risk management portfolio (see section 8.4.1)

Executive

2003

GGRM Infrastructure GGRM Infrastructure is well developed and supports service delivery

4.3 Develop standard operating procedures across Area for community teams

Community Service Managers,TL’s

2004


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Time Frame

4.4 Standardise like service names across the Area eg. ACAT’s

Community Service Managers,TL’s

2004

4.5 Present budget and expenditure information (quarterly to GGRM Area Mgt Meeting) in a format that enables:

- comparisons of resource levels across sectors - monitoring of the balance of resources between inpatient and non-

inpatient services

Business Managers

4.6 Ensure area-wide representation on all committee, via - review of committee memberships - development of outcome targets for all committees

Chair @ committee

4.7 Attract new funding to support equitable services in all sectors, particularly Canterbury rather than expand/develop new services in the other 2 sectors

4.8 Assess the feasibility of managing some waiting lists on an Area basis

4.9 Implement the proposed change of the reporting of Canterbury Aged Care Community Services from Canterbury Hospital management to GGRM management and ensure the full transfer of budget (see section 8.4.1) – MOU with TCH

Executive; TCH

July 2002

4.10 Clarify the future of General Medicine at Balmain Hospital (see section 8.4.1)

GM


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Time Frame

4.11 Develop strategies to increase customer focus within GGRM

4.12 Develop staff expertise and collect area wide clinical indicators for benchmarking and quality purposes

Quality GGRM operates with a quality framework in place (see section 8.4.2)

4.13 Develop strategies to ensure the GGRM Quality Committee addresses the needs of all GGRM staff and patients

Quality Committee

4.14 Continue to implement risk management strategies emanating from the GGRM Risk Management planning process


Risk Management GGRM operates within a Risk Management Framework (see section 8.4.3) 4.15 Integrate risk management principles into standard GGRM work

practices Dec 2003

4.16 Evaluate risk management strategies introduced during the Risk Management Project


Dec 2003

5 Partnerships


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Time Frame

5.1 Review and if required formalise (MOU) GGRM’s relationship with other key clinical groups/stakeholders. These stakeholders can be divided into two groups: internal stakeholders (including Mental Health, Population Health, Neurosciences, Bone and Joint, Cardiovascular Services, Palliative Care, Allied Health) and external stakeholders (the Divisions of GP, Guardianship Tribunal, Office of the Protective Commissioner, Department of Housing, other government departments, non government organisations, Councils).

5.2 Consolidate and establish new partnerships with non-government agencies and private practitioners, including GP’s.

5.3 Continue to strengthen relationships with GPs regarding discharge planning

5.4 Ensure consumers continue to be represented on relevant GGRM committees – policy for consumer representation

5.5 Negotiate with Mental Health to maximise the effectiveness of the provision of psychogeriatric services, including new Croydon site (see section 8.5.5)

Clinical Director

5.6 Develop management/supervisory plans with Mental Health to aid with staff management of joint GGRM/Mental Health staff (see section 8.2.1) - MOU

GGRM maintains working relationships with all relevant stakeholders (see section 8.5)

5.7 In conjunction with Allied Health Services identify options for providing podiatry services and ensure consultation with HACC providers in the planning process (section 8.5.6).

Allied Health Director

Dec 2003


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Time Frame

5.8 Investigate the interface between Geriatric & Rehabilitation Medicine and nursing homes to identify problems and options (section 8.5.3).

5.9 Follow Clinical Council decision as to governance of GPC, Balmain Hospital and Homeopathic Clinic, as they relate to GGRM

5.10 Develop strong partnerships with CSAHS Human Resource Departments to aid staff recruitment processes (see section 8.2.1).


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10.References ACSA (2001) Community Care Programs: The Future, Discussion Paper 1, prepared by the National Community care Advisory Committee. Boyce, McNeil, Graves and Dent (1997) Quality and Outcomes Indicators for Acute Healthcare Services, Commonwealth Department of Health and Human Services. Broe T (2002) slide presentation to CSAHS Clinical Council, March. Central Sydney Area Health Service (1993) Clinical Strategic Plan, prepared by McCaughan B, Picone D and Hardwick J, CSAHS, Camperdown. Central Sydney Area Health Service (1996) GGRM Strategic Plan, CSAHS, Camperdown. Central Sydney Area Health Service (1996) The Service Delivery Plan for GGRM, CSAHS, Camperdown. Commonwealth Department of Human Services and Health (1995) Efficiency and Effectiveness Review of the Home and Community Care Program, Aged and Community Care Division, AGPS, Canberra. Commonwealth Department of Health and Aged Care (2001) Two Year Review of Aged Care Reforms: Government Response, Commonwealth of Australia, Canberra. Davis, P. (2002) The Canterbury Hospital Department of General Internal Medicine: Service Description and Plan (unpublished) Gray L (2001) Two Year Review of Aged Care Reforms, Final Report, Commonwealth of Australia, Canberra. Greater Metropolitan Services implementation Group. (2001) Report of the Greater Metropolitan Services implementation Group. NSW Health Department, Sydney. http://internal.health.nsw.gov.au/policy/gap/metro/GMSIGmetro.pdf House of Representative Standing Committee on Community Affairs (1994) Home But Not Alone: Report on the Home and Community Care Program, Canberra. Lincoln Gerontology Centre (1998) National framework for comprehensive assessment of the HACC program, Commonwealth Department of Health and Aged Care, Canberra. National Ageing Research Institute and Bundoora Extended Care Centre (1999) Targeting in the Home and Community Care Program: main report: report on a consultancy carried out for the Commonwealth, state and territory departments administering the HACC program, Commonwealth Department of Health and Aged Care, Canberra. NSW Ageing and Disability Department (1998) Community Care Assessment in NSW: A Discussion Paper, Sydney. NSW Ageing and Disability Department (1998) NSW Healthy Ageing Framework, 1998-2003, ADD and NSW Health, Sydney. NSW Health (2000) The Report of the NSW Health Council – A Better Health System for NSW, Better Health Centre, Sydney.

http://internal.health.nsw.gov.au/policy/gap/metro/GMSIGmetro.pdf�


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NSW Health (2001) Improving the Aged/Acute Care Interface in NSW; Technical Discussion Paper, Sydney. NSW Health (2001) Partners in Health: Report of the Consumer and Community Participation Implementation Group, Better Health Centre, Sydney. Singh N (2001) ‘Prescribing exercise it’s never too late’ Medicine Today, September.

Working Group on the Care of Older People in the NSW Health Care System (2002) Managing the Care of Older People in the NSW Health Care System, Sydney.


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Appendix A: List of people consulted

Name Position Richard Gilbert Area Director of Planning Dr Peter Kennedy Area Director of Health Services Dr John Cullen Clinical Director, GGRM Dr George Szonyi Director of Medical Services E sector Julie-Ann O’Keeffe A/Manager of Community Aged Services, E sector Tony Ciesiolka Community Options, E sector Michelle Gravolin ACAT team leader, E sector Lisa Shanahan Community Options, E sector Rosemary McAllister NUM, Day Hospital Dr Peter Henke Director of Rehabilitation Ilse Upenieks Operational Nurse Manager, Balmain Hospital Dr Nalin Singh Geriatrician, E sector Rhonda Stiller Manager of Community Aged Services, W sector Kerry Mina ACAT leader, W sector Anne Mannix Inner West Live At Home, W sector Carmel de Martin Team leader, AECD Dr Ross Hawthorne Director of Rehabilitation, W sector Dr Treit Bui Director of Geriatric Services, C’bury Jenny Gilroy Manager, Community Aged Care Services, C’bury Dr Helen Jagger Director of Medical Services Prof Le Couteur CERA Carolyn Virgona Community Respite Team Mary Davis Residential Information Service Anne Marie Crozier GPC Paul McMahon Lucan Care Nora McGuire Consumer Dr Joanne Williams GP Wendy Jamieson Area Quality Manager Dr Margy Halliday Area OH&S Coordinator Ann Kelly Nursing Coordinator, GGRM Sharon Wessels PADP Dr Victor Storm Clinical Director, Mental Health Dr Paul Davis General Physician Dr Peter Holman Clinical Director, Bone and Joint Services Katherine Moore Area Director, Allied Health Dr David Kitching Psychogeriatrician, Concord Les Hillier Finance Angela Manson Multicultural Health Dr Diana Horvath CEO Chris Rissel Health Promotion Ben Mifsud Podiatry Frances Tinsley Day centres, E sector Glenda Thomas Community Nursing Prof Michael Besser Neurosciences Peter Clout Manager, GGRM Ken Cahill ex General Manager GGRM Louise Robertson ISD Greg Perry SNAP Coordinator, NSW Health GGRM Education sub committee GGRM Quality GGRM Nurse Management Meeting of GGRM Allied Health


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Appendix B: Recommendations from the previous plan

GERIATRIC MEDICINE Designated Beds 8.1.1.1 The existing patient load at RPAH be consolidated into a single ward of 22 beds (including 2 rehabilitation medicine beds) with appropriate nursing and allied health staff. The ward should have appropriate day care and therapy areas as well as wheelchair and frame accessible toilet and bath facilities. (To achieve this consolidation resources will need to be transferred from other wards where these patients are currently accommodated). 8.1.1.2 Wards 520 and 530 at CRGH continue to be designated as General and Geriatric Medicine wards and be adequately staffed with nurses and allied health personnel. 8.1.1.3 Ward 17 at CRGH be designated as an Area facility for medically ill, behaviourally disturbed patients (see 8.5 Psychogeriatric Services) Transitional Care 8.1.2.1 A working party (including representatives from other clinical directorates with patients who need a similar type of care e.g. orthopaedics) be established to quantify the need for transitional care beds and determine how these needs will be met. Physical Facilities – Community Health 8.1.3.1 A team leader for the 12 aged care community allied health staff be appointed in the Eastern Sector and the feasibility of their co-location on one site together with the community nurses be assessed. 8.1.3.2 If the mental health services re-development occurs at CRGH a plan to accommodate aged care community services be developed. 8.1.3.3 As part of the Canterbury Hospital re-development, aged care community services be adequately accommodated. Disparity in Resource Allocation 8.1.4.1 A review of staffing levels and caseload for all services (inpatient and non inpatient) be conducted to determine the extent of the disparity in medical, nursing and allied health staff between sectors. 8.1.4.2 The enhancement of community services in the Canterbury Sector be seen as a priority. 8.1.4.3 The deployment of resources between inpatient and community services be closely monitored to ensure the appropriate transfer of resources as the focus of care shifts. In particular as the need for home based therapy increases, staff numbers in the community will need to be enhanced. Intake and Discharge Planning 8.1.5.1 A centralised professional intake system be established in the Eastern Sector. 8.1.5.2 Good liaison and communication be established with Emergency Departments in each sector to facilitate appropriate triaging and a smooth transition to the ward.


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8.1.5.3 Review discharge procedures and provide information about community services in each sector. Case Management 8.1.6.1 Client Characteristics/needs which would necessitate a “case manager” be identified so that the appropriate targeting of service provision can occur. REHABILITATION MEDICINE Designated Beds 8.2.1.1 A 20 bed rehabilitation ward be established at CRGH to accommodate the existing rehabilitation patient load. The preferred option would be a purpose built unit with a multi-disciplinary team providing inpatient and outpatient services and linked to the AECD. If capital funds are not available, an existing ward area should be designated for rehabilitation patients with appropriate nursing and allied health staff. (This strategy implies a transfer of resources from other clinical services where these patients are currently treated). 8.2.1.2 The existing geriatric and rehabilitation medicine patient load at RPAH be consolidated in a single ward of 22 beds (see strategy 8.1.1.1). Coordination of Services 8.2.2.1 The hospital and community based Rehabilitation Medicine services provided at CRGH, and community within the community be integrated into one department. 8.2.2.2 The position of Head of Department of Rehabilitation Medicine Services within the western sector be advertised and filled. 8.2.2.3 Negotiations continue with the Department of Veterans Affair to see if RGH can continue to provide rehabilitation services to Veterans on a funder-provider basis. Outpatient Services 8.2.3.1 The Area Director of Rehabilitation review inpatient and outpatient needs and develop a plan for services across the Area on a rational and cost effective basis. 8.2.3.2 The feasibility of providing Industrial Rehabilitation services on a for-profit basis be examined. 8.2.3.3 Establish an outpatient rehabilitation consultative service for Canterbury Hospital. GENERAL MEDICINE Role of General Medicine 8.3.1.1 Further discussion and planning occur to determine the future role of the General Medicine department at CRGH and its links with Geriatric Medicine. 8.3.2.1 The need for general medical beds at Balmain be closely monitored and reviewed. 8.3.3.1 GGRM staff continue to be involved in the functional service planning for the new Canterbury Hospital to consolidate a role for GGRM.


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8.3.3.2 The teaching role of Canterbury Hospital in General Medicine be enhanced and developed through links with General Medicine at CRGH, Registrar rotation and service provision. GENERAL ISSUES Casemix 8.4.1.1 A Casemix Committee for the GGRM directorate be established. 8.4.1.2 A casemix strategy be developed for the GGRM directorate. The aim of the strategy is: • to maximise the efficiency of service provision; • to ensure clinicians are well informed about the implications of casemix and proposed

developments in casemix; • to produce data of high quality with accurate and comprehensive documentation of

primary diagnosis, complications, co-morbidities and episode of care changes; • to identify issues that must be resolved at an Area level and to develop processes for

this to occur. 8.4.1.3 CRGH and Canterbury Hospital participate in the imminent SNAP (Sub Acute Non Acute Project) trial. Quality Assurance 8.4.2.1 Multi-disciplinary QA be piloted on directorate specific basis to evaluate the efficacy of this approach and the GGRM be the pilot directorate. 8.4.2.2 All aged care community services begin an accreditation process with the appropriate accreditation body. 8.4.2.3 QA outcome programs based on clinical indicators be developed in all sectors. Staff Development 8.4.3.1 Staff development be piloted on a directorate specific basis to evaluate the efficacy of this approach and that GGRM be the pilot directorate. Health Promotion 8.4.4.1 The proposed philosophy and strategies for health promotion be adopted. Health Outcomes 8.4.5.1 A Health Outcomes Committee for GGRM be established. 8.4.52 Specific goals, target and outcome measures be developed in the following priority areas: • falls; • burns management; • treatment of fractured neck of femur; • injury prevention; • acute management of injury; • long term care of people with injury; • incontinence; • dementia;


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• stroke management; • amputee management; • Ischaemic Heart Disease; • Asthma/CAL NESB Access and Equity 8.4.6.1 Specific strategies be adopted to improve access and equity to services for people from non-English speaking backgrounds particularly in the Canterbury municipality. Organisational Structure 8.4.7.1 The proposed organisational structure and provision for GP and consumer involvement in management committees be endorsed. Nursing 8.4.8.1 Nursing priorities be acknowledged and strategies adopted to achieve the stated goals. Allied Health 8.4.9.1 The proposed allied health structure be costed an implementation issues discussed with site managers and the Area Director of Allied Health. Podiatry 8.4.10.1 The proposed Area model for podiatry services be endorsed. PADP 8.4.11.1 The proposed recommendations of the sub-committee be adopted and implemented. Relationship with GPs 8.4.12.1 On-going dialogue, co-operation and shared care projects continue with the Division of General Practice. 8.4.12.2 GGRM give high priority to further enhancing the quality of discharge communication to GPs through all available mechanisms. 8.4.12.3 Appointment of GPs to the GGRM Management Committee and sector level committees. Community Health Data Collection 8.4.13.1 A community health data collection committee be established to facilitate the collection of meaningful, comparable data. Nursing Home and Hostel Liaison and Information 8.4.14.1 The recommendations of the sub-committee be adopted and implemented. Opportunities for Efficiency


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8.4.15.1 The proposed Casemix Committee and Health Outcomes Committee work together in monitoring the efficiency of the continuum of services in terms of cost and patient outcomes. Nursing Home Care 8.4.16.1 GGRM medical and nursing staff, together with the Division of General Practice and Emergency Department staff, develop a program that will assist in the enhancement of nursing skill levels in nursing homes for the purpose of managing more acute patients within the facility, rather than transferring to Emergency departments in the acute care setting. Psychogeriatric Services 8.4.17.1 Ward 17 at CRGH be designated as an Area facility for medically ill, behaviourally disturbed patients and increased from 15 to 25 beds. (This expansion will require a transfer of resources from Rozelle Hospital as part of the mental health restructure). 8.4.17.2 Admission and Discharge protocols be developed for Ward 17 and distributed to CSAHS facilities. 8.4.17.3 Discussions begin between GGRM and the Mental Health directorate regarding the development of an appropriate mechanism to determine future working relationships, and to provide a forum where border issues can be discussed and resolved in an efficient, effective manner.


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Appendix C Organisational charts

GGRM

* ACAT *COPS *TACS/CVS * Day Centres (2)

Community Service Manager

Community

Balmain Hospital* 3 wards * PADP * Continence

RPAHospital* Day Hospital

* Ward

Hospital

Eastern SectorClinical Director

Concord Hospital* Day Hosp.

* AECD Clinics* Wards 35, 17, 20,19

Canterbury Hospital* Banksia Ward* Boronia Ward

Hospital

Aged care ServicesEmergency Team (ASET)

Western Sector* ACAT * COPS * CRT

* CRC * AECD/HBT * DTC * DAS

Canterbury Sector* ACAT

* Karinya Day Centre

Community Service Manager

Community

Western/Canterbury SectorClinical Director


GGRM Clinical DirectorGGRM Business/General Manager

GGRM Area Nurse Coordinator


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Chief Executive Officer CSAHS WESTERN SECTOR

Deputy CEO, CSAHS Director, Health Services CSAHS

General Manager, General Manager Director, Clinical Services GGRM Community Services Concord Hospital GGRM Director, Clinical Services Western Sector Site Business Manager Head of Department Head of

Department Geriatric Medicine Rehabilitation Medicine Service Manager Ward 17 Inpatient Consultations Ward 19 Inner West Care

Ward 20 General Clinics

Ward 24 Pain Clinic

Consultations Ward 19

Inner West

Aged Community

Live at Home Services Team

Community Respite Service Aged & Extended Kalparrin Care Department Kindilan Home Based Therapy


90

Dementia Support CLASP Outpatient Clinics

Carer Respite Centre

Day Hospital

Residential Information Service

NDEMS *

Carer Education Project no line management accountability

*Neurodegenerative Education & Management Service

denotes different cost centre management


91

Balmain Hospital & Aged Community Services Organisational Chart

General ManagerBalmain Hospital

&Aged Community Services

AUXILIARY GM's SecretaryAdministrative Support Secretary

Librarian

VolunteersClergy

Staff DevelopmentCoordinator

Clinical NurseConsultant

(HACC)

After HoursCoordinator

Infection Control /Diabetic Educator

NUMWakefield

Ward

NUMJohn Beasley

Ward

NUMLeverWard

NUMGeneralPracticeCasualty

OperationalNurse

Manager

Directorof

Nursing

ClinicalServicesSecretary

Directorof

ClinicalTraining

Service DirectorGeriatrics& GeneralMedicine

ServiceDirector

Rehabilitation

ServiceDirector

General PracticeCasualty

Aged CareAssessment Team

ACAT

Day CentresJane Evans D/CSita Carter D/C

Inner City Liveat Home Program

COPS

NSW TransculturalAged Care Services

* CVS* Multicultural ACA

Service ManagerAged Community

Services

Directorof

MedicalServices

SpeechPathology

SocialWork

OccupationalTherapy

Physiotherapy

Medical Records

Dietetics

Allied Health

Maintenance

CleaningPortering

Food Services

Support Services

Human ResourcesPay OfficePathologyPharmacy

RadiologyPodiatry

Linen

Biomedical CSSDNeuropsychology

ContractedServices

AdmissionsAccounts

FinanceManager

Provision of Aids forDisabled People

PADP

Central Sydney Area Health Service


92

GGRM Services at RPAH – Organisational Chart

Operational NurseManager

Director of NursingRPAH

Aged care ServicesEmergency Team

RPAH

Geriatric WardRPAH

NUMAmbulatory Care

Ambulatory CareRPAH

Service DirectorGeriatrics

Service DirectorRehabilitation

GGRM Eastern SectorClinical Director

GGRM Area NurseCoordinator

GGRM Clinical Director GGRM General Manager

General ManagerRPAH

Director of Medical ServicesRPAH

Central Sydney AreaHealth Service


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GGRM Committee Structure

GGRM Strategic PlanProject Team

Quality of CareCommittee

Education Committee Information ManagementTechnology Committee

Risk Management Multicultural Aged Care

Community Team Leaders Day Centres

Allied Health Nursing ManagementCommittee

Sector Feedback (x 3) via:* Eastern Sector Executive Committee

* Western Sector Clinical Management Committee* Other Forums

GGRM AreaManagement Committee


94

Appendix D: Casemix reports


95

Appendix E: GGRM Clinical Indicators

• Functional assessment – timely assessment of function on admission (Balmain) • Functional assessment – recent assessment of function prior to patient

separation (Balmain) • Rehabilitation plan – timely establishment of a multi-disciplinary rehabilitation

plan (Balmain) • Rehabilitation plan – rehabilitation plan prior to patient separation (Balmain) • Program interruption – unplanned interruption to a patient’s rehabilitation program

(Balmain) • Assessment of cognitive function (CRGH only) • No. of patients experiencing falls while inpatients • No. of patients acquiring pressure areas while in hospital • Multi-disciplinary management of stroke (Canterbury) • Functional assessment – independent rise from chair on admission to John

Beasley Rehabilitation Unit (JBW) • Functional assessment – independent rise from chair on discharge from JBW • Functional assessment – independent walking velocity on admission to JBW • Functional assessment – independent walking velocity on discharge from JBW • Functional assessment – independent ascent and descent of one step on

admission to JBW • Days between request received for consultation and patient seen GGRM Performance Indicators INDICATOR TARGET TIMEFRAME/

STRATEGY 1. Safety 1.1 Number of reported incidents per FTE involving

risk to the safety of a staff member 5% reduction per year

P.A.

2. Effectiveness 2.1 Percentage of GGRM policies reviewed 80% P.A. 2.2 Percentage of staff attending non-compulsory

training event 60% P.A.

2.3 Percentage of staff who have attended all mandated training

90% P.A.

3. Appropriateness 3.1 Percentage of clients with a documented

assessment and care plan, agreed to by the client or caregiver

80% Each team snapshot audit x 1 p.a.

3.2 Percentage of clients meeting care plan goals within timeframe

60% Each team snapshot audit x 1 p.a.

4. Consumer Participation 4.1 Percentage of teams that demonstrate at least 1

quality activity that involves input from the community

80% P.A.

4.2 Percentage of research projects involving stakeholders

60% P.A

5. Efficiency 5.1 Percentage of car-days cars are not used 20% 3 month audit

of car usage p.a.

5.2 Percentage of research projects with peer-reviewed publications or technical reports arising

70% P.A.


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within 2 years of completion of data entry 5.3 Staff absentee rate per 100 FTE 2.5% P.A. 5.4 Staff turnover rate per 100 FTE 1.8% P.A. 6. Access 6.1 Percentage of clients seen with an interpreter 20% Each team

snapshot audit x 1 p.a.

6.2 Clients from CALD access ACAT services are reflective of local demographics

Audit x 1 p.a.

6.3 ACAT waiting times

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