Introduction: Older people in Hawkes Bay have increasingly complex health and social needs. Many remain in their own homes, receiving support from multiple agencies. engAGE was designed to better meet growing demand.
Targeted population: Community-dwellers (i.e. not resident in Age Related Residential Care) over 65 years or ‘like in age and need’ i.e. 55 years and over Maori and Pacifica.
Stakeholders: Primary Care, community services involved in the care of older people, the Hawkes Bay District Health Board Older Peoples’ Health Service.
Practice change implemented: engAGE community multidisciplinary teams (MDT’s) are based geographically around General Practice groupings, consist of staff from primary care, Hospital Older Persons’ Health Services and community providers and meet weekly in a General Practice setting. Referrals come from primary care, acute hospital and community agencies. Comprehensive interprofessional assessment takes place in the client’s home and creative solutions are developed through team discussion to maximise independence. Input continues until goals are met or no further improvement is possible.
engAGE Intermediate Care Bed (ICB) services provide an alternative to an inpatient stay
in an ARRC facility for clients not well enough to be at home but not requiring hospital care. Admissions come from community (step-up) or acute hospital (step-down). Clients receive MDT input in partnership with their primary care team for up to 6 weeks.
Aim: engAGE MDTs provide faster and more appropriate care and support, aiming to impact waiting times for allied health input and care support packages. Staff knowledge of systems, older peoples’ health issues and satisfaction will improve.
Comprehensive MDT input and ICB services aim to improve health outcomes and increase independence, reducing emergency department presentations, inpatient bed occupancy and readmission rates for older people and improving satisfaction of clients and caregivers. Older people will remain at home for longer as measured by time from engAGE input to entry into ARRC. Improved service efficiency, hospital inpatient and ARRC resident costs avoided will contribute to financial sustainability services.
Timeline: Cross sector Steering Group and Working Group 2011. Pilot MDT with ICB services in a single locality 2012, second MDT 2014. Four further MDTs November 2015. ICB services April 2016.
Highlights: engAGE has been well received by clients and staff in primary care, community providers, and hospital. Closer relationships, face to face communication and information sharing have improved system efficiency. Growing group expertise has allowed interprofessional working. Waiting times for allied health input have reduced. ICB’s are well utilised and well received by clients. KPI reporting is in progress.
Sustainability: Ongoing support by primary care is critical to sustainability. High workload impacts on primary care attending meetings. The primary care business model is a challenge to integration and a request by primary care for appropriate remuneration for time spent with engAGE requires resolution.
Transferability: engAGE is highly transferable to other locations and populations e.g. community mental health, services for youth, children living in poverty.
Conclusions: engAGE, in its early stages, is providing responsive, comprehensive input to older people in the Hawkes Bay community.