Level 5 New Ward Block-

Model of Care Frailty and GEM Beds Prepared by: James Jenkins Version: 0.3 | 21 February 2019

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Document Control

Version Date Prepared by Comments

0.1 7.2.19 James Jenkins Draft

0.2 30.1.19 James Jenkins Draft 2

0.3 21.2.19 James Jenkins Draft 3

*Drafts should use format vX.1 (eg. start at v0.1). Final versions should use format vX.0 (eg. v1.0).

Distribution

Name Title Function*

Kieran Kinsella Executive Director Rural and District Wide Services

Wendy Hoey Executive Director Rockhampton Hospital

Deb Hirning Director of Nursing, Aged Care Clinical and Rehabilitation Services

Struan Ferguson Deputy Director, Allied Health, Clinical Support Services

Celia Anich Deputy Director, Allied Health, Clinical Support Services

Dr Dhiraj Saini Geriatrician SAGE Unit

Colin Bartlem Manager Health Planning, District Finance

Kaylene Tansley ABF Coordinator, Business Analysis & Decision Support Unit

Leanne Law Senior Administration Officer, Corp Serv

Kim Kekewick Director of Corporate and Support Services, Rockhampton Business Unit

* The values applicable to the function field are Review, Approve, For Information

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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1 Table of Contents

2 Executive Summary 4 3 Background 5 4 Service Scope and Description 5

4.1 Description of the Service 5

4.2 Purpose of the Service 5

4.2.1 The Frailty Unit 5 4.2.2 The GEM Unit 6

4.3 Patient Type 7

5 Service Processes 8 5.1 Referral process 8

5.2 Frailty Out of Hours & Weekends 9

5.3 Patient Flow 10

5.4 Discharge process 11

5.5 The Team 11

5.5.1 Medical 11 5.5.2 Nursing 12 5.5.3 Allied Health Team 14 5.5.4 Operational Service Officer Resource Allocation 15 5.5.5 Administration Officer Resource Allocation 15

6 Data Measures 15 Appendix A - Example of Frailty Screening Tool 16 Appendix B - Example of Frailty Initial Screening Questionnaire 17 Appendix C – Example of nurse data collection 18

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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2 Executive Summary

Level 5 of the New Ward Block at Rockhampton Hospital will provide care for 2 key patient cohorts including:

- 11 Bed Cancer Inpatient Unit

- 16 Bed Acute Care of the Elderly (Frailty and GEM)

The Acute Care of the Elderly unit is designed to provide inpatient care for patients over the age of 65 years (or over 50 years for Indigenous) that required specialised geriatric assessment and treatment inclusive of both the acute medical phase and evaluation for this patient cohort. With a total of 16 beds, the unit has the capability to flex GEM and Frailty beds based on hospital demand. The Frailty beds provide fast-tracked assessment and early decision making for geriatric and frail patients, whereas the GEM beds enable short term care for patients requiring further assessment for age related syndromes / younger onset dementia / delirium and those who are at high risk if discharged home. This cohort of patients often recover medically before they are able to recover functionality which implies the need to change the focus of the care provided. This unit has an emphasis on maintaining patient’s level of independent function, muscle strength and independence while in hospital to help them return home as soon as possible. Therefore, discharge planning including liaison and referral with general practitioners and other community support services, commences at point of admission to ensure appropriate care needs are met. This model is evidence based, with the care provided aiming to:

- Improve discharge planning and reduction in pre-morbid functioning

- Reduce intrinsic complications and adverse events (falls, polypharmacy, infection risk)

- Reduced patient deconditioning and extended length of stay

- Increase patient and staff satisfaction

- Reduce hospital bed block and occupancy rates

- Provide disease-specific care including addressing the acute presentation in addition to any pre-existing co-morbidities resulting in individual holistic care.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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3 Background

A model of care review has occurred for the New Ward Block Level 5 at Rockhampton Hospital. This was previously known as SAGE (Sub-Acute and Geriatric Evaluation Unit) housing 11 Maintenance patients and 16 GEM patients. Under the new proposal, the 11 Maintenance patients will transition to North Rockhampton Nursing Home (NRNC) where interim care can be provided while awaiting permanent placement. This has resulted in 16 beds remaining for care of geriatric patients and 11 beds being reallocated for acute care patients.

4 Service Scope and Description

4.1 Description of the Service

The Acute Care of the Elderly unit is located on the 5th floor of the Cancer Care Services Building at Rockhampton Hospital. The unit provides services with:

24 hours of operation

Multi-day stay < 48 hours to 7 days

Specialist Geriatric assessment within an interdisciplinary team environment

Geriatric consultation service available on wards as well as inpatient on the Acute Care of the Elderly unit

In-reach team assisting in identifying patients as early as possible. This in-reach team will be known as the Sub-Acute Flying Evaluation Team (SAFE) for efficient patient focussed patient flow, with comprehensive coordination and discharge planning

Geriatrician Clinic (outpatient referral model)

4.2 Purpose of the Service

4.2.1 The Frailty Unit

The Frailty unit model of care aims to enhance services provided to frail older people with the provision of dedicated beds in the Acute Care of the Elderly unit. It is an assessment and planning unit that provides capacity to take older frail patients directly from GP’s/ED, and these patients will avoid the medical team admission process entirely reducing the timeline from assessment to treatment. These beds will assist to relieve pressure on medical beds and services, provide earlier specialist assessment, enabling swift diagnostics without the reliance on the old pathways of attending the ED resulting in a better care pathway for this cohort of patients.

The Frailty unit aims to avoid inappropriate hospital admissions of older persons whilst streamlining their care to the right place, right person at the right time.

The Frailty unit is closely linked with the geriatric clinic, and Emergency Department and will have access to other specialties and services within the community.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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The Frailty Unit aims to:

Fast track patients for rapid assessment

Provide treatment for patients to return to place of residence within 48 hours of hospital presentation

Avoid unnecessary and unscheduled hospital admissions

Improved care coordination with medical and allied health professionals

The key functions of the Frailty Unit are:

Providing frail older people with a dedicated space and Multi-Disciplinary Team (MDT) at the front door to speedily provide specialist care to patients requiring urgent comprehensive geriatric assessment.

Dedicated consultant-led assessment with access to therapy, and Community In reach Service and older person’s specialised nurses, pharmacists and allied health practitioners.

Access to rapid diagnostic tests and other medical and surgical specialities.

Access to community services and pathways.

Work closely with the Nurse Navigator care provision framework.

4.2.2 The GEM Unit

Geriatric Evaluation and Management (GEM) is care in which the primary clinical purpose or treatment goal is improvement in the functioning of a patient with multi-dimensional needs associated with medical conditions relating to ageing, such as tendency to fall, incontinence, reduced mobility and cognitive impairment. The patient may also have complex psychosocial problems. The unit is a patient-centred, interdisciplinary team based model of care which encourages patient participation from admission to discharge to achieve their desired outcomes. This unit has an emphasis on maintaining a patient’s level of independent functioning, muscle strength and independence while in hospital to help them to return home quickly. Discharge planning, including liaison and referral with general practitioners, and other community support services, occurs soon after admission.

The GEM Unit aims to:

Assist older person to discharge with a coordinated interdisciplinary approach to the destination of their choice safely and efficiently

Provide coordinated, detailed and relevant interdisciplinary discharge planning

Prevent premature admission to a residential facility

Prevent readmission to hospital

Reduce unnecessary length of stay in an acute setting

Provide evidence based assessment and management

Provide skilled staff in the care of the older person.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Involve the older persons and their carers in all phases of their care and support them in navigation of the Aged Care system

Establish a detailed understanding of local resources for the support of older persons.

Provide information, advice and support to families and carers in the care of the older person

Ensure timely discharge and a safe return to a community based setting if able, with the support of other key stakeholders as relevant

Assist families in the preparation of transfer to residential age care facility if required.

The key functions of the GEM Unit are:

Provide a supportive time limited intervention within an environment where staff are perceptive to the needs of the older person

To take direct admission from acute wards, Emergency Department and direct community referral for further comprehensive Interdisciplinary assessment and management of Geriatric syndrome e.g. Falls, continence and cognitive impairment

Encourage the older person to maintain function and promote quality of life through a goal therapy Interdisciplinary program with the aim to discharge to their destination of choice.

Interdisciplinary coordinated discharge planning

Assist the older person to return to community living with additional supports where possible

Facilitate a smooth transition to appropriate services.

Liaise with relevant community and residential services according to patients needs.

Identify the goals of presentation that are important to the patient and/or carers

Provide priority step down to NRNC Interim Care beds

4.3 Patient Type

Patients generally over the age of 65 with common geriatric syndromes / conditions are expected to be admitted to the Acute Care of the Elderly unit and include:

impaired cognition

high falls risk

continence issues

polypharmacy

frailty

functional decline

depression

non-cancer palliation

complex health care management

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Patients should meet the following eligibility criteria for the Acute Care of the Elderly unit:

Must be over the age of 65 year (50 years for indigenous) or:

o Have younger onset dementia

o Have geriatric syndromes under the age 65 years

Require specialist geriatric assessment

Require further investigations for geriatric syndromes

Require complex discharge planning

Are not safe to be discharged home without further support or frailty intervention

Requires assessment of function ADL’s and IADL’s

Patients not suitable for the Acute Care of the Elderly unit would include:

Patients who need or may need cardiac monitoring

Sepsis

Seizures

GI bleeds

Patients who are haemodynamically unstable

Patients requiring oxygen administration (since admission)

Patients only requiring an increase in community service packages (no acute issue)

Acute psychiatric event

Failed medical discharge

5 Service Processes

5.1 Referral process

The objective of the process of admission is to identify and transfer the older person as quickly as possible to the Acute Care of the Elderly Unit, to avoid unnecessary movement between wards and unnecessary delays to the older person receiving specialised care and assessment. Referral to the Frailty unit occurs directly from:

- Emergency Department

- QAS

- CHAIS team

- Acute Inpatient Wards

- General Practitioners

- Outpatients

This referral pathway enables patients to be fast-tracked to the Frailty unit for a comprehensive assessment and treatment plan development. Patient criteria for referral to the Frailty unit includes:

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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- Patients with complex needs requiring rapid comprehensive geriatric assessment and management plan.

- Patients who cannot wait for an outpatient appointment and need rapid access to more extensive diagnostic test and follow on management.

- Patients with exacerbation of chronic conditions requiring rapid investigation and treatment in order to avoid admission e.g. chronic mobility problems, falls, heart failure, dementia.

- Complex, older patients who are frequent attendees to GP surgeries or ED.

- Patients who require up to 24hrs for assessment and diagnosis.

Referrals to the GEM Unit will primarily occur from:

- The Frailty unit

- Acute inpatient wards

Patients may also be identified by the Sub-Acute Flying Evaluation (SAFE) Team:

- At the point of admission through linkages in the Emergency department (EDIS referral to Nurse Practitioner, Clinical Nurse cognition, Complex Care coordinator)

- Through attending daily discharge planning meetings on ward

- Through following identified patients on the wards

- Notified of potential patients being transferred to hospital from the community

- Through potential community referrals

The CN SAFE will monitor and liaise daily with the In-reach services and the medical team who has been assigned to the patient. As soon as the person has been identified as medically stable the CN SAFE/ CHAIS organises a referral to the Acute Care of the Elderly unit and will arrange to attend an initial assessment with the Geriatrician/medical officer to assess eligibility / suitability for Acute Care of the Elderly unit.

5.2 Frailty Out of Hours & Weekends

Medical consultant or registrars can admit directly to the Frailty Unit pending review of exclusion criteria and frailty maximum capacity. This will be managed by the Acute Care of the Elderly Unit Shift Co-ordinator out of hours with referral from the Medical consultant and Registrar only. Any referral suggested by any junior doctor or duty nurse manager must be reviewed first. Patients to be admitted to the Frailty Unit out-of-hours (i.e. 5pm – 9am Monday - Friday and weekends) who have been accepted by the ED registrar or consultant must have clerking completed by Emergency Department and Duty Nurse Manager contacted to update Frailty unit capacity.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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5.3 Patient Flow

The following outlines the anticipated patient pathway for the Frailty Unit:

Referral received through ED, GP, CHAIS team, or SAFE team

Referral accepted by Geriatrician and CN SAFE Team based on Frailty Score and entry criteria

Patient transferred to Frailty unit (with assessment by SAFE and/or CHAIS) based on bed availability

Patient assessed by multi-disciplinary team

Plan established and documented to facilitate discharge within 48hrs

If a longer patient admission is required, the GEM patient pathway will be followed

Referrals will be made to the acute medical teams for review where a patient requires acute medical input

The following outlines the anticipated patient pathway for the GEM Unit:

Collateral information is obtained from the referral source, initial assessment by the Geriatrician/ medical officer and clinical nurse coordinator Sub-Acute Flying Evaluation Team (SAFE), and discharge, from the patient, the patient’s family and other agencies.

On commencement of the GEM episode the patient is SNAPed

The patient once admitted to the unit is assessed by the interdisciplinary team according to clinical need. A FIM is completed within 72 hours of the commencement of the GEM episode.

Individual plans are developed, relative to the patients’ deficits and potential capacity to improve, at the interdisciplinary Case Conference and or patient centred care planning.

Patient goals are established at commencement of the GEM episode and documented in the medical chart

Patients discharge destination is established at initial case conference***

Continuity of care is discussed and planned at the weekly case conference.

Daily scheduled meeting with interdisciplinary team updates each patients progress

Patient specific interventions are implemented by the interdisciplinary members with the goal of achieving optimal function, health and well being

Therapeutic interventions in a group setting are offered where group dynamics are shown to be more efficacious to successful outcomes and for service delivery efficiency

Progress on the individual care plan is reviewed by the interdisciplinary team each week at case conference

When it is collectively agreed that a patient’s improvement has plateaued or is at baseline, options for discharge are considered (as per ***).

Care planning involves discussions with the patient, the patients’ family/carer, community agencies that are already involved or could potentially enable the patient to be discharged into the community.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Daily interdisciplinary meetings will assist with communication and scheduling of therapy program and care. Board rounds will be held daily during a patient’s admission to assess their progress and ability for discharge.

5.4 Discharge process

Coordinated discharge planning from commencement of assessment will result in a smooth discharge to destination of choice with the required support to prevent or reduce episodes of readmission to hospital. Providing immediate discharge summary to ongoing care providers will assist in the continuity of care.

Discharge pathways for Frailty Unit:

Discharge home without formal community supports Discharge home with formal community supports HITH Transfer to GEM Unit TCP Transfer/Discharge to Rehabilitation (either inpatient rehabilitation under care of the

hospital or as part of community rehabilitation pathways under the care of the local teams) Discharge pathways for GEM Unit:

Discharge home without formal community supports

Discharge home with formal community supports

Discharge to alternative accommodation in the community

Discharge to a Transition Care Program

Discharge to a residential aged care facility

5.5 The Team

5.5.1 Medical

The Medical team is comprised of:

- Consultant Geriatrician

- Principal House Officer

- Resident Medical Officer

Medical staff are responsible for the admission of patients into the Acute Care of the Elderly unit, and the overall clinical / medical decision-making for the patients’ care which includes:

Initial medical intake assessment

Completing episode of care change form indicating care type (ie SNAPing)

Medical history taking

Medical treatment planning

Request for diagnostic investigations

Prescription of medications

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Ongoing responsibility for medical management including referral to other medical specialties as required

Ongoing discussion with patient (if able) or their statutory health attorney about treatment options, about risks of treatment and procedures, and obtaining informed consent.

Coordination of discharge decision-making process

Specific Consultant Duties

Responsible for the Frailty and GEM Beds

Responsible for the Acute Care of the Elderly Team

Clinically responsible for the patients admitted to the Frailty and GEM Beds

Liaise with administrative and nursing staff to make arrangement for the receipt of patients and patient discharge.

Lead MDT ward rounds daily Monday – Friday mornings

Review all patients results each afternoon to advise on care plan.

Specific Junior Doctor Duties

Complete a comprehensive geriatric assessment collaboratively with the members of the MDT team which would include a comprehensive history, drug review and examination.

If more relevant history needs to be obtained from the GP or the patient’s next of kin, the team will contact these individuals for further information.

Decision regarding the appropriate investigations will be discussed with the consultant

Any abnormal test result will be flagged up and discussed with the consultant for appropriate action.

After review by the consultant, a management plan will be established and this will then be summarized by the junior doctor, a discharge summary prepared. The patient discharge summary will be communicated back to the GP and appropriate specialties.

5.5.1.1 Projected Medical staff profile

Geriatrician 1.0 FTE

Registrars 1.0 FTE

Resident Medical Officers 1.0 FTE

Intern (when accredited) 1.0 FTE

5.5.2 Nursing

The Nursing team is comprised of:

- Nurse Unit Manager

- Clinical Nurse Coordinator Sub-Acute Flying Evaluation Team (SAFE CN)

- Clinical Nurse (CHAIS and ward-based)

- Registered Nurse

- Enrolled Nurse (Medication Endorsed)

- Assistant in Nursing

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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The Acute Care of the Elderly unit will have a nursing skill mix of registered staff and unregulated workers. Nursing staff are responsible for providing a continuity of care which is attained through assessment, individualised patient care planning implementation of care and evaluation. The aim is to maximise restoration and decrease functional decline leading to the return of the person to the community or facilitate placement in a residential care facility.

Specific Nursing Duties

Greet Frailty Unit patient on arriving in Frailty bed space.

Attend the 8.30am daily board round, to establish plans for patients.

Complete nursing assessment form ensuring the following observations have been done:

- Heart rate, respiratory rate, oxygen saturation, temperature

- Blood pressure – lying and standing at 1 minute, 3 minutes and 5 minutes

- Weight and height

- Urine dipstick

- Electro-cardiogram

- Body Mass Index

- Blood glucose monitoring

Ensure patient has brought medication with them and prompt timely administration as appropriate.

Take bloods.

Any observation abnormalities must be documented and escalated to appropriate senior nurse and Frailty team

Ensure throughout patient stay the patient has appropriate food and drink – ensure orders for lunch are placed in time with the ward catering team.

Ensure patient is comfortable and offered toilet facilities regularly.

Update patient regularly on the progress of their investigations and the processes taking place.

To be available to answer any questions patients or relatives may have in relation to their stay within the unit or refer to the Frailty team for further clarification or information.

Work with Frailty team and administration staff to ensure transport is booked for home journey, and carers/care agency is suitably informed of estimated arrival of patient at their home address.

Medication provision if appropriate for scripts etc.

Ensure as patient leaves hospital that all necessary paperwork is in their possession.

5.5.2.1 Projected Nursing staff profile: (See Attached HPDDS and Roster Coster)

Notational Ratios Registered Staff:

Early Shift 1:4

Late Shift 1:4

Night Shift 1:7

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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5.5.3 Allied Health Team

The Allied Health team is comprised of:

- Physiotherapy

- Occupational Therapy

- Social Work

- Speech Pathology

- Dietitian

- Pharmacy

- Podiatry

- Psychology

- Allied health assistant

- Pharmacy assistant

The allied health team are responsible for providing individual patients assessments and care planning in their field of expertise whilst encouraging a patient centred approach. The aim is to maximise restoration and decrease functional decline leading to the return of the person to the community or facilitate placement in a residential care facility. This may include home assessments conducted by relevant allied health professionals.

Specific Therapy Duties

All patients screened to establish therapy needs between 10.00am and 1.00pm

Attend the daily board round

All patients identified of requiring therapy input goals and care plan developed and communicated to Frailty Team.

Liaise with patient family, Social Services, rehabilitation units and other community services as required.

Commence patient therapy on the unit as soon as possible.

Specific Pharmacy Duties

Review patients on admission. Liaise with primary care providers/nursing homes/family

Obtain and document best possible medication history

Screen for ADR’s and medication related contributors to patient deterioration and add to the patient’s plan.

Support the appropriate use of Therapeutic drug monitoring in the delivery of patient care.

Recommend, where appropriate, changes in therapy to support the patient’s goals of treatment, including the deprescribing of medications that no longer support the current care plan.

Support the education of patients and carers in the correct use of the medications.

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Supply or facilitate the supply of new medications.

Produce discharge medication records for patients.

Assist with communication with GPs, community pharmacies and residential facilities on discharge.

5.5.3.1 Projected Allied Health Staffing profile

Allied Health staffing profile will be based on patient care requirements and service demand. s part of the Allied Health Re-alignment, there is now the opportunity to provide a flexible and sustainable allied health workforce that are able to provide services based on clinical demand.

5.5.4 Operational Service Officer Resource Allocation

Operational Staff are managed under Rockhampton Hospital are allocated according to Daniel’s methodology whereby staffing numbers are assigned according to bed number and floor space.

5.5.5 Administration Officer Resource Allocation

Administration staff are resourced to provide administration support to both patients and staff for inpatient and outpatient functions.

6 Data Measures

Process Measures:

Number of patients reviewed

Source of referral

Clinical interventions, including:

Diagnostic tests

Onward referrals

Specialty advice during stay

Other interventions

Discharge destination

Patient experience

Yearly audit for GP feedback

Rate of Hospital Acquired Complications

ALOS

Balancing Measures:

Clinical incidents associated with the service

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Appendix A - Example of Frailty Screening Tool

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Appendix B - Example of Frailty Initial Screening Questionnaire

Central Queensland Hospital and Health Service Level 5 NWB – Frailty and GEM

Model of Care – Level 5 NWB Version: 0.3 | 21 February 2019 | Document owner: James Jenkins

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Appendix C – Example of nurse data collection