Culture trumps everything: The (un)expected truth about building a frailty team across the continuum for a vulnerable population

摘要

Introduction : Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet few intervention studies have addressed the specific care needs of this vulnerable, high-risk population. This paper presents Mater Aged Care in an Emergency (MACIAE), a service dedicated to supporting aged care facility residents, their families, facility carers and GPs, with the goal of providing a seamless care transition in order to ensure the highest and safest standard of care with the upmost compassion and dignity. The program was designed with patients and families/ carers, ACFs, local general practices, Primary Health Networks, ambulance services, hospital providers and researchers. Methods : The study was implemented 2013-2016. All older adults presenting from ACFs to the ED of Mater Hospital Brisbane, Australia were included. The evaluation was a pre/post design using retrospective baseline data from hospital records, and prospectively collected post-implementation data. The objectives were to determine whether this intervention significantly impacted on patient outcomes and organisational outcomes. Ethics approval for the study was obtained through the Mater Research Ethics Committee. Results : This study demonstrates the significant improvements can be achieved by a specific aged care service working across the continuum. Participants (n=1130) were from over 200 ACFs. Intervention resulted in 30% drop ward admissions; reduced LOS from 6.5 to 4.0 days (national average 8.0 days); reduced 28-day representation rates from 17.8% to 4.6%; 88% of patients commenced on an End of Life pathway were able to be transferred to their environment of preference; and, there were over 300 Advanced Care Plans implemented. Satisfaction from acute, primary care and ACF providers was very high. A cost-benefit analysis demonstrated a 10:1 outcome. Discussion : This study demonstrates significant improvements were achieved by integration of an acute frail older person service into an ED, which works with families, primary health and social care to implement strategies to meet the needs of this population. Lessons learnt : Key to implementing and sustaining this model of integrating care are leadership; culture – it makes or breaks it; time – it takes longer than you think; data - speaks louder than words; and, passion - to keep you going through the tough times. Limitations : The present study involved a pre-post implementation study design, therefore we cannot speculate whether or not our results were entirely due to the MACIAE service implementation. Future studies should consider implementation of a Randomised Controlled Trial. We also note that this study was implemented in only one hospital. Suggestions for future research : In January 2018, the Older Person Centred Care Team formed, merging three existing teams, focused on managing frail and older patients and families/carers across the continuum. Current research is focused on rapid assessment of frailty, embedding a case management approach to support care closer to home and involving patients/ families/ carers in decisions about a model that meets their future needs.