1. ACAT Referral Mechanisms Liverpool/ Fairfield Aged Care Assessment Team Rozina Shekhar CNC Community Aged Care

2. Why Change?? Why be bothered

3. ACAT Referral Mechanisms ACAT referrals are typically for clients aged 65 years and over. More than 80% of these referrals will have a chronic illness Those aged 75 years and over will typically have 3 or more chronic conditions i.e. - congestive cardiac disease, obstructive pulmonary disease, renal disease, degenerative arthropathy, stroke, psycho-geriatric conditions. Background

4. ACAT Referral Mechanisms The elderly population is particularly vulnerable to acute illness and its atypical presentation, which is often masked by existing co-morbid chronic conditions. Background Literature shows: There is evidence that confusional states and geriatric syndromes are generally not well identified by GPs and health professionals.

5. ACAT Referral Mechanisms Early identification of reversible illness at the point of referral offers a more positive outcome for acute illness with early intervention. RACF(Residential Aged Care Facilities) population profiles have changed with an increased incidence of acute illness, shorter lengths of stay and behavioural problems. With current and future increases in the elderly population there is a need to improve models of ACAT referrals. Background

6. ACAT Referral Mechanisms Background The importance of using clinical staff at the point of referral to ensure a more comprehensive history of the presentation and therefore a more accurate prioritisation of the client. Intake is viewed as the beginning of a comprehensive assessment rather than a collection of demographic data

7. DEMOGRAPHICS Estimated Population Projections Age 65+ SWSAHS NSW Health Interim Projections June 2003

8. Benefits of Improved Referral Mechanisms Health professionals are usually the first contact and referral source for ACAT clients.Therefore the use of improved referral mechanisms offers the following benefits: Improved early identification and treatment of reversible pathology e.g delirium or complex dementias. Enhanced links between ACAT, G.P.s, health professionals and RACF. Improved management of acute and chronic illness with reduced morbity/ mortality and improved functional status.

9. General Principles of Referral Process Use of self rostering by all ACAT,ASET,Rehab and PHST clinical staff for intake 2,½ Days Month. Use of ACE and PASS data bases to screen all referrals to eliminate duplication and identify recent presentations to hospital etc. Intake meeting attended daily by all staff to ensure multi disciplinary approach to case management.

10. General Principles of Referral Process Referrals presented to team at intake by clinician that took the referral the previous day. Allocation of case manager/s at intake meeting giving early allocation and contact clinician. Letter of service acceptance mailed to client and G.P.

11. General Principles Use of validated tools with the intake pro-forma: CAM scale to identify acute confusion from chronic confusion. One question GDS for depression. Series of questions to identify changes in health and physical function i.e. geriatric syndromes.

12. intake pro-forma

13. General Principles Recent(draft) development of a priority risk assessment questionnaire to prioritise clients assessment times i.e. within 48hrs, between 3 and 14 days and more than 14 days. To increase efficiency and accuracy of referrals the following additional referral forms were developed:

14. General Principles A GP referral form Sent and returned via fax from the intake clinician. It encourages the addition of Medical Director reports and current path results (when appropriate). It may also act as a prompt to attend pathology/ review client.

15. General Principles Further enhancement to our referral process is the use of a GP letter that informs them of : Reason for referral. Case managers contact details. Geriatricians secretary contact if GP wants to discuss referral with Geriatrician on call.

16. General Principles It also requests the following as the start of the assessment Medical History Medication History Request for (dependant on presentation/Hx) -Organic screen -CT Scan of head -ECG/CXR Further enhancement to our referral process is the use of a GP letter cont’d :

18. General Principles Development of a Residential Aged Care Facility (RACF) referral form that incorporates validated assessment tools used by ACAT. It has advantages for low to high assessments and identifying acute and difficult behaviour presentations. A brief overview: Consider if acute or chronic presentation and involve GP in assessment.

19. General Principles Encourage the use of organic screen and physical assessment if acute illness is suspected. All clients referred by RACF must have been seen by GP within the last 2 months. Brief over view of presenting problems. Physical assessment including temp, pulse L/S BP and Resps. Residential Aged Care Facility (RACF) referral form cont’d

20. General Principles Measurement of functional decline with use of pre morbid and morbid Barthels ADL index. BEHAVE-AD Scale (modified) to identify problem behaviours and impact on care and carers. Confusion Assessment Method (CAM) to identify delirium (Acute confusion). This form is faxed on request for referral with most facilities now using a master copy for future referrals. Residential Aged Care Facility (RACF) referral form cont’d

21. General Principles EACH and CACP referral pro-forma Consider if acute or chronic presentation and involve GP in assessment. Brief over view of presenting problems. Medical Hx Social and Personal Hx Carer Hx Functional profile -Falls, weight loss, sensory impairment, continence

22. General Principles EACH and CACP referral pro-forma cont’d Lawton IADL measure Measurement of functional decline with use of pre morbid and morbid Barthels ADL index. Confusion Assessment Method (CAM) to identify delirium (Acute confusion). Premorbid and morbid behaviour changes This form is faxed on request for referral by service providers.

23. General Principles The clinical history and information is then reviewed at the following intake meeting. This identifies : If acute or chronic presentation. Priority for intervention i.e. admission to hospital or A&E presentation with ASET involvement or -Rapid ACAT R.N response to referral. -Acute or normal home visit with or without a doctor. -Acute clinic. Identifies best use of multi disciplinary case management with the information available.

24. Outcomes G.P.s better able identify and intervene with initial management prior to ACAT attending. More accurate prioritisation of clients. Screening of inappropriate referrals with clinicians taking referrals. A multidisciplinary approach taken from initial intake/ point of referral.

25. Outcomes Increased communication between GPs, RACF and ACAT. More accurate clinical information prior to attending clinics etc. Intervention commences at a much earlier stage ensuring a better outcome for the client.