1. Department of Health Nicole Doran Ambulatory and Coordinated Care Department of Health November 2009 Transition Care Program: Victorian Update Improving care for older people

2. Overview Policy directions –NPA:Sub-acute –COAG Long Stay Older Patients’ Initiative –Sub-acute Services Planning Framework –HIP Guidelines –Right care/Right time/Right place –FIM across Rehab, GEM and Restorative Care Improved pathways and models of care –Acute GEM –Restorative Care –Residential In Reach –HARP: Better care for older people (HARP BCOP) Innovative resources –Best care for older people everywhere: The toolkit

3. Sub-acute Planning Framework

4. What drives demand?

5. Forecasting for Sub-acute Services

6. Sub-acute Service System Sub-acute bed based services Rehabilitation (adult and paediatric) Geriatric Evaluation and Management/Restorative Care 41 facilities – 23 in metro/18 rural region Over 1800 beds 50% rehabilitation and 50% GEM 75% in metro/25% in rural regions Substitution and diversion services Hospital in the Home Post Acute Care Sub-acute Ambulatory Care Services Chronic and Complex Care Services: HARP, Family Choice Program, Victorian Respiratory Support Service Transition Care Program Facility and Home based packages

7. Integrated guidelines Enable better client journey across the care continuum Patient flow unhampered by program boundaries Right care, right place, right time

8. Impact of ageing on acute care People over 85 years will increase from 1.6% of the population to around 5 – 7% In the next 20 years 50 % of acute care beddays will be used for patients over 70 years Patients over 85 years will utilise 14.5 % of the acute care beddays

9. The people who use or service: Our patients are older and frailer 52% of people admitted to sub-acute services are 80 years or older 40% patients in rehabilitation are >80 Frailer on admission and discharge

10. Older people use hospitals differently More complex needs Multiple diagnoses Increased risk areas

11. Sub-acute and Residential Aged care Access Indicator Project 1. Number of patients within the health service (acute & subacute beds) awaiting a residential care or TCP placement. An indicator to reflect patient flow 2. Average inpatient length of stay (LOS) in subacute care per month An indicator to reflect efficiency 3a) Average Admission Barthel score per month b) Average discharge Barthel score per month c) Average Barthel improvement per day An indicator to reflect effectiveness, complexity and measure improvement but not necessarily access 4. Formal separations per subacute bed per month An indicator to measure efficiency 5. Number of subacute referrals accepted per bed per month An indicator to reflect the demand on the system 6. Number of people in acute beds waiting for subacute beds An indicator to reflect patient flow

12. Geriatric medicine patient journey Usual care pathway: 57 inpatient days Better care pathway: 14 inpatient days A cute Inpatient 25 days Sub-acute Inpatient (GEM) 35 days Transition Care Program 56 days at home ED GEM Plus 14 days APU

13. Residential Aged Care journey Usual care pathway: 57 inpatient days Better care pathway: HITH/HARP In reach A cute Inpatient 25 days Sub-acute Inpatient (GEM) 35 days ED 20 hrs RACS HITH or HARP In-reach

14. Resources to support improved care

15. Move to Functional Improvement Measure (FIM) Health service driven revisions to VAED to incorporate FIM measures Movement away from data based on diagnosis/acute focus, to patient focus GEM uses Barthel Index, move to FIM to align service reporting Incorporate measures of frailty

16. What will we achieve Improved access and equity of services Improved consistency of service quality Better patient journeys Avoidance of unnecessary hospital admissions Prevention of functional decline Minimised long term care needs Avoidance of premature entry into RACS Better patient experience