CHAPTER 24 Innovative responses to a changing health care environment
FRAMEWORK
All recent government reports acknowledge the need for innovative approaches to the practice and education of health practitioners; these issues are addressed here along with the ageing workforce. The issue of access for older people and health professionals who live in rural areas is raised and different approaches to meeting their needs used by the authors are described in the vignettes. These models will be closely watched for application to other sites. [RN, SG]
Changes in demand
There have been, and continue to be, enormous changes in the health care environment and health care demands. There are several factors that contribute to increased demands. Consumers have a higher expectation of service, of effective health outcomes, and are expecting increased participation and engagement in their own care and the care of their families. Fast declining, except perhaps amongst the old-old, are the days of meekly responding ‘yes, doctor’ or ‘yes, nurse’. Expectations, fuelled in part by general societal changes, are underpinned by more accessible information (often Web-based), formation of disease-focused associations, and a steady flow of information in newsprint. Consequent upon the information explosion and broad availability of health information we have a much more informed public; we know knowledge is power, and so a better informed consumer results in higher expectations. Although there is little evidence to substantiate it, the fear of litigation and loss of reputation has driven a concomitant aversion to risk and attention to risk management.
There have been, and continue to be, enormous changes in the health care environment and health care demands.As noted elsewhere in this book, health professionals and organisations are required to base clinical practice on the best available evidence and to embed clinical governance, consumer participation in health care decisions, and continuous quality improvements (Muir Grey 2001; Pickering & Thompson 2003; Swage 2003). The ageing of the population, predominantly through the reduction in infant, child and to a lesser extent young adult mortality and public health care measures, has seen the major burden of disease now coming from chronic disease and disability. The major disease burdens as published in 2005 are:
(Australian Health Workforce Advisory Committee, Australian Medical Workforce Advisory Committee and
People over 65 years of age represent 13% of the Australian population yet occupy more than 47% of public hospital beds (Gray et al 2004). The ageing of the population will continue to increase the demand for health services at a time when health providers are under increasing funding pressures. Community demand and health care costs led to an emphasis away from care in acute hospitals towards more self and supported care in the community. Older people are likely to have comorbid conditions, many of which will reduce functional ability, but with appropriate services independence may be preserved.
This major shift in type and place of service delivery requires a major rethink in how services are delivered, who should deliver them, and what skills are required (Russell 2007). Numerous reviews and innovative programs have been funded to address workforce issues, reduce admission to hospital, shorten the length of stay, and prevent readmission (for examples, see Department of Human Services [DHS] 2007; Struber 2004). While creative solutions should accommodate the present, more visionary planning focused on the future is needed. It will take at least 10 years to bring about any major change as educational institutions will also need to incorporate industry expectations into curriculum.
This major shift in type and place of service delivery requires a major rethink in how services are delivered, who should deliver them, and what skills are required.Information and assistive technologies have changed the way we do business generally, caused workforce reengineering, and aided in the independence of many individuals who previously depended on high levels of support (see Chapter 23). New technologies constantly arrive on the market and although expectations often exceed reality, inevitably they will enable even more social participation and independence for future generations.
Changes in supply
The literature leaves no doubt that workforce shortages are a current reality internationally and will worsen as the baby boomers retire (McGrath et al 2006; Struber 2004; Weller 2006; World Health Organization [WHO] 2006). Medicine, nursing and most areas of allied health are reporting demand exceeding supply, especially in rural areas. While demand is increasing because of the bulge in the population of older people and expected increase in the old-old, the relatively smaller populations of generations X and Y equals demand outstripping supply. Additionally, the feminisation of the medical workforce has been associated with more part-time workforce participation and some literature suggests that generations X and Y are more interested in lifestyle balance than previous generations — again reducing available full-time health professionals. This is likely to be particularly important in the case of males where a small percentage reduction in anticipated hours will have a significant effect. The increasing average age of the health workforce also suggests a looming crisis as the baby boomers retire unless incentives and workforce redesign makes working more attractive!
The literature leaves no doubt that workforce shortages are a current reality internationally and will worsen as the baby boomers retire.
The increasing average age of the health workforce also suggests a looming crisis as the baby boomers retire.Innovation in care of older people
Innovation in care of older people is not a new concept. In the 1930s Dr Marjorie Warren, a medical officer at the West Middlesex Infirmary, was given the responsibility for the care of 714 chronically ill patients at the nearby Poor Law Infirmary. She created the first geriatric medical unit in the United Kingdom, instituting medical treatment, rehabilitation and discharge planning for a previously neglected population. She was able to increase the turnover three times the previous rate and reduce the need for chronic beds to 240 (Barton & Mulley 2003).
In 1979, Rubenstein and colleagues established an inpatient unit to provide diagnosis, rehabilitation and discharge planning for older hospital inpatients at high risk of nursing home discharge. Patients treated in this unit had a one year mortality rate of 23.8% compared with 48.3% for those who had received usual care, in addition to lower rates of nursing home discharge (26.7% versus 26.9%) (Rubenstein et al 1984). A meta-analysis of 28 randomised controlled trials involving 9871 subjects confirmed the reduction in institutional admission and mortality at 6 months for patients who had undergone comprehensive geriatric assessment (Stuck et al 1993). Other innovative approaches have included specialist inpatient units for older people including ortho-geriatric units and acute care units. Community Aged Care Assessment Teams now cover the whole of Australia, providing assessment of the accommodation and care needs of older and disabled people in their own homes. Specialist outpatient services have been developed including memory clinics, continence clinics, falls and balance clinics, pain clinics and wound clinics.
A meta-analysis of 28 randomised controlled trials involving 9871 subjects confirmed the reduction in institutional admission and mortality at 6 months for patients who had undergone comprehensive geriatric assessment.About one-third of Australians aged more than 65 years live in rural areas, including outer regional (86%), remote (10%) and very remote (4%) sites (Davis & Bartlett 2008). People over 65 years in Australia make up 12.3% of people in major cities, 14.1% in inner regional areas, 12.8% in outer regional areas, 9.7% in remote areas and 7.7% in very remote sites (Larson 2006). Older adults from rural areas are typified by self-reliance, stoicism, hardiness and a preference for informal networks and accordingly have less frequent use of, and delays in using, health services. Increased geographical distances to access services and decreased use of health services combine to exacerbate risk for disease already increased by excess weight, smoking, drinking and occupational and environmental dangers inherent in rural areas (Davis & Bartlett 2008).
People living in rural regions frequently endure a lack of health services and insufficient community and economic resources compared to their urban counterparts and the criteria for service provision derived from urban settings fail to meet the needs of rural older people (see Chapter 4). Providers of aged care health services in rural areas need to have awareness of the structure and operation of rural aged care and the special needs of older people in rural areas, such as transport (Davis & Bartlett 2008). For example, older women in rural areas are less likely to consult general practitioners, specialists and allied health professionals despite similar quality of life and disabilities compared with urban older women. This is associated with higher rates of hospitalisation and greater use of community and respite services (Byles et al 2006).
There is now established evidence that comprehensive geriatric medical assessment backed up by specialised geriatric services can provide better management and outcomes for frail older individuals (Dainty 2007). The resources to provide such services are scarce in smaller or more rural communities where practitioners need to garner a wide range of interdisciplinary skills, particularly when the service system is fragmented into different sectors, agencies and institutions, none of which can provide the specialised focus that this segment of the population needs (Crilly et al 1999).
VIGNETTE 1
A mentorship approach to geriatric medical specialty training and workforce issues in rural Australia
The role of the mentors was primarily to sponsor and support the self-education of the GP. Fortnightly visits were undertaken by the specialist geriatricians from Sydney for 18 months to provide support in the following four areas: mentorship, education, service delivery and service planning. There was a strong focus on evidence-based practice as it applies to aged care (Nay & Fetherstonhaugh 2007). The visiting academic specialists performed ward rounds and consultation rounds with the local practitioner providing an apprenticeship approach to patient care. Between visits, phone/email advice on a range of geriatric issues or complex community consultations was available.
In addition, the geriatricians and GP provided learning materials and sponsorship to attend tertiary geriatric medical services. The staff and students received a one-hour lecture on aged care issues, such as falls, dementia, delirium, incontinence, polypharmacy, palliative care, pressure care and so forth, following established geriatric medical curricula (Le Couteur 1996). Educational activities were undertaken in the acute hospital wards and residential care facilities on a variety of aged care issues. The presence of outside external specialists in the field was felt to be important for the promotion of aged care in the community, and in providing alternative perspectives on local service delivery. To this end, the visiting specialists were involved on various aged care advisory committees (Graffen et al 2005).
The satisfaction with this model by the medical practitioners and the Area Health Service was deemed to be very high. Those involved in the mentorship program felt that this model was worthy of dissemination and implementation in other regional areas, where there is a lack of specialist geriatricians and little likelihood that such geriatricians will be available in the foreseeable future. In addition, it could be adapted for other sub-specialty medical areas; for example palliative care, sexual health, and women’s health could also be used in a modified format for allied health specialties (Graffen et al 2005).
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