Rest home in the home

1 July 2013

Canterbury quakes saw Christchurch lose more than 650 residential care beds. One response was TotalCare – a collaborative approach led by community-based Nurse Maude to offer residential care in the home. Nursing Review reports on Sheree East’s recent presentation on the scheme to the Home Health Association conference.

February 22 2011 saw some rest homes turn into sand pits and others left cracked, broken, and unlivable.

In all, eight rest homes were forced to close by the February and early September earthquake, leading to more than 650 residential care beds being lost from the city. The hospital also lost beds, creating pressure on where and how to care for the city’s vulnerable elderly.

Sheree East, director of nursing for Nurse Maude, says one response by the region was the development of TotalCare – a ‘stay at home’ alternative to clients who would otherwise require admission to residential care. Nurse Maude is also involved in the CREST (Community Rehabilitation & Enablement Support Team) scheme, which is another Canterbury older person’s health response to the quake but focusing specifically on offering elderly patients intensive interdisciplinary support in the home on being discharged from hospital and also to prevent avoidable hospital admissions.

TotalCare was modelled on Waikato’s Community First programme and funded Nurse Maude, which has been providing community health care to Christchurch for 115 years, to deliver suitable clients a high and complex care service in their home.

East reports that the results for the nearly 70 clients to date who have been part of TotalCare have been positive, with the number of emergency department presentations by clients halved since before TotalCare and reduced hospital admission stays.

East says there were overall high levels of satisfaction reported by patients and their ‘significant others’, though patients were more satisfied than their ‘significant others’, who expressed a desire to be more involved and engaged in the delivery of the care.

But generally, she says, “families love it and clients want it”. It has led to “excellent outcomes of care” and allowed couples to stay together in their own home. It has also been positive for the workforce involved, with the registered nurses gaining increased case management experience and familiarity with the Omaha System for documentation and a new IT system. In addition, the enrolled nurses involved were new graduates who were mentored, gained orientation to residential care, and got to put new competencies to use.

East says the scheme extends the role of community-based services but it also requires “full engagement and agreement across service providers”.

Patients were referred by a clinical assessor or social worker from Canterbury District Health Board’s Older Persons Health Service and an interRAI patient assessment sent to the TotalCare team. The team’s registered nurse co-coordinator attends a client assessment with the clinical assessor and there are family conferences and discussion with the patient’s general practice to establish relationships before the client is transferred to TotalCare.

Nurse Maude has two TotalCare teams – each led by an RN coordinator and each providing care for up to 35 TotalCare clients. Each team also has an enrolled nurse and there were about 22 full time equivalent (FTE) support workers across the two teams. Occupational therapy and physiotherapy support were also available, plus on-call nursing support, monitoring, and interface with the local St Johns Ambulance service and support of the other Nurse Maude community health services.

Sixty-one per cent of TotalCare clients were aged 85 years or older, half lived alone, and the majority owned their own home.

They had a range of health and care needs with more than half (55 per cent) at high risk of developing pressure sores, the vast majority were at risk of falling, more than half (56 per cent) had a cognitive disability, and three-quarters had continence issues, and about a quarter were classified as being independent on admission to the scheme.

The vast majority needed help with their personal care (90 per cent) and more than two-third with their medication regime (as the majority had eight or more medications prescribed), their health care supervision, continence, and nutrition.

In all, the nearly 70 patients received nearly 4000 registered nurse interventions (categorised under the Omaha System) with the most common being to address physical symptoms or for wound care. Other interventions included medication administration or co-ordination, general nursing care, communication, and bladder care.

TotalCare feedback from family and patients

“This service has been great for my aunt as prior to this she ended up in hospital every 3–4 months, but since she has been under the TotalCare service, she hasn’t had any admissions in over a year! She really wants to be in her own home, so it is perfect.”

“Marvelous service – grateful. Absolutely fabulous for my age group. I’m hard to please. Like place nice – so this service achieves that. Like independence – don’t like to be ‘taken over’.”

“No suggestions for improvement, very satisfied, helping me to stay at home and don’t want to go into a rest home.”