The homely touch

1 November 2011

Seeing the elderly in their own homes was a key to the success of an early intervention pilot for a specialist gerontology nurse role in primary care. Nursing Review finds out more about the piloted role and its future.

An elderly heart attack victim returns home from hospital with a bagful of pills. When Elly Dagley visits a few weeks later, she finds him taking one drug at double the prescribed dose, one at half the dose and the third “just right”. Within four hours she has been in touch with his GP and his pharmacist, his drugs are in blister-packing and his risk of being back in hospital with another attack is reduced.

The gentleman in question was only visited in home because he was one of 416 older people sent a simple self-check questionnaire in the post by Dagley, a gerontology nurse specialist.

The postal survey was part of a pilot project looking at developing the role of the gerontology nurse specialist (GNS) role in primary care and introducing proactive screening in primary care for high-risk older people.

Harbour Health PHO (now known as Waitemata PHO since merging with Waiora and Coast to Coast PHOs in July) won Health Workforce New Zealand funding for phase one of the project in 2010 and worked in league with The University of Auckland and Waitemata District Health Board’s gerontology nurse specialist service on the project that ended this winter.

Primary care and residential aged care has been the focus for almost all of Dagley’s career before she took up the pilot GNS role, working with general practices in North Auckland.

One aim of the pilot was to identify older people at risk rather than waiting for them to be identified during visits to their GP and nurse. So the locally-developed BRIGHT questionnaire (see sidebar) was sent out to elderly patients (aged 75 or over) in three practices.

Nearly 75 per cent of the quick tick box questionnaires were returned within four weeks and Dagley did phone follow-ups with those that hadn’t responded. Her final response rate was that 99 per cent of the 416 had either completed the questionnaire or were found to have moved into residential care, passed away or moved out of town.

About 14 per cent of respondents (62) had scored three or more ‘yes’ questions, flagging the need to do a follow-up and a full geriatric assessment in the home by Dagley. The assessment took about 90 minutes and included all major aspects of their health and daily life functioning.

Going into people’s homes to carry out the assessment was one of the key advantages of the pilot for Dagley. “When we see people outside of their own setting, they tend to put their best foot forward.” Seeing people in their own environment gives the opportunity for a real assessment of how they are coping. “It’s very much about assessing the whole person and their environment as well – it’s a chance to get the big picture and put all the pieces together” – including the chance to identify potential safety issues with stairways, loose rugs, bathrooms or other risks not seen during a practice-based clinic. “I visited one gentleman who’d had a fire on his back deck.” The man with Alzheimer’s had put hot embers from his fire on the deck and his family was unaware of the incident. He now has smoke alarms throughout the home and a more aware family.

Sometimes the answers were simple but well received. For example, one gentleman’s answers to the gastrointestinal section made it clear that he suffered, from constipation and drank few fluids, like many other elderly people. So Dagley set him a daily target for drinking water that had the desired result.

The consequences for another gentleman, who was struggling with his post-heart attack medication, could have been serious without the visit, as he wasn’t due to visit his GP for several more weeks.

The home-based assessments led to patient-centred care plans being drawn up and discussed with the GP. The plans included long-term condition symptom management and referral to other services when indicated. Referral included to physiotherapy to help with mobility, occupational therapy for help with daily living, continence nurse for bladder and bowel control problems, GP for reviews of conditions exacerbated since the last visit, mental health services for dementia assessment, and social work services for support for the elderly to stay at home.

Phase one of the pilot has now concluded. Eight months’ worth of data have been collected by Dagley with the support of the pilot team led by Paul Carver of Waitemata PHO and Michal Boyd of Waitemata DHB/The University of Auckland, and with Ngaire Kerse as advisor.

A full, independent evaluation of the pilot was completed in mid-September but is yet to be released. Funders Health Workforce New Zealand, however, says the report shows that the most valuable aspects of the role included time savings for health professionals, having the consultations at home, integration with the DHB GNS service, and the value added to the primary care setting. Dagley also reports that the qualitative evaluation showed GPs, GNSs and patients were very positive about the pilot during feedback interviews and a patient questionnaire also reported high scores.

Health Workforce New Zealand said in October “it was likely” that the project would be extended to a second phase to include patients recently discharged from hospital and early intervention for dementia.

But Dagley says as yet funding had not been confirmed or secured for phase two which would look also at the viability of the role and the potential cost reduction through reducing hospital visits and people staying at home and out of residential aged-care facilities for longer.

Meanwhile, Waitemata PHO is to continue to fund Dagley’s role, which she says provides a model for an advanced nursing role in primary care. But there is still no dedicated funding stream for advanced nursing roles like GNSs or NPs to work in primary healthcare.

Dagley is hoping to finish her masters degree next year and says the role’s pathway could include nurse practitioner, but at present she is focusing on completing her masters and carrying on her with GNS role that has proved its place in primary care.

“There were very few (pilot patients) who didn’t benefit from the input that I gave them,” says Dagley. “Most are coping in their current situation – that’s why they haven’t presented or been referred, but many were struggling. For a lot of housebound elderly, having someone who showed they cared enough to visit them at home also made a difference. “I wouldn’t like to do this role from a clinic – to lose home visits would be to lose some of the value of the project.”

Questionnaire a ‘bright’ idea

The BRIGHT questionnaire uses 11 straightforward ‘yes’ or ‘no’ questions about everyday activities like showering and dressing, to identify the elderly at risk.

Brief Risk Identification for Geriatric Health Tool was developed by Professor Ngaire Kerse and aged-care NP Michal Boyd at The University of Auckland.

Boyd says they began work on the questionnaire in 2006 and the results of an initial pilot were published in 2008.

Since 2008, Kerse has been carrying out a very large randomised controlled trial, involving almost 4000 people, and the outcomes of that study are still unknown.

Boyd says the researchers’ experience from the initial pilot was that it was helpful in identifying high-risk people.

“It needs to be followed up with a specific gerontology assessment,” says Boyd. So it could not be introduced without the resources for a back-up service to support the people identified.