Chapter 7 - Transitional care
There [needs to] be a
better integration of aged care and the acute sector to achieve a continuum of
care interface to provide the most appropriate and cost effective care.
This chapter discusses the effectiveness of current arrangements
for the transition of the elderly from acute hospital settings to aged care
settings or back to the community.
Evidence to the inquiry emphasised the importance of
effective Government initiatives at the acute-aged care interface to improve
the health and independence of older people who experience a hospital stay, and
increase the likelihood of older people returning home rather than entering
residential aged care. The Australian
Medical Association illustrated the problem in graphic terms:
Thousands of Australians are trapped in the wrong environment
for the type of care they need. There are many people in hospital who no longer
need acute care, but are unable to care for themselves at home and cannot
access appropriate residential or community care. Similarly, there are people
in nursing homes who should be in hospital, and people in the community who
ought to be in either hospital to treat particular conditions, or in aged care
In February 2001, Commonwealth and State/Territory
Health Ministers agreed to jointly examine the acute-aged care interface
through collaborative work progressed by the all-jurisdiction Care of Older
Australians Working Group (COAWG) under the Australian Health Ministers’
Advisory Council. Since then COAWG has completed a work program, including a
national census of older people in public hospitals, a stocktake of innovative
service delivery models at the acute-aged care interface and a mapping exercise
of service provision for older people in the hospital and aged care sectors.
In 2003-04, COAWG developed a National Action Plan for
Improving the Care of Older People Across the Acute-Aged Care Continuum,
covering the period 2004-2008. Transition care is an important area addressed
in the National Action Plan.
Commonwealth Government initiatives
The Commonwealth Government has introduced a number of
initiatives to assist frail older people following a hospital episode. These
include the Transition Care Program, the Pathways Home Program and the Aged Care
Innovative Pool. Through these initiatives, the Government aims to work with
the States and Territories to assist older people in making a smooth transition
from hospital to home or other long-term care arrangements.
The need for more flexible care arrangements was
highlighted by the Review of Pricing Arrangements in Residential Aged Care (the
In the main, the current planning arrangements for the release
of new aged care places are not able to respond as flexibly as is desirable for
the development of new care approaches or to encourage innovation in service
delivery. This has been addressed to an extent by the introduction of the
Innovative Pool of flexible care places, which has trialled services linked to
the acute care-aged care interface, the disability-aged care interface and
dementia care. These opportunities should be enhanced.
Transition Care Program
The Commonwealth in the 2004-05 Budget announced the establishment
of a national Transition Care Program to assist older people after a hospital
stay. The Government has committed to expanding the Transition Care Program to
2000 flexible aged care places by 2006-07. In the 2005-06 Budget, the
Government announced that that it will allocate 1500 places by the end of
Under the program, transition care is provided for
older people with low level rehabilitation and support to improve their
independence and confidence after a hospital stay. It will also allow older
people and their families time to determine whether they can return home with
additional support from community care services or need to consider the level
of care provided by an aged care home. Transition care is provided in either a
residential or community setting. It is estimated that the average period of
care will be 8 weeks, meaning that when fully established in 2007 the Program
will assist up to 13 000 older Australians each year.
Recent amendments to the Aged Care Act 1997 also provide that in cases where residents of
aged care homes temporarily leave the facility for transition care, their
places will be kept in the facility until their return.
Pathways Home Program
The Commonwealth funds the Pathways Home Program under
the 2003-08 Australian Health Care Agreements. The Program provides one-off
capital and infrastructure funding of $253 million over five years to assist
States and Territories to expand their provision of step down and
The Minister for Health and Ageing, as at July 2004,
has approved a range of projects across New South Wales,
Western Australia, South
and the ACT, with a total value of $249 million. The Department of Health and
Ageing (DoHA) stated that individually
and in combination, these projects will substantially improve the number and
quality of rehabilitation and stepdown services that patients will be able to
access. All the projects were designed by the States and Territories to ensure
that they meet local needs, and the States and Territories will meet the
ongoing recurrent costs of their projects.
The Aged Care Innovative Pool, established in 2001-02,
is a national pool of flexible care places available for allocation to
innovative services outside of the Aged Care Approvals Round. This Pool allows
the Commonwealth Government, in partnership with other stakeholders, to
allocate places to services that will pilot the provision of aged care services
in new ways and via new models of partnership and collaboration.
Projects that are approved under the Innovative Pool
have clear client eligibility criteria, controlled methods of service delivery
and are time-limited. Evaluation is an integral element of all projects
involving alternative service models.
Under the Innovative Pool, the Commonwealth and State
and Territory Governments provided funding for Innovative Care Rehabilitation
Services (ICRS) pilots in 2001-02 and 2002-03. The Commonwealth provided
funding for short term personal and nursing care and the State/Territory
government provided funding for intensive rehabilitation support for these
pilots. In 2001-02 nine ICRS pilots were approved, with a total of 341 places
and in 2002-03 a further three ICRS pilots were approved with 52 places.
In 2003-04, Intermittent Care Services were a focus of
the Innovative Pool. The target area of Intermittent Care Services is a broad
category focussing on short-term interventions for older people who require
additional support to remain in, or return to, their own homes (and avoid entry
to residential aged care or hospital) when they experience a change in
circumstance or care needs. It is intended to be similar in operation to the
short-term, post-hospital rehabilitation category in the 2002-03 ICRS pilots
but wider in scope, particularly in terms of the eligible client group it
addresses and the services that can be provided. The services to be provided to
clients could include a range of assessment, rehabilitation, treatment,
guidance and case management services, intended to determine what the most
appropriate long term care arrangement is for the client, and equipping them as
well as possible to benefit from that arrangement. In 2003-04, six ICRS pilots
were approved, with a total of 396 places.
Effectiveness of programs
Submissions generally supported these Commonwealth transitional
care initiatives although some concerns were raised, especially in relation to
the scope of the programs. Catholic Health Australia
characterised the programs as 'fragmented' and argued that 'these disparate
arrangements will not be sufficient in the medium to longer-term' to meet the
needs of the elderly. The Queensland
Government also noted that the Commonwealth, in creating special programs, has
further fragmented the system and made it more difficult for clients, service
providers, and health professional 'to find the right care in the right place
at the right time'. The Government
also commented that while these programs operate at the health and aged care interface
they do not resolve the 'key problems' of the shortages of residential aged
care beds or the need for high support care packages in the community.
The Tasmanian Government, while welcoming the
Transition Care Program, noted that it will impose 'rigorous reporting
requirements around the utilisation of any approved places and a requirement
for some level of State contribution'. The Government also argued that the
Pathways Home Program is 'restrictive' in its permitted application of funds.
The investment must be in step-down and rehabilitation services,
with a strong emphasis toward capital expenditure on new infrastructure or
refurbishment of existing infrastructure. As a consequence, innovative
proposals for Tasmania targeting
local needs cannot be met with funds under this program.
Submissions emphasised that transitional programs need
to be developed in partnership with the different levels of government and
non-government community agencies with input from district health services and
divisions of general practice to ensure a consistent integrated approach.
State Government and other initiatives
The States have implemented a number of initiatives to
assist with the transition of the elderly from acute hospital settings to aged
care settings or back to the community. These initiatives often involve
partnerships with hospitals and service providers. The examples referred to
below do not cover all programs but are illustrative of a range of initiatives
currently undertaken. Initiatives in the private sector have also been
NSW Health has developed a special program, called
ComPacks, to provide assisted discharge and post-discharge care to selected
in-patients at risk of unnecessarily protracted hospital stays because of high
community support needs. Under the pilot program, case managers work with
multidisciplinary hospital and community health teams prior to a patient's
discharge to identify the patient's in-home care needs and put in place
customised community care packages comprising services which will allow the
person to return home safely with the support they require.
Submissions commented on the effectiveness of this pilot.
ACOSS argued that results of this program to date have been 'very successful'
and ACOSS urged the Commonwealth to support such initiatives more widely. Aged and Community Services (ACS) of
NSW & ACT also commented that the program 'could potentially be used to
facilitate the more effective discharge of older people from hospital to
residential care facilities'.
the Government funds a number of initiatives including a well-developed sub-acute
service system that includes both an inpatient and community focus – with a
particular focus on rehabilitation services and inpatient geriatric evaluation
and management services. The Government also has developed a targeted Interim
Care Program that provides temporary support and active management of older patients
who have completed their acute or sub-acute episode of care, have been recently
assessed by an Aged Care Assessment Service and recommended for residential
aged care, and are suitable for immediate placement in a residential care
facility if a place were available.
One submission noted that the Victorian Government has
been 'particularly pro-active' in developing and funding initiatives in the
area of transitional care. COTA
National Seniors noted that an evaluation of the Interim Care Program found
that increasing numbers of older people were able to return home following
rehabilitation with increased physical functioning and an improved quality of
In South Australia,
the Acute Transition Alliance (ATA) pilot program is a partnership between the
State and Commonwealth Governments, public hospitals and aged care providers.
The program provides short term community support services and rehabilitation
either in a person's own home or temporarily in an aged care facility to improve
the physical functioning of older people following a hospital stay. Another
program, City Views, provides a residential transition care facility offering
specialised rehabilitation and care services to support recovery and provide
transition pathways into the aged care system which aims to reduce hospital
stays and improve outcomes for older people awaiting residential placement. ACS
SA & NT argued that both programs have produced 'excellent outcomes in
terms of both benefits to consumers and the hospital system'.
Another program in South
Homelink, is a short-term, community based
health crisis intervention program aimed at avoiding older persons' admission
to public hospitals. The program works in conjunction with GPs and public
hospitals to provide external assistance and support to older people who would
otherwise be admitted to hospital. The Hogan Review commented that this project
is a 'most useful pilot study' to aid the elderly and 'has much potential for
helping the elderly stay in their own homes'.
Submissions noted that there is a continuing need to
provide incentives to take these various pilots programs and convert them into
mainstream services especially where the programs have demonstrated service
improvement and enhanced systems efficiency.
Private sector initiatives were also noted during the
inquiry. The Village Life model provides a form of 'transitional care' between
independent living and low care nursing. Village Life Ltd, which is a listed
public company, provides managed rental accommodation for low income retirees
not currently provided for in retirement village facilities, mainly because of
financial barriers. Residents pay rent equal to the standard single age pension
plus rent assistance and are provided with a furnished unit and daily living
assistance in areas such as shopping and meal preparation, home maintenance and
heavy laundry. Village Life aims to provide quality lifestyle options with the
aim of delaying entry into aged care facilities by approximately five years. At
present there are 4000 residents in 70 villages throughout Australia. The
average age of residents is about 75 years.
Some criticisms of the model were made. One witness
noted that it did not provide for continuity of care, especially once an
elderly person's care needs increased and that the model would be difficult to
apply in situations where elderly residents developed dementia.
A number of
issues were raised in relation to the acute-aged care interface and these are
Evidence indicates that for older people early
discharge from acute settings back into the community or to residential care
can be very difficult unless there is adequate follow-up and access to
significant formal and informal support including short and long-term
residential and/or community care.
Evidence indicated that discharge planning needs to be
significantly improved. The Royal District Nursing Service (RDNS) argued that the
quality of discharge planning in the acute sector is 'erratic' and frequently fails
to recognise the needs and issues faced by clients on their return to their
homes. This often leads to distress for clients and their families and even
readmission to acute care, an event that may have been avoided with better
planning and communication between the acute and community services.
NCOSS also noted that it appears to be assumed by
hospitals that because community care services exist, there will be adequate
supports for people returning home, despite the fact that community care was
never intended to respond to the needs of people with sub-acute needs and is
not designed as a quick response solution to early discharge.
also commented that:
The inadequacy of effective discharge planning for older people
leaving hospital and the lack of timely and effective multi-disciplinary
intervention in the post-acute phase places a huge burden on the acute hospital
system, the residential and community care sectors and, most importantly, on
older people and their carers. This burden is exacerbated where people have
multiple vulnerabilities, or are isolated from supportive communities.
Submissions noted that planning for discharge should be
coordinated across a range of medical, allied health and community care
professionals and involve the older person, their families and carers. ACOSS noted that 'evidence to date
is that this rarely occurs in ways that provide security and comfort to the
older person, seamless service provision and optimal health and emotional
The RDNS commented that standardising and formalising
of referral protocols between the acute and community sectors may offer some
means of addressing this issue and would be an initial step in future
developments such as the electronic exchange of information.
COTA National Seniors stated that post discharge
community care services are inadequately resourced and poorly planned. COTA
argued that the Commonwealth, in conjunction with the States, should develop a
national framework for discharge planning and the provision of post acute and
convalescent services and facilities, including those in the community – 'they
could ensure that adequate discharge, post acute, convalescent and rehabilitation
support services back up acute hospital services and facilities. Finally, they
could ensure that hospital patient discharge remains a medical decision, not a
Common assessment processes
Submissions argued that common assessment procedures
for patients need to be implemented across the various health sectors.
The Australian Nursing Homes & Extended Care
Association (ANHECA) argued that there is significant scope to improve
communication between the acute and residential sectors through the adoption of
advanced IT systems and the integration of other health-specific IT systems to
assist in the communication channels between the two sectors.
The Association argued that it is essential, that a
patient being transferred from acute to residential care have information
forwarded at the time of transfer, detailing a recommended medication regime,
any diagnostic results, and any suggested treatment regime that needs to be
applied in the future. Similarly, a resident being transferred from the
residential to the acute sector should have information forwarded to the
hospital at the time of transfer providing the patients' medical problems and
supplying an up-to-date copy of the resident's medical history to avoid
unnecessary duplication of patient information on presentation to the hospital.
This Committee' s report Healing our Hospitals noted that there is increasing recognition across
the health sector of the potential benefits of electronic health records in
improving efficiency, safety and quality of care over paper-based systems. At the national level the
Commonwealth has been working with the States to develop HealthConnect, a national health information
network, which is expected to lead to integrated patient records across the
health sector. The recent June 2005 Council of Australian Governments (COAG)
Meeting noted that the health system could be improved by accelerating work on
a national electronic health records system.
Submissions argued that rehabilitation services for
people leaving hospital need to be expanded. The Australian Nursing Federation (ANF)
commented that rehabilitation is an essential part of the transition process. Rehabilitation
incorporates the skills of a multidisciplinary team such as nurses, medical
specialists and allied health professionals. The ANF noted that rehabilitation
of older people following an acute health episode requires expert knowledge and
care, and any program needs to factor in the resources needed to employ professionals
in the field.
The NSW Aged Care Alliance stated that geriatric
rehabilitation is 'essential' at the interface between acute in-patient care
and the next phase, whether it be transitional care, home or residential care.
The Alliance also suggested that
geriatric rehabilitation facilities should be available for those older people
living in the community who have developed disabilities, which may be
remediable without admission to the acute hospital system.
Lack of residential aged care
Submissions noted that the effectiveness of transition
strategies depends on a number of complementary strategies, including the
provision of an adequate supply of residential aged care places.
The Victorian Government stated that:
The lack of available residential aged care beds, especially
high care places, puts extreme pressure on available hospital beds. The
effectiveness of transition arrangements for the elderly from acute hospital
settings to aged care settings will depend upon the provision of more high care
In the 2004-05 Budget, the Commonwealth provided $58.4
million over four years to increase the aged care provision ratio from 100
operational places for every 1000 people aged 70 years or over, to 108 operational places. The balance within
the provision ratio was also re-weighted to double the proportion of places
provided in the community (from 10 to 20 places). The proportion of places
provided as high level residential care remained the same – at 40 places for
every 1000 people aged 70 years or over. The 2004-05 Budget provided for an estimated
27 900 new aged care places to be allocated over the next three years,
including 13 030 in 2004. In the 2005-06 Budget it was announced that a
further 11 426 new aged care places will be released in 2005, including
5274 residential places, 4352 CACPs and 1800 flexible care places.
In a joint submission from the Department of Ageing,
Disability & Home Care (DADHC) and NSW Health it was noted that while the
Commonwealth increased its allocation of residential aged care beds to the
States in the 2004 Budget, the inadequate growth in funded residential aged
care places and the considerable lag time between residential aged care beds
being approved and becoming operational poses problems. At the same time, the
demand for assessments of older people for aged care places has been increasing
– 'put simply, there are insufficient aged care places to meet the demand'.
The Committee questioned DoHA
as to why the Government continues to fund low-care places in residential aged
care where there is relatively less demand compared with the high level of
demand for high care places. The Department argued that the policy of ageing in
place 'means that you enter as low care and then you become high care'. The Committee questioned this
argument noting that while more aged people are using CACPs or HACC services,
when they enter residential aged care they are increasing entering as high care residents.
The Department provided data that shows that of those
that entered permanent residential aged care in 2002-03, 61 per cent of
admissions were at the high care level and 38 per cent were at the low care
level. The Department stated that not all people entering residential aged care
at the low care level become high care residents. Of those that enter care at
the low care level, 65 per cent move to high care and 35 per cent are
discharged while still at the low care level. Of those who do move to high
care, the average period in low care is 35 months.
Evidence suggests that transitional care needs a more
coordinated and strategic policy and funding commitment to meet future needs. DoHA
noted that the acute-aged care interface is one of a number of areas where
Commonwealth funded and State/Territory funded programs intersect and
acknowledged that 'there are significant opportunities for the Australian
Government and States and Territories to work together to ensure better
outcomes for older people faced with this transition'.
The recent June 2005 COAG Meeting acknowledged that the
elderly face problems at the interfaces of different parts of the health system
and recognised that the health system could be improved by:
- simplifying access to care services for the elderly
and people leaving hospital;
- helping public patients in hospital waiting for
nursing home places; and
- improving the integration of the health care
COAG agreed that senior officials would consider these ways
of improving the health system and report back to it in December 2005 with a
plan of action to progress these reforms.
Submissions noted that progress towards a continuum of
care for older people requires strategies for the integration of primary care,
community care, health promotion, rehabilitation, acute care, sub-acute care
and residential care.
State Governments and departments commented that the division
of Commonwealth-State responsibilities in the areas of aged care and health
poses difficulties in implementing effective transitional care programs. The
Queensland Government argued that arrangements for these programs remain
'fundamentally flawed' – 'for many years there have been significant disputes
between the two levels of government over the interface between acute and
DADHC/NSW Health noted that the Commonwealth needs to
focus on fundamental reforms at the health and aged care interface and adopt a 'whole-systems'
What is required is an effective whole-systems approach to
health and aged care...The progression in program and service integration across
acute care, residential care and community care for older people has been slow
and generally services and funding arrangements still remain inevitably
fragmented, complex and inflexible.
...[without change] the challenge to manage growth in demand
efficiently, service duplication and gaps, and ensuring older people have
access to services in the right place and at the right time will continue. The
cost shifting between jurisdictions, and the requirement to focus resources on
managing program complexities, will also continue.
The Hogan Review also commented generally on the
duplication and overlap in the delivery of services to the aged.
Where programs are intertwined to the extent that health and
aged care services are, it is essential that significant effort is expended on
minimising overlap and duplication, providing a single point of access for
consumers and maximising coordination and communication.
The review argued that enhanced service delivery is
needed and noted that the following broad principles should be followed,
- improvements to lines of communication with the
- further development of, and support for, joint
pilot programs such as the Acute Transition Alliance and flexible funding
- further consideration and development of joint
Commonwealth-State Government programs, where the Commonwealth contributes
funding to a greater or lesser extent and the State delivers the program.
A number of initiatives have been undertaken at the
Commonwealth and State levels towards improving the effectiveness of current
arrangements for the transition of older people from hospital settings to aged
care settings or back to the community. While these initiatives are welcome,
evidence suggests that a more co-ordinated approach needs to be adopted between
different levels of government to address a system that remains fragmented and
ill-equiped to meet the transitional care needs of the elderly now and into the
suggests that in a number of areas from discharge planning, assessment
procedures and rehabilitation services significant improvements are needed. The
effectiveness of transitional programs also depends on a number of
complementary strategies, including the provision of an adequate supply of
residential aged care places. Both Commonwealth and State and Territory
Governments need to work together collaboratively towards the implementation of
a system that delivers a continuum of care providing the most appropriate and cost
effective care across the acute-aged care interface.
7.58 That the Commonwealth
and the States and Territories improve coordination in the development and
implementation of transitional care programs, and that the development of
programs include input from the community sector and health professionals.
7.59 That the results of
innovative pilot programs funded by the Commonwealth and the States and
Territories be widely disseminated and that mechanisms be developed to
coordinate information about these pilots across jurisdictions so that
innovative models of transitional care can be more readily developed based on
7.60 That, the Commonwealth,
in conjunction with the States and Territories, develop a national framework
for geriatric assessment and discharge planning and the provision of post-acute
and convalescent services and facilities, including community services; and
that discharge planning be coordinated across a range of medical, allied health
and community care professions and involve the patient, their family and carers
in the development of these plans.
7.61 That common assessment procedures for patients be
implemented across the various health sectors so that medical records and
diagnostic results can be easily transferred across these sectors.
Senator Gavin Marshall
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