One of the basic requirements for better health care of older people is proper assessment. Assessment has become a jargon word with attributed meaning when it really describes a necessary process. ...This process contains four core steps: (1) confirm a medical diagnosis; (2) delineate social situation and resources; (3) determine disability; and (4) decide rehabilitation potential. Through this many people are able to improve their mobility and function by minimizing their disability and handicap, although impairments might remain. A fundamental step that enables the multidisciplinary team to participate effectively in this is goal‐setting, whereby patient/client, the family, and the therapists agree to the plan. The subsequent care plan may result in documentation left with the patient/client, a summary being sent to the local general practitioner, and/or an action plan for therapists/care workers to follow. For staff in the community setting there may be consequent case work (as the therapy input is given), case management (as the total scenario is supported), or case coordination (as various activities are recruited) for a client.
In Australia since 1985, under the Commonwealth funded Home and Community Care program, there is significant funding to assist people in their home through the provision of services and support. It has only been more recently that rehabilitation (client relearning skills, equipment being provided, environment being altered) has been acknowledged as providing independence and quality‐of‐life. A new major push has been to support health promotion, illness prevention, and early intervention to prevent later dependency. The role of carers is now acknowledged by the recognition of carers as clients too, in realization of the impact providing care has on carers. Not to be lost in this is the rights of the client versus the needs of the carer.
In Adelaide, a new organization, Metropolitan Domiciliary Care, is resulting from the amalgamation of four regional domiciliary care services. City‐wide, it covers a population of 1 million people, gets about 1700 referrals per month, and has over 12 500 active clients. Its role is to support people in their own home and prevent unnecessary institutionalization. A new client intake system for referrals has been devised that prioritizes and streams people to the service delivery system through an initial needs assessment (screening) or provides information and support or referral to another agency. The aim is to have a single common entry point (access) for all clients and then consistent and equitable services supplied across the city. The community care service is provided by 10 regional multidisciplinary teams. This might be a single service by way of therapy, support or prevention activity or a package of care that might need comprehensive assessment and ongoing case management, with multiple services. This development is consistent with the Federal Government's ‘A New Strategy for Community Care Consultation Paper’ (March 2003 CDHA).
Although currently focused on the health and care/support of older people it is possible that the same system could assist the Disability and Mental Health sectors. The aim would be to become the provider of choice for integrated community support services for all people with reduced capacity.
While Minimum Data Sets will provide the outputs, one of the crucial requirements is to be able to measure client outcomes. This is currently being trialed in pilot stage and the subject of another presentation at this Congress.
Objectives: to determine the prevalence of under-nutrition using brief screening methods and to determine the relation between these results and (1) those of a more standard nutritional assessment ...and (2) discharge outcomes. Design: prospective study. Subjects: 65 (21 males) patients older than 65 years. Setting: sub-acute care facility. Measurements: the Mini Nutritional Assessment, standard nutritional assessment, ‘rapid screen’ and discharge outcome. Results: the prevalence of under-nutrition was high, ranging from 35.4% to 43.1%, depending on the screening method used. Compared to the standard nutritional assessment the ‘rapid screen’ consisting of (1) body mass index <22 kg/m2; and/or (2) reported weight loss of >7.5% over the previous 3 months and the two-tiered Mini Nutritional Assessment process (at risk subjects (46% of total) further evaluated using standard nutritional assessment) had sensitivities of 78.6 and 89.5% and specificities of 97.3 and 87.5% respectively in diagnosing under-nutrition. Under-nourished patients as identified by the standard nutritional assessment (50.0% (under-nourished) versus 21.6% (nourished); P = 0.017), the two-tiered Mini Nutritional Assessment process (50.0% (under-nourished) versus 21.6% (nourished); P = 0.017) and the rapid screen (56.5% (under-nourished) versus 21.4% (nourished); P = 0.004) were more likely to be discharged to an acute hospital or an accommodation with increased support (poor discharge outcomes) than nourished patients. Conclusion: all screening methods identified patients more likely to have a poor discharge outcome. The highly specific but less sensitive ‘rapid screen’ may be the best method in facilities with limited resources as it can be easily incorporated into nursing/medical admissions and avoids biochemical investigations in all patients. The more sensitive two-tiered Mini Nutritional Assessment is better if resources permit.
OBJECTIVES: To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.
...DESIGN: Baseline analysis of subject characteristics with low MNA scores (<24) and follow‐up of the consequences of these low scores.
SETTING: South Australia.
PARTICIPANTS: Two hundred fifty domiciliary care clients (aged 67–99, 173 women).
MEASUREMENTS: Baseline history and nutritional status were determined. Information about hospitalization was obtained at follow‐up 12 months later.
INTERVENTION: Letters suggesting nutritional intervention were sent to general practitioners of subjects not well nourished.
RESULTS: At baseline, 56.8% were well nourished, 38.4% were at risk of malnutrition, and 4.8% were malnourished (43.2% not well nourished). Independent predictors of low MNA scores (<24) were living alone, and the physical and mental component scales of the 36‐item Short Form Health Survey. Follow‐up information was obtained for 240 subjects (96%). In the ensuing year not well‐nourished subjects were more likely than well‐nourished subjects to have been admitted to the hospital (risk ratio (RR) = 1.51, 95% confidence interval (CI) = 1.07–2.14), have two or more emergency hospital admissions (RR = 2.96, 95% CI = 1.15–7.59), spend more than 4 weeks in the hospital (RR = 3.22, 95% CI = 1.29–8.07), fall (RR = 1.65, 95% CI = 1.13–2.41), and report weight loss (RR = 2.63, 95% CI = 1.67–4.15).
CONCLUSION: The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well‐nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.
A retrospective audit of length of hospital inpatient stay of all patients admitted to the Royal Adelaide Hospital Burns Unit over a 5-year period was performed. Data gathered from the Burns Unit ...database and records allowed patient division into two comparison groups: those younger than 70 years and those aged 70 years or older. Further comparison based on discharge destination was made in the ≥70 years group. Outcomes included length of stay, burn size, and discharge destination. A total of 1641 patients were included. The median length of stay was 5.0 days for patients younger than 70 years and 10.0 days for those aged 70 years or older (P < .0001). The mean percentage of TBSA burned was similar. A greater proportion of those aged 70 years or older were discharged to supported care facilities, such as nursing homes, and a greater proportion needed assessment for placement (P < .001) when compared with those younger than 70 years. The median length of stay of those aged 70 years or older who did not need assessment for placement was 9.0 days compared with 38.0 days for those who needed assessment (P < .0001). Elderly patients have, generally, nearly twice the length of stay of younger patients; when further subdivided according to discharge destination, the effect of placement delay (a social issue) becomes apparent and disturbing. This has significant implications, given the limited capacity and high cost of burn unit admission. A geriatrician will be appointed to the Burn Service over the next 12 months to assess whether earlier geriatric assessment can decrease the length of inpatient admission by facilitating a more efficient placement process.
In response to concerns about, and issues pertaining to, medication use practices in residential aged-care facilities (RACFs), the Australian Pharmaceutical Advisory Council (APAC) established a ...working party on quality use of medicines (QUM) in nursing homes and hostels. The APAC is a representative ministerial advisory forum bringing together key stakeholders from the medical, nursing and pharmacy professions, as well as pharmaceutical industry, consumer and government sectors. The working party developed the integrated best practice model for medication management in RACFs.
This study arose from concerns that, despite the availability of such guidelines to inform best practice in RACFs, there remain barriers to its implementation. Thus, the focus of this research was to explore factors influencing the implementation of best practice with respect to QUM in RACFs.
This multimethod, multidisciplinary study was conducted in a representative sample of 12 RACFs in one Australian state - South Australia. The methods used were Critical Incident Technique (CIT) interviews, focus groups, nominal groups and Participatory Action Research.
In stage one of the research the CIT interviews identified four major issues/factors influencing the implementation of best practice: contextual/structural, boundaries, day-to-day practices and keeping up. These themes were developed in the focus and nominal group sessions and the project team prepared a discussion paper summarising stage one results. In stage two participants were asked to use the discussion paper to develop a way forward. Medication Advisory Committees (MACs) emerged as a key strategy. Each participating RACF was then supported to establish and maintain a MAC. A second workshop heard feedback from the facilities on factors supporting the MACs and barriers to their functioning. Eleven of the 12 RACFs had a functioning MAC at the end of the project. Key support factors included: an external facilitator to help organise MAC meetings, provision of resources, such as terms of reference, agendas, policy statements and the sharing of information between MACs. In stage three a set of agreed recommendations was prepared and submitted to the funding body. The recommendations reported here informed the development of the peak guidelines for medication management and administration in Australia.
This project has been groundbreaking in its impact on Australian aged-care practice. A major outcome has been significantly improved communication and collaboration between industry organisations, academic disciplines, professional bodies and educators involved in the RACFs.
This study investigated the effect of a twice-weekly, six-month progressive walking program on 80 healthy women aged 60 to 70 years. Aerobic fitness, blood pressure, skinfold thickness, spirometric ...variables, and activity profile were studied. No significant differences existed between the training group (TG) and the control group (CG) at the commencement of the study. However, after 26 weeks of training, the TG registered significantly lower heart rates than the CG, both at rest (p = .019) and during the five to six minutes of an ergometer work test (p = .003). A Mann-Whitney U test on the difference scores (26 weeks-0 week) indicated higher scores for the TG compared with the CG for Maximum Current Activity (p = .001) and Normative Impairment Index (p = .002), which are both components of the Human Activity Profile. These data suggest that adherence to a low-frequency training program can elicit positive physiologic changes in elderly women. Furthermore, increased habitual activity patterns are likely to be indicative of improvements in functional ability, lifestyle, and independence.
A double-blind trial of phenytoin therapy following craniotomy was performed to test the hypothesis that phenytoin is effective in reducing postoperative epilepsy. A significant reduction in the ...frequency of epilepsy was observed in the group receiving the active drug up to the 10th postoperative week. Half of the seizures occurred in the first 2 weeks and two-thirds within 1 month of cranial surgery. High rates of epilepsy were observed after surgery in patients with meningioma, metastasis, aneurysm, and head injury. Routine prophylaxis with phenytoin (in a dosage of 5 to 6 mg/kg/day) would seem to be indicated, particularly in high-risk patients and, where possible, this treatment should be started 1 week preoperatively. Seizure control is best when therapeutic levels of phenytoin are maintained.
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