DOI: 10.1111/ajag.12042
Research Hospital Dementia Services Project: Aged care and dementia services in New South Wales hospitals Brian Draper School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
Charles Hudson Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia
Ann Peut and Rosemary Karmel Australian Institute of Health and Welfare, and Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
Natalie Chan Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia
Diane Gibson Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
Aims: To describe the availability of aged care and dementia services in public hospitals in New South Wales (NSW), Australia in 2006/2007. Method: Hospitals were surveyed about issues relevant to dementia in acute care including the types of aged care wards and staff, policies, practices, clinics, community services and resources for dementia care. Results: Responses were obtained from 163 hospitals (82%); responding hospitals represented 93.4% of NSW hospital beds, 96.7% of multiday episodes of care. Hospitals that had a Specialist Mental Health Service for Older People (SMHSOP) and an Aged Care Service (ACS) had the highest levels of dementia-related services and policies. Few hospitals without ACS or SMHSOP had clinics for dementia assessment, secure beds for disturbed behaviour, or services to manage patients with dementia and medical or behavioural comorbidity in the community. Conclusion: Dementia services in NSW hospitals are closely aligned with ACS and SMHSOP, with limited dementia services in hospitals without ACS or SMHSOP. Key words: acute geriatrics, dementia, hospitals, service delivery.
Introduction Hospitals are increasingly focused on the management of acute severe disorders and lengths of stay are decreasing worldwide [1]. Hospital performance criteria reflect an acute Correspondence to: Professor Brian Draper, Academic Department for Old Age Psychiatry, Prince of Wales Hospital. Email: [email protected] Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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care paradigm and influence staff training and orientation, treatment protocols, hospital design and even political expectations. Although people with dementia are frequently admitted to a hospital, in most cases the principal reason for admission is an acute disorder such as an injury from a fall, an infection or stroke [2–4]. Hospitals can be dangerous and unfriendly places for people with dementia, which is often unrecognised by staff until a complication such as delirium, a fall or behavioural disturbance occurs that impacts upon acute care [5]. The organisational focus on efficient, cure-oriented treatment often means the particular needs of people with dementia are not addressed well [6]. Hospital outcomes of dementia patients including mortality, length of stay and discharge destinations are significantly worse than those of patients without dementia [3]. Little is known about system-wide hospital features that might influence the quality of care of dementia patients in Australia. Previous Australian surveys of aged care service provision in acute hospitals in 1992 and 2001 did not specifically examine dementia care [7,8]. The Hospital Dementia Services (HDS) project is an innovative mixed methods study that explores how hospital-based aged care and dementia services influence hospital outcomes for people with dementia in New South Wales (NSW), Australia. One in three people with dementia in Australia resides in NSW, which has a large and diverse target population covering metropolitan, regional, rural and remote areas [9]. Full details of the HDS project methodology are published elsewhere [10]. In brief, it includes data linkage of existing administrative datasets from 2006/2007 containing patient trajectories in hospitals and into residential aged care; surveys of all NSW public hospitals about aged care and dementia-specific services; and site visits in selected locations to describe key operational aspects of different hospitalbased service models for patients with dementia. This paper focuses on the hospital surveys. The aim is to describe the availability and types of aged care and dementia care services in NSW public hospitals according to hospital size and peer group category.
Method Surveys were developed for three groups of hospitals: those with hospital-based Aged Care Services (ACS); those with hospital-based Specialist Mental Health Services for Older People (SMHSOP); and a General Hospital (GH) survey for hospitals that had neither ACS nor SMHSOP. Hospitals that 237
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had both ACS and SMHSOP received both surveys. The surveys were adapted with permission from the ACS hospital survey developed by Gray and colleagues for their 2001 investigation of Australian hospitals [8]. The GH survey was sent to the general manager of hospitals without an ACS or SMHSOP. An ACS was defined as ‘an individual or individuals employed by the hospital or a department, unit or program with specific responsibilities for the assessment and/or management of complex health and functioning problems of older people and which has designated beds in which to provide these services for admitted patients.’ A geriatrician alone did not constitute an ACS. These surveys were sent to the director of the ACS. A SMHSOP was defined as ‘an individual or individuals employed by the hospital or a department, unit or program with specific responsibilities for the assessment and/or management of mental health problems of older people and which has designated beds in which to provide these services for admitted patients’. An old age psychiatrist alone did not constitute a SMHSOP. These surveys were sent to the director of the SMHSOP. The National Public Hospital Establishments Database was used to provide the initial list of 228 hospitals. A hospital was defined as a site that operates overnight hospital beds. In this survey, each site of a multi-site hospital (operating across two or more sites under one administrative structure) and each hospital on a multi-hospital site (on a site shared with other hospitals but under separate administrative structures) were treated as a separate hospital. The following were not regarded as hospitals: facilities with residential aged care beds only, freestanding day hospitals, and day centres. Paediatric, obstetrics and gynaecology, correctional, drug and alcohol, and palliative care hospitals were excluded. After these exclusions, 198 public hospitals were included in the surveys. The three surveys covered the same set of issues relevant to dementia care in acute hospitals. The issues included the types of wards (acute aged care, rehabilitation aged care, general rehabilitation, general purpose, acute psychogeriatric), numbers of beds, availability of secure areas for the management of disturbed behaviour or delirium, and the presence of on-site residential care beds. Policies and practices regarding the use of these beds specifically related to patients with dementia were ascertained. The availability of specialist medical, nursing and allied health staff to provide geriatric and psychogeriatric consultations was determined. Outpatient clinics were detailed including whether there was a memory clinic. Information was obtained about access to the Aged Care Assessment Team, the availability and types of community services, and pre-admission services and postdischarge services. These included specialist aged care staff in emergency wards, staff with dementia expertise who worked 238
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on the hospital/community interface, and services provided to residential aged care facilities. Hospital and area health service policies about delirium and dementia were noted, along with the presence of regular forums where dementia care issues were addressed. After piloting, the surveys were mailed in 2009/2010 and focused on services available in 2006/2007 in order to correspond with the linked administrative database. Survey respondents were given the opportunity to describe changes in their hospital post 2006/2007. All hospitals not responding were contacted by telephone. Reminder letters were mailed with new surveys to all non-responding hospitals in three additional mail outs. Each round was followed by targeted telephone follow-up, prioritising hospitals thought to have ACS or SMHSOP, and larger hospitals. A peer group classification system for Australian public hospitals, developed to allow meaningful comparison of cost data within groups of similar hospitals according to the casemix and extent of their inpatient activity and their geographic location, was used [11]. Institutional Ethics Committee approval was obtained from the NSW Population and Health Services Research Ethics Committee, the Australian Institute of Health and Welfare Ethics Committee, the University of NSW and University of Canberra Human Research Ethics Committees, and 19 sitespecific approvals that together covered all of the public hospitals in NSW. Signed consent was received from all survey respondents. Data were checked for quality by checking for internal consistency of survey responses and missing data were imputed from other responses where possible. Telephone follow-up was performed to clarify some invalid or missing responses. For further quality control, clarifications were sought on site visits to 20 of the hospitals. For the hospitals with both ACS and SMHSOP, responses to their two surveys were compared for inconsistencies and reconciled as much as possible, yielding a final dataset with one record per hospital. Data were analysed using SAS EG 4.3.
Results Of the 36 hospitals with ACS, 35 returned ACS surveys (response rate 97%). SMHSOP surveys were sent to 14 hospitals with 14 returned (100%); and general surveys to 156 hospitals with 122 returned (78%). The overall hospital response rate was 82% (n = 163, eight hospitals returned both ACS and SMHSOP surveys as they had both types of services). The responding hospitals represented 93.4% of NSW hospital beds and 96.7% of multiday episodes of care. Response bias was noted with higher response from hospitals with more than 50 beds compared with those with up to 50 Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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Table 1: Hospital location, peer group classification and size for NSW hospitals with and without ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122)
Hospital location (remoteness†) Major city Inner regional Outer regional Remote and very Remote Peer group classification‡ Principal referral acute hospitals Large/medium acute hospitals Small, acute and ungrouped hospitals Subacute and non-acute hospitals Psychiatric hospital Bed numbers 50 or fewer 51–100 101–200 201–300 More than 300
ACS only (N = 28, n = 27)
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
m
%
m
%
m
%
12 57 42 11
27 87 100 100
22 5 — —
49 7 0 0
3 3 — —
7 5 0 0
8 — — —
18 0 0 0
45 65 42 11
8 32 50 31 1
31 80 98 79 14
12 8 1 5 1
46 20 2 13 14
— — — 1 5
0 0 0 3 71
6 — — 2 —
23 0 0 5 0
26 40 51 39 7
91 15 9 5 2
95 63 53 45 13
5 4 6 3 9
5 17 35 27 60
— 3 2 1 —
0 13 12 9 0
— 2 — 2 4
0 8 0 18 27
96 24 17 11 15
28 40 26 7 100 16 25 31 24 4 100 59 15 10 7 9 100
†Based on the Australian Standard Geographical Classification Remoteness Structure developed by the Australian Bureau of Statistics (ABS: 2006). ‡Based on the Australian Institute of Health and Welfare National Public Hospital Establishment Database. N = total number of hospitals; n = number of responding hospitals, m = number of hospitals with the characteristic. ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
beds (93 vs 76%; Pearson c2 exact test = 8.96, d.f. = 1, P = 0.003); from hospitals in major cities, inner regional areas and remote/very remote areas compared with outer regional areas (88% vs 69%; Pearson c2 exact test = 10.99, d.f. = 1, P = 0.0009). Based on peer group classification, responses were obtained from all principal referral acute hospitals (26) and psychiatric hospitals (7) as well as 87% (40 out of 46) of medium to large acute hospitals; however, only 81% (51 out of 63) of small acute and other hospitals and 70% (39 out of 56) of subacute and non-acute hospitals responded. This may partially reflect the follow-up process, where larger hospitals were considered a priority for follow-up. Whether responding hospitals had an ACS or SMHSOP in 2006/2007 is reported in Table 1 by location, size and peer group classification. Overall, 21% of responding hospitals had an ACS and 9% had a SMHSOP. Notably, ACS and SMHSOP were located only in major cities or inner regional areas. The majority (69%) of principal acute referral hospitals had an ACS, and similarly the majority of psychiatric hospitals (5 out of 7) had a SMHSOP. However, 20% of responding medium to large acute hospitals had an ACS and none had a SMHSOP. In hospitals with over 300 beds, 87% of responding hospitals had an ACS, while in hospitals with ⱕ50 beds, 5% of responding hospitals had an ACS and none had a SMHSOP. Of the 35 ACS respondents, 69% provided acute medical care. 20 ACS (57%) had a designated aged care unit (DACU) (mean 34.6 beds, range 8–80) with the remainder using general purpose beds. DACUs were used for a range of Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
purposes including acute care (100%), rehabilitation (85%), psychogeriatric assessment (55%); palliative care (30%) and interim residential care (20%). None was being used for respite care or permanent residential care. All of the DACUs admitted patients with dementia but 10 (50%) had no secure beds for the management of disturbed behaviour or delirium, while 5 (25%) had some secure beds and five had all beds secure (25%). Nine of the DACUs had a lower age limit for admissions, ranging from 60 to 70 years. 22 ACS managed patients in general purpose wards (mean 17.6 beds, range 1–45) and these were mainly orthopaedics (m = 10), general medicine (m = 8) and stroke wards (m = 4). While all of these wards admitted patients with dementia only two wards had secure beds. 10 of the 14 SMHSOP services had beds in a designated SMHSOP unit (mean 16 beds, range 6–32) and eight of these had an age limit of 65 and over. Four of the designated SMHSOP units had all their beds secure for the management of disturbed behaviour or delirium, two had some beds secure, and four designated SMHSOP units had no secure beds. The other four SMHSOP services had shared beds with other services. Of the 10 designated SMHSOP units, only seven admitted patients for the treatment of severe behavioural disturbance. In hospitals without an ACS or SMHSOP, a geriatrician and/or psychogeriatrician provided consultations in 48 (40%) hospitals (n = 121). The regional locations of consultancy services for physical and mental health in older people 239
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Table 2: Regional location of consultancy services for physical and mental health in older people in NSW hospitals without ACS or SMHSOP beds in 2006/2007 Service location Major city (n = 11)†
Visiting geriatrician or psychogeriatrician Visiting staff for physical health in older people • Geriatrician • Non-medical Aged Care Assessment Team member • Other visiting aged care staff
Outer regional (n = 42)
Remote and very remote (n = 11)
N
%
N
%
N
%
N
%
N
%
7 10 7 5 1
64 91 64 46 9
27 56 24 39 19
47 98 42 68 33
13 37 11 29 9
31 88 26 69 21
1 10 1 9 3
9 91 9 82 27
48 113 43 82 32
40 93 36 68 27
Major city (n = 11)† Visiting staff for mental health in older people • Psychogeriatrician • General psychiatrist • Non-medical SMHSOP team member • Non-medical general mental health • Other visiting mental health staff • Geriatrician
Inner regional (n = 57)
Total (n = 121)†
9 2 1 0 2 3 5
Inner regional (n = 56)†
Outer regional (n = 42)
47 9 14 16 18 13 16
30 0 7 3 14 8 8
82 18 9 0 18 27 46
84 16 25 29 32 23 29
71 0 17 7 33 19 19
Remote and very remote (n = 11) 7 0 3 2 3 3 1
64 0 27 18 27 27 9
Total (n = 120)‡ 93 11 25 21 37 27 30
78 9 21 18 31 23 25
†1 missing; ‡2 missing. ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
in NSW hospitals without ACS or SMHSOP are listed in Table 2. Hospitals that had both SMHSOP and ACS had the highest levels of dementia-related services and policies (see Table 3). 37 responding hospitals (23%) had services designed to prevent acute hospital admission of older persons with either medical and/or behavioural comorbidity. All hospitals with SMHSOP had a community SMHSOP service, but only nine SMHSOP services (64%) provided outreach to prevent admissions of patients with dementia and disturbed behaviour. A lower proportion of hospitals with an ACS but no SMHSOP service (m = 6, 22%) provided outreach to prevent admissions of patients with dementia and medical comorbidity. Hospitals without an ACS or SMHSOP infrequently had services designed to prevent acute hospital admission of older persons (m = 20, 16%) while hospitals with SMHSOP and ACS had the highest proportion (m = 6, 75%). Few hospitals utilised these services ‘frequently/ always’ to prevent acute admissions. Only two general hospitals (2%) did not have access to an Aged Care Assessment Team. Few hospitals without an ACS or SMHSOP had resources for dementia care. Although the majority of principal referral acute hospitals (m = 18, 69%) had clinics for dementia assessment, a minority of hospitals in other peer groups had them (15%). Secure beds for the management of disturbed behaviour or delirium were most likely to be available in psychiatric hospitals (m = 6 out of 7) or principal referral acute hospitals (m = 9 out of 23, or 39%), with few hospitals in other peer groups having any. Among all responding hospitals, 139 hospitals had an emergency department (ED) (85%); of these, 27 (20%) had aged care staff working in the ED and another 38 (29%) had access to such staff (n = 134; five missing). In hospitals without an ACS, 68 EDs (51%) had no access to aged care staff. 240
Dementia was an exclusion criterion for rehabilitation in eight (27%) general rehabilitation units (n = 30, 2 missing); this was based solely on severity of cognitive impairment in two units and presence of behavioural disturbance in another two while the remainder had either a general exclusion or a combination of criteria. Dementia was not an exclusion criterion in any of the rehabilitation units run by an ACS. Post-discharge services are reported in Table 4. Overall, hospitals with both ACS and SMHSOP services had higher numbers of post-discharge services than other hospitals.
Discussion The key finding from these surveys of NSW public hospitals and their associated community services is that dementiarelated services are predominantly found in hospitals that have ACS or SMHSOP wards, which themselves are mainly in larger principal referral acute hospitals located in major cities or inner regional areas. This relationship between the presence of hospital dementia-related services and ACS probably reflects the way dementia services in Australia have largely been funded through aged care resources rather than via health initiatives [12]. At a hospital level, the reliance on ACS to develop services for people with dementia means that as over 80% of NSW hospitals do not have ACS, most of these hospitals have limited capacity to assess and manage dementia. One of the overriding objectives of the HDS project is to identify service structures and processes that affect outcomes of hospitalisation for people with dementia, which are demonstrably worse than for people without dementia [3,13]. These surveys indicate that in NSW hospitals access to dementia expertise and service structures is limited to Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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Table 3: Dementia services and related policies in NSW hospitals according to presence of ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122) m
%
ACS only (N = 28, n = 27) m
%
Services as alternative to acute hospital admission for dementia with medical comorbidity • Initial contact in patient's own home 6§ 5 4 15 (frequently/always) • Initial contact in residential aged care 1‡ 1 3 11 (frequently/always) • Initial contact in emergency 9‡ 8 4 15 department (frequently/always) Services as alternative to hospital admission for dementia with behavioural disturbance • Initial contact in patient's own home 1‡ 1 4 15 (frequently/always) • Initial contact in residential aged care 0‡ 0 3 11 (frequently/always) • Initial contact in emergency 3‡ 3 3 11 department (frequently/always) Community SMHSOP service 24 20 17 63 Any clinic for dementia assessment 8 7 22 82 • Memory clinic for dementia 5 4 5 19 assessment • General clinic that does dementia 5 4 20 74 assessment Secure beds for managing disturbed 8§ 7 7¶ 32 behaviour/delirium Hospital/community interface staff for 26 21 11 41 coordinating dementia care ACAT based at hospital 25‡ 21 19 70 Access to ACAT but not based at hospital 93‡ 78 8 30 16† 13 7 26 On-site dementia day care centre or psychogeriatric day hospital/day centre Clinical dementia research NK NK 3 11 Training provided for dementia care NK NK 13 48 Any dementia forum/committee 50 41 17 63 • Hospital forum/committee 26 21 9 33 • Area health dementia committee 24 20 8 30 • Don't know 10 8 0 0 Any dementia policy 67 55 16 59 • Hospital policy 8 7 7 26 • Area health policy 59 48 9 33 • Don't know 16 13 5 19 Any delirium policy 62 51 22 82 • Hospital policy 15 12 12 44 • Area health policy 47 39 10 37 • Don't know 11 9 2 7
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
m
%
1
17
2
25
13§
8
1
17
3
38
8‡
5
0
0
4
50
17‡
11
2
33
4
50
11‡
7
2
33
4
50
9‡
6
1
17
4
50
11‡
7
6 1 1
100 17 17
8 7 3
100 88 38
55 38 14
34 23 9
1
17
7
88
33
20
6
100
5
63
26††
17
1
17
5
63
43
26
0 6 0
0 100 0
5 8 3
63 100 38
49‡ 110‡ 26†
30 68 16
0 2 4 2 2 0 6 1 5 0 1 0 1 1
0 33 67 33 33 0 100 17 83 0 17 0 17 17
3 8 8 7 1 0 7 4 3 1 8 7 1 0
38 100 100 88 13 0 88 50 38 13 100 88 13 0
6‡‡ 23‡‡ 79 44 35 10 96 20 76 22 93 34 59 14
15 56 49 27 22 6 59 12 47 14 57 21 36 9
Responding hospitals with missing data: †1 missing, ‡2 missing, §3 missing, ¶5 missing, ††8 missing, ‡‡n = 41. N = total number of hospitals; n = number of responding hospitals, m = number of hospitals with the characteristic. ACAT, Aged Care Assessment Team; ACS, Aged Care Services; NK, not known; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
mainly urban areas. There are a few memory clinics for initial assessments or wards designed to safely manage behavioural disturbances. Delirium and dementia policies were acknowledged by less than two-thirds of the hospitals, although it is noted that the presence of a hospital policy or procedure was not a good marker of practice in the National Audit of Dementia Care in General Hospitals in the UK [14]. One approach to minimise the adverse effects of hospitalisation for people with dementia is to develop intensive community-based treatment options to manage less severe Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
medical and behavioural problems in situ, particularly for those in residential care [15–18]. Very few hospitals had such outreach services even when we included services based in EDs. There were more discharge planning services to reduce length of stay and prevent readmissions, particularly for physical health problems, but even here a large minority of hospitals did not have these services. There is strong evidence that integrated hospital and community services are an effective model of service delivery in aged care for physical and mental health problems [19,20]. Other efforts to improve the care of dementia patients in acute hospitals have included staff education, standardised care protocols that include 241
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Table 4: Subacute or post-acute services to facilitate discharge of older persons from NSW hospitals according to presence of ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122)
Post-discharge services • Transitional care program • Time-limited residential care • Time-limited community care • Indefinite community care • Community therapy/nursing • Other services
ACS only (N = 28, n = 27)
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP, (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
M
%
m
%
m
%
70† 24‡ 15‡ 28‡ 20‡ 44‡ 14‡
58 20 13 23 17 37 12
20 16 2 6 1 8 4
74 59 7 22 4 30 15
0 0 0 0 0 0 0
0 0 0 0 0 0 0
8 6† 1† 5† 0† 4† 4†
100 75 14 71 0 57 57
98† 46§ 18§ 39§ 21§ 56§ 22§
61 29 11 24 13 35 14
Responding hospitals with missing data: †1 missing, ‡2 missing, §3 missing. N = total number of hospitals; n = number of responding hospitals; m = number of hospitals with the characteristic; ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
cognitive screening, involvement of skilled experts and environmental modification [5].
Acknowledgements This study was funded by the National Health and Medical Research Council (ID465701). Project partners included NSW Health, Alzheimer’s Australia, the Aged and Community Services Association of NSW and ACT, the Benevolent Society and Alzheimer’s Australia (NSW), and project collaborators who were based at the Australian Institute of Health and Welfare, University of Canberra, University of New South Wales, University of Queensland, La Trobe University and University of Sydney. We acknowledge the staff and managers of participating hospital sites for their support. We also acknowledge AIHW research personnel who contributed to obtaining ethics approvals, final survey design, pilot testing and conducting the survey (Ingrid Seebus, Louise York, Le Anh Pham, Gail Brien, Phil Anderson). We thank Len Gray for allowing us to adapt the Aged Care Services hospital survey.
Consultations from visiting specialist aged care staff, particularly geriatricians and psychogeriatricians, were also less available in outer regional, remote and very remote parts of NSW. It is unclear from these surveys how effective such consultations are likely to be in terms of patient outcomes. The HDS project has also included site visits to 20 hospitals and the importance of access to specialist aged care staff for assistance in aspects of dementia assessment and management was a common theme in staff interviews [21]. Some possible ways of increasing services to very remote, remote and outer regional areas include the use of telemedicine, ‘fly-in, fly out’ geriatricians and psychogeriatricians, and schemes to support, both financially and by mentoring, the on-site training of nursing and allied health staff in aged care. Various limitations to the survey are acknowledged. Survey data were obtained from key informants at each site. It is not possible to verify that precise information was provided in each case. In particular, although the survey was conducted in 2009/2010, the survey questions related to July 2006 to June 2007. Respondents were instructed to draw on the assistance of staff that was present at that time; however, some respondents nonetheless commented that it was difficult to access or remember the relevant information. The overall hospital response rate (82%) compares favourably to 79 and 89% in previous comparable surveys [7,8]. In conclusion, these survey data provide additional evidence that acute general hospitals have limited resources dedicated to dementia care. In the context of NSW, where health resources for dementia have been almost inextricably linked with aged care initiatives, there is evidence that in the absence of hospital-based aged care services there are only limited health services for people with dementia. Recent policy initiatives in NSW seek to redress this issue by putting dementia into the mainstream of health service development [22]. 242
Key Points • Few NSW hospitals have resources for dementia care. • Dementia services are closely aligned with aged care services. • Aged care services are mainly located in large urban hospitals. • Acute community aged care associated with acute hospital care is uncommon.
References 1 2 3
OECD. Health at A Glance 2011: OECD Indicators. Paris, France: OECD Publishing, 2011. [Cited 16 June 2012.] Available from URL: http://dx.doi.org/10.1787/health_glance-2011-en Natalwala A, Potluri R, Uppal H, Heun R. Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002–2007. Dementia and Geriatric Cognitive Disorders 2008; 26: 499–505. Draper B, Karmel R, Gibson D, Peut A, Anderson P. The Hospital Dementia Services Project: Age differences in hospital stays of older people with and without dementia. International Psychogeriatrics 2011; 23: 1649– 1658. Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
D e m e n t i a
4 5
6 7
8
9
10 11 12
Zuliani G, Galvani M, Sioulis F et al. Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia. International Journal of Geriatric Psychiatry 2012; 27: 313–320. Moyle W, Olorenshaw R, Wallis M, Borbasi S. Best practice for the management of older people with dementia in the acute care setting: A review of the literature. International Journal of Older People Nursing 2008; 3: 121–130. Cunningham C, Archibald C. Supporting people with dementia in acute hospital settings. Nursing Standard 2006; 20: 51–55. Dorevitch M, Gray L. National Survey of Hospital Geriatric Services: A Study of Hospital-Based Geriatric Services in Australia. Commonwealth Department of Health, Housing, Local Government and Community Services. Canberra: AGPS, 1993. Gray L, Dorevitch M, Smith R, Black K, Ibrahim J, Virgona M. Service Provision for Older People in the Acute – Aged Care System Final Report. Melbourne: National Ageing Research Institute and Centre for Applied Gerontology, 2002. Access Economics. Dementia estimates and projections: Australian states and territories, Report for Alzheimer's Australia. 2005. [Cited 18 June 2012.] Available from URL: http://www.fightdementia.org.au/ common/files/NAT/20050200_Nat_AE_DemEstProjAust.pdf Peut A, Hales C, Gibson D, Draper B, Karmel R, Anderson P. The Hospital Dementia Services Project: A Study Description. Canberra: AIHW, 2011. Australian Institute of Health and Welfare. Australian Hospital Statistics 1998–99. Health services series 15. Cat. HSE 11. Canberra: AIHW, 2000. Peut A, Hogan R, Goss J, Mann N, Levings B. Dementia in Australia: National Data Analysis and Development. Canberra: AIHW, 2007.
Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
s e r v i c e s
13 14 15 16 17
18 19 20 21 22
i n
N S W
h o s p i t a l s
Mukadam N, Sampson EL. A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients. International Psychogeriatrics 2011; 23: 344–355. Royal College of Psychiatrists' Centre for Quality Improvement. Report of the National Audit of Dementia Care in General Hospitals 2011. London: Royal College of Psychiatrists, 2011. Draper B, Meares S, McIntosh H. A psychogeriatric outreach service to nursing homes in Sydney. Australasian Journal on Ageing 1998; 17: 184–186. Caplan GA, Meller A, Squires B, Chan S, Willett W. Advance care planning and hospital in the nursing home. Age and Ageing. 2006; 35: 581– 585. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department – The DEED II study. Journal of the American Geriatrics Society 2004; 52: 1417–1423. Hales C, Ross L, Ryan C. National Evaluation of the Aged Care Innovative Pool Dementia Pilot. final report. Canberra: AIHW, 2006. Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: A synthesis of the evidence. International Journal of Geriatric Psychiatry 2003; 18: 222–235. Draper B, Low LF. What is the effectiveness of acute hospital treatment of older people with mental disorders? International Psychogeriatrics 2005; 17: 539–555. Bail K, Hudson C, Grealish L et al. Characteristics of rural hospital services for people with dementia: Findings from the Hospital Dementia Services Project. Australian Journal of Rural Health (In press). NSW Department of Health. The NSW Dementia Services Framework 2010–2015. Sydney: NSW Department of Health, 2010.
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Research Hospital Dementia Services Project: Aged care and dementia services in New South Wales hospitals Brian Draper School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
Charles Hudson Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia
Ann Peut and Rosemary Karmel Australian Institute of Health and Welfare, and Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
Natalie Chan Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia
Diane Gibson Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
Aims: To describe the availability of aged care and dementia services in public hospitals in New South Wales (NSW), Australia in 2006/2007. Method: Hospitals were surveyed about issues relevant to dementia in acute care including the types of aged care wards and staff, policies, practices, clinics, community services and resources for dementia care. Results: Responses were obtained from 163 hospitals (82%); responding hospitals represented 93.4% of NSW hospital beds, 96.7% of multiday episodes of care. Hospitals that had a Specialist Mental Health Service for Older People (SMHSOP) and an Aged Care Service (ACS) had the highest levels of dementia-related services and policies. Few hospitals without ACS or SMHSOP had clinics for dementia assessment, secure beds for disturbed behaviour, or services to manage patients with dementia and medical or behavioural comorbidity in the community. Conclusion: Dementia services in NSW hospitals are closely aligned with ACS and SMHSOP, with limited dementia services in hospitals without ACS or SMHSOP. Key words: acute geriatrics, dementia, hospitals, service delivery.
Introduction Hospitals are increasingly focused on the management of acute severe disorders and lengths of stay are decreasing worldwide [1]. Hospital performance criteria reflect an acute Correspondence to: Professor Brian Draper, Academic Department for Old Age Psychiatry, Prince of Wales Hospital. Email: [email protected] Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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care paradigm and influence staff training and orientation, treatment protocols, hospital design and even political expectations. Although people with dementia are frequently admitted to a hospital, in most cases the principal reason for admission is an acute disorder such as an injury from a fall, an infection or stroke [2–4]. Hospitals can be dangerous and unfriendly places for people with dementia, which is often unrecognised by staff until a complication such as delirium, a fall or behavioural disturbance occurs that impacts upon acute care [5]. The organisational focus on efficient, cure-oriented treatment often means the particular needs of people with dementia are not addressed well [6]. Hospital outcomes of dementia patients including mortality, length of stay and discharge destinations are significantly worse than those of patients without dementia [3]. Little is known about system-wide hospital features that might influence the quality of care of dementia patients in Australia. Previous Australian surveys of aged care service provision in acute hospitals in 1992 and 2001 did not specifically examine dementia care [7,8]. The Hospital Dementia Services (HDS) project is an innovative mixed methods study that explores how hospital-based aged care and dementia services influence hospital outcomes for people with dementia in New South Wales (NSW), Australia. One in three people with dementia in Australia resides in NSW, which has a large and diverse target population covering metropolitan, regional, rural and remote areas [9]. Full details of the HDS project methodology are published elsewhere [10]. In brief, it includes data linkage of existing administrative datasets from 2006/2007 containing patient trajectories in hospitals and into residential aged care; surveys of all NSW public hospitals about aged care and dementia-specific services; and site visits in selected locations to describe key operational aspects of different hospitalbased service models for patients with dementia. This paper focuses on the hospital surveys. The aim is to describe the availability and types of aged care and dementia care services in NSW public hospitals according to hospital size and peer group category.
Method Surveys were developed for three groups of hospitals: those with hospital-based Aged Care Services (ACS); those with hospital-based Specialist Mental Health Services for Older People (SMHSOP); and a General Hospital (GH) survey for hospitals that had neither ACS nor SMHSOP. Hospitals that 237
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had both ACS and SMHSOP received both surveys. The surveys were adapted with permission from the ACS hospital survey developed by Gray and colleagues for their 2001 investigation of Australian hospitals [8]. The GH survey was sent to the general manager of hospitals without an ACS or SMHSOP. An ACS was defined as ‘an individual or individuals employed by the hospital or a department, unit or program with specific responsibilities for the assessment and/or management of complex health and functioning problems of older people and which has designated beds in which to provide these services for admitted patients.’ A geriatrician alone did not constitute an ACS. These surveys were sent to the director of the ACS. A SMHSOP was defined as ‘an individual or individuals employed by the hospital or a department, unit or program with specific responsibilities for the assessment and/or management of mental health problems of older people and which has designated beds in which to provide these services for admitted patients’. An old age psychiatrist alone did not constitute a SMHSOP. These surveys were sent to the director of the SMHSOP. The National Public Hospital Establishments Database was used to provide the initial list of 228 hospitals. A hospital was defined as a site that operates overnight hospital beds. In this survey, each site of a multi-site hospital (operating across two or more sites under one administrative structure) and each hospital on a multi-hospital site (on a site shared with other hospitals but under separate administrative structures) were treated as a separate hospital. The following were not regarded as hospitals: facilities with residential aged care beds only, freestanding day hospitals, and day centres. Paediatric, obstetrics and gynaecology, correctional, drug and alcohol, and palliative care hospitals were excluded. After these exclusions, 198 public hospitals were included in the surveys. The three surveys covered the same set of issues relevant to dementia care in acute hospitals. The issues included the types of wards (acute aged care, rehabilitation aged care, general rehabilitation, general purpose, acute psychogeriatric), numbers of beds, availability of secure areas for the management of disturbed behaviour or delirium, and the presence of on-site residential care beds. Policies and practices regarding the use of these beds specifically related to patients with dementia were ascertained. The availability of specialist medical, nursing and allied health staff to provide geriatric and psychogeriatric consultations was determined. Outpatient clinics were detailed including whether there was a memory clinic. Information was obtained about access to the Aged Care Assessment Team, the availability and types of community services, and pre-admission services and postdischarge services. These included specialist aged care staff in emergency wards, staff with dementia expertise who worked 238
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on the hospital/community interface, and services provided to residential aged care facilities. Hospital and area health service policies about delirium and dementia were noted, along with the presence of regular forums where dementia care issues were addressed. After piloting, the surveys were mailed in 2009/2010 and focused on services available in 2006/2007 in order to correspond with the linked administrative database. Survey respondents were given the opportunity to describe changes in their hospital post 2006/2007. All hospitals not responding were contacted by telephone. Reminder letters were mailed with new surveys to all non-responding hospitals in three additional mail outs. Each round was followed by targeted telephone follow-up, prioritising hospitals thought to have ACS or SMHSOP, and larger hospitals. A peer group classification system for Australian public hospitals, developed to allow meaningful comparison of cost data within groups of similar hospitals according to the casemix and extent of their inpatient activity and their geographic location, was used [11]. Institutional Ethics Committee approval was obtained from the NSW Population and Health Services Research Ethics Committee, the Australian Institute of Health and Welfare Ethics Committee, the University of NSW and University of Canberra Human Research Ethics Committees, and 19 sitespecific approvals that together covered all of the public hospitals in NSW. Signed consent was received from all survey respondents. Data were checked for quality by checking for internal consistency of survey responses and missing data were imputed from other responses where possible. Telephone follow-up was performed to clarify some invalid or missing responses. For further quality control, clarifications were sought on site visits to 20 of the hospitals. For the hospitals with both ACS and SMHSOP, responses to their two surveys were compared for inconsistencies and reconciled as much as possible, yielding a final dataset with one record per hospital. Data were analysed using SAS EG 4.3.
Results Of the 36 hospitals with ACS, 35 returned ACS surveys (response rate 97%). SMHSOP surveys were sent to 14 hospitals with 14 returned (100%); and general surveys to 156 hospitals with 122 returned (78%). The overall hospital response rate was 82% (n = 163, eight hospitals returned both ACS and SMHSOP surveys as they had both types of services). The responding hospitals represented 93.4% of NSW hospital beds and 96.7% of multiday episodes of care. Response bias was noted with higher response from hospitals with more than 50 beds compared with those with up to 50 Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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Table 1: Hospital location, peer group classification and size for NSW hospitals with and without ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122)
Hospital location (remoteness†) Major city Inner regional Outer regional Remote and very Remote Peer group classification‡ Principal referral acute hospitals Large/medium acute hospitals Small, acute and ungrouped hospitals Subacute and non-acute hospitals Psychiatric hospital Bed numbers 50 or fewer 51–100 101–200 201–300 More than 300
ACS only (N = 28, n = 27)
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
m
%
m
%
m
%
12 57 42 11
27 87 100 100
22 5 — —
49 7 0 0
3 3 — —
7 5 0 0
8 — — —
18 0 0 0
45 65 42 11
8 32 50 31 1
31 80 98 79 14
12 8 1 5 1
46 20 2 13 14
— — — 1 5
0 0 0 3 71
6 — — 2 —
23 0 0 5 0
26 40 51 39 7
91 15 9 5 2
95 63 53 45 13
5 4 6 3 9
5 17 35 27 60
— 3 2 1 —
0 13 12 9 0
— 2 — 2 4
0 8 0 18 27
96 24 17 11 15
28 40 26 7 100 16 25 31 24 4 100 59 15 10 7 9 100
†Based on the Australian Standard Geographical Classification Remoteness Structure developed by the Australian Bureau of Statistics (ABS: 2006). ‡Based on the Australian Institute of Health and Welfare National Public Hospital Establishment Database. N = total number of hospitals; n = number of responding hospitals, m = number of hospitals with the characteristic. ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
beds (93 vs 76%; Pearson c2 exact test = 8.96, d.f. = 1, P = 0.003); from hospitals in major cities, inner regional areas and remote/very remote areas compared with outer regional areas (88% vs 69%; Pearson c2 exact test = 10.99, d.f. = 1, P = 0.0009). Based on peer group classification, responses were obtained from all principal referral acute hospitals (26) and psychiatric hospitals (7) as well as 87% (40 out of 46) of medium to large acute hospitals; however, only 81% (51 out of 63) of small acute and other hospitals and 70% (39 out of 56) of subacute and non-acute hospitals responded. This may partially reflect the follow-up process, where larger hospitals were considered a priority for follow-up. Whether responding hospitals had an ACS or SMHSOP in 2006/2007 is reported in Table 1 by location, size and peer group classification. Overall, 21% of responding hospitals had an ACS and 9% had a SMHSOP. Notably, ACS and SMHSOP were located only in major cities or inner regional areas. The majority (69%) of principal acute referral hospitals had an ACS, and similarly the majority of psychiatric hospitals (5 out of 7) had a SMHSOP. However, 20% of responding medium to large acute hospitals had an ACS and none had a SMHSOP. In hospitals with over 300 beds, 87% of responding hospitals had an ACS, while in hospitals with ⱕ50 beds, 5% of responding hospitals had an ACS and none had a SMHSOP. Of the 35 ACS respondents, 69% provided acute medical care. 20 ACS (57%) had a designated aged care unit (DACU) (mean 34.6 beds, range 8–80) with the remainder using general purpose beds. DACUs were used for a range of Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
purposes including acute care (100%), rehabilitation (85%), psychogeriatric assessment (55%); palliative care (30%) and interim residential care (20%). None was being used for respite care or permanent residential care. All of the DACUs admitted patients with dementia but 10 (50%) had no secure beds for the management of disturbed behaviour or delirium, while 5 (25%) had some secure beds and five had all beds secure (25%). Nine of the DACUs had a lower age limit for admissions, ranging from 60 to 70 years. 22 ACS managed patients in general purpose wards (mean 17.6 beds, range 1–45) and these were mainly orthopaedics (m = 10), general medicine (m = 8) and stroke wards (m = 4). While all of these wards admitted patients with dementia only two wards had secure beds. 10 of the 14 SMHSOP services had beds in a designated SMHSOP unit (mean 16 beds, range 6–32) and eight of these had an age limit of 65 and over. Four of the designated SMHSOP units had all their beds secure for the management of disturbed behaviour or delirium, two had some beds secure, and four designated SMHSOP units had no secure beds. The other four SMHSOP services had shared beds with other services. Of the 10 designated SMHSOP units, only seven admitted patients for the treatment of severe behavioural disturbance. In hospitals without an ACS or SMHSOP, a geriatrician and/or psychogeriatrician provided consultations in 48 (40%) hospitals (n = 121). The regional locations of consultancy services for physical and mental health in older people 239
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Table 2: Regional location of consultancy services for physical and mental health in older people in NSW hospitals without ACS or SMHSOP beds in 2006/2007 Service location Major city (n = 11)†
Visiting geriatrician or psychogeriatrician Visiting staff for physical health in older people • Geriatrician • Non-medical Aged Care Assessment Team member • Other visiting aged care staff
Outer regional (n = 42)
Remote and very remote (n = 11)
N
%
N
%
N
%
N
%
N
%
7 10 7 5 1
64 91 64 46 9
27 56 24 39 19
47 98 42 68 33
13 37 11 29 9
31 88 26 69 21
1 10 1 9 3
9 91 9 82 27
48 113 43 82 32
40 93 36 68 27
Major city (n = 11)† Visiting staff for mental health in older people • Psychogeriatrician • General psychiatrist • Non-medical SMHSOP team member • Non-medical general mental health • Other visiting mental health staff • Geriatrician
Inner regional (n = 57)
Total (n = 121)†
9 2 1 0 2 3 5
Inner regional (n = 56)†
Outer regional (n = 42)
47 9 14 16 18 13 16
30 0 7 3 14 8 8
82 18 9 0 18 27 46
84 16 25 29 32 23 29
71 0 17 7 33 19 19
Remote and very remote (n = 11) 7 0 3 2 3 3 1
64 0 27 18 27 27 9
Total (n = 120)‡ 93 11 25 21 37 27 30
78 9 21 18 31 23 25
†1 missing; ‡2 missing. ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
in NSW hospitals without ACS or SMHSOP are listed in Table 2. Hospitals that had both SMHSOP and ACS had the highest levels of dementia-related services and policies (see Table 3). 37 responding hospitals (23%) had services designed to prevent acute hospital admission of older persons with either medical and/or behavioural comorbidity. All hospitals with SMHSOP had a community SMHSOP service, but only nine SMHSOP services (64%) provided outreach to prevent admissions of patients with dementia and disturbed behaviour. A lower proportion of hospitals with an ACS but no SMHSOP service (m = 6, 22%) provided outreach to prevent admissions of patients with dementia and medical comorbidity. Hospitals without an ACS or SMHSOP infrequently had services designed to prevent acute hospital admission of older persons (m = 20, 16%) while hospitals with SMHSOP and ACS had the highest proportion (m = 6, 75%). Few hospitals utilised these services ‘frequently/ always’ to prevent acute admissions. Only two general hospitals (2%) did not have access to an Aged Care Assessment Team. Few hospitals without an ACS or SMHSOP had resources for dementia care. Although the majority of principal referral acute hospitals (m = 18, 69%) had clinics for dementia assessment, a minority of hospitals in other peer groups had them (15%). Secure beds for the management of disturbed behaviour or delirium were most likely to be available in psychiatric hospitals (m = 6 out of 7) or principal referral acute hospitals (m = 9 out of 23, or 39%), with few hospitals in other peer groups having any. Among all responding hospitals, 139 hospitals had an emergency department (ED) (85%); of these, 27 (20%) had aged care staff working in the ED and another 38 (29%) had access to such staff (n = 134; five missing). In hospitals without an ACS, 68 EDs (51%) had no access to aged care staff. 240
Dementia was an exclusion criterion for rehabilitation in eight (27%) general rehabilitation units (n = 30, 2 missing); this was based solely on severity of cognitive impairment in two units and presence of behavioural disturbance in another two while the remainder had either a general exclusion or a combination of criteria. Dementia was not an exclusion criterion in any of the rehabilitation units run by an ACS. Post-discharge services are reported in Table 4. Overall, hospitals with both ACS and SMHSOP services had higher numbers of post-discharge services than other hospitals.
Discussion The key finding from these surveys of NSW public hospitals and their associated community services is that dementiarelated services are predominantly found in hospitals that have ACS or SMHSOP wards, which themselves are mainly in larger principal referral acute hospitals located in major cities or inner regional areas. This relationship between the presence of hospital dementia-related services and ACS probably reflects the way dementia services in Australia have largely been funded through aged care resources rather than via health initiatives [12]. At a hospital level, the reliance on ACS to develop services for people with dementia means that as over 80% of NSW hospitals do not have ACS, most of these hospitals have limited capacity to assess and manage dementia. One of the overriding objectives of the HDS project is to identify service structures and processes that affect outcomes of hospitalisation for people with dementia, which are demonstrably worse than for people without dementia [3,13]. These surveys indicate that in NSW hospitals access to dementia expertise and service structures is limited to Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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Table 3: Dementia services and related policies in NSW hospitals according to presence of ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122) m
%
ACS only (N = 28, n = 27) m
%
Services as alternative to acute hospital admission for dementia with medical comorbidity • Initial contact in patient's own home 6§ 5 4 15 (frequently/always) • Initial contact in residential aged care 1‡ 1 3 11 (frequently/always) • Initial contact in emergency 9‡ 8 4 15 department (frequently/always) Services as alternative to hospital admission for dementia with behavioural disturbance • Initial contact in patient's own home 1‡ 1 4 15 (frequently/always) • Initial contact in residential aged care 0‡ 0 3 11 (frequently/always) • Initial contact in emergency 3‡ 3 3 11 department (frequently/always) Community SMHSOP service 24 20 17 63 Any clinic for dementia assessment 8 7 22 82 • Memory clinic for dementia 5 4 5 19 assessment • General clinic that does dementia 5 4 20 74 assessment Secure beds for managing disturbed 8§ 7 7¶ 32 behaviour/delirium Hospital/community interface staff for 26 21 11 41 coordinating dementia care ACAT based at hospital 25‡ 21 19 70 Access to ACAT but not based at hospital 93‡ 78 8 30 16† 13 7 26 On-site dementia day care centre or psychogeriatric day hospital/day centre Clinical dementia research NK NK 3 11 Training provided for dementia care NK NK 13 48 Any dementia forum/committee 50 41 17 63 • Hospital forum/committee 26 21 9 33 • Area health dementia committee 24 20 8 30 • Don't know 10 8 0 0 Any dementia policy 67 55 16 59 • Hospital policy 8 7 7 26 • Area health policy 59 48 9 33 • Don't know 16 13 5 19 Any delirium policy 62 51 22 82 • Hospital policy 15 12 12 44 • Area health policy 47 39 10 37 • Don't know 11 9 2 7
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
m
%
1
17
2
25
13§
8
1
17
3
38
8‡
5
0
0
4
50
17‡
11
2
33
4
50
11‡
7
2
33
4
50
9‡
6
1
17
4
50
11‡
7
6 1 1
100 17 17
8 7 3
100 88 38
55 38 14
34 23 9
1
17
7
88
33
20
6
100
5
63
26††
17
1
17
5
63
43
26
0 6 0
0 100 0
5 8 3
63 100 38
49‡ 110‡ 26†
30 68 16
0 2 4 2 2 0 6 1 5 0 1 0 1 1
0 33 67 33 33 0 100 17 83 0 17 0 17 17
3 8 8 7 1 0 7 4 3 1 8 7 1 0
38 100 100 88 13 0 88 50 38 13 100 88 13 0
6‡‡ 23‡‡ 79 44 35 10 96 20 76 22 93 34 59 14
15 56 49 27 22 6 59 12 47 14 57 21 36 9
Responding hospitals with missing data: †1 missing, ‡2 missing, §3 missing, ¶5 missing, ††8 missing, ‡‡n = 41. N = total number of hospitals; n = number of responding hospitals, m = number of hospitals with the characteristic. ACAT, Aged Care Assessment Team; ACS, Aged Care Services; NK, not known; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
mainly urban areas. There are a few memory clinics for initial assessments or wards designed to safely manage behavioural disturbances. Delirium and dementia policies were acknowledged by less than two-thirds of the hospitals, although it is noted that the presence of a hospital policy or procedure was not a good marker of practice in the National Audit of Dementia Care in General Hospitals in the UK [14]. One approach to minimise the adverse effects of hospitalisation for people with dementia is to develop intensive community-based treatment options to manage less severe Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
medical and behavioural problems in situ, particularly for those in residential care [15–18]. Very few hospitals had such outreach services even when we included services based in EDs. There were more discharge planning services to reduce length of stay and prevent readmissions, particularly for physical health problems, but even here a large minority of hospitals did not have these services. There is strong evidence that integrated hospital and community services are an effective model of service delivery in aged care for physical and mental health problems [19,20]. Other efforts to improve the care of dementia patients in acute hospitals have included staff education, standardised care protocols that include 241
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Table 4: Subacute or post-acute services to facilitate discharge of older persons from NSW hospitals according to presence of ACS and SMHSOP in 2006–2007 Service type No ACS No SMHSOP (N = 156, n = 122)
Post-discharge services • Transitional care program • Time-limited residential care • Time-limited community care • Indefinite community care • Community therapy/nursing • Other services
ACS only (N = 28, n = 27)
SMHSOP only (N = 6, n = 6)
Both ACS and SMHSOP, (N = 8, n = 8)
Total (N = 198, n = 163)
m
%
m
%
M
%
m
%
m
%
70† 24‡ 15‡ 28‡ 20‡ 44‡ 14‡
58 20 13 23 17 37 12
20 16 2 6 1 8 4
74 59 7 22 4 30 15
0 0 0 0 0 0 0
0 0 0 0 0 0 0
8 6† 1† 5† 0† 4† 4†
100 75 14 71 0 57 57
98† 46§ 18§ 39§ 21§ 56§ 22§
61 29 11 24 13 35 14
Responding hospitals with missing data: †1 missing, ‡2 missing, §3 missing. N = total number of hospitals; n = number of responding hospitals; m = number of hospitals with the characteristic; ACS, Aged Care Services; NSW, New South Wales; SMHSOP, Specialist Mental Health Services for Older People.
cognitive screening, involvement of skilled experts and environmental modification [5].
Acknowledgements This study was funded by the National Health and Medical Research Council (ID465701). Project partners included NSW Health, Alzheimer’s Australia, the Aged and Community Services Association of NSW and ACT, the Benevolent Society and Alzheimer’s Australia (NSW), and project collaborators who were based at the Australian Institute of Health and Welfare, University of Canberra, University of New South Wales, University of Queensland, La Trobe University and University of Sydney. We acknowledge the staff and managers of participating hospital sites for their support. We also acknowledge AIHW research personnel who contributed to obtaining ethics approvals, final survey design, pilot testing and conducting the survey (Ingrid Seebus, Louise York, Le Anh Pham, Gail Brien, Phil Anderson). We thank Len Gray for allowing us to adapt the Aged Care Services hospital survey.
Consultations from visiting specialist aged care staff, particularly geriatricians and psychogeriatricians, were also less available in outer regional, remote and very remote parts of NSW. It is unclear from these surveys how effective such consultations are likely to be in terms of patient outcomes. The HDS project has also included site visits to 20 hospitals and the importance of access to specialist aged care staff for assistance in aspects of dementia assessment and management was a common theme in staff interviews [21]. Some possible ways of increasing services to very remote, remote and outer regional areas include the use of telemedicine, ‘fly-in, fly out’ geriatricians and psychogeriatricians, and schemes to support, both financially and by mentoring, the on-site training of nursing and allied health staff in aged care. Various limitations to the survey are acknowledged. Survey data were obtained from key informants at each site. It is not possible to verify that precise information was provided in each case. In particular, although the survey was conducted in 2009/2010, the survey questions related to July 2006 to June 2007. Respondents were instructed to draw on the assistance of staff that was present at that time; however, some respondents nonetheless commented that it was difficult to access or remember the relevant information. The overall hospital response rate (82%) compares favourably to 79 and 89% in previous comparable surveys [7,8]. In conclusion, these survey data provide additional evidence that acute general hospitals have limited resources dedicated to dementia care. In the context of NSW, where health resources for dementia have been almost inextricably linked with aged care initiatives, there is evidence that in the absence of hospital-based aged care services there are only limited health services for people with dementia. Recent policy initiatives in NSW seek to redress this issue by putting dementia into the mainstream of health service development [22]. 242
Key Points • Few NSW hospitals have resources for dementia care. • Dementia services are closely aligned with aged care services. • Aged care services are mainly located in large urban hospitals. • Acute community aged care associated with acute hospital care is uncommon.
References 1 2 3
OECD. Health at A Glance 2011: OECD Indicators. Paris, France: OECD Publishing, 2011. [Cited 16 June 2012.] Available from URL: http://dx.doi.org/10.1787/health_glance-2011-en Natalwala A, Potluri R, Uppal H, Heun R. Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002–2007. Dementia and Geriatric Cognitive Disorders 2008; 26: 499–505. Draper B, Karmel R, Gibson D, Peut A, Anderson P. The Hospital Dementia Services Project: Age differences in hospital stays of older people with and without dementia. International Psychogeriatrics 2011; 23: 1649– 1658. Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
D e m e n t i a
4 5
6 7
8
9
10 11 12
Zuliani G, Galvani M, Sioulis F et al. Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia. International Journal of Geriatric Psychiatry 2012; 27: 313–320. Moyle W, Olorenshaw R, Wallis M, Borbasi S. Best practice for the management of older people with dementia in the acute care setting: A review of the literature. International Journal of Older People Nursing 2008; 3: 121–130. Cunningham C, Archibald C. Supporting people with dementia in acute hospital settings. Nursing Standard 2006; 20: 51–55. Dorevitch M, Gray L. National Survey of Hospital Geriatric Services: A Study of Hospital-Based Geriatric Services in Australia. Commonwealth Department of Health, Housing, Local Government and Community Services. Canberra: AGPS, 1993. Gray L, Dorevitch M, Smith R, Black K, Ibrahim J, Virgona M. Service Provision for Older People in the Acute – Aged Care System Final Report. Melbourne: National Ageing Research Institute and Centre for Applied Gerontology, 2002. Access Economics. Dementia estimates and projections: Australian states and territories, Report for Alzheimer's Australia. 2005. [Cited 18 June 2012.] Available from URL: http://www.fightdementia.org.au/ common/files/NAT/20050200_Nat_AE_DemEstProjAust.pdf Peut A, Hales C, Gibson D, Draper B, Karmel R, Anderson P. The Hospital Dementia Services Project: A Study Description. Canberra: AIHW, 2011. Australian Institute of Health and Welfare. Australian Hospital Statistics 1998–99. Health services series 15. Cat. HSE 11. Canberra: AIHW, 2000. Peut A, Hogan R, Goss J, Mann N, Levings B. Dementia in Australia: National Data Analysis and Development. Canberra: AIHW, 2007.
Australasian Journal on Ageing, Vol 33 No 4 December 2014, 237–243 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
s e r v i c e s
13 14 15 16 17
18 19 20 21 22
i n
N S W
h o s p i t a l s
Mukadam N, Sampson EL. A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients. International Psychogeriatrics 2011; 23: 344–355. Royal College of Psychiatrists' Centre for Quality Improvement. Report of the National Audit of Dementia Care in General Hospitals 2011. London: Royal College of Psychiatrists, 2011. Draper B, Meares S, McIntosh H. A psychogeriatric outreach service to nursing homes in Sydney. Australasian Journal on Ageing 1998; 17: 184–186. Caplan GA, Meller A, Squires B, Chan S, Willett W. Advance care planning and hospital in the nursing home. Age and Ageing. 2006; 35: 581– 585. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department – The DEED II study. Journal of the American Geriatrics Society 2004; 52: 1417–1423. Hales C, Ross L, Ryan C. National Evaluation of the Aged Care Innovative Pool Dementia Pilot. final report. Canberra: AIHW, 2006. Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: A synthesis of the evidence. International Journal of Geriatric Psychiatry 2003; 18: 222–235. Draper B, Low LF. What is the effectiveness of acute hospital treatment of older people with mental disorders? International Psychogeriatrics 2005; 17: 539–555. Bail K, Hudson C, Grealish L et al. Characteristics of rural hospital services for people with dementia: Findings from the Hospital Dementia Services Project. Australian Journal of Rural Health (In press). NSW Department of Health. The NSW Dementia Services Framework 2010–2015. Sydney: NSW Department of Health, 2010.
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