Overcoming HINH challenges with Advance Care Planning

Ageing Australians make up the largest consumer group of healthcare. The risk of developing hospital acquired iatrogenic complications for older patients led to the development of hospital avoidance programmes, which aim to provide care in the patients’ own environment, such as their home or Nursing Home.

With a team of nurses, general practitioners and aged care facility staff  all working together, the Hospital in the Nursing Home (HINH) service can provide education, support and advice so that unnecessary presentations to hospitals are prevented and residents are cared for in the most appropriate environment.

Rhonda Purtill, HINH Manager at the Royal Brisbane and Women’s Hospital joined us recently to discuss the significance of HINH service and how Advance Care Planning can assist in overcoming the challenges when adopting the HINH programme.

1) Hospital in the Nursing Home (HINH) service provides an alternative option for the acute management of residents in aged care facilities.  How was the HINH service developed and why?
The Hospital in the Nursing Home Service RBWH Metro North was developed in February 2006 in order to support elderly residents to remain in their aged care facilities.

Evidence suggests that elderly people attending emergency departments and acute care settings are more prone to developing iatrogenic events e.g increase in falls, infection, disorientation, delirium.

Aged care facility residents have a unique set of needs usually complex with associated diminished capacity. It can be a frightening experience because of the change in environment. Acute hospital staff often lack the expertise in caring for these people and they are often time poor, especially in emergency departments. There is a much higher risk of developing a hospital acquired complication. Crilly, Chaboyrer and Wallis 2011 remind us that functional decline occurs by the second day of hospitalisation and rarely returns to baseline.

It is the delivery of the right care at the right time in the right place and for the right resident for all the right reasons.

2) What are some of the benefits with the HINH service?
Providing Residents with appropriate clinical interventions within their own environment and within their home.

• There is documented research to support this model that reducing hospital admissions in Aged Care Facility Residents (ACFR) has the potential to improve patient outcomes.
• Research measures HINH effectiveness in reducing emergency department presentation, hospital admission, length of stay and re-admission.
• HINH positively affects all these.
• User satisfaction – resident, General Practitioners, Aged Care Facility (ACF) staff, families, hospital staff.
• Reduce inappropriate hospital admissions through:
  – Effective communication
  – Patient-centred programs
  – Clinician engagement
  – Community involvement
  – Clinical support
  – Joint partnerships between ACF/GP’s and acute hospital based care
  – Increasing access to clinical support and reduce feelings of isolation

3) What are the key challenges when we adopt the HINH service to care for the residents?
Some of the key challenges include:

• Resident factors – acuteness of illness, quality of life, likelihood of illness causing death or disability.
• Is it going to be disruptive and cause more distress to transfer by ambulance?
• Structural issues – Facility decisions about transferring resident to hospital are affected by factors like number and skill level of staff, available alternatives to hospital, clinical support especially after hours, potential risk of malpractice and negligence, and poor communication systems between hospitals and nursing homes.
• Physician factors – Time poor and often low numbers of available GP’s who work within nursing homes, and variability’s in attitudes toward treatments and their perceived confidence to manage.
• Family factors – Perception of the level of care available in the ACF, information provided to them by ACF staff and GP’s, and the decision-making within the family unit

4) How can Advance Care Planning (ACP) assist in overcoming these hurdles?
Some of the ways include:

• “ACP is the process of discussing and documenting the type and levels of treatment a person may want in the future in the event they cannot speak for themselves at the time” (Stanley et al 2011).
• Ideally, it should be the resident themselves, but many high care residents have lost the capacity to consent and therefore, substitute decision-makers are used (e.g. families or significant others).
• “Thinking ahead” about future care and wishes are fundamental to be able to deliver the “right care right time right place” – high quality, end of life care.
• Large variation as to how Aged Care Facility (ACF) approach ACP.
• Whose responsibility is it anyway? It is EVERYONE’s!
• Open and frank discussion by GPs and ACF managers about a resident’s condition and prognosis allows the resident and their family to have a clearer idea about possible future scenarios, so as to not have to make these decisions without preparation.
• Avoid unplanned and unnecessary hospital transfers and interventions.
• ACP puts residents wishes FIRST.
• Also, clearer guidelines for staff provides care plan that is developed in accordance with patients’ and/or families’ wishes in caring for a deteriorating resident.

5) You will be speaking at the upcoming Hospital in the Home Conference on the 26^th and 27^th May in Melbourne, on the topic Hospital in the Nursing Home Service- Advance Care Planning – It’s Everybody’s Business! Is there a key message you’d like to share with the conference audience?
How can we as a society openly discuss how we wish to die without it being seen as a taboo subject? Let us break down the barriers and demystify the dying process before we are no longer able to make the appropriate decision and choose, dying is a part of living.

To find out more about the event, please visit the 14^th Annual Hospital in the Home Conference website.