None listed
Conditions
Brief summary
Bay of Plenty DHB is one of five District Health Boards currently trialling the use of a new assessment tool, the Minimum Data Set-Home Care (MDS-HC). The MDS-HC is used to determine the level of need and services required for older people (65+) living in the community. In conjunction with a well-executed care plan, the use of the MDS-HC is expected to improve the quality of care that DHBs can provide. DHBs across the country need information on the best way to implement the tool and this study is the first step towards providing the information and evidence for national implementation, should it prove to be beneficial in the medium to long-term. 320 older people who are referred for assessment through Support Net will be recruited to take part, half will receive standard NASC assessment whereas the other half will receive the MDS-HC assessment. Interviews with the older people will occur at baseline before the assessment and at one, four months and twelve month follow-up. Comparisons will include functional and social measures, cost of services as well as the differences in care plans and services recommended between the two assessment systems.
Interventions
A partnership was developed between the hospitals and a private residential aged care provider to run an off-site 36-bed transitional care facility. The private provider supplied the accommodation, catering, cleaning, nursing and carer staff while the hospitals provided the allied health staff, medical staff, and a transitional care nurse coordinator.
The intervention was based on a medical rehabilitation model which included: goal setting, early multidisciplinary assessment (pharmacist, geria
A partnership was developed between the hospitals and a private residential aged care provider to run an off-site 36-bed transitional care facility. The private provider supplied the accommodation, catering, cleaning, nursing and carer staff while the hospitals provided the allied health staff, medical staff, and a transitional care nurse coordinator. The intervention was based on a medical rehabilitation model which included: goal setting, early multidisciplinary assessment (pharmacist, geriatrician/rehabilitation specialist, physiotherapist, social worker, general practitioner), weekly case conferences, and family meetings to discuss patient and family goals. The transitional care nursing coordinator was responsible for liaison with the family and ensured appropriate transfer of information from hospital to the transitional care facility, including transfer of the hospital medical case notes. The control group (patients randomised to usual care) remained in hospital across a range of medical and surgical wards and discharge was managed as usual by ward social workers and welfare officers.
Sponsors
Professor Maria Crotty
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Blinded (masking used)
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1.Males and females aged 65 or greater years on the day of baseline examination; or aged 55 if of Mäori or Pacific Ethnicity and eligible for NASC/ OPAT services.2.All participants must be eligible for assessment by the three designated MDS-HC assessors.
Exclusion criteria
1.Those clients with a terminal illness and are currently receiving palliative care services2.Participants directly transferred from hospital to permanent residential care after the initial assessment.
Outcome results
None listed