HAART - Close to home services for hospital avoidance

Aim

To support older people in the local community catchment area who are at risk of hospital presentation or admission as well as providing a preventative health strategy whereby older people are provided a multifaceted intervention at their ‘minor’ presentation (i.e. minor injuries unit or GPs).

Outcomes

• Screening frailty and home safety within 24-48 hours for 560 clients who presented to the Kallangur Satellite Health Centre Minor Injury and Illness Unit since opening in December 2023.
• 398 of those clients referred on to the HAART MDT for assessment and intervention.
• 713 accepted referrals to HAART from various sources such as GP’s, community agencies and other health services for comprehensive multidisciplinary interventions and individualised goal planning.
• Supporting health equity through a close connection to the SHC First Nations hub, the percentage of clients who identify as Aboriginal and/or Torres Strait Islander is between 5-7%, whereas the Kallangur catchment area has a population of 3%.
• Positive consumer feedback regarding safety and functional improvements.

Background

• The ageing population is growing, with research showing that more than one third of the Bribie Island catchment and 12.2% of the Kallangur catchment (16828 people) in 2019 were over the age of 65 years. That number is projected to increase by 8623 persons in Bribie and 13780 persons in Kallangur between 2016 and 2036, which is more than the net population growth. Both Kallangur and Bribie Island catchments display a greater proportion of the population experiencing socioeconomic disadvantage, with Bribie Island having a rate more than double that for QLD and four times that of Brisbane North.  These issues, combined with cost of living and transportation issues were creating significant challenges for these communities.
• There was a clear need for responsive, close to home, community-based services focussed on preventing the older person attending hospital. These services would ideally include falls prevention, management of deconditioning and frailty, memory and dementia services and rehabilitation to take the pressure off the inpatient hospital system.
• The endorsement of a Rapid Geriatric Assessment and Rehabilitation Service Model of Care (MOC) for Kallangur and Bribie Island in June 2023 by Metro North saw the commencement of brand-new services to be established alongside the opening of the Kallangur Satellite Hospital (now Satellite Health Centre) in December 2023 and Bribie Island Satellite Health Centre in March 2025.
• This Model of Care was in response to the Pine Rivers Satellite Hospital Health Service Plan V3
• HAART aligns strategically with multiple MNHHS plans including:

1. “A five-year health care plan for older people who live in Brisbane North 2017-22" which outlined the need to work with GPs to increase the use of comprehensive risk screening, assessment and care planning, identify and implement evidence-based hospitalisation prevention strategies and develop a local catchment approach to delivering connected health care for older people.
2. “MN Health Rehabilitation Clinical Services Plan 2017-22" where the objective was to increase ambulatory rehabilitation service capacity across MN.
3. “MN Health Outpatient Service Plan 2022-25" where service directions one and two outline the requirement for equitable access to contemporary models of care delivered locally through digital platforms.

• The HAART service was designed to provide alternative pathways for geriatric clients to rapidly access assessment and intervention services close to home through the SHC’s, supporting hospital emergency department avoidance and providing a streamlined referral pathway for GPs to access comprehensive, interdisciplinary assessment.

Discussion

Key factors and strengths necessary to the success of the service are:

• a diverse and skilled multidisciplinary team who work collaboratively allowing for seamless service provision
• strong referral numbers due to the co-location with services at the Satellite Health centres, especially, Minor Injuries and Illness unit and the First Nations hub
• availability of the Rapid OT seven days a week for referrers and to be able to provide a rapid response
• Aacess to ieMR First Net Emergency encounters to allow for a pulling of referrals by the Rapid OT from Minor Injuries and Illness Unit for appropriate clients that would otherwise be missed
• close to home services within a local community catchment allowing connection with local GPs and increased community awareness.

Limitations and learnings:

• Feedback from the Community engagement team on the original MOC name of Rapid Geriatric Assessment and Rehabilitation Service (RGAARS) led to a name change to Older Persons Assessment and Rehab Service (OPARS) as older person was identified as more contemporary than geriatric. Once the service commenced, clients did not relate well to the term “Older Person”. Consumer engagement led to the current name “Healthy Ageing Assessment and Rehabilitation Team (HAART).
• Access to clinic spaces is very limited in Kallangur HAART with daily activity targets being achieved. Clinics have now been opened at Pine Rivers Community Health Centre two days a week. Pine Rivers is seen as a suitable model as the facility is within the Kallangur catchment area. A review of this is still in progress. Telehealth is being encouraged which will also reduce the amount of travel required by clients while on the program. Delays in accessing aged care services is increasing the Length of Stay for some clients who are assessed as unsafe to be discharged without ongoing supports. LOS variances will be reviewed in future service evaluations.
• When Kallangur commenced, the IT systems for documentation, scheduling, referrals, and data collection were not established. Work arounds were required and continued process changes have occurred as the systems catch up and there was limited data available to guide service development until July 2024. Learnings from Kallangur HAART implementation will benefit new services being established, such as Bribie Island.

Where else in QH can the project succeed?

• HAART services could easily be scaled across Qld Health. It has been identified that what HAART offers in Kallangur and Bribie Island catchments is not available outside of these services. Service demand highlights the need for similar services elsewhere. However, expansion of Kallangur services outside catchment would reduce the success of the MOC and its fidelity i.e. Responsive close to home multidisciplinary services to support connection with the local community.

Next Steps:

1. Bribie Island HAART will be fully established by the end of June 2025 evidencing that HAART can be scaled to other health service areas.
2. Robust service evaluation using over 12 months of data to identify areas of service development and future planning

References

Australian Bureau of Statistics. (2020). Estimated resident population by statistical area, level 2 (SA2), Queensland, 2006 to 2019p, Population by age and sex. Cat no. 3235.0. Retrieved from Australian Bureau of Statistics (abs.gov.au) Australian Bureau of Statistics. (2018a).

Queensland Government population projections, Population by age and sex, regions of Australia, 2016. Cat no. 3235.0. Retrieved from Australian Bureau of Statistics (abs.gov.au) Australian Bureau of Statistics. (2018b).

Census of population and housing: socio-economic indexes for areas (SEIFA), Australia, 2016. Cat no.  2033.0.55.001. Retrieved from Australian Bureau of Statistics (abs.gov.au) Pine Rivers Satellite Healthcare Facility Health Service Plan V3.0 Public Health Information Development Unit (PHIDU). (2021).

Social Health Atlas of Australia, Queensland, Population Health Areas. Queensland Government Statistician's Office. Accessed online 15 May 2021 Queensland Government. (2019). 2019 Population health report: Brisbane North PHN and Metro North Hospital and Health Service. Queensland Health. (2020).

The health of Queenslanders 2020: report of the Chief Health Officer Queensland. Queensland Government. Brisbane. Queensland Treasury (2021). ABS 2033.0.55.001 Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia, 2016, (Queensland Treasury derived).

Queensland Treasury. (2019). Queensland statistical areas, level 3 (SA3), 2016. Retrieved from Queensland statistical areas, level 3 (SA3), 2016 | Queensland Government Statistician's Office, Queensland Treasury (qgso.qld.gov.au) Rapid Geriatric Assessment and Rehabilitation Service, Metro North Satellite Hospitals (Kallangur) (Bribie Island) Model of Care V 1.0