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National Evaluation of the Transition Care Program: Executive summary

This report provides the Executive Summary of the National Evaluation of the Transition Care Program.

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National Evaluation of the Transition Care Program: Full report

National Evaluation of the Transition Care Program

Final Evaluation Report

31 May 2008

Jointly funded by the Commonwealth, state and territory governments

Executive Summary

Key Findings

• The Transition Care Program provided additional treatment and care options following hospitalisation that were highly valued by patients and their families.

• Functional improvements occurred. When compared with similar groups of frail older people discharged from hospital during the same time period, those who received Transition Care had fewer readmissions to hospital and were less likely to move into permanent residential aged care.

• These outcomes are achieved at a comparatively high cost. For every day a recipient of Transition Care survives without institutional care i.e. without hospital or residential aged care over a six month period it costs $344 per day. Costs were evaluated during an early phase of the program when they are likely to be high.

• The program was implemented within a health context where older people across Australia have widely variable access to rehabilitation and geriatric hospital beds. It did not appear that areas which were short of aged care services or subacute beds had been prioritised in the allocation of the first 2,000 Transition Care places.

What is Transition Care?

Transition Care is a form of flexible care provided to an older person at the end of an inpatient hospital episode in the form of a package of services that includes at least low intensity therapy and either nursing support or personal care. The care is characterised as goal-oriented, time limited, therapy focused, and necessary to complete the care recipient’s restorative process, optimise their functional capacity, and assist them and their families to make long term arrangements for care.

Transition Care is legislated under the Aged Care Act 1997 and in the 2004-5 Federal Budget the national Transition Care Program was announced as part of the Government Investing in Australia’s Aged Care: More Places, Better Care package. The Australian Government committed to providing 2,000 flexible aged care places for Transition Care with a proportion allocated to each state and territory broadly in line with their proportion of people aged 70 years and over.

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What did we do?

We carried out six studies to assess the introduction of this new program across Australia:

1. The Regional Characterisation Report described Commonwealth aged care places and state funded acute and rehabilitation beds for older people across Australia in June 2006.

2. The Quality Report summarised 23 reports on the program operation which had been completed by Transition Care services between 28 September 2006 and 18 May 2007, an average of nine months following service commencement.

3. The Models of Transition Care Report described the characteristics of Transition Care recipients and the three main types of Transition Care: predominantly community-based services, residential-based services, and services that offered a combination of community-based and residential-based places.

4. The Recipient Snapshot Report described the reports of older people and their families on the program three months after their discharge from the Transition Care Program between 1 February and 30 June 2007. No one in either Western Australia or Northern Territory was interviewed. We interviewed people on the phone (374 interviews with an older person who received Transition Care and 256 with a family member or carer who acted as a proxy) which represented a fifth of those who had received the program. We asked them about: their living arrangements and use of community care services; their satisfaction with the program; how well the move from Transition Care to the community or residential aged care went (we used an American instrument to measure how successful this had been, the Care Transition Measure); about their level of functional independence (using the Modified Barthel Index); any hospital readmissions; any costs incurred and their self-rated health. We also asked carers about their experiences.

5. Controlled Comparisons, Costs and Effects Report. We followed 2,443 people who were approved for Transition Care between 1 October 2006 and 31 March 2007 by an Aged Care Assessment Team (ACAT) and who were discharged from Transition Care by 30 September 2007. In the data linkage component, administrative health records were matched on name (if available), sex, and date of birth, with elements of address used to refine the matches. This enabled us to calculate how many hospital readmissions, transfers into residential aged care and deaths occurred at both three and six months following approval for Transition Care. We compared their outcomes with two groups of similar older people coming out of hospital at the same time; i) people who were approved for a Transition Care place but who did not receive it (n=879); and ii) people approved for Community Aged Care Packages between 1 October 2006 and 31 March 2007 (n=2,188). We estimated the costs of providing the program after taking into account any savings achieved by reducing readmissions and movement into permanent residential aged care.

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What did we find?

• We found that the Transition Care Program was identifying people with a need for further care following a stay in hospital and that recovery continued after discharge from hospital.

• Those selected were medically frail and 37% of older people who received the program had returned to hospital at least once by three months. By six months this proportion had risen to 47%. Those receiving Transition Care in a community-based setting were more likely to be readmitted (51%) when compared with those who received Transition Care in a residential-based setting (43%). Despite this, there was little evidence of medication review or medical assessment.

• About a quarter (22%) of people ended up in permanent residential aged care three months after approval and by six months this was 30%. Those who had received Transition Care in a residential-based setting were more likely to go onto long term care with 58% living in residential aged care at six months. This group were frail and had an average admission score on the Modified Barthel Index of 51.1 out of a possible 100 (a measure of function where higher scores reflect higher levels of function).

• By six months 13% of people who received Transition Care had died. Of those who received Transition Care only in a residential setting, 20% died and amongst those older than 85 almost a quarter had died by six months.

• When we compared the outcomes of the people who received Transition Care with other frail groups discharged from hospital in the same time period we found that Transition Care reduced the risk of entering an institution (hospital and residential aged care) in the six months post ACAT approval. The hazard (risk) of a hospital readmission in the six months post ACAT approval was significantly greater in two control groups relative to the Transition Care recipients. Similarly, the hazard of an admission to residential aged care in the six months post ACAT approval period was lower among Transition Care recipients overall. However the risk was similar for those who received Transition Care only in a residential setting and those who were approved but did not enter the program.

• Three months after ACAT approval, a recipient of Transition Care only in a community setting had survived an additional 11.8 days without admission into hospital or residential aged care when compared with those in the Control 2 group and the additional cost to achieve this for an individual Transition Care recipient was $888 per day. At six months this reduced to $344 per day.

• Nursing and allied health hours on the Transition Care services affected outcomes. The risk of hospital readmission decreased with more nursing hours. The risk of residential aged care admissions decreased with more allied health hours.

• In the telephone interviews most recipients and carers felt that they had a good understanding of their health issues and that staff had taken their wishes into account when planning services. Carer’s experiences were assessed in telephone interviews and varied but overall moderate levels of strain (as measured by the Modified Caregiver Strain index) were reported. The average age of the 386 carers who were interviewed was 63 years and carers were predominantly spouses or daughters. Carers reported most difficulty with restrictions on their free time, the recent changes to their personal plans and they found it difficult to deal with the degree to which the person they cared for had changed from their former self.

• The Transition Care services reported difficulties engaging GPs but it also appeared the models did not emphasise assessment or management of medical issues. Few pharmacists or medical specialists (such as geriatricians or medical rehabilitation specialists) were listed as staff in the Quality Reports.

• When we began the National Evaluation of the Transition Care Program in 2006 there were three rehabilitation and geriatric evaluation and management (GEM) beds per 1,000 older persons aged 70 and over compared with 26 acute hospital beds per 1,000 older people, but there was considerable variation across Australia with Victoria having the most rehabilitation beds.

• Transition Care places are making a significant contribution to post acute services in many areas of Australia but the jurisdictions’ approach to allocation was unclear and many areas of service need had not been allocated places.

• While the Transition Care Program was not intended to substitute for rehabilitation services it appeared to take on this role in regions with limited services. However, it seemed less efficient than conventional rehabilitation programs. Comparisons between the outcomes from Victorian GEM units and residential-based Transition Care found that the Victorian GEM units admitted more disabled patients and achieved functional improvements more rapidly.

• A similar inefficiency was noted in the use of community-based Transition Care places for people with high Modified Barthel Index scores which suggested that in other jurisdictions they might have received home rehabilitation programs. Transition Care requires an ACAT assessment to be completed while home rehabilitation services do not. The delay associated with this extra step i.e. accessing an ACAT assessment may introduce delays in hospital discharge. Delays of up to a week between ACAT assessment and entry into Transition Care occurred, suggesting people were waiting in hospital for the program.

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What did we conclude?

• At the individual level positive outcomes were achieved. Transition Care was valued by patients and carers and although it configured very differently across jurisdictions it seemed to increase the options for older people following hospitalisation. Appropriate people were offered the program and improvements in individuals’ function occurred. When comparisons were made with other frail older people discharged from hospital at the same time, decreases in the risk of transfer back to hospital and permanent residential aged care were seen.

• These positive outcomes were achieved using flexible models and could be implemented in rural settings. Higher nursing and allied health staffing hours were associated with better outcomes.

• The interface between Transition Care and hospital rehabilitation services needs to be clarified. The level of access to rehabilitation and geriatric beds in a region influenced recipient selection and in many regions the Transition Care Program appeared to be fulfilling the traditional role of rehabilitation services. These programs seem less efficient than conventional rehabilitation particularly when providing a substitute for GEM type wards.

• Transition Care provided in a residential-based setting requires more evaluation to clarify which groups will benefit, to explore whether this care should be delivered to a minimum number of co-located recipients, to identify minimum staffing levels and quality measures. Transition Care provided in a residential-based setting alone did not appear to prevent transfer to residential aged care.

• The economic evaluation of the program suggested that the program was not low cost. Some of the inefficiencies are probably related to evaluating the early phase of a new program addressing complex policy issues. Issues that could be examined include: providing incentives to reduce episode costs or rewarding Transition Care services for complex cases e.g. those with dementia.

• Without increasing medical, pharmacy and nursing input into the programs, further reductions in readmissions will be difficult. Transition Care services struggled with the interface with acute care (communication and support) therefore measures of the quality of transfer from hospital need monitoring.

• Strategies to improve communication from hospitals (such as pay for performance approaches which have been used in the US) should be explored. Given the shortfall in health and aged care services for older people and the significance of Transition Care places to communities, transparent allocation of Transition Care places should ideally occur. In the short term priority should be given to areas of service need including rural areas.

• It seems unlikely that simply adding more Transition Care places to regions will change hospital flows if there is an inadequate investment in geriatric rehabilitation beds. If population based planning benchmarks of the ideal number of rehabilitation beds for older people could be developed in tandem with the expansion of the Transition Care Program, greater effects on flows across care sectors are likely to occur.

• A broader range of interventions and models in the program could be considered. For example, models for people with dementia could be developed further. One of the requirements for admission to the Transition Care Program is that patients are medically stable, but one fifth of those in residential based Transition Care had died by six months post ACAT approval. Thus end-of-life care is an issue faced by Transition Care services, and this may reflect selection issues or the rapid onset of some medical conditions among frail older people. Evaluation of new models should include an economic evaluation with 12 month follow-up and assess medication costs.

• We demonstrated that using linked datasets is a feasible way of assessing the outcomes of the Transition Care Program. Cognitive and other health issues can make interviewing a representative sample of older people difficult but this approach allows timely evaluation of a national program at the acute and aged care interface. Further analyses of linked data sets are likely to assist with future iterations of the Transition Care Program.

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