RDNS Active Service Model Evaluation Project Final Report

Transcription

1 RDNS Active Service Model Evaluation Project Final Report RDNS Home and Community Care Program, Active Service Model Implementation Prepared by Deborah Manning, Project Officer RDNS Scott Phillips (Director Kershaw Phillips Consulting) July 2013 This project was supported with funding under the HACC Program by the Commonwealth and Victorian Governments.

2 Table of Contents Acknowledgements... 1 List of abbreviations Executive Summary Scope and focus of the evaluation Strengths and weakness of the evaluation design Context of ASM program implementation at RDNS and across Victoria Overview of findings Conclusion Recommendations Introduction RDNS Active Service Model Implementation Project outcomes and objectives Activities implemented Stage of ASM implementation Other studies of implementing similar approaches Evaluation Overview Scope of the evaluation Limitations Main evaluation questions Methodology Data collection and analysis Sampling methodology Care record audit process, data recording and analysis Case study review, data recording and analysis Client profile data extraction, review and analysis Staff focus group, recruitment, schedule and analysis Evaluation results General findings ASM program uptake by service users and staff ASM Client Profile... 26

3 4.1.3 Average length of stay Detailed Findings Translation of ASM principles into practice Autonomy Capacity building Holistic view of peoples needs and care Person centred care (flexible and responsive) Working Collaboratively and in Partnership Benefits to the Individual and Organisation Individual Organisation Enablers and barriers Enablers Barriers Using models of change to explain the ASM journey Models of change Stages of change (applying the Prochaska model) Transitioning to an ASM approach (applying the Bridges model) A systematic and strategic approach to change using ASM (applying the Kotter model) Conclusion and Recommendations Implications for translating ASM principles into practice Understanding the Rationale for an ASM approach Holistic view of a person s needs and person centred care Collaboration Paradigm shift dependency to independence Continuity of care Importance of labelling of ASM Dementia and ASM care assumptions ASM approaches for specific types of nursing care Evaluation Methodology and Learnings Evaluation design Learnings associated with methods used Challenges Other specific recommendations (for RDNS)... 58

4 5.4 Conclusion References Appendix 1: Client Record Audit Tool (ASM evaluation) Appendix 2: ASM Reflective Practice Case Studies Analysis Template Appendix 3: ASM Staff focus group Questions and prompts schedule Appendix 4: Examples of preferred ASM language Appendix 5: Guidelines for an ASM approach to nursing care Guidelines for an ASM approach to Medicines Management Guidelines for an ASM approach to Dementia Management Guidelines for an ASM approach to Wound Management... 71

5 Acknowledgements RDNS would like to acknowledge the Victorian and Australian governments for the funding support for this project, through the Home and Community Care program (HACC). The RDNS ASM Project Board and the Project Management Group (RDNS and Department of Health) are acknowledged for their guidance and support for improving the conduct and reporting of the evaluation. The participation of nursing staff involved in the focus group discussion is also recognised, as is the contribution of those staff that developed case studies over the implementation of the ASM program that were analysed in the project. Other people that made significant contributions towards this study include Janeen Cato (Manager Clinical Support), Erika Van Der Spuy (Senior Data Analyst), Ann Jonhson (ASM Medicines Management Project Officer), Dee Sauvarin (DVA Project Officer) and Kath Paine (Department of Health ASM Senior Project Officer) for her guidance and ASM expertise. Finally, the collaborative effort by Scott Phillips and Deborah Manning in working together in development of this report is also acknowledged. RDNS Active Service Model Evaluation Final Report Page 1

6 List of abbreviations ASM CPD CNC DAA DH GP HACC HAS HITH LOS LUPP RDNS SCTT UR Active Service Model Continuing professional development Clinical Nurse Consultant Dose administration aide Department of Health General Practitioner Home and Community Care Program HACC assessment service Hospital in the Home Length of stay Leg Ulcer Prevention Program Royal District Nursing Service Service coordination tool templates Unit record RDNS Active Service Model Evaluation Final Report Page 2

7 1. Executive Summary 1.1 Scope and focus of the evaluation The evaluation was undertaken to examine impacts of the RDNS Active Service Model (ASM) Implementation Project, to inform RDNS future directions in implementation of ASM and planning for the evaluation of the ASM approach state wide. The focus of the evaluation is on the implementation of the ASM approach in the context of HACC community nursing. As an activity, HACC community nursing has a strong focus on clinical intervention. A project brief scoping the evaluation was prepared by RDNS in collaboration with the Department of Health. The evaluation commenced in November 2012, with the purpose of determining the extent to which ASM principles have been translated into practice across RDNS HACC services and of what benefit this has been to people receiving services and the organisation. A key aim was to identify barriers and enablers associated with implementing the ASM approach to care. 1.2 Strengths and weakness of the evaluation design A mixed methods approach was adopted for the evaluation. This included a predominantly qualitative focus to the data collection and analysis with some semi-quantitative analysis of findings. A collaborative research approach was utilised, involving both RDNS and Department of Health staff in an action learning process throughout the research journey. This methodology and process was employed to ensure that the research produced credible findings to inform the state wide evaluation planning of the ASM approach to care and RDNS next steps in implementation. The methodology of the evaluation included: 1. Analysis of ASM case studies of reflective practice generated by RDNS staff over the previous two years of ASM implementation (n=109) 2. File audit involving analysis of a sample of RDNS HACC client records utilising an ASM approach to care with comparison to a sample of client records with usual care. 3. A focus group discussion with RDNS staff was conducted to reflect on staff learnings and insights and assist with interpretation and verification of findings from the case study analysis and file audit. 4. Service data was extracted and analysed for a client profile comparing ASM coded HACC clients and usual care HACC clients. RDNS Active Service Model Evaluation Final Report Page 3

8 The main strengths of the methodology were as follows: The audits were conducted by a single researcher with no prior knowledge of which records were coded with an ASM program code (electronic identifier). It was hoped this method would limit any measurement bias. A total of 81 case studies from the available 109 were reviewed by a single researcher. Content was extracted and collated onto an excel spreadsheet from which further coding and analysis and aggregation of data was undertaken, to highlight qualitative themes and semi-quantitative findings. The focus group discussion involved nine participants from across RDNS. They were representative of staff that had been involved in ASM activities such as the Leg Ulcer Prevention Program (LUPP), Dementia Model of Care, and Medicines Management, assessment tool review or ASM training. 1.3 Context of ASM program implementation at RDNS and across Victoria The RDNS Active Service Model Implementation Project was initiated in 2010/11 to identify and implement a service delivery model that ensures a wellness and active ageing approach to care. In order to achieve this, activities were focused upon incorporating ASM principles into existing models of HACC service delivery as well as exploring new and innovative models, utilising an ASM approach. Now in the third year, the ASM implementation remains focused upon sustainability of the approach as business as usual more broadly, and in particular, the continued application of ASM approaches to assessment and care planning as part of RDNS HACC assessment service role. RDNS implementation of the ASM approach is occurring within the context of the Department of Health embedding this approach in the HACC sector across Victoria. Progress has been conceptualised and monitored by the Department in relation to three outcomes stages. These are: Stage 1 Outcomes: HACC funded agencies have increased knowledge about the application of an ASM approach and have increased commitment to implementing an ASM approach Stage 2 Outcomes: HACC agencies have started to implement an effective ASM approach systematically in practice. Stage 3 Outcomes: Improved HACC Service delivery and better outcomes for clients. The current evaluation shows that RDNS is already at stage 2 of the 3 outcome stages and there is some early indication of achievement of stage 3 outcomes. RDNS Active Service Model Evaluation Final Report Page 4

9 1.4 Overview of findings This section provides an initial brief description of general findings (see section 4.1). This is followed by a description of detailed findings (see section 4.2). General findings are described in relation to ASM uptake by service users and staff, an ASM client profile and average length of stay. The ASM approach was provided to new as well as existing service users. It tended to be embraced by people (new or existing service users) who were more active in the community and wished to return to former levels of independence. Use of an ASM program code allocated to client records by staff helped initially to monitor staff uptake of the approach. Subsequently use of the code plateaued. Precisely why this occurred is unclear. One possible explanation could be that staff required more education around the use of the code when implementing an ASM approach (a theme which recurred in focus group discussions). An alternative explanation could be that, as the ASM approach increasingly became business as usual for all people receiving services, staff no longer saw the need to allocate an ASM code. In this way, use of an ASM code was seen as a facilitator for prompting staff to think in ASM terms when the approach was first being introduced. The ASM client profile was analysed in relation to demographic and treatment characteristics. Average length of stay analysis revealed that of the discharged clients, ASM clients had a marginally shorter length of stay than usual care clients. Detailed findings are described in terms of translation of ASM principles into practice, benefits to the individual and organisation, and barriers and enablers to implementing an ASM approach. 1.5 Conclusion Overall, the findings suggest some progress in the translation of ASM principles into RDNS practice, with positive outcomes associated with improvements in peoples ability to manage their own care and achievement of partial, if not full independence. Clear benefits for RDNS clients and carers are evident in social and emotional as well as physical health terms. In RDNS experience, the benefits of an ASM approach can be demonstrated in a HACC community nursing context, when the primary focus of care is clinical intervention. RDNS Active Service Model Evaluation Final Report Page 5

10 1.6 Recommendations The following recommendations have been developed from the project findings. While focused mainly on RDNS, these recommendations never the less could be applicable more broadly, to other community nursing services and possibly other HACC services generally, in the next phase of ASM implementation. As a value add component, the recommendations include reference to evaluation learnings as well as a set of non-prescriptive how to guidelines for an ASM approach for specific types of nursing care. Understanding the Rationale for an ASM approach Recommendation 1: Refresher education should be provided to RDNS staff about the rationale for the ASM approach, its key principles and components and strategies for applying these in practice. Prior to this education being offered, the ASM education overlay included in orientation and in-service programs should be reviewed. Ensure content remains consistent with the ASM principles. Recommendation 2: Education offered should be made more accessible to staff through the provision of alternatives other than traditional face to face methods. In addition, provision for appropriate follow up support and reflective practice opportunities should be encouraged to promote discussion and applied learning. Holistic view of a person s needs and person centred care Recommendation 3: Continue to make improvements to care documentation and supporting processes for referral and care coordination using the HACC Assessment Service guidelines. This should include refinement of holistic assessment tools and care plans to reflect person centred goals and actions that focus on physical, social and mental health and wellbeing outcomes. 1 Collaboration Recommendation 4: Improve opportunities for promoting a culture of collaboration with a focus on interdisciplinary practices, for example, secondary consultations and case conferences. This 1 Strengthening assessment and care planning: A guide for HACC assessment services in Victoria, Department of Health RDNS Active Service Model Evaluation Final Report Page 6

11 could be done through the Department of Health supporting the gathering and sharing of knowledge and practice about ASM collaboration as part of HACC service system development. RDNS and other organisations continue to participate in regional forums such as ASM alliances for these purposes. Recommendation 5: At the agency level including RDNS, staff should adopt case conferences for development of appropriate ASM approaches when coordinating care for complex clients making use of teleconferences and communications to keep everyone involved and informed. Paradigm shift dependency to independence Recommendation 6: Promote successes and learnings of an ASM approach to staff, clients, family and carers and other health and community services to show that ASM principles positively enable people to achieve greater levels of independence and wellness, provided that the approach is tailored to each client s specific situation. Education programs can be used for this purpose, as can sharing of stories through other media and channels. Recommendation 7: Review indicators of dependency for consideration of more strength based indicators of capacity that are better aligned to an ASM approach. Continuity of care Recommendation 8: Continuity of philosophy of an ASM approach across the continuum of care should be supported where possible to link hospital based initiatives e.g. Improving Care for Older People with ASM and similar initiatives in home and community care settings. Importance of labelling of ASM Recommendation 9: The label of Active Service Model should be maintained as a positive metaphor for promoting uptake of enablement, restorative, person centred approaches. Recommendation 10: The requirement for staff to use the ASM program code should be discontinued altogether. If not, then coding guidelines for sustained use of the code, including guidance on when to discharge people from the program, indicating reasons for success or failure of the approach should be developed and promoted. RDNS Active Service Model Evaluation Final Report Page 7

12 Dementia and ASM care assumptions Recommendation 11: Staff should consider creative means for goal setting with people with advanced dementia and cognitive impairment. This will facilitate consideration of the supports required to enable those people to participate in goal setting and self care, to the greatest extent possible. Use of person centred approaches such as life story could be used in the ways suggested in the Department of Health Strengthening assessment and care planning: Dementia Practice Guidelines for HACC assessment services (2012). ASM approaches for specific types of nursing care Recommendation 12: ASM approaches for specific types of nursing care are promoted to improve understanding of an ASM approach in the clinical context of HACC community nursing (see appendix). Evaluation Methodology and Learnings Recommendation 13: A mixed method evaluation approach with a qualitative focus is helpful in drawing out themes and relationships and provides practical examples to demonstrate evidence of translation of ASM principles into practice. Recommendation 14: Survey instruments and measures developed and used in this evaluation may be useful for other organisations to adapt and use as appropriate to their context (see appendix). To ensure ASM practice is continued in a consistent and effective manner the following recommendations are made specifically for the RDNS ASM implementation: i. Complete initiatives currently underway to improve care documentation for capturing person centred goals and holistic practice. In particular, this requires changes to existing care plan documentation and client management systems. ii. Link performance management and development requirements to reflective practice of ASM including history audits and ASM case study development. Encourage and support this practice through allocation of continuing professional development (CPD) points to reflective activity. iii. Review client self management policy and case conferencing policy to ensure ASM approaches and strategies are included in case conferencing activities where appropriate RDNS Active Service Model Evaluation Final Report Page 8

13 iv. Encourage continued discussion and reflection at team meetings about ASM approaches for complex clients v. Disseminate evaluation findings and learnings to staff and guidelines for ASM practice vi. Support interdisciplinary practices (both internally and externally) to improve communication, referral and knowledge about other professionals and services and what is available for clients e.g. secondary consultations, joint assessments and case conferences. vii. Explore opportunities for further funding to conduct research and evaluation for determining an ASM visit profile e.g. including length of stay, visit duration and frequency of visits. This will assist in understanding the impacts and challenges of an ASM approach concerning resource allocation and demand management. RDNS Active Service Model Evaluation Final Report Page 9

14 2. Introduction The Active Service Model (ASM) is a quality improvement initiative that focuses on promoting person centred care, capacity building and restorative care in delivery of Home and Community Care (HACC) services. The initiative is a policy direction of the Department of Health, emphasising early intervention and prevention in all services for older people in our community. The goal of the ASM approach is to support frail older people and people with disabilities to live in the community as independently and autonomously as possible. It is based on the premise that many people have the potential to make gains in their wellbeing and independence. Services funded by the HACC program can actively facilitate people achieving this objective. The ASM approach is a health promoting philosophy of care. This philosophy shifts thinking from doing for people to doing with people. The ASM aims to ensure staff work with people so that they can retain or improve their independence and/or autonomy as far as possible, so they stay involved in everyday activities to maintain or rebuild their confidence and stay active and healthy. The ASM approach and principles include: People wish to remain autonomous. People have the potential to improve their capacity. People s needs should be viewed in a holistic way. HACC services should be organised around the person and his or her carer, that is, the person should not be slotted into existing services. A person s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and family; support workers and between service providers. The estimated benefits of the ASM approach to care are: Demonstrated improvements in people s independence and wellness through implementation of the ASM approach Demonstration of greater satisfaction amongst people receiving care and among staff Improved understanding and expectations of an ASM approach RDNS Active Service Model Evaluation Final Report Page 10

15 2.1 RDNS Active Service Model Implementation The RDNS Active Service Model Implementation Project was initiated in 2010/11 to identify and implement a service delivery model that ensures a wellness and active ageing approach to care. In order to achieve this, activities were focused upon incorporating ASM principles into existing models of HACC service delivery as well as exploring new and innovative models, utilising an ASM approach Project outcomes and objectives At initiation, the project was focused on achieving the following outcomes: Systems and processes that enable RDNS staff to optimise a person s/carer s autonomy and improve their capacity. Ensure new work practices e.g. intake and initial needs identification, holistic assessment and care planning are developed and adopted by RDNS staff. Enhanced stakeholder communication, leading to a positive environment for implementing project initiatives that meet customer requirements. Explore and identify opportunities for RDNS to partner with other HACC services in relation to facilitating an individual s outcomes and goals of care. Project objectives were developed as follows, to support the desired outcomes: Achieving workforce engagement and organisation change through active involvement of staff. Identifying specific practice changes that will promote person centred care and achieve a person s identified goals. Developing models of service delivery that provide a responsive and efficient service, and identify capacity building potential for a person and carers, concentrating initially on the Dementia Model of Care and a Leg Ulcer Prevention Program. Ensuring implementation of the ASM Project contributes to the achievement of RDNS Strategic Objectives. Integrating an ASM approach into new service opportunities. Evaluating the ASM Implementation Project and making recommendations concerning ongoing holistic and person centred care initiatives across RDNS. The project approach actively involved clinical staff in the identification, development and implementation of ASM initiatives. This approach was guided by Prince2 project management methodology. A project initiation document and project plan was developed and included twelve work packages or key areas of work. Some broadly covered communication, human resources, staff training and development, review of policies and procedures and evaluation. Other work packages were more specific including review of the RDNS admission model, implementation of the HACC assessment service and partnership development with other HACC services. There were also work packages covering three key areas of clinical practice, including medicines management, wound management and development and implementation of a dementia model of care. RDNS Active Service Model Evaluation Final Report Page 11

16 2.1.2 Activities implemented The key activities implemented under the ASM project involved the following: 1. Achieving workforce engagement and organisation change through active involvement of staff. A Project Team was established comprising initially of a Project Coordinator. Project governance was also established and included forming of an ASM Project Board with representation from senior management and a Supplier Panel. The ASM Project Board provided the approval and guidance to ensure project objectives were achieved. Advice and support was also provided from the Supplier Panel, an ASM Steering Committee and Clinical Working Groups. A range of management and clinical staff were represented on the ASM Steering Committee whilst the working groups were comprised of representatives from each site, District Nurse Liaison and the Customer Service Centre. ASM champions were also appointed at each site and other program areas to support practice change at an operational level. The ASM Project Coordinator conducted multiple ASM Road Shows to every RDNS site and most divisions across RDNS. An ASM promotional poster was developed and displayed across the organisation, encouraging staff to access additional information. An ASM webpage was also created on the RDNS intranet with information and resources for staff to access. Resources included a plain English ASM statement which was developed to assist staff in understanding this approach, and over one hundred ASM reflective practice case studies written by staff. A Frequently Asked Questions section was also available on this site where staff could post ASM related questions and seek a response from ASM Steering Group members. A communications plan was developed and implemented which included these initiatives among others. 2. Identifying specific practice changes to promote person centred care and achieve a person s identified goals. Nursing staff were required to use an ASM program code to capture statistics on the number of people they were engaging in an ASM approach to care. The RDNS Institute facilitated access to an ASM champion trained in Motivational Interviewing. Approximately 200 staff have completed the Motivational Interviewing education and whilst the impact of this training has not been formally evaluated, anecdotally, staff indicate a greater understanding of motivational interviewing techniques. All RDNS in-service training courses have been updated to include an ASM overlay. An electronic Initial Needs Screening tool has been developed and piloted, underpinned by the ASM principles, involving the Customer Service Centre, District Nurse Liaison and two support sites. The tool provides a dependency score enabling admissions to be prioritised. RDNS completed the pilot of this tool in September 2012 and further work will occur in order to support implementation of the tool to screen all HACC admissions. Similarly, the general assessment tool has been reviewed and a new holistic assessment tool developed and piloted with plans for this tool to be implemented for all future HACC admissions. This tool is consistent with the HACC assessment service guidelines and requirements of a Living at Home Assessment which applies an ASM approach to assessment and care planning. RDNS Active Service Model Evaluation Final Report Page 12

17 3. Developing models of service delivery that provide a responsive and efficient service, and identify capacity building potential for a person and carers, concentrating initially on the Dementia Model of Care, the Leg Ulcer Prevention Program and Medicines Management. Dementia Model of Care The RDNS Dementia Model of Care was fully implemented across the organisation in This is a best practice Model for people with dementia or a cognitive impairment, who receive home based nursing care. Using an ASM approach to care, the model is effective in promoting early intervention, maintaining independence and appropriate and timely referrals. An example of this is forward planning regarding the impact of change in the person s condition and involving and preparing family and carers to manage these changes. Outputs included provision of a standardised best practice model for dementia care, an electronic assessment tool, clinical guidelines, carer support strategies and an electronic Services Directory. This work resulted in a shift in practice, whereby formal and informal support strategies for carers of people with dementia were introduced. Leg Ulcer Prevention Program (LUPP) RDNS has implemented the Leg Ulcer Management Program (LUPP), an innovative education program for people with venous leg ulcers, using a multimedia approach, across Victorian sites. LUPP utilises multimedia, including DVD and traditional written education materials, activities for the person involved and staff, which is facilitated and monitored by nursing staff. It is designed around key elements which influence healing of venous leg ulcers and optimising prevention of ulcer reoccurrence. The program aims for improving a person s knowledge, adoption of healthy behaviours, self-management practices, increased use of best practice compression bandaging and engagement of the person and nurse in health promotion activities. The program was developed by the RDNS Institute and evaluated in a pilot study in Following the pilot study, LUPP was implemented under the ASM program as standard practice which was evidence based. Audits of uptake of LUPP as standard practice are intended. Further research is now underway to build upon the LUPP concept with development of a Skin Awareness Program (SAP) and e-learning package. Medicines Management Project The ASM Medicines Management (MM) Project has provided clinical staff with education and training in strategies to promote people s functional capacity with safe self administration of medicines underpinned by ASM principles. Included is the development and implementation of a unique set of Medicines Reminder Cards, in six languages, soon to be nine. A major focus of this project has been to expand the sphere of practice of community care aides (CCAs) to further assist people with medicines. As well, the RDNS Home Medicines Review request process has been revised in consultation with key stakeholders in the Medicines Management Reference Group. Work is ongoing around sustaining clinical competencies and the ASM approach towards medicines management. The challenge remains to measure the impact of an ASM approach on episodes of care associated with medicines management through interpreting client care data and staff coding practices. The project is ongoing throughout RDNS Active Service Model Evaluation Final Report Page 13

18 4. Ensuring implementation of the ASM Project contributes to the achievement of RDNS strategic objectives. The ASM approach supports and contributes to the RDNS strategic plan and goal to strengthen core business. The ASM model of care is a quality improvement initiative that focuses upon delivering effective community care services that benefit people in supporting them to improve or maintain independence and wellness. 5. Integrating an ASM approach into new service opportunities. An ASM approach has been integrated into the following activities: Induction and orientation of new staff Staff performance appraisals Most staff education in service programs Policies & procedures that support ASM implementation Client Services Managers (CSMs) continuing to explore opportunities for integration of service delivery with other HACC Assessment Service (HAS) providers Underpinning the Broadband Enabled Innovation Project which supports medicines management via video conferencing telecommunications and the National Broadband Network to appropriate people 6. Evaluating the ASM Project and making recommendations with regard to ongoing holistic and person centred care initiatives across RDNS. Evaluation activities included implementation of a pre and post Staff Satisfaction Survey across the organisation in December 2010 and January 2012 respectively. Other activities have included monitoring of recruitment of people to the ASM program code over the course of implementation and review of incidents and complaints from people on the ASM program code. ASM related indicators have also been integrated into organisational quality improvement audits and the RDNS Client Satisfaction Survey. People on the ASM program were also included among the random sample for the Client Satisfaction Survey to allow for comparison of the results within the sample. RDNS Active Service Model Evaluation Final Report Page 14

19 2.1.3 Stage of ASM implementation The development of this report follows two and half years of implementation of the ASM approach to nursing care for people receiving RDNS HACC services (Victorian sites and programs). Now in the third year, the ASM implementation remains focused upon sustainability of the approach as business as usual more broadly, and in particular, the continued application of ASM approaches to assessment and care planning as part of RDNS HACC assessment service role. The implementation process at RDNS has been strategically managed, coordinated and guided by a Project Coordinator and a Project Board, involving all areas of the organisation. This has been essential to ensure momentum, manage the flow of information and coordinate responses. Staff have been directly involved in discussion of issues and challenges. Changes to service delivery have not been immediate, although staff have been encouraged to reflect on areas requiring review or change, as well as identify strengths of current practice. Managers across the organisation have led, and are expected to continue to lead, the change and ensure sustainability within their workplace environment. Multiple changes have been implemented with the introduction of the ASM. These demonstrate significant commitment at senior management level. Key areas of support include: promoting the ASM concepts at the governance level and gaining support and authorisation; training for staff, and implementing initiatives including the Dementia Model of Care, Leg Ulcer Prevention Program and Medicines Management Project. RDNS has used group approaches where appropriate, to ensure staff engagement. We have used change management strategies to embed the model including staff engagement, harnessing support, articulating goals, identifying accountabilities and team development. The project has resulted in increased capabilities in regards to the ASM approach and considerable progress towards changes being embedded across the organisation. These change management activities and the executive level of support for them suggest that RDNS is already at Stage 2 of the three outcomes areas of progress conceptualised by the Department of Health (2010 pg. 4). There is also early indication of achievement of Stage 3 outcomes (improved HACC service delivery and better outcomes for clients). 2 Examples include improved models of care (e.g. Dementia Model of Care, Leg Ulcer Prevention Program), new holistic assessment tools and ASM case studies which demonstrate better outcomes for clients. These concepts are explored further in this report when discussing the use of theoretical models to explain RDNS systematic and strategic approach to transitioning towards an Active Service Model of care. 2 Stage 1 Outcomes: HACC funded agencies have increased knowledge about the application of an ASM approach and have increased commitment to implementing an ASM approach Stage 2 Outcomes: HACC agencies have started to implement an effective ASM approach systematically in practice. Stage 3 Outcomes: Improved HACC Service delivery and better outcomes for clients. RDNS Active Service Model Evaluation Final Report Page 15

20 2.1.4 Other studies of implementing similar approaches Several other programs have adopted comparable models of care to the Victorian Active Service Model approach. Other similar concepts include independence or wellness programs such as in Western Australia (WA), restorative care in the USA and re-ablement or enablement in the UK. Models of Homecare Re-ablement in the UK have been developed and implemented by each Council and are underpinned by national policy from the Ministry of Health. The focus in service delivery is on doing with rather than doing for and time limited interventions. Significant variation in these models of care has resulted from the flexibility afforded Councils to implement the policy in ways that suit local requirements. Evaluation has shown that re-ablement programs resulted in reductions in the need for ongoing care in comparison to usual care (Glendinning et al., 2010). Development of restorative approaches to home and community care in the USA has been limited, as funding tends to be by individuals and private health insurance funds. Despite this, a number of large scale research projects have been undertaken to evaluate the effectiveness of a more restorative approach (Tinetti et al., 2002). In New Zealand (NZ), there is a comprehensive system of home care provision at low cost to eligible citizens across the country. Community care assessments are undertaken by government-funded teams, who then put forward detailed recommendations and funding towards a specific package of care to privately run service providers. The system is currently coordinated by each district health board. Several new developments with a more restorative emphasis are under way within the NZ home care system. This includes recent improvements in assessment tools, training in more restorative methods for staff at all levels, development of new funding models to provide an incentive for a more restorative model, and development of new types of services oriented around social goals (Ministry of Health New Zealand 2006). The Silver Chain Home Independence Program (HIP) in Western Australia was developed as an early intervention programme directed at optimising functioning, preventing or delaying further functional decline, promoting healthy ageing and encouraging the selfmanagement of chronic diseases. It is designed to be targeted at individuals when they are first referred for home care services or at existing home care clients who request an increase in level or amount of service, with the expressed intention of minimising the individual s need for ongoing support services (Lewin et al., 2006). The HIP program has been evaluated using a non-randomised controlled trial. This study demonstrated that clients who received a restorative home care program would have better outcomes than clients receiving usual home care. Both the WA Silver Chain and the UK programs have targeted relatively low dependency clients, who are referred at the point of entry to home care services. Following the completion of the program, clients are then referred for ongoing standard HACC services if required. RDNS Active Service Model Evaluation Final Report Page 16

21 Common elements involved in the enablement programs mentioned include: A multidisciplinary team comprised of a combination of allied health staff and home care agency staff Comprehensive assessment (face to face and in the person s home) A combination of interventions incorporating both functional and social goals Time-limited duration The WA state government has funded the roll-out of a broad-based training package within a range of existing home care providers outlining the principles of restorative care. The Wellness Approach to Community Homecare or WATCH (O Connell, 2006) has now been formally recognised as a key priority for the WA HACC system. This approach encourages HACC services to work with people to retain or regain skills and prevent loss of independence. Evaluation of the Wellness Approach found most HACC service providers supported the philosophy of care and that sound progress was being made with implementation. Barriers identified included complexity of Wellness paperwork, lack of change management resources and a need to tailor the program for special needs and rural populations. This approach is distinct from a restorative or enablement model, in that it is proposed as an underlying philosophical approach to providing services which reinforces and supports each person s level of independence. In Victoria, the Department of Health has similarly adopted the Active Service Model more broadly as a quality improvement initiative to underpin the delivery of all HACC services. Pilot projects were formally evaluated (focusing upon different models or areas of ASM practice) to assist in the development of the Active Service Model and explore associated implementation issues. An implementation plan was developed by the Department based upon a detailed literature review and discussion paper and significant consultation with the sector, service users and carers. HACC funded agencies in Victoria, like RDNS are now working towards an ASM approach through implementation of their own ASM plans. The literature suggests a restorative home care service may be of benefit to older people, and may improve the ability of HACC services to support people to live independently in the community. It is unclear however, from the present literature which components are integral to achieving positive outcomes or the most appropriate assessment approach, staff mix, program duration or whether or not such an approach can be integrated more broadly into home and community care services, as is the approach in Victoria. Learnings from the UK suggest that regardless of the structure, programs that have been most successful have involved substantial efforts to re-train care staff with new skills and a new model of practice as well as considerable re-organisation of the service. Those that have simply re-named services and have not involved re-training and re-structure have not been successful (Pilkington 2006). RDNS Active Service Model Evaluation Final Report Page 17

22 2.2 Evaluation Overview The Department of Health approached RDNS to undertake an evaluation of impacts of the RDNS Active Service Model Implementation Project to inform planning for the evaluation of the ASM program state wide. A project brief scoping the evaluation was prepared by RDNS in collaboration with the Aged Care Branch, which was approved by the Victorian and Commonwealth Governments. The evaluation commenced in November 2012, with the purpose of determining the extent to which ASM principles have been translated into practice across RDNS HACC services and of what benefit this has been to people receiving services and the organisation. A key aim was to identify barriers and enablers associated with implementing the ASM approach to care. The key objectives for the evaluation were: 1. To collaborate with the Department of Health and establish appropriate governance structures to monitor the project s progress and reflect on outcomes 2. To develop and use agreed quantitative and qualitative methodologies, tools and indicators to measure ASM related outcomes for people receiving RDNS HACC services 3. To collect, collate, analyse and interpret data consistent with the agreed methodologies 4. To develop a final report describing the major themes and issues regarding translation of ASM principles into practice and their policy and program implications 5. To report on the extent to which the implementation has demonstrated an improvement in people s independence or wellness The outcomes expected from the project included: Demonstrated progress towards translation of translation ASM principles into practice as part of a person centred approach to care Contribution to the evidence base for further implementation of the ASM model Strengthening of the collaborative relationship between RDNS and the Department of Health The expected benefits of the evaluation were: Development of appropriate measures of translating ASM principles into practice Demonstrated evidence of the extent of integration of ASM principles into practice Identification of barriers, limitations and learnings associated with implementation of the ASM approach to care Scope of the evaluation The scope of the evaluation was restricted to mainly qualitative methods focused upon information that could be extracted from a review of a random sample of RDNS care records, ASM reflective practice case studies and client service data. RDNS Active Service Model Evaluation Final Report Page 18

23 It was agreed that the random sample for the care record audit be drawn from people receiving RDNS HACC services with an ASM program code and compared to a sample of clients receiving usual care. The sampling methodology is explained in more detail in 3.2. People receiving services and their carers were not included directly in the data collection due to fixed timelines and concerns about limitations of this approach and ethical considerations. To overcome this, it was considered that RDNS staff could serve as proxies for understanding the perceptions and experiences that people and their carers may have concerning ASM care approaches. A focus group discussion with nursing staff was conducted for this reason and to also verify and test findings from the client record audit and analysis of case studies. Despite development and implementation of an organisational Client Satisfaction Survey incorporating ASM related indicators and benchmarking, a decision was made to not include this specifically in the scope of the evaluation. This was due to a lack of opportunity to influence the ASM indicators being investigated. However, it was agreed that results of any significance would be shared. Whilst the methodology included development of a client profile, it was not considered in scope to include visit data or develop a visit profile due to concerns over data quality and cleansing and exceeding set project timelines. However, some semi-quantitative analysis of the record audit data was included to indicate the average length of stay associated with the sampled records. It was not within the scope of the project to consult with or collect data involving other HACC services. Nor was the project to explore sector wide or system impacts or benefits. However, if such information were to be identified, it would be documented and shared Limitations Whilst the approach to implementation of the ASM model within RDNS has been focused upon change management strategies to bring about practice improvements, challenges exist with the capacity to effectively identify and measure changes in professional practice. Work is still underway concerning the introduction of a new intake and screening tool, holistic assessment tool and updated care planning documentation. For this reason, interpretation of the data and findings presented in this report should be made with some acknowledgement of limitations in these areas. Care documentation currently has not yet been modified to facilitate recording of assessment information, nursing care plans and progress notes in a format that demonstrates an ASM approach to the fullest. Despite this, the professional practice of RDNS staff and supporting policies, processes and systems were well established and to some extent were already consistent with aspects of an ASM approach to care. To this end, identification and measurement of ASM progress and impacts should recognise both the strengthening of existing practices as well as introduction of new ones. RDNS Active Service Model Evaluation Final Report Page 19

24 2.2.3 Main evaluation questions As the purpose of the evaluation was to determine the extent to which ASM principles have been translated into practice and of what benefit this has been to a person s outcomes, the ASM principles were used to guide the development of the survey instruments involved in the evaluation activities. Table 1 identifies examples of practice for each of the ASM principles which have been incorporated into the survey instruments developed for the case study analysis, file audit and staff focus group. Table 1: ASM principles and examples of practice ASM Principle People wish to remain autonomous People have the potential to improve their capacity People s needs should be viewed in a holistic way HACC services should be organised around the person and his or her carer, that is, the person should not be slotted into existing services (flexible and responsive) A person s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and family; support workers and between service providers Examples of practice Involved in making decisions about their life/care and priorities Improvement or maintenance of functional ability Focus on strengths/abilities and not just deficits/needs What people can do as well as what they cannot do Supports independence to manage activities of daily living Improve confidence and motivation to manage aspects of /all care Wellness promotion both functional and social goals/actions Holistic needs (not just presenting needs) are considered in conversation with a person at assessment, in care planning and throughout care delivery Individualised approach adopted Respect for person/diversity (including special needs)/personal preferences Involved in decisions & care planning Evidence of getting to know person (beyond diagnosis) Support to identify goals Flexible service sensitive to a person s needs and values; provides choice; service provided at times which suit the person and organised around the person Communication Interdisciplinary practices Referral (including e-referral) RDNS Active Service Model Evaluation Final Report Page 20