The Integrated Rehabilitation and Enablement Program (iREAP)

iREAP is an eight-week program that delivers integrated rehabilitation services to older people in the community who have or are at risk of frailty, falls, Parkinson’s Disease and other neurodegenerative conditions.

Aim

To reduce frailty and improve physical outcomes and quality of life in clients with complex health needs living in the community.

Benefits

• Streamlines referral pathways for General Practitioners (GPs).
• Reduces the risk of avoidable hospital admissions.
• Enhances relationships between GPs and the community.
• Provides timely access to intensive, evidence-based treatments.
• Improves clinical outcomes, including physical capabilities and quality of life.
• Improves clients’ level of health knowledge, skills and confidence in self-managing their chronic condition.
• Involves the client in care planning, rehabilitation and goal setting.

Background

Frailty is commonly associated with ageing, with 10 per cent of people aged over 65 and 25-50 per cent of people aged over 85 experiencing the condition¹. Frailty causes people to become weak and is associated with a higher risk of disability, admission to hospital and death¹. Falls are also common in frail people living in the community, with 30-40 per cent of people aged over 65 having at least one fall each year². In addition to frailty, people aged over 60 are at a higher risk of Parkinson’s Disease, a progressive neurodegenerative disease.

Geriatric syndromes such as frailty and Parkinson’s Disease have become more common in Australia due to its ageing population. In South Eastern Sydney Local Health District (SESLHD), the population of people aged over 65 years is expected to increase by 30 per cent in the years ahead, equivalent to an additional 85,500 people by 2031³. Falls are the leading cause of injury in older people in SESLHD, causing 24 people to be hospitalised each day³. Due to their complex nature, clients with these conditions tend to have a longer length of stay in hospital⁴.

Prior to the project, older people were provided with outpatient rehabilitation services from a single discipline, with minimal coordination between departments. Services were also reactive in terms of managing existing conditions, rather than working to prevent illness, injury and decline. As a result, it was determined that a proactive and multidisciplinary rehabilitation program would improve client outcomes and quality of life, while streamlining their healthcare journey.

Implementation

• Focus groups, surveys and stories were gathered from key stakeholders in October 2015, including GPs, consumers and carers. These were used to identify gaps in service provision and areas for improvement.
• A project team was created, including representatives from each allied health discipline. The team developed an eight-week program based on a literature review of best practice in terms of frailty, falls, neurodegenerative conditions and integrated care^5,6,7.
• A Care Coordinator and Allied Health Assistant were recruited to the new iREAP team and allocated responsibility for coordinating care within allied health, geriatric medicine and continence teams within existing outpatient services.
• A new referral pathway was developed in March 2016, in conjunction with GPs and clinicians. It aimed to streamline the referral process through a single point of contact, a central location to load referral documents onto the Primary Health Network website and structured communication to the client’s GP on discharge.
• An education forum was held in July 2016 in partnership with the Primary Health Network, to educate GPs on the new program, including referral criteria and processes.
• The program was trialled on four clients in March 2016, who received:
  • a personalised care plan
  • a comprehensive geriatric assessment
  • speech pathology screening and intervention if required
  • podiatry and dietetics screening and intervention if required
  • occupational therapy and physiotherapy intervention through group and individual activities, based on clinical need
  • referral to psychology, hydrotherapy, continence nursing and social workers as required
  • the opportunity to complete the program as an outpatient if appropriate, providing an alternative to an inpatient rehabilitation stay.
• An education program was developed in February 2016 to improve knowledge of falls, frailty and neurodegenerative conditions among clients. Ten one-hour education sessions were delivered by community health, allied health and nursing staff across the eight-week program.
• iREAP continues to run in two groups: a falls and frailty group and a neurodegenerative group. There are a maximum of eight clients in each group, with personalised rehabilitation plans for each participant.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

Diagnostic phase: July 2015 – February 2016
Implementation: March 2016 – July 2017
Evaluation: March 2017 – August 2017

Implementation Sites

War Memorial Hospital Waverley, SESLHD

Partnerships

• Central Sydney Primary Health Network
• Agency for Clinical Innovation
• The Innovation Hub at SESLHD
• Parkinson’s Disease NSW Counselling Service
• Community Pharmacy

Evaluation or Results

• An evaluation of data collected between March 2016 and July 2017 showed that iREAP is an effective model for improving outcomes in older people with complex needs living in the community.
• A total of 76 clients completed the program during the evaluation period—35 in the frailty and falls group and 41 in the neurodegenerative group.
• Ten potential hospital admissions were avoided through geriatric assessment, speech pathology screening and a reduction in frailty and falls risk.
• Significant improvements were seen in the mean Clinical Frailty score, which reduced from five to three (p <0.001), with the mean Timed Up and Go score reducing from 19.3 to 14.4 seconds (p <0.001).
• The frailty and falls group demonstrated a significant improvement in the Falls Efficacy Scale, reducing from 33 to 29 (p <0.001).
• There were improvements to clients’ quality of life, shown in the World Health Organisation Quality of Life Scale, which improved from 78 to 82 (p=0.035).
• The Parkinson’s Disease Questionnaire (PDQ-39) showed improved quality of life for clients, reducing from 49 to 39 (p = 0.001).
• Clients’ knowledge of their condition improved from 59 per cent to 78 per cent, measured using a locally-developed test that was incorporated into the education program (p<0.001).
• There was an increase in efficiency of outpatient services, with a 40 per cent increase in outpatient non-admitted activity by staff.
• Patient experience feedback shows the iREAP model is embraced and highly valued by clients who participate, improving their healthcare journey.
• Further evaluation of the program is planned, to see if these changes are sustained over time and have a long-term impact on preventing falls and hospital admissions.

Lessons Learnt

• iREAP demonstrated that clinical redesign can lead to better patient-centred care through coordination and goal-orientated approaches, with a focus on empowering clients to manage their own health.
• Partnerships with primary health organisations were crucial in establishing an proactive approach that improved the client’s journey.
• The use of existing staffing and physical resources was a challenge, however the ACI Building Partnerships Framework provided a guide for navigating the change.
• Engaging a local project team and early consumer input were important aspects in delivering the new model of care.

References

1. Clegg A, Young J, IIiffe S et al. Frailty in elderly people. Lancet 2013:381(9868):752-62.
2. Cesari M, Vellas B, Jsu FC et al. A physical activity intervention to treat the frailty syndrome in older persons – results from the LIFE-P study. Journals of Gerontology Series A, Biological Sciences and Medical Sciences 2015:70(2):216-22.
3. South Eastern Sydney Local Health District (SESLHD). Aged Care Services Plan 2015-2018. Taren Point NSW: SESLHD; 2015.
4. Rose M, Pan H, Levinson M et al. Can frailty predict complicated care needs and length of stay? Internal Medicine Journal 2014;44(8):800-5.
5. Fiatarone MA, O’Neill EF, Ryan ND et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. New England Journal of Medicine 1994;330(25):1769-75.
6. Tinetti ME. Clinical Practice: Preventing falls in elderly persons. New England Journal of Medicine 2003;348(1):42-9.

Further Reading

• British Geriatrics Society. Fit for Frailty: Consensus best practice guide for the care of older people living with frailty in the community and outpatient settings. London: British Geriatrics Society; 2014.
• National Institute for Health and Care Excellence. Falls: Assessment and Prevention of Falls in Older people. London: National Institute for Health and Care Excellence; 2013.
• South Eastern Sydney Local Health District (SESLHD). Integrated Care Strategy 2015. Caringbah NSW: SESLHD; 2015.
• Sherrington C, Michaleff Z, Fairhall N et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British Journal of Sports Medicine 2016. DOI: 10.1136/bjsports-2016-096547.

Contact

Name: Genevieve Maiden
Position: iREAP Care Co-ordinator
Organisation: War Memorial Hospital Waverley, SESLHD
Email: genevieve.maiden@health.nsw.gov.au
Phone: 02 9369 0457