1. Nurses can identify frail older people in general
practice populations and make a difference to
outcomes using PENCAT
Threepoints that summarise the implications of the abstract for clinical practice:
People aged 65+ make up 32% of consultations in Australian General Practice (but only 14% of the overall population) and in
the community many of this group have unrecognised functional decline and frailty, a core factor for admission to hospital and
premature entry to residential aged care facilities.
A model of primary care based rehabilitation/restoration for older people is possible when general practice and community aged
care providers collaborate to improve outcomes for frail older people.
General Practice Nurses are an important a link in this relationship due to their role in performing 75+ health assessments, care
planning, and the care coordination of the older person with complex needs. However there has not been a formal system for
nurses to target such assessments for this most “at risk” group in general practice populations. The PENCAT tool can be used to
identify older people most at risk of frailty and functional decline using a “recipe”.
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Introduction
• According the BEACH study, people aged 65+ make up 32%
of all consultations in Australian General Practice but only
14% of the overall population) (http://ses.library.usyd.edu.au//
bitstream/2123/11882/4/9781743324226_ONLINE.pdf). Many older
people in the community have unrecognised functional decline and
frailty, a core factor for admission to hospital and premature entry
to residential aged care facilities. (1 in 5 people attending a hospital
emergency department are aged 65+ ) This will become a greater
issue as our community continues to live longer, and requires home
based community aged care rather than moving to residential aged
care. The number of RACF beds will never be enough for our aging
population, so a focus on keeping older people well at home for longer
is an imperative, and primary health care nurses have a critical role in
recognizing who is at risk.
• A model of primary care based rehabilitation/restoration for older
people is possible when general practice and community aged care
providers collaborate to improve outcomes for frail older people.
• General Practice Nurses are an important link in this relationship due
to their role in performing 75+ health assessments, care planning, and
the care coordination of the older person with complex needs.
• However there is no formal system for nurses to target such
assessments for the most “at risk” in general practice populations. This
group is the most in need of preventive and restorative services in
order to change the trajectory of functional decline
ACH Group is a leading provider of community aged care services in
South Australia and Victoria. It is the lead organization which successfully
applied for project funding via the Commonwealth’s Better Health
Connections program to develop a project called Connecting Health
and Aged care Services Effectively (CHASE). The CHASE project used
evidence from case note audit results which showed a large number of
people aged 75+ attending a hospital Emergency Department have not
had health assessments and if they have had care plans, they are often
simply disease specific rather than focusing on the true complex care and
functional needs of the older person.
The project developed and refined the use of the PEN Computer Systems
Clinical Audit Tool (PENCAT extraction tool) to find older people most
at risk of frailty or its related complications in order to target health
assessments, care plans and team care to those who most need access
to more services, including restorative care. Access to Emergency
Department data about presentations and the corresponding General
Practice data were cross referenced to assess the relevance of the
various PENCAT search results.
Conclusion
• Frail older people were identified in three General Practices using the
PENCAT tool. This group of people were invited to become part of the
CHASE project and were offered a 75+ home health assessment,
• many issues were identified at the health assessment, triggering
referral to a variety of restorative programs provided by private allied
health, community aged care providers or state health services. The
intent of the referrals was to improve function, preventing further
decline and premature admission to Residential Aged Care Facilities
(RACFs) or admission to hospital
• The project triggered a change in culture of the general practices
involved with a focus on quality care of older people not just based on
medical issues but on functional and social issues.
What is the recipe for the Classic CAT?
1. Perform a new extract of your practice population
2. Choose a search of:
a. All patients aged 75+ (can be changed to 85+, if high numbers of
older people appear in the search and in order to prioritise the care)
b. Have been seen within the last 6 months
c. Are taking 8+ medications
d. Have one or more of the following health conditions:
i. Dementia
ii. Stroke
iii. Chronic Obstructive Pulmonary Disease (COPD)
iv. Heart failure
v. Depression
vi. Chronic Kidney Disease (CKD)
e. And have not had one or more of the following MBS items:
i. Health assessment (items 705-707)
ii. Care plan (item 721)
iii. Team Care Arrangement (723)
iv. Care plan/TCA review 732
3. Perform the search and print the resulting list which will describe
which “at risk” complex older people in your practice have not been
approached for all the planned health assessment/prevention activities
which are possible in general practice
4. Unfortunately Australian General Practice software vendors have yet
to differentiate community and RACF dwelling members of the general
practice population, so the initial list will need to be manually reviewed,
and RACF residents excluded from the list
5. Make contact with the older person and/or their carer and offer to make
an appointment for the required assessment
6. Don’t forget to update their social history, and include a frailty screen in
your assessment!
7. Make referrals to day therapy services, community aged care
providers, exercise classes and other providers who can
a. Improve the function of the older people, in order to reduce their
decline
b. Reduce the social isolation , which impacts on older people
c. Restore the older person to Good Health!