Setting new goals with restorative care
17 May 2016
Mary’s* ongoing frozen shoulder continued to impact on her mood and capacity to do what she once loved. Mary was a participant in Catholic Healthcare’s community services’ Short-Term Restorative Care (STRC) pilot. She was central in designing the “how-to-steps” of her restorative goal so that she could get back into the ocean pool. “The long summer is one to remember especially in my 90th year,” says Mary. She feels that she can once again manage her health condition through exercise; she feels motivated and plans to keep on having fun. “Every day is a blessing. I was lucky to be selected for the pilot program and feel younger than I have in a long time. Thanks Catholic Healthcare’s community services for your health and wellness guidance.”
MOVE TOWARDS HEALTH AND WELLNESS
Functional decline of our senior citizens may seem inevitable to the many people with whom they are surrounded. This includes their key support networks – the carer, the spouse and the doctor. After years of an illness model of health within Australia and beyond, Catholic Healthcare’s community services believes we must quickly move towards a health and wellness focused system. Many people are living with chronic conditions and lack of support to manage their health and wellness. This often means functional decline is inevitable. Then add a person’s years to the probability of being able to actively manage health and wellness and we are faced with a large challenge, the organisation says.
STRENGTHENING THE FOCUS ON WELLNESS
Catholic Healthcare’s community service’s General Manager, Janis Redford set upon ensuring there was an organisation-wide approach that supports the delivery of health and wellness programs and services. “In 2014, we commenced the development of a formal Health and Wellness Framework. A consultant was engaged to work with the senior leadership team and key stakeholders to develop the framework through extensive research and through one-on-one discussion and workshops with staff,” says Redford. “Internal workshops were undertaken to seek feedback on the draft Health and Wellness Framework. This process of engaging with a broad group of staff to seek their input led to a vision, framework document and action plan that became the foundation for our health and wellness approach.”
The framework includes six key domains - Being Active, Healthy Eating & Drinking, Staying Connected, Lifestyle, Clinical Care and Healthy Mind. It also acknowledges that the development and implementation of services and programs within each of the six domains, will occur using a range of technology and communication channels, recognising that staff and the culture of the organisation are key enablers of the success of the implementation, says Redford. “As a result of this work, in 2015 we established the Health and Wellness Unit, employing a Health and Wellness Manager. Having a dedicated resource to implement the Health and Wellness Framework was essential for ensuring sustainability and maintaining the focus. We are in the process of expanding the unit to recruit more expertise and increase the development of programs.” Following this, the organisation trained its community workers and co-ordinators to adopt reablement approaches. This skill set was evident in the 2015/2016 restorative pilot program where community workers were confident in stepping up to assist health coaches to guide health and wellness outcomes.
“Supporting our frontline workforce to become more diverse and adaptable has meant that they can assist greatly in improving health outcomes. Given the struggle with sourcing staff within the aged care sector we have focused on building skills internally and supported a group of staff to undertake further formal education. There are so many programs and services where they will be making a difference as the swing from traditional services occurs. Senior citizens want more things that are meaningful to them. It is exciting to see people’s health and wellness flourish,” says Redford. According to Dr Cathie Buckley, lead of the organisation’s Short-Term Restorative Care (STRC) pilot, Catholic Healthcare’s community services has been increasingly focused on promoting client health and wellness since 2010, informed by its overarching Health and Wellness Framework, which underpins its programs and approach.This organisational approach is aligned with the broader changes underway in the aged care sector, where the move towards consumer directed care and client empowerment has coincided with a mindset shift away from the management of illness towards the promotion of health and wellness, says Buckley.
“We’ve not only embraced that change, we wanted to provide thought leadership to the sector in relation to that emerging philosophy of care, such as wellness and restorative care,” says Buckley. Daniel Davies, Health and Wellness Manager and clinical lead on the STRC pilot, says the organisation has adopted the World Health Organisation’s definition of wellness, which outlines it as an “active process of becoming aware of and making choices towards a healthy and fulfilling life, a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity.”
“We’ve had decades of the illness model, and the aged care reforms have turned that on its head, hence we saw the opportunity to run a restorative pilot to enhance people’s function, independence and quality of life,” says Davies. The health coaching model cemented that senior citizens are central to the “active process of becoming aware of and making choices towards a healthy and fulfilling life.”
A NEW TARGET FOR WELLNESS
Catholic Healthcare’s community services undertook significant research to look for a suitable tool or model it could use for its restorative care pilot. While there has been much research conducted in the rehabilitation setting, less has been carried out focusing on community aged care. The studies it found kept leading it back to a group of researchers at the University of Auckland’s Faculty of Medical and Health Sciences, who had developed and tested a unique tool for use in a restorative care program, the TARGET (Towards Achieving Realistic Goals in Elders Tool). The TARGET tool stood out to Catholic Healthcare’s community services for a few reasons. First, it put the client at the centre of the goal setting process. This meant goals were chosen because they were personally significant, not simply prescribed by a health professional. Utilising a health coach to guide a restorative process further assisted as there was a formulation of a partnership that assisted in attaining goals. “In a lot of the restorative care or reablement programs the outcome measures are around the ability to improve function of specific body parts – for instance, how quickly can you sit and stand as an indicator of the strength of your quad muscles. Whereas TARGET had a very different approach, in which the client decides their own goal, a goal that was meaningful and meant that they could achieve what in essence was important to the person.” This usually related to performance of a task or activity, says Buckley. “Now we’re in the consumer directed care environment, we wanted to hear the client’s voice; what were the things that were important to them. We believed that even within a restorative model, if a person chooses their own goals then their motivation would be enhanced and goal attainment would be more in reach.”This proved true, as indicated by the outcome measures utilised at baseline and eight weeks, adds Davies.
As a result, some of goals that clients set included: moving around the house safely, being able to knit again, getting back into the swimming pool, showering and shaving independently, and cooking hot meals without help. The second unique aspect of TARGET was its approach to setting an overarching goal as well as interval goals. “There’s a distal, or long-term goal, and underneath that sits smaller, proximal, shortterm goals,” explains Davies. “That way you establish the mini steps that progress you towards that overarching distal goal. It makes achieving that end point less overwhelming.” It made goal attainment achievable within an eight-week timeframe. Third, the TARGET tool allowed for the adoption of a health coach approach, which Catholic Healthcare’s community services was keen to utilise.
“We surround the client with a care ecosystem,” says Buckley. At the heart of that ecosystem is the pair of health coaches – a physiotherapist and an occupational therapist – who lead and supported the other members of the team, which include the care workers, case managers, family carers and GP. Under the program, all members of the team are provided with the TARGET tool which clearly outlined the client’s goals and how they wanted to achieve them. The use of the term health coaches to describe the two allied health professionals was very intentional, explains Buckley.
“There’s a societal view that ageing is intrinsically linked to functional decline...We wanted a coaching model that would challenge those beliefs, and provide motivation, which was key. “It also made the allied health professionals less daunting for the participants in the study, so they felt they could work with them, and the TARGET tool allows them to be part of the decisionmaking process,” adds Davies. The health coaches not only motivated the client, but also further engaged the community care workers through upskilling them so that they could assist study participants to practice activities of daily living and practice their exercises. It noted that over the period of the eight weeks of interventions that the participants were able to perform more of their personal care tasks and meal preparation tasks. Weekly meetings with the health coaches and care advisors monitored the client’s progress and utilised the teams’ collective experience in overcoming any barriers as they arose.
PUT TO THE TEST
The eight-week program using the TARGET Tool commenced in November 2015 with 10 community clients on the NSW Central Coast, who each commenced the pilot within a two-week timeframe. “We deliberately chose a small sample size so that we could get that deep understanding of any barriers, and opportunities for an innovative model of care that potentially could be applied across the organisation. Many researchers describe the value of a small sample size,” explains Davies.While flexibility was important to the pilot, a thorough evaluation required that assessments be conducted at certain points in time. These were undertaken at the beginning (to capture baseline measurements) then in week five and again at week eight before exiting the pilot. Allowing clients to set their own goals was clearly a unique and positive feature of the pilot, Buckley explains, but from a research perspective it made measuring the outcomes more challenging; how do you apply a uniform research approach when the participants all had different goals with different timeframes to achieve them? While participants selected their own goals and the pace at which they’d achieve them. The organisation aimed for functional and quality of life improvements. Health coaches also had to engage the clients in negotiating and agreeing what goals could be achieved, and by when.
Ultimately, the results from the pilot were very encouraging: 90 per cent of clients improved their level of functioning, all clients achieved at least one physiotherapy goal and 88 per cent achieved at least one occupational therapy goal. Improvement in functioning was seen in key domains including mobility, transferring, feeding, showering and walking, says Davies. “Those are the key domains where when people improve, the need for traditional care services can be reduced, which is consistent with the government’s definition of restorative care.” Overall there were 38 distal goals and 97 proximal goals coded against the 157 World Health Organisation’s International Classification of Functioning domains. This demonstrated a reasonably wide spectrum of goals, and acknowledged what were the areas that people wanted to improve upon in their lives. Mean changes across the functional and quality of life outcome measures supported evidence of change.
Carers and case managers reported a 75 to 100 per cent overall client improvement in activities of daily living. Significantly, the pilot also suggested there was a reduced burden on carers, which was a surprise finding, says Buckley. “Around 90 per cent of the carers rated the improvement of the clients and the impact of that on their activities of daily living as extremely high,” she says. This high impact reduction of carer burden could be significant, as carer burden has been linked to rates of hospitalisation and premature admission to residential aged care. However, Buckley stresses that studies with larger samples are needed to more thoroughly examine the potential impact on carers.
ISSUES THAT AROSE
As Catholic Healthcare’s community services expected, the pilot also highlighted some key issues and challenges that need to be addressed as the organisation seeks to progress its health and wellness agenda. For instance, some clients were reluctant to accept a reduction in personal care or domestic assistance hours as they were concerned about whether they could get that help back again if they needed it, recalls Buckley. For Davies, this highlighted that although there was currently flexibility within the system to utilise a higher or lower package, a decrease to a lower level package was usually not being taken up by senior citizens. Arguably there are a few key reasons for this; the length of time it takes to change packages, the lack of level 3 or 4 packages available if the senior citizen requires a higher level package in the future, and the lack of options to stay on a lower package and receive additional funding for brief intensive restorative programs. Therefore, in turn, the client’s health and wellbeing does not progress in a positive direction. “Surely for many senior citizens the expectation of progressing to a higher funded package sets the expectation that there is inevitable functional decline! Our pilot study clearly indicated that senior citizens can make functional improvements and prevent this progression,” says Davies.
“If society is to truly move away from the illness model, there should be better availability of brief intensive support, as well as more incentives to remain on a lower level package and actively manage your health.” The pilot has also highlighted that the organisation’s frontline care workers can be supported to act as therapy aides, says Davies. “It’s shown we can utilise our Certificate III and IV trained community workers in some circumstances, under the direction of a health coach, to provide guidance for repetition of exercise and activities of daily living. They performed the task very well,” he says.
Armed with these insights from its pilot, Catholic Healthcare’s community services is now working with their research partners at the University of Auckland, as well as researchers at the Hunter Medical Research Institute, with which it has subsequently formed a partnership, about what future research projects could be undertaken. Catholic Healthcare’s community services is also implementing a new training curriculum for staff focusing on health and wellbeing to further support them in embedding wellness for senior citizens. “We’ve been undertaking this work for a while, but it’s a significant culture change,” says Davies. “It’s more about continuously improving and refining the model of care. These are exciting times.”
*Names have been changed