STATEMENT: AOTI concerned about HSE “Flexing the ECC Model” Document
AOTI response to the HSE document “Flexing the ECC model to provide an interface with both public and private nursing homes to improve hospital avoidance and to support post-hospital discharge”
The Association of Occupational Therapists of Ireland (AOTI) is the professional body serving, promoting and representing Occupational Therapists in the Republic of Ireland. We are the voice for the Occupational Therapy profession. Occupational Therapists help people to do the everyday activities they want and need to do when faced with illness, injury, disability or challenging life circumstances.
AOTI acknowledges the pressure acute hospitals are experiencing as well as the fragmented experience of older people attending these hospitals for unscheduled care. We welcome consideration of ways to improve a person’s experience navigating the system. However, the “Flexing the ECC Model” document appears to focus on the crisis in Emergency Departments (ED) and patient flow through the hospital, rather than taking a holistic approach to providing healthcare to the older person presenting to the hospital.
The document refers to delivering high quality care in the right place, at the right time, by the right team, in line with Sláintecare. However, to create an easier pathway to nursing homes would seem to be at odds with the premise of Sláintecare. The document does not appear to recognise that Occupational Therapists working in specialist Integrated Care for Older People (ICPOP) teams are currently working at full capacity with waiting lists. It is not possible to absorb additional caseloads without negatively impacting existing over-stretched community services. We also have concerns around equity of service provision given the expectation that services will be provided for clients transitioning into the nursing homes and not for existing residents. It goes without saying that currently teams would not have the capacity to provide services to full nursing homes without a significant increase in recruitment of specialist staff.
The document proposes that the decision for discharge to nursing home could be made by frailty at the front door teams. This is concerning given the potential for premature admission to a nursing home. Older people require time to recover from acute illness or injury, followed by a period of multidisciplinary rehabilitation to maximise their engagement in valued activities. There is also additional concern relating to individuals who are in a nursing home for short term rehabilitation. There is no clear process of linking these individuals back to primary care teams for follow up and support when leaving the nursing home.
The document fails to address potential clinical governance or indemnity issues for services providing “in-reach” services to private nursing homes, and from acute care to community care. There is no clear definition of the term rehabilitation and who is responsible for carrying out the recommended rehabilitation interventions following the Comprehensive Geriatric Assessment (CGA). This is a cause for concern given that a lack of rehabilitation will likely result in reduced ability and poorer outcomes in the older adult population.
Disappointingly, there was a clear lack of engagement with key stakeholders such as clinical staff and, crucially, service users. There appears to be a lack of consideration of service users’ will and preference, as championed by the Assisted Decision Making (Capacity) Act 2015. The “Flexing the ECC Model” document appears to be more focused on the needs of the health service rather than those of the individual, prioritising improvement of the flow of patients through acute hospitals rather than meeting older people’s unique and individual needs. Furthermore, no alternative solutions to nursing home care are identified in the paper.
AOTI strongly believe that an alternative model should be considered. This should have a rehabilitation and home-first focus. If direct discharge home is not viable, there should be access to rehabilitation beds which are staffed by specialist nursing and health and social care professionals such as Occupational Therapists. This would enable a holistic focus on the needs of the older person, promoting their engagement in everyday activities and maximising their independence.
The wishes of the older person should be at the core of any discharge plan, with nursing home care being a last resort rather than a default option. AOTI is concerned that some older people may avoid attending the ED for necessary medical care if they perceive they may be sent directly to a nursing home. Conversely, older people may be brought to the ED prematurely if it is believed this could be a direct pathway to nursing homes.
All older people attending acute care should be provided with an opportunity to recover prior to a life-changing decision being made relating to nursing home placement. Opportunities to maximise mental, physical and social functioning in familiar environments following an acute episode should be first option.
There is a notable absence of mental health considerations throughout the “Flexing the ECC” document. An older person’s ED admission and/or need for nursing home placement often occurs due to worsening of mental health symptoms (e.g. behavioural and/or psychological symptoms of dementia) or due to carer burnout. There has been no inclusion of mental health services within the proposed pathway or service integration which is at the core of Sláintecare. While there currently is input from mental health teams to nursing homes and acute hospitals, this often does not include Occupational Therapy, or indeed any health and social care professional input. We propose that formal links with mental health specialties needs to be a core consideration.
In summary, the “Flexing the ECC Model” document has been drafted without adequate consultation with clinical staff. It reflects a poor understanding of good practice in the provision of healthcare to older people. It is our view that the model appears to be reactionary in nature. Re-routing current ICPOP teams to cover nursing home care is not a viable solution to bed management issues within the acute sector. The proposed model is in direct opposition to the client-centred values which are core to Occupational Therapy.
We propose an alternative model where recruitment of dedicated teams is prioritised. These teams would provide specialised rehabilitation in home-based/in-patient settings to facilitate discharges from acute care. In addition, there would be dedicated teams who would meet the needs of older people transferring to and residing in nursing homes. Existing initiatives such as Pathfinder and EDITH (in which Occupational Therapists are core team members) were expressly set up to support older people to remain at home even though they or a family member have phoned for an ambulance. These services need to be optimised with the development of clearer rehabilitation pathways & services between acute and community services.
1st December 2023