overall winners of the 2013 NZACA/EBOS HEALTHCARE ... · 2013 NZACA/EBOS HEALTHCARE Excellence in...

Excellence in CARE

NOV

2013

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One voice for the aged residential care sector www.nzaca.org.nz

NOV 2013 ISSUE 3

P2 CEO’S MESSAGE: COMPLAINTS & REALITY

P4 WENDY ALDRED | LAW ON ADVANCE DIRECTIVES

P14 3 WAYS TO HIT THE HEADLINES

P18 JUDITH JOHNSON WORDS FROM THE WISE

ISSN 2324-5190

Photo supplied by the Matamata Chronicle

Pohlen Hospital, Staff and Residentsoverall winners of the 2013 NZACA/EBOS HEALTHCARE Excellence in Care Awards

NZACA are launching a new website – a ‘one-stop shop’ of information on Aged Residential Care.

Currently, if a person needs to learn about different topics of the aged care process, such as finances and the Needs Assessment process, they need to access multiple websites to find the information. ‘Find a Rest Home’ covers all topics of aged residential care in one website, making it very easy for people to find out everything they need to know about aged residential care.

The website has information on the entire process of getting into aged residential care, from how to get an assessment right through to entering a rest home or hospital.

The website includes an easy-to-use search engine, which identifies all the nearest aged care facilities to the user. The user enters in their address, and the search engine locates the nearest aged care facilities. Each rest home and hospital has a page for their facility, which provides an introduction to what their facility has to offer.

We will be launching this website to the public soon, so we need all NZACA members to log on to the page for their facility and check the information we have placed on their page. Instructions on how to edit the facility pages have been emailed to every NZACA member.

If you would like to know more about ‘Find a Rest Home’, or need help updating the page for your facility, please contact Asti Laloli on 04 473 3159 or email [email protected].

Home Page

Find a Rest Home Function

Facility Page

Disclaimer:The information in this publication is given in good faith and has been derived from sources believed to be reliable and accurate. However, neither New Zealand Aged Care Association nor the publishers accept any form of liability whatsoever for its contents, including advertisements, editorials, opinions, advice or information, or any consequence of its use.

AdVERtISINgFor enquiries regarding advertising or to place an advertisement in Excellence in CARE please contact: Robyn gray National Office New Zealand Aged Care Association PO Box 12481 Wellington 6144Phone: 04 473 3159 Fax: 04 473 3554

NZACA NAtIONAl OFFICE StAFF

Martin taylor [email protected]

Robyn grayConference [email protected]

Alyson KanaPolicy [email protected] Jennifer [email protected]

Asti [email protected] Accounts [email protected]

Excellence in CARE November 2013 www.nzaca.org.nz

UPfront2. CEO’s Report

Martin Taylor - Complaints and Reality

Features4. “I wouldn’t want them to keep me alive if I

was in that condition” The Law on Advance Directives By Wendy Aldred, Barrister, Waterfront Chamber

6. Moving with the Times - Conference Report By Robyn Gray, Conference Manager, NZACA

8. PULSE - Do you have a positive workforce culture? Are you making record profits? Stephen Becsi, CEO Bethanie Group Inc

10. The NZACA Group Buying Programme Managed by Obtain Ltd

12. Research Roundup A summary of the latest in evidence-based practice and care. Prepared by Fran Robertson of Equinox Health Ltd

14. Health Ed Trust Update By Julie Sparks, General Manager, Health Ed Trust

16. C. Difficile - An emerging problem By Judy Forrest, Infection Control Consultant

18. Words from the Wise Is your Home/Hospital ready for Christmas? By Judith Johnson, Consultant to the Aged Care Sector

20. Medichart Cloud-based medicine management in the aged care sector in NZ

21. The Masonic Villages Manawatu Aged Care initiative to be promoted nationally

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1. Excellence in CARE � NOVEMBER 2013

CEO’s Message Complaints and RealityDear Members

By the time this article is published, the NZ Herald would have started their exposé on the aged care sector. The problem with this exposé was revealed when an internal email from the cabal of Herald journalists was leaked, showing how ‘objective’ they are. The leaked email proposes to start the exposé on a Monday with the headline: ‘What’s wrong with our rest homes… the worst horror story we could find’. This theme continues on day two with “maybe another news pointer on a horror story, perhaps one that comes in response to Monday’s story”.

This approach is not unique to the Herald. Recently, the Dominion Post ran an article with the headline, ‘Flood of Rest Home Complaints’, which ran counter to the statistics – which show a low number of Health and Disability Commission complaints and an overall drop each year for the last four years.

The problem with this type of media approach is it drives public opinion that expectations are not being met. And this is without ever trying to establish a benchmark of what is reasonable in the first place.

The reality is that by any measure, aged residential care complaints are low. For example, aged residential care providers generated 106 HDC complaints in 2012. This figure was greater than complaints about dentists, who had 83, but fewer than those about GPs, who had 305.

Over the same period, DHBs collectively generated over 700 HDC complaints (if their OIA responses are to be believed). Furthermore, DHBs tell us they received about 8,000 complaints themselves from consumers in last financial year.

Despite these facts and figures, neither the media nor public seem to think the level of complaints about DHBs or GPs or dentists is either untoward, or even worth mentioning.

The reality is both the public and the media have unrealistic expectations around complaints in the aged care sector, and instead of criticising the sector for 106 HDC complaints each year, they should recognise that this is a low number when you consider over 300 million of hours of care are delivered each year by 690 facilities, to 40,000 elderly people, by 35,000 caregivers and nurses.

All things considered, these facts underline how well the aged care sector is performing, and the media and the public need to accept this.

Martin TaylorCEONZ Aged Care Association

UPfront THE CEO’S MESSAGE

CEO

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Feature THE LAW ON ADVANCE DIRECTIVES

It is a matter of fundamental principle that a competent patient has the right to refuse medical treatment: this right is guaranteed and protected by section 11 of the New Zealand Bill of Rights Act 1990.

Advance directives (sometimes called “living wills”) are one of the measures that a competent adult can take to control the medical care and treatment they receive if they later become incapable of making or communicating decisions. However, a “positive” advance directive expressing the patient’s wish to receive a particular treatment will not apply to requiring such treatment to be given if it is not clinically indicated.

“Advance directive” is defined in the Health and Disability Commissioner’s Code of Rights as meaning a written or oral directive:

- by which a consumer makes a choice about a possible future health care procedure; and

- which is intended to be effective only when he or she is not competent.

In New Zealand there are no statutory requirements setting out what is necessary for an advance directive to be valid. Right 7(5) of the HDC Code simply provides that every consumer of health and disability services may use an advance directive “in accordance with the common law”.

Advance directives may be oral or written

At common law, as reflected in the HDC Code, an advance directive need not be written, but the potential for problems with an advance directive that has only been communicated verbally are obvious – especially in cases of life and death. Where the validity of an oral advance directive is at issue, there will need to be particularly clear evidence that the patient intended the directive to apply in the specific circumstances.

In a recent English case, for example, the Court of Protection refused to recognise as a valid advance directive a patient’s statement made some years before her illness to family members that she would not wish to be kept alive if she were to become gravely ill. She went on to suffer from viral encephalitis, which resulted in her being kept alive artificially in a “minimally conscious state” in a care home.

In that case, the Court emphasised the importance of the sanctity of human life, and said that given the informality of the circumstances (“off-the-cuff” verbal statements to family, made years earlier), it would be wrong to give significant weight to these statements. On that basis, the Court refused an application by the woman’s family to approve the withdrawal of artificial nutrition and hydration.

Requirements for a valid advance directive

The basic requirements for a valid advance directive are:

- It must have been created at a time when the patient was competent.

- It must be applicable to the clinical circumstances that have arisen (for example, a statement that the patient does not wish to be resuscitated (CPR) will not prevent medical professionals from administering other kinds of life-prolonging treatment, such as artificial nutrition and hydration).

It is probably fair to state that where an advance directive has been prepared and signed in consultation with the patient’s medical practitioner, it is more likely to be upheld than where an instruction has been prepared by the patient alone. Evidence that the patient took advice on and understood the legal effect of the document will provide more comfort for a clinician who must later decide whether the directive may be relied upon when making treatment decisions.

THE LAW ON ADVANCE DIRECTIVES Wendy Aldred, Barrister, Waterfront Chambers

“I WOULDN’T WANT THEM TO KEEP ME ALIVE IF I WAS IN THAT CONDITION”


Changes in the patient’s circumstances may cast doubt on validity

Doubt will be cast on the validity of an advance directive if there is any evidence that, since signing the directive, the patient’s circumstances have changed so that it may be supposed that he or she would no longer wish the advance directive to be acted upon.

An example is provided by the 2003 English case of HE v NHS Trust, in which a young woman needed an urgent blood transfusion to be kept alive due to a congenital heart defect. She had, several years beforehand, converted to the Jehovah’s Witness faith and signed a form specifying that in the event that she required emergency surgery, she did not wish to receive a blood transfusion. Her father gave evidence that since signing the directive, his daughter had converted to the Muslim faith and would no longer wish the directive to apply. Further, she had not mentioned the advance directive when she had sought medical help after collapsing but before losing consciousness.

In those circumstances, the Court refused to uphold the directive, finding that it was the person seeking to rely on it who bore the burden of proving its continued validity and that “if there is doubt, the doubt falls to be resolved in favour of the preservation of life”. The Court also confirmed that, just as there was no requirement that an advance directive be in writing, revocation of an authority could also be accomplished informally (so that the lack of a written revocation of the advance directive was not significant).

Importance of making an advance directive known

It is obviously important that the existence and contents of an advance directive are made known, so that they can be given effect in the right circumstances.

Certainly the patient’s medical practitioner and solicitor should be advised of the directive and provided with a copy, and most patients will wish to inform a trusted family member or their EPOA.

It is good practice for rest home providers to ask residents or intending residents to provide a copy of any current advance directive and to hold a copy on the resident’s file.

Summary

The English cases demonstrate that the courts will be very careful about upholding an advance directive where there is any evidence that casts doubt on whether the patient would have intended it to apply if they had capacity at the relevant time. Medical professionals will likewise exercise caution when considering whether to withhold treatment on the basis of an advance directive, particularly where such treatment may restore the patient’s health.

It is likely that this difficult area of the law will be further clarified at some point by the New Zealand courts. In the meantime, the position appears to be that an advance directive is more likely to be valid if it is recent, clearly applicable to the precise clinical circumstances that have arisen, and if it has been the subject of consultation between the patient and his or her advisers.

Wendy Aldred, BarristerWaterfront Chambers [email protected]

Wendy specialises in law affecting the health and aged care sectors and writes regularly for Excellence in Care. Please feel free to contact Wendy if there is a topic with a legal flavour that you would like to be covered in a future edition.

Please note that this article is not intended to be a substitute for legal advice in relation to any of the matters covered.

23. Excellence in CARE � JULY 20135. Excellence in CARE � NOVEMBER 2013

Conference ReportThe annual NZACA conference just keeps growing in size.

This year we had sold all stands by the end of May and had a waiting list.

A record number of exhibiting companies – 86 in total – showcased the latest products for use in the aged care sector.

The opening presentation on the Wednesday morning, by ‘Charles Davis’, set the scene for three days of thought-provoking sessions and workshops. ‘Charles’, from the ‘exclusive’ Silver Horns Retirement Complex in Texas, was our hoax presenter from Australia, and he certainly had the delegates wondering what was going on. By all accounts, the delegates really enjoyed his presentation.

Following on from the opening session, we welcomed back Martin Green, Chief Executive of the English Community Care Association in the United Kingdom. Martin’s first session was titled ‘Behind the camera lens – Media investigations gone wrong’. He gave examples from the UK, providing the delegates with an insight into how the media can often get things wrong and how the sector needs to be proactive, transparent and needs to show accountability.

Andrew Carle, Executive-in-Residence Director of the Program in Senior Housing Administration at George Mason University in Fairfax, Virginia was our second international presenter on the stage. Andrew presented two topics: ‘Information Technology and Senior Housing’ and ‘“Nana” Technology’.

Andrew introduced the latest technology being used and developed for use by aged care operators, from resident software packages through to GPS shoes which track residents with dementia so they are never lost.

Dianne Adamson from Australia presented two sessions and repeated them the following day: ‘Change Your Conversation, - Create a greater awareness of the impact of your conversations’ and ‘Building teams to create a positive staff culture’. Dianne is a vibrant presenter and each of her sessions was packed out. Many delegates have asked us to invite Dianne back next year. A new initiative this year was the breakfast on the second morning, in and around the Exhibition stands. This was very popular with the delegates and exhibitors alike and allowed more time to do business in a relaxed setting, while enjoying breakfast on the go.

As usual, the social functions were well attended. We went off site for the Welcome Function to The Wharf, just below the Auckland Harbour Bridge. We enjoyed drinks and nibbles in a beautiful setting and were entertained by Greg Ward, our MC.

The much anticipated conference dinner and awards night was not disappointing. The theme for the evening was ‘All the Fun of the Circus’. The smell of popcorn and candy floss greeted guests as they arrived for a pre-dinner drink. Delegates and exhibitors alike had taken up the challenge and most came dressed to party. We had clowns (several), jugglers, fortune tellers, ring masters, lion tamers, candy floss girls and a variety of animals – indeed creating all the fun of the circus.

The announcement of the overall winners of the awards was much anticipated. We had a record number of


Feature CONFERENCE 2013 - REPORT

entries this year, and we acknowledge the time and effort it takes to enter these awards. Congratulations to all who entered. We are also grateful for the time and effort that the judges put into marking these awards.

Our new award for 2013 was the Bidvest Excellence in Food Award for Care Homes and Hospitals. The two judges (Roy Reid, President of Grey Power and Pip Duncan) did an excellent job travelling to the finalists’ sites for an unannounced inspection of the kitchen and then staying for lunch.

We appreciate the support of Bidvest in sponsoring this award, and we hope in 2014 we will have more entries in this important award category.

The winners for 2013:

Telecom Community Connections Award Winner: Radius Lexham Park, Katikati.

Jackson Van Interiors Built and Grown Environment Award Winner: Mercy Parkland Ltd Auckland

Health Ed Trust Training and Staff Development Award Winner: Oceania Group NZ

QPS Benchmarking Innovative Delivery AwardWinner: Pohlen Hospital

Bidvest Excellence in Food Award for Care Homes and Hospitals Winner: Everil Orr Village, Auckland

The overall winner for the NZACA/EBOS Healthcare Excellence in Care Awards for 2013 was Pohlen Hospital, Matamata.

The judging panel for all categories, other than the Bidvest Excellence in Food Award, was comprised of John Matthews (EBOS), Barbara Martin (RN and retired manager), Roy Reid (President Grey Power) and Martin Taylor (CEO NZACA).

Thank you to all of our sponsors for their continuing support in the sponsorship of these awards and to EBOS Healthcare for becoming our new partners in sponsoring the overall award.

We hope many more organisations will take up the challenge and enter the 2014 awards.

Robyn GrayConference ManagerNZACA

Conference 2014 15 – 17 OctoberWELLINGTONTSB Arena and Shed 6


Do you have a positive workforce culture? Are you making record profits?

Stephen Becsi – CEO Bethanie Group Inc was a keynote speaker at the NZACA Conference in August 2013.

He made some very bold statements, but had the evidence to back them up.

Stephen and Bethanie Aged Care have since been nominated for some major Australian awards and are finalists for:

- the CEO Magazine Executive of the Year Awards – finalist in the Health and Pharmaceutical Executive of the Year category: Nov 28th 2013, Sydney

- the Australian Institute of Management Western Australia Pinnacle Award – finalist for the Human Resource Management Excellence Award: Nov 28th 2013, Perth

- the Australian Human Resources Institute Awards as a finalist in the CEO Award category: Dec 5th 2013, Melbourne.

Pulse Australasia’s programmes were acknowledged as being one of the key components in contributing to Stephen’s and Bethanie’s success. The core programme, “Culture Pulse”, was used to improve internal staff culture and to build a positive workforce culture, resulting in record profits for the group and returning the company an extraordinary 24 times (2,400%) ROI on its investment in culture transformation. Little wonder that the Corporate Leadership Council of Australia is able to claim that “culture has eight times more influence on bottom line than strategy”.

PWC’s latest audit report stated:

“Through successful investment in cultural transformation, Bethanie is seeing improvements around staff retention, staff commitment, giving

rise to improved care and improved experiences for residents.”

This report highlighted the significant progress made since an internal staff satisfaction survey in 2010 revealed a number of less than complementary findings relating to the Bethanie organisational culture. Results at that time indicated that many staff did not enjoy working with their co-workers, and that working relationships across different levels of the business and between departments were dysfunctional and strained. It was felt that addressing this workplace negativity – as well as the associated issues of high staff turnover, absenteeism and agency usage – had the potential to ultimately improve both the level of care provided to Bethanie’s residents and clients and the financial performance of the company. As such, Stephen and his executives set about focusing on culture transformation as Bethanie’s most important strategic imperative.

A key part of the culture transformation process was the partnership that has been developed with Pulse Australasia. Bethanie first engaged Pulse Australasia in May 2011. As part of this collaboration, six ‘Signature Behaviours’ that Bethanie believed were central to achieving its vision were developed. Embedding these as core day-to-day behaviours in all staff then commenced through the introduction of the Culture Pulse


Feature STEPHEN BECSI - PULSE

programmes, which were run as surveys three times per year. Through this repeated process, the importance of the Signature Behaviours was continually reinforced, and areas for improvement were highlighted and actioned.

Results from these regular surveys, along with other key workforce statistics such as retention and injuries, were reported on an electronic real-time dashboard. The dashboard used a number of KPIs (financial and non-financial) so that an overall score for each of the strategic objectives could be calculated and monitored. The dashboard enables executives and managers to drill down and quickly identify which areas of their business are functioning well and which may require more resources and attention.

Bethanie is now seeing the benefits of its investment in the cultural transformation programme through increased staff retention, increased staff engagement, lower absentee rates and, most importantly, higher care outcomes and a better care experience for clients and residents.

Bethanie’s investment in its organisational culture has also had a material impact on its financial performance and results. The graph below shows Bethanie’s EBITDA per bed per annum, and how this compares against the national average across the Australian sector. Preliminary data confirms the

upward increase in EBITA per bed per annum has continued and now exceeds $12,000. As can be seen, Bethanie’s performance in this regard compares very favourably to the rest of the Australian aged care sector.

We would like to congratulate Stephen and, regardless of the outcome of the above awards, Pulse Australasia is honoured to be part of Stephen’s leadership journey and will continue to support his growth.

Chris Gorman CEOPulse Australasia+61 2 9229 [email protected]

6th November 2013

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The NZACA Group Buying Programme

Frequently Asked Questions

Q: Does it cost to sign up with Obtain to access the deals on the NZACA Group Buying Programme?

A: No, NZACA has negotiated with Obtain a free subscription for NZACA members, so you get access to the savings for free.

Q: How much can I save through Obtain?

A: Prices on Obtain catalogues are anywhere from 5% to 60% off suppliers’ normal list or trade prices (and sometimes more with special promotions). The actual savings for your business will vary, depending on the mix of products and the volume being purchased. Any saving you can make for your organisation contributes directly to your bottom line. Some of our facilities are saving up to $3,000 per month on continence products alone.

Q: How do I join the Group Buying Programme?

A: Obtain has built a special web-based purchasing system where you can access all of the broad range of goods and services in one place. Go to www.NZACA.obtain.co.nz and click on the register tab and fill out the registration forms. This is a five minute process. Once you have registered, Obtain will verify your facility’s membership of NZACA and activate your account. You will receive an email confirming this, and you can login to the site.

NZACA members are enjoying better pricing and service from leading suppliers by combining their buying power through the NZACA Group Buying Programme managed by Obtain Ltd.

Obtain is able to negotiate with suppliers based on the group’s combined spend, measured in the hundreds of millions of dollars.

More than 150 NZACA members have signed up for the programme, and many are enjoying significant savings. The more that support the programme, the better the savings that can be generated for members.

So, how does it work? We’ve provided answers to some frequently asked questions to help explain, or you can call us on 0800 OBTAIN or email us at [email protected]

Q: How does the NZACA online purchasing system work?

A: You can browse multiple supplier catalogues on the site, and load products from as many suppliers as you wish into one shopping cart. Then, in a single purchasing process, purchase all of the products you need.

Q: How are orders processed?

A: Orders are generated from a single checkout to multiple suppliers through our unique Obtain purchasing technology. Orders from each supplier are automatically split and dispatched directly to the suppliers ordered from. They will then process the order, dispatch it to you directly and invoice you according to the terms and conditions.

Q: What if I don’t have an account with some of the suppliers on Obtain? Can I still purchase from them?

A: You can apply for an account with our suppliers from the system. You can also use a credit card to purchase from some Obtain suppliers. This can be from multiple suppliers, as our order processing technology splits the appropriate credit card payment amount to the appropriate supplier, and confirms the orders once successful payment has been made.


Feature GROUP BUYING POWER

Q: How does this appear on my credit card statement?

A. Our technology allows you to make one credit card entry to complete your purchase from multiple suppliers, and it will list all of the separate credit card transactions by supplier on your credit card statement.

Q: What happens if I already trade with some of the suppliers on Obtain?

A: In almost all cases, regardless of your existing terms or contract with our suppliers, you will be given the better Obtain pricing. When you login for the first time, you can enter your current supplier customer account number and you will receive the NZACA buying group pricing from that supplier.

Q: Will I no longer have a direct relationship with the supplier?

A: You will continue to have a relationship with the suppliers, and you will be invoiced by and make payments direct to the supplier. You will also continue to receive the same service and support including rep visits, training and education on their products, follow-up service and support and special offers.

Q: What happens if I have a problem with an order?

A: You make contact with the supplier in the same way you currently do. All of the suppliers’ contact details are provided on the site, and in the order confirmation emails you will receive.

Q: What should I do if the products don’t arrive, there is an issue with the products, or I need to return them?

A: You should make contact directly with the supplier of the goods in question. For every order to a supplier you hold an account with, the system will automatically send an order confirmation email. This will contain the information and other details you need to contact the supplier if required.

Q: What if something I need is not listed on the catalogues?

A: Contact Obtain and let us know. We are working on adding to our product catalogues and services.

Q: What if I need a quote for something that cannot be listed on a catalogue?

A: For goods and services not suited to a catalogue listing or for high value items there is a Request for Quote tab in the top navigation bar. Go there to click on the relevant request for quote form, fill out the required information, press the submit button and the supplier will contact you directly.

Q: What other advantages does Obtain provide?

A: Obtain provides greater awareness and control over your organisation’s purchasing, as well as saving you time and improving the efficiency of your purchasing.


Palliative Care in Residential Aged Care Facilities

Connolly, M., Broad, J., Boyd, M., Kearse, N., Gott, M. (2013). Residential aged care: The de facto hospice for New Zealand’s older people. Australasian Journal on Ageing. DOI:10.1111/ajag.12010

There has been increasing awareness of the palliative care needs of residents in aged care facilities in recent years, with many facilities in New Zealand introducing end of life pathways and staff training focusing on palliative care. The purpose of this study was to describe short-term morbidity in residential aged care residents. It involved analysing data from a census-type survey of 152 facilities in Auckland.

This research found that 12.6% of people admitted to residential aged care facilities die within six months of admission. However, for those admitted to a private hospital from an acute hospital, the mortality rate rose to 36.5% in six months. The authors claim that this is particularly interesting, considering they have previously demonstrated that 60% of private hospital admissions result from a public hospital stay. The predictors for mortality included:

• advanced age• admission directly to private hospital from public hospital • unscheduled GP visits within prior 2 weeks• admission as a short-stay resident (respite) • inability to manage personal care.

An interesting point raised in this paper is that older people are being discharged from public hospitals to private hospitals, specifically for end of life care. The authors question whether end of life issues are discussed with patients and families prior to discharge. If not, this could lead to unrealistic expectations from families, as well as leading to conflict with facility staff when the resident’s condition deteriorates.

Another point discussed is the disparity in staffing levels and resources available in private hospitals, compared to hospices. If the healthcare system is using private hospitals as the discharge destination for older people with palliative care needs, then that raises issues regarding the palliative care resources within private hospitals.

Managing Type 2 Diabetes

Abdelhafiz, A., Sinclair,A., (2013). Management of Type 2 Diabetes in Older People. Diabetes Theory. 4:13-26

There has been much written about the increasing prevalence of type 2 diabetes in the western world, due to lifestyle factors such as diet and exercise. As the numbers of older people increase, so will the numbers of those with diabetes, especially when factors such as obesity are added in. However, because older people are often excluded from clinical trials, there is a lack of evidence-based guidelines specifically relating to diabetes in older people. The purpose of this systematic review was to explore the literature relating to the management of type 2 diabetes in older people and to bring together some principles for best practice.

The authors discuss the challenges associated with managing diabetes in older people, which include:

• greater number of co-morbidities• memory loss and cognitive impairment, limiting

self-management• unpredictable eating and exercise patterns• complications of diabetes, impacting independence

and quality of life.

The article includes specific recommendations regarding the management of diabetes in older people, particularly regarding medications and insulin. For example, they suggest that metformin be used as first-line therapy, as it is less likely to cause hypoglycaemia than sulfonylureas such as glipizide and gliclazide.

One of the main points discussed in this paper is the importance of comprehensive geriatric assessment for older people presenting with symptoms of diabetes. This is especially important in people who cannot describe their symptoms, and for those with histories of recurrent urinary tract infections or slow-healing wounds.

Another point made is that management plans for older people with diabetes should be individualised and should take into account the person’s co-morbidities and functional status, as well as their wishes and preferences regarding their healthcare and lifestyle. The authors assert that for frail older people, quality of life is often more important than ideal diabetes control. Older people often have limited food intake and maintaining blood glucose levels between 4 and 15mmol/L is usually sufficient to prevent either hypoglycaemia or hyperglycaemia, while allowing some flexibility in the diet offered.

Adverse Consequences of Electronic Health Records

Yu, P., Zhang, Y. et al (2013). Unintended adverse consequences of introducing electronic health records in residential aged care homes. International Journal of Medical Informatics 82(9). 772–788.

In the last Research Roundup, we included a paper that analysed the benefits of electronic health records in residential aged care facilities. The authors have now published a subsequent paper which discusses the unintended adverse consequences associated with electronic health records so, in the interests of presenting a balanced analysis, we have reviewed and summarised that paper.

As with the previous paper, this was a qualitative study using semi-structured interviews. Nurses, caregivers and managers were interviewed, with 110 staff members participating, altogether.

The unintended adverse consequences of electronic health records can be divided into three broad groups: environmental, staff-related and system-related.

Research RoundupA summary of the latest in evidence-based practice and care.

Research RoundupA summary of the latest in evidence-based practice and care Prepared by Fran Robertson of Equinox Health Ltd

Feature RESEARCH ROUNDUP


The environmental factors include:

• Lack of space for computers, which meant that offices became crowded with lack of working space.

• Insufficient numbers of computers, which meant that staff were having to wait for a computer to become free before they could write their progress notes.

• Lack of portability. Several participants said that because they can’t take the computer to the bedside, they record information on paper then enter it electronically, which is double-handling of data.

The staff-related factors include:

• Limited computer literacy. Not all staff members were comfortable using a computer. Allowing staff members with limited computer skills to learn the system at their own pace, with plenty of sup-port, is essential.

• Inadequate training. Comprehensive training should occur not only before the system is introduced, but should continue beyond the implementation date, to support staff as they adjust to using the system in their day-to-day working lives.

The system-related factors include:

• Inadequate functionality and poor user-interface design. For example, the choices in drop-down boxes were sometimes too limited to allow for the accurate description of complex clinical situations.

• Lack of automatically generated care plans. Some systems didn’t automatically transfer data between pages, which meant staff had to enter the same piece of information several times.

The overriding message that comes out of this paper is that, although there are obvious benefits to using an electronic system, challenges and adjustments should be anticipated and planned for. It is important to select a system that fits with the work patterns and processes of the organisation, as well as ensuring that educational and technical support is available while staff members adjust to the new system.

Staff-Family Relationships

Bauer, M., Fetherstonhaugh, D., et al. (2012). Staff-Family Relationships in Residential Aged Care Facilities: The Views of Residents’ Family Members and Care Staff. Journal of Applied Gerontology, 32(7). 1–22.

Most people working in the residential aged care sector are aware of the potential for conflict between care staff and residents’ families, and how distressing it can be for all involved when relationships between staff and family become strained. It is well-documented that good communication is essential to maintaining positive relationships.

The aim of this qualitative study was to describe the perceptions of staff and families regarding the factors that contribute to constructive relationships.

The research involved structured interviews and focus groups within five residential age care facilities in Victoria, Australia. Altogether, 27 staff members and 14 family members participated in the study. The authors describe three main themes that emerged from the interview process.

1) Building trust This was enhanced when family members felt welcome and when staff were approachable and knowledgeable about the resident. One of the barriers to achieving this was when facilities were staffed by non-permanent staff who weren’t familiar with the residents and could not answer questions regarding their wellbeing.

2) Involvement Family involvement in the care of residents was perceived by both staff and families as positive. Staff members expressed appreciation when family members assisted residents at meal times and helped with activities and outings. This also allowed family members to form accurate views regarding the residents’ abilities and needs, which led to fewer unrealistic expectations.

3) Keeping the Family HappyOne of the main ways to achieve this is to keep the family informed regarding the resident’s wellbeing. Family members who were confident that they would be notified of any changes in the resident’s condition were more relaxed and trusting towards facility staff.

The authors suggested that it is important to remember that families are usually under stress when an elderly relative moves into residential care. This stress often involves guilt and/or grief and can sometimes manifest as anger. They recommend that one way to achieve constructive relationships between staff and families is to discuss the family’s expectations and anticipated level of involvement during the admission process. This allows a positive relationship with the family – and with the resident – to be established right from the beginning.


Three ways to hit the headlines for the right reasons It’s well known that the major daily newspaper circulations are dropping but did you know that readership and circulation of local community papers is on the rise? These local papers are one of the best ways to build a relationship with your community, so if you come across trying times in the national media, you will have the locals with you and not against you.

Local newspapers are always on the lookout for stories and if you can provide a good human interest story with a photo, they will really appreciate your efforts and in most cases publish your news. The readership of these papers is the very group of people who will decide whether your facility is worth supporting or not.

Three ways to hit the headlines1) Focus on staff. An easy story to send to the papers is on educational achievement, along with a photo of a group of (or even just two) smiling caregivers with their badges and certificates. Many of these students have overcome adversity to achieve their qualifications and their stories are worth telling. Another idea to focus on is a staff member’s long service. Many facilities have staff who have worked there for 20-25 years, and this recognition is a great way to appreciate your staff member and show the community that your facility is a great place to work. But don’t just limit your stories to your staff; there will be other things happening constantly around you that are worth some PR.

2) Highlight a resident’s event, such as a 100th birthday, a 50-year wedding anniversary, or another milestone or achievement. Other examples could include singing in a local music festival or an interesting outing. Talking to your diversional therapists could be very productive here. Always try and include a backstory for the person – we all like to read about funny incidents in people’s lives.

3) Promote upgrades or changes. Has your rest home been redecorated, opened a new wing, put in a new kitchen or respite area? Has a new manager arrived? Maybe your garden has a spectacular floral display this year, or you have a resident who loves to grow veggies in the garden. Use any excuse to invite a reporter in to take a few photos of smiling residents and happy times.

The overall principle here is that you build a relationship with the staff at the local paper, so that if media problems do occur they will come to you first. After all, there are bound to be isolated instances in every facility that the media would love to have a field day with. However, if you have a good relationship with your local paper and community, the national media sensationalism will be rejected.

I can hear you all saying we don’t have time for this… no excuses! How can you NOT find the time, because if the worst does happen you will be wishing that you had.

Have a look at the reat example on the next page – well done Norfolk Court Rest Home in Dargaville.

Feature HEALTH ED TRUST

By Julie SparksGeneral ManagerHealth Ed TrustPh 03 3798519Email [email protected]


Rest Home Staff Earn Qualifications Eleven staff at Norfolk Court Rest Home in dargaville have been presented with certificates, after qualifying across a range of NZQA-approved training programmes around aged care.

At the ceremony, five others from the 40-strong staff were also recognised for long service at the 64-bed rest home, which has been running for 21 years.

Bronwyn Collins, Raewyn Watson, Promise Wyllie, Anne Burke and Lillian Nesbit totalled more than 65 years’ service between them.

The year-long national certificate courses are delivered by the Aged Care Programme (ACE) administered by Health Ed Trust (a not-for-profit organisation), and students are assessed by an on-the-job assessor, gaining fully-recognised qualifications covering dementia and aged care.

Norfolk CEO, Stuart House, said the facility was in the process of expanding – converting the existing hospital section into a full rest home hospital with 22 beds and 24-hour nursing staff, adding to the current rest home and specialised dementia care facilities.


Clostridium difficile (commonly termed C. diff) is an infection that is becoming problematic in many residential care facilities in New Zealand. New, highly virulent strains are causing severe illness and even deaths in residents. C. difficile was first identified in the 1970s as the major cause of antibiotic associated inflammation of the bowel (colitis), but it wasn’t until the early 2000s that the infection proved to be responsible for devastating outbreaks in North America and Europe.

A highly virulent strain of C. difficile was reported in Canada in 2003 – with approximately 1,400 cases reported, which resulted in a large number of deaths. A similar outbreak took place around the same time in the UK, and again a few years later. By 2008, C. difficile was problematic in Europe, and by 2010 it was isolated in Australia. In recent years, the superbug has been isolated in New Zealand, with the first confirmed cases in Auckland in 2010.

Clostridium difficile is a bacterium found in the gut. Certain antibiotics can disturb the balance of bacteria in the gut,

allowing C. difficile to multiply rapidly, producing toxins which cause illness. C. difficile infection primarily affects the elderly. Symptoms range from mild to severe diarrhoea, with severe cases leading to pseudomembranous colitis and subsequent bowel perforation and death in some instances. Transmission is in faeces, via direct contact or indirect contact – via staff hands, contaminated surfaces or equipment. The bacteria produce spores which can survive for many months in the environment, unless destroyed by a thorough cleaning process and the use of correct cleaning chemicals. Those at most risk are residents who have been treated with antibiotics for long periods of time; those with serious underlying illnesses, who are immune-compromised; and the elderly.

Stopping antibiotics will usually stop the diarrhoea, but the organism forms large numbers of heat-resistant spores that are difficult to kill through regular cleaning, which means they can remain alive on surfaces and equipment within the facility for a long period of time.

C DIFFICILE – AN EMERGING PROBLEM IN RESIDENTIAL CAREBy Judy Forrest, Infection Control Consultant Bug Control New Zealand Ltd

Feature INFECTION PREVENTION


In the event of a case of C. difficile identified in your facility, it is essential that staff take immediate action to prevent further spread.

Resident/s must be isolated using full contact precautions (gloves and long-sleeved gown when entering room). C. difficile spores are difficult to kill, so good cleaning is essential. Cleaning of the room should be increased to at least twice per day, using a product known to kill the C. difficile spores, such as available chlorine or other approved products.

Strict attention to hand hygiene is vital, but staff need to be aware that alcohol-based hand rub doesn’t kill the spores. After using an alcohol-based hand rub, a soap and water hand clean should be undertaken as soon as possible after attending affected residents.

Staff must receive education and information on the prevention and management of C. difficile.

For further information about C. difficile and other organisms that may cause an outbreak in your facility, contact Bug Control to find out about our Infection Prevention and Control Quick reference flip chart. The chart provides useful, bullet pointed information on key management strategies for C. difficile, ESBLs, VRE, MRSA, influenza, gastroenteritis and scabies.

mobility | seating | commercialVAN INTERIORS

www.jel.co.nz | freephone 0800 274427 | email [email protected]

NZ’S LEADING VAN INTERIORSPECIALISTS


Feature WORDS FROM THE WISE

Perhaps before you answer the above, you need to consider what Christmas means to your residents and staff. For most people, whatever their beliefs, it is a family time – a time of sharing and caring, a time to reminisce on days past, a time of thinking of friends/family that have passed. A time to make memories. It is also a time which we must make special, as statistics (from the Ministry of Health), tell us that for 60% of our residents, this will be their last Christmas. How can we make it special?

PlanningAs managers, we need to give guidance so Christmas is an enjoyable time for all (if staff are unhappy, it rubs off on residents). In terms of staffing, leave should be well sorted by now – staff need to know well in advance if they are working over Christmas or not. We should recognise staff input to our business and show we value them. This needs to be ongoing through the year, but at Christmas we can make a special effort with a function/present etc. We need to be well organised. Start early – if you are having bright ideas now, maybe they are best saved for next year. You may have a resident committee that you involve. Have you asked the residents what they want? If you are buying personalised gifts, it is best done throughout the year. If you have a Christmas raffle, this should be well sorted by now.

Planning and organisation make for a more pleasant workplace, as well as a more pleasant environment for residents and families. Perhaps you could draw up a ‘Christmas Calendar’, setting out all Christmas activities. All staff need to know what activities are planned so they can keep residents informed and have them ready and in the right place for the different activities. The recreation staff cannot be doing all the reminding/transferring of residents – the Christmas load needs spreading to make it manageable. The events also need to be communicated to residents and families – perhaps you have done this via a newsletter, but it is both helpful and good marketing to put up a Christmas Calendar as well.

Liaison with familiesCheck whether residents/families have given notice of whether the resident will be out for all or part of Christmas; will they be joined by any friends or family if they are staying in? Have family got a wheelchair if they need it to take the resident out, or will there be a problem on the day?

Keeping residents happy and informedThis information could be put on a spreadsheet – staff need to know what’s happening, so when residents comment along the lines of “I don’t know if I will see my family at Christmas”, staff will be able to reassure them positively as to what they are doing and give them something to look forward to. This allays anxiety. Keep in mind that this will probably have to be repeated by a number of people over the period leading up to Christmas.

Staff can assist in making residents feel ‘special’ by giving time and assisting residents to choose(when able) the clothes they wish to wear for Christmas events. This can be done well in advance – have the outfit hanging ready with jewellery, etc, so there is no rush on the day.

MedicationsHave you planned for outgoing residents’ medications to be ready? If you want to alienate families just keep them waiting on their busy Christmas Day for someone to get the medications out! Please don’t.

Making the day specialTake care that Christmas day doesn’t simply end up seeming like any other, in spite of you puting a lot of effort in. What makes occasions special is often the change in routine. If you are having a lovely Christmas dinner, do you want ‘task-oriented’ staff rushing residents in and out of the dining room? Plan how you can make the day feel different. Change the routine of the day. Perhaps meet in the lounge for a cocktail before going through to the dining room for the dinner. Perhaps have the Hairy Fairy

Is your Home/Hospital ready for Christmas?By Judith Johnson, Consultant to the Aged Care Sector

WORDS FROM THE WISE


call in. (I wonder how many gardeners/GPs thought they would be asked to do that!) Maybe you have decided to have a Christmas barbecue, for a change.

Are the staff wearing anything different? This could be Christmas hats or earrings, or decorated Christmas shoes – a good one for residents, also. Find out whether you have staff who enjoy Christmas and get into the spirit of it – it can be contagious! Give those staff members a specific role – as ‘Christmas Champion’. By changing the routine or place of events you can help break staff ‘task-focused’ patterns of behaviour. It is all about making it a happy time for all and that takes planning and effort and often change. It is your role as a leader to make those changes, if needed. (SWITCH, a book by Chip and Dan Heath on ‘How to change things when change is hard’, is a read I recommend.)

Make it a positive experience for all – not a hassle. Christmas should be a time when residents feel especially cared for and loved.

good luck and Merry Christmas to you all – you do a fabulous job caring for our aged.

Cranberries in the SnowA delicious cookie in the jar recipe, makes a great gift. Makes 18 cookies.

directionsLayer the ingredients in a 1 quart or 1 litre jar, in the order listed.5/8 cup all purpose flour1/2 cup rolled oats1/2 cup all purpose flour1/2 tsp baking soda1/2 tsp salt1/3 cup packed brown sugar1/3 cup white sugar1/2 cup dried cranberries1/2 cup white chocolate chips 1/2 cup chopped pecansAttach a tag with the following instructions: Cranberries in the SnowPreheat oven to 350 degrees F (175 degrees C) Grease a cookie sheet or line with parchment paper. In a medium bowl, beat together 1/2 cup softened butter, 1 egg and 1 teaspoon of vanilla until fluffy. Add the entire jar of ingredients, and mix together by hand until well blended. Drop heaping spoonfuls onto the prepared baking sheets.Bake for 8 to 10 minutes, or until edges start to brown. Cool on baking sheets, or remove to cool on wire racks.

CHRISTMAS RECIPE

The Hairy Fairy...


Medichart was developed in New Zealand by a pharmacist and It developer, after their time spent working in the community pharmacy environment, dealing with medicine charts and ARRC facilities. the issues around errors, risk and harm were causing concern for doctors, nurses and pharmacists related to interpretation of medicine charts, multiple paper charts in use for one patient and the timeliness of chart updates and changes.

Medichart worked to develop a cloud-based application, where a master medicine chart is managed and able to be viewed, changed or actioned by health professionals involved with the care of a particular patient or facility. As the chart is held live in the cloud, there is only one current chart that all users work off, reducing duplication and transposing errors, and ensuring the chart is always up to date. All access requires sophisticated authentication processes, which were put in place at the beginning of the development. In initial trials, the system proved incredibly successful.

The servers for Medichart are being shifted into the Connected Health environment, in accordance with the NHIT requirements over the next month. This will allow simpler connections within the Health system to the Medichart interface.

One issue currently faced by Medichart is the acceptance of a digital authentication (or signature) on the actual chart itself. Whilst the health regulation around this is related to prescriptions and supply, the ink signature on the chart is a requirement, based on the current guidelines for rest home practice. Part of the ARRC audit is in relation to this issue.

Medichart believes this particular point is currently out of date with technology advances and actually increases risk to patients and facilities, rather than reducing it. We have many examples of written charts where the doctor has ‘edited’ a medicine line with no re-date or indication that there has been a change, when or how this has been done. There are many charts where the medicine line is simply crossed out, with no signature or date from the person that has actioned this. Often, scribbled

medicine quantities, strengths and directions have rendered the chart almost unreadable. In addition to this, there can be multiple charts in play – faxed copies, amended copies, copies being used to administer from while an original is couriered to a GP’s practice for amendment, etc.

this all adds up to risk!

Medichart solves all of these problems, reduces risk and ensures all groups involved in the medicine management of a patient have the correct information. We are seeking approval for rest home facilities to have this kind of system implemented for recording, tracking and managing the patients’ medicine charts. This is proving to be a long, protracted affair with all organisations acknowledging a change is required, but being unwilling to put their hand up and say ‘Yes’.

Medichart is currently working with the NHIT Board and MOH to get approval to accept the electronic authentication of users. While we are not seeking approval for electronic prescriptions at this point (only charting), these two issues seem to be lumped together.

Prescriptions are covered by law; charts appear only to be covered by accepted practice and audit requirements, which theoretically should be simple to amend.

There is a willingness from health authorities to correct this situation ASAP, so facilities can use the standalone system to improve safety, reduce costs and bring clarity to the charts. We are currently going through the waiver process on behalf of the aged care industry.

Support from the industry is immensely valuable and appreciated, as Medichart continues to advocate to the health authorities for this change.

Medichart Ltd

Greg GarrattChris Parmenter

Medichart – Cloud-based medicine management in the aged care sector in NZJuly 2013


Manawatu aged care initiative to be promoted nationallytwo Horowhenua rest homes and hospitals have dramatically reduced the number of hospital emergency visits and admissions by their residents, following the appointment of a Nurse Practitioner (NP) specialising in the care of older people.

Sylvia Meijer’s appointment in 2009 – the first of its kind in New Zealand – was the brainchild of The Masonic Villages Trust, which did not want to lose Meijer’s services at its Horowhenua Village once she had graduated as an NP.

“With an increasing population of older people in the district and a declining number of GPs to service them, the role appeared to be the perfect solution to a growing problem,” says Horowhenua Masonic Village Manager, Sue Maney.

The success of the Nurse Practitioner Older Adult role has been clearly demonstrated in a report by Auckland University, commissioned by the Central PHO and MidCentral District Health Board in 2012.

This shows that when an NP was involved in aged care facilities, there was a 28% drop in hospital emergency department visits, versus a 21% increase in facilities without an NP – a 49% difference. Acute hospital admissions decreased and some unnecessary medications were also discontinued.

Based on these positive findings, those involved in the project have approached Health Minister Tony Ryall to ensure ongoing funding and to promote the concept elsewhere in New Zealand.

When The Masonic Villages Trust first came up with the NP concept, it realised that it couldn’t justify employing a full-time NP. So Masonic chief executive, Warick Dunn, approached Enliven Presbyterian Support Central General Manager, Nicola Turner, who was keen for Enliven’s two care facilities – Levin Home for War Veterans and Reevedon – to come on board.

Together they approached MidCentral DHB, which referred the proposal to the Central Primary Health Organisation (PHO), where the idea was met with enthusiasm.

“That gave us a three-way funding model. The Masonic Village, Enliven and the PHO were a perfect match. It was fantastic,” says Maney.

As a result, Meijer became the country’s first NP Older Adult, working for Central PHO. She works with community patients and the residents of the Masonic Village and Enliven. She also leads the Horowhenua Health for Older People team, which includes a GP with special interest in older people, a clinical pharmacist and allied health staff. “Sylvia comes from a nursing perspective and can look at things holistically. She can spend time with family and staff and give them a sense of security. At present, we could not

operate properly without an NP,” says Maney. “We have a strong nursing structure but with the way GP services are in Levin it would be difficult to maintain the standards we have without her.”

Meijer is full of praise for the way the three organisations picked up the idea and singles out Masonic for being astute enough to identify the potential in the first place.

“It was a leap of faith, full of courage. For us working in the aged care sector, it was the common sense way to go, but we had to prove it to others. The evaluation report simply confirms our faith,” she says.

To be an NP you need a minimum of a Master’s Degree, and most have additional postgraduate qualifications. Meijer has a Master of Philosophy on the assessment of older people in aged care facilities, as well as three postgraduate qualifications in nursing and aged care, along with a management diploma.

“The NP is not just a nice-to-have, but vital,” says Maney. Staff nurses have a list of residents with concerns and Meijer is able to assess what she can do and prescribe, and what needs to go further to the doctor.

“She effectively screens the workload, so the doctor sees only those patients who need a GP’s skills.”

Meijer thrives on the collaborative nature of her work. She is in constant contact with other primary health care nurses in the district, clinicians and support agencies. She says working collaboratively has enormous benefits for the people they are trying to help.

“All the things I have done in nursing up to now have been building up to this point. From the bottom of my heart, really, it’s just such the right place for me personally.”

MidCentral District Health Board Director of Nursing, Chiquita Hansen, says she is delighted with the report’s findings. She says it was especially pleasing to learn of the decrease in acute admissions and presentations to the emergency department.

“It is important that the nurse practitioner is employed by the PHO and comes from the primary health care sector, as is her involvement in management teams like the Health for Older Person team. It keeps lines of communication open between GPs and the aged care facilities.”

Hansen also felt using an NP was great for aged care facilities, because it gave the registered nurses and staff back-up, instilling confidence all round. Also good news was the indication from doctors that they were more inclined to want to support aged care facilities with an NP on staff.

She describes Warick Dunn and Nicola Turner as innovative and courageous. “They anticipated a problem and were proactive about finding a solution.”


One voice for the aged residential care sector www.nzaca.org.nz

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