RDNS Active Service Model Evaluation Project Final...

RDNS Active Service Model Evaluation Project Final Report

RDNS Home and Community Care Program,

Active Service Model Implementation 2010-2013

Prepared by

Deborah Manning, Project Officer RDNS

Scott Phillips (Director Kershaw Phillips Consulting)

July 2013

This project was supported with funding under the HACC Program by the Commonwealth and Victorian Governments.

Table of Contents

Acknowledgements ................................................................................................................................. 1

List of abbreviations ................................................................................................................................ 2

1. Executive Summary ......................................................................................................................... 3

1.1 Scope and focus of the evaluation .......................................................................................... 3

1.2 Strengths and weakness of the evaluation design ................................................................. 3

1.3 Context of ASM program implementation at RDNS and across Victoria ................................ 4

1.4 Overview of findings ............................................................................................................... 5

1.5 Conclusion ............................................................................................................................... 5

1.6 Recommendations .................................................................................................................. 6

2. Introduction .................................................................................................................................. 10

2.1 RDNS Active Service Model Implementation ........................................................................ 11

2.1.1 Project outcomes and objectives .................................................................................. 11

2.1.2 Activities implemented ................................................................................................. 12

2.1.3 Stage of ASM implementation ...................................................................................... 15

2.1.4 Other studies of implementing similar approaches ...................................................... 16

2.2 Evaluation Overview ............................................................................................................. 18

2.2.1 Scope of the evaluation ................................................................................................ 18

2.2.2 Limitations ..................................................................................................................... 19

2.2.3 Main evaluation questions ............................................................................................ 20

3. Methodology ................................................................................................................................. 21

3.1 Data collection and analysis .................................................................................................. 21

3.2 Sampling methodology ......................................................................................................... 22

3.3 Care record audit process, data recording and analysis ....................................................... 22

3.4 Case study review, data recording and analysis ................................................................... 23

3.5 Client profile data extraction, review and analysis ............................................................... 23

3.6 Staff focus group, recruitment, schedule and analysis ......................................................... 24

4. Evaluation results .......................................................................................................................... 25

4.1 General findings .................................................................................................................... 25

4.1.1 ASM program uptake by service users and staff .......................................................... 25

4.1.2 ASM Client Profile ......................................................................................................... 26

4.1.3 Average length of stay .................................................................................................. 27

4.2 Detailed Findings ................................................................................................................... 28

4.2.1 Translation of ASM principles into practice .................................................................. 28

4.2.1.1 Autonomy ..................................................................................................................... 29

4.2.1.2 Capacity building .......................................................................................................... 30

4.2.1.3 Holistic view of peoples’ needs and care ..................................................................... 32

4.2.1.4 Person centred care (flexible and responsive) ............................................................. 33

4.2.1.5 Working Collaboratively and in Partnership ................................................................ 34

4.2.2 Benefits to the Individual and Organisation ................................................................. 35

4.2.2.1 Individual ...................................................................................................................... 36

4.2.2.2 Organisation ................................................................................................................. 37

4.2.3 Enablers and barriers .................................................................................................... 39

4.2.3.1 Enablers ........................................................................................................................ 40

4.2.3.2 Barriers ......................................................................................................................... 43

4.3 Using models of change to explain the ASM journey ............................................................... 47

4.3.1 Models of change .............................................................................................................. 47

4.3.2 Stages of change (applying the Prochaska model) ........................................................... 48

4.3.3 Transitioning to an ASM approach (applying the Bridges model) .................................... 50

4.3.4 A systematic and strategic approach to change using ASM (applying the Kotter model) 51

5. Conclusion and Recommendations............................................................................................... 53

5.1 Implications for translating ASM principles into practice ..................................................... 53

5.1.1 Understanding the Rationale for an ASM approach ..................................................... 53

5.1.2 Holistic view of a person’s needs and person centred care ......................................... 54

5.1.3 Collaboration ................................................................................................................. 54

5.1.4 Paradigm shift – dependency to independence ........................................................... 55

5.1.5 Continuity of care .......................................................................................................... 55

5.1.6 Importance of labelling of ASM .................................................................................... 55

5.1.7 Dementia and ASM care assumptions .......................................................................... 56

5.1.8 ASM approaches for specific types of nursing care ...................................................... 56

5.2 Evaluation Methodology and Learnings ............................................................................... 57

5.2.1 Evaluation design .......................................................................................................... 57

5.2.2 Learnings associated with methods used ..................................................................... 57

5.2.3 Challenges ..................................................................................................................... 58

5.3 Other specific recommendations (for RDNS) ........................................................................ 58

5.4 Conclusion ............................................................................................................................. 59

6. References .................................................................................................................................... 60

Appendix 1: Client Record Audit Tool (ASM evaluation) .................................................................. 61

Appendix 2: ASM Reflective Practice Case Studies – Analysis Template ...................................... 66

Appendix 3: ASM Staff focus group – Questions and prompts schedule ......................................... 67

Appendix 4: Examples of preferred ASM language ........................................................................... 68

Appendix 5: Guidelines for an ASM approach to nursing care ......................................................... 69

Guidelines for an ASM approach to Medicines Management ...................................................... 69

Guidelines for an ASM approach to Dementia Management ...................................................... 70

Guidelines for an ASM approach to Wound Management .......................................................... 71

Acknowledgements

RDNS would like to acknowledge the Victorian and Australian governments for the funding support for this project, through the Home and Community Care program (HACC).

The RDNS ASM Project Board and the Project Management Group (RDNS and Department of Health) are acknowledged for their guidance and support for improving the conduct and reporting of the evaluation.

The participation of nursing staff involved in the focus group discussion is also recognised, as is the contribution of those staff that developed case studies over the implementation of the ASM program that were analysed in the project.

Other people that made significant contributions towards this study include Janeen Cato (Manager Clinical Support), Erika Van Der Spuy (Senior Data Analyst), Ann Jonhson (ASM Medicines Management Project Officer), Dee Sauvarin (DVA Project Officer) and Kath Paine (Department of Health ASM Senior Project Officer) for her guidance and ASM expertise.

Finally, the collaborative effort by Scott Phillips and Deborah Manning in working together in development of this report is also acknowledged.

RDNS Active Service Model Evaluation Final Report Page | 1

List of abbreviations

ASM Active Service Model

CPD Continuing professional development

CNC Clinical Nurse Consultant

DAA Dose administration aide

DH Department of Health

GP General Practitioner

HACC Home and Community Care Program

HAS HACC assessment service

HITH Hospital in the Home

LOS Length of stay

LUPP Leg Ulcer Prevention Program

RDNS Royal District Nursing Service

SCTT Service coordination tool templates

UR Unit record


1. Executive Summary

1.1 Scope and focus of the evaluation

The evaluation was undertaken to examine impacts of the RDNS Active Service Model (ASM) Implementation Project, to inform RDNS future directions in implementation of ASM and planning for the evaluation of the ASM approach state wide.

The focus of the evaluation is on the implementation of the ASM approach in the context of HACC community nursing. As an activity, HACC community nursing has a strong focus on clinical intervention.

A project brief scoping the evaluation was prepared by RDNS in collaboration with the Department of Health. The evaluation commenced in November 2012, with the purpose of determining the extent to which ASM principles have been translated into practice across RDNS HACC services and of what benefit this has been to people receiving services and the organisation. A key aim was to identify barriers and enablers associated with implementing the ASM approach to care.

1.2 Strengths and weakness of the evaluation design

A mixed methods approach was adopted for the evaluation. This included a predominantly qualitative focus to the data collection and analysis with some semi-quantitative analysis of findings. A collaborative research approach was utilised, involving both RDNS and Department of Health staff in an action learning process throughout the research journey. This methodology and process was employed to ensure that the research produced credible findings to inform the state wide evaluation planning of the ASM approach to care and RDNS next steps in implementation.

The methodology of the evaluation included:

1. Analysis of ASM case studies of reflective practice generated by RDNS staff over the previous two years of ASM implementation (n=109)

2. File audit involving analysis of a sample of RDNS HACC client records utilising an ASM approach to care with comparison to a sample of client records with usual care.

3. A focus group discussion with RDNS staff was conducted to reflect on staff learnings and insights and assist with interpretation and verification of findings from the case study analysis and file audit.

4. Service data was extracted and analysed for a client profile comparing ASM coded HACC clients and usual care HACC clients.


The main strengths of the methodology were as follows:

• The audits were conducted by a single researcher with no prior knowledge of which records were coded with an ASM program code (electronic identifier). It was hoped this method would limit any measurement bias.

• A total of 81 case studies from the available 109 were reviewed by a single researcher. Content was extracted and collated onto an excel spreadsheet from which further coding and analysis and aggregation of data was undertaken, to highlight qualitative themes and semi-quantitative findings.

• The focus group discussion involved nine participants from across RDNS. They were representative of staff that had been involved in ASM activities such as the Leg Ulcer Prevention Program (LUPP), Dementia Model of Care, and Medicines Management, assessment tool review or ASM training.

1.3 Context of ASM program implementation at RDNS and across Victoria

The RDNS Active Service Model Implementation Project was initiated in 2010/11 to identify and implement a service delivery model that ensures a ‘wellness’ and ‘active ageing’ approach to care. In order to achieve this, activities were focused upon incorporating ASM principles into existing models of HACC service delivery as well as exploring new and innovative models, utilising an ASM approach.

Now in the third year, the ASM implementation remains focused upon sustainability of the approach as ‘business as usual’ more broadly, and in particular, the continued application of ASM approaches to assessment and care planning as part of RDNS’ HACC assessment service role.

RDNS implementation of the ASM approach is occurring within the context of the Department of Health embedding this approach in the HACC sector across Victoria. Progress has been conceptualised and monitored by the Department in relation to three outcomes stages.

These are:

Stage 1 Outcomes: HACC funded agencies have increased knowledge about the application of an ASM approach and have increased commitment to implementing an ASM approach

Stage 2 Outcomes: HACC agencies have started to implement an effective ASM approach systematically in practice.

Stage 3 Outcomes: Improved HACC Service delivery and better outcomes for clients.

The current evaluation shows that RDNS is already at stage 2 of the 3 outcome stages and there is some early indication of achievement of stage 3 outcomes.


1.4 Overview of findings

This section provides an initial brief description of general findings (see section 4.1). This is followed by a description of detailed findings (see section 4.2). General findings are described in relation to ASM uptake by service users and staff, an ASM client profile and average length of stay.

The ASM approach was provided to new as well as existing service users. It tended to be embraced by people (new or existing service users) who were more active in the community and wished to return to former levels of independence.

Use of an ASM program code allocated to client records by staff helped initially to monitor staff uptake of the approach. Subsequently use of the code plateaued. Precisely why this occurred is unclear. One possible explanation could be that staff required more education around the use of the code when implementing an ASM approach (a theme which recurred in focus group discussions). An alternative explanation could be that, as the ASM approach increasingly became ‘business as usual’ for all people receiving services, staff no longer saw the need to allocate an ASM code. In this way, use of an ASM code was seen as a facilitator for prompting staff to think in ASM terms when the approach was first being introduced.

The ASM client profile was analysed in relation to demographic and treatment characteristics.

Average length of stay analysis revealed that of the discharged clients, ASM clients had a marginally shorter length of stay than usual care clients.

Detailed findings are described in terms of translation of ASM principles into practice, benefits to the individual and organisation, and barriers and enablers to implementing an ASM approach.

1.5 Conclusion

Overall, the findings suggest some progress in the translation of ASM principles into RDNS practice, with positive outcomes associated with improvements in peoples’ ability to manage their own care and achievement of partial, if not full independence. Clear benefits for RDNS clients and carers are evident in social and emotional as well as physical health terms. In RDNS experience, the benefits of an ASM approach can be demonstrated in a HACC community nursing context, when the primary focus of care is clinical intervention.


1.6 Recommendations

The following recommendations have been developed from the project findings. While focused mainly on RDNS, these recommendations never the less could be applicable more broadly, to other community nursing services and possibly other HACC services generally, in the next phase of ASM implementation.

As a value add component, the recommendations include reference to evaluation learnings as well as a set of non-prescriptive ‘how to’ guidelines for an ASM approach for specific types of nursing care.

Understanding the Rationale for an ASM approach

Recommendation 1:

‘Refresher’ education should be provided to RDNS staff about the rationale for the ASM approach, its key principles and components and strategies for applying these in practice. Prior to this education being offered, the ASM education overlay included in orientation and in-service programs should be reviewed. Ensure content remains consistent with the ASM principles.

Recommendation 2:

Education offered should be made more accessible to staff through the provision of alternatives other than traditional face to face methods. In addition, provision for appropriate follow up support and reflective practice opportunities should be encouraged to promote discussion and applied learning.

Holistic view of a person’s needs and person centred care

Recommendation 3:

Continue to make improvements to care documentation and supporting processes for referral and care coordination using the HACC Assessment Service guidelines. This should include refinement of holistic assessment tools and care plans to reflect person centred goals and actions that focus on physical, social and mental health and wellbeing outcomes.1

Collaboration

Recommendation 4:

Improve opportunities for promoting a culture of collaboration with a focus on interdisciplinary practices, for example, secondary consultations and case conferences. This

1 Strengthening assessment and care planning: A guide for HACC assessment services in Victoria, Department of Health 2010.


could be done through the Department of Health supporting the gathering and sharing of knowledge and practice about ASM collaboration as part of HACC service system development. RDNS and other organisations continue to participate in regional forums such as ASM alliances for these purposes.

Recommendation 5:

At the agency level including RDNS, staff should adopt case conferences for development of appropriate ASM approaches when coordinating care for complex clients making use of teleconferences and email communications to keep everyone involved and informed.

Paradigm shift – dependency to independence

Recommendation 6:

Promote successes and learnings of an ASM approach to staff, clients, family and carers and other health and community services to show that ASM principles positively enable people to achieve greater levels of independence and wellness, provided that the approach is tailored to each client’s specific situation. Education programs can be used for this purpose, as can sharing of stories through other media and channels.

Recommendation 7:

Review indicators of dependency for consideration of more strength based indicators of capacity that are better aligned to an ASM approach.

Continuity of care

Recommendation 8:

Continuity of philosophy of an ASM approach across the continuum of care should be supported where possible to link hospital based initiatives e.g. ‘Improving Care for Older People’ with ASM and similar initiatives in home and community care settings. Importance of labelling of ASM

Recommendation 9:

The label of Active Service Model should be maintained as a positive metaphor for promoting uptake of enablement, restorative, person centred approaches.

Recommendation 10:

The requirement for staff to use the ASM program code should be discontinued altogether. If not, then coding guidelines for sustained use of the code, including guidance on when to discharge people from the program, indicating reasons for success or failure of the approach should be developed and promoted.


Dementia and ASM care assumptions

Recommendation 11:

Staff should consider creative means for goal setting with people with advanced dementia and cognitive impairment. This will facilitate consideration of the supports required to enable those people to participate in goal setting and self care, to the greatest extent possible. Use of person centred approaches such as life story could be used in the ways suggested in the Department of Health Strengthening assessment and care planning: Dementia Practice Guidelines for HACC assessment services (2012).

ASM approaches for specific types of nursing care

Recommendation 12:

ASM approaches for specific types of nursing care are promoted to improve understanding of an ASM approach in the clinical context of HACC community nursing (see appendix).

Evaluation Methodology and Learnings

Recommendation 13:

A mixed method evaluation approach with a qualitative focus is helpful in drawing out themes and relationships and provides practical examples to demonstrate evidence of translation of ASM principles into practice.

Recommendation 14:

Survey instruments and measures developed and used in this evaluation may be useful for other organisations to adapt and use as appropriate to their context (see appendix).

To ensure ASM practice is continued in a consistent and effective manner the following recommendations are made specifically for the RDNS ASM implementation:

i. Complete initiatives currently underway to improve care documentation for capturing person centred goals and holistic practice. In particular, this requires changes to existing care plan documentation and client management systems.

ii. Link performance management and development requirements to reflective practice of ASM including history audits and ASM case study development. Encourage and support this practice through allocation of continuing professional development (CPD) points to reflective activity.

iii. Review client self management policy and case conferencing policy to ensure ASM approaches and strategies are included in case conferencing activities where appropriate


iv. Encourage continued discussion and reflection at team meetings about ASM approaches for complex clients

v. Disseminate evaluation findings and learnings to staff and guidelines for ASM practice vi. Support interdisciplinary practices (both internally and externally) to improve

communication, referral and knowledge about other professionals and services and what is available for clients e.g. secondary consultations, joint assessments and case conferences.

vii. Explore opportunities for further funding to conduct research and evaluation for determining an ASM visit profile e.g. including length of stay, visit duration and frequency of visits. This will assist in understanding the impacts and challenges of an ASM approach concerning resource allocation and demand management.


2. Introduction The Active Service Model (ASM) is a quality improvement initiative that focuses on promoting person centred care, capacity building and restorative care in delivery of Home and Community Care (HACC) services. The initiative is a policy direction of the Department of Health, emphasising early intervention and prevention in all services for older people in our community. The goal of the ASM approach is to support frail older people and people with disabilities to live in the community as independently and autonomously as possible. It is based on the premise that many people have the potential to make gains in their wellbeing and independence. Services funded by the HACC program can actively facilitate people achieving this objective.

The ASM approach is a ‘health promoting philosophy of care’. This philosophy shifts thinking from ‘doing for’ people to ‘doing with’ people. The ASM aims to ensure staff work with people so that they can retain or improve their independence and/or autonomy as far as possible, so they stay involved in everyday activities to maintain or rebuild their confidence and stay active and healthy.

The ASM approach and principles include: • People wish to remain autonomous. • People have the potential to improve their capacity. • People’s needs should be viewed in a holistic way. • HACC services should be organised around the person and his or her carer, that is, the

person should not be slotted into existing services. • A person’s needs are best met where there are strong partnerships and collaborative

working relationships between the person, their carers and family; support workers and between service providers.

The estimated benefits of the ASM approach to care are: • Demonstrated improvements in people’s independence and wellness through

implementation of the ASM approach • Demonstration of greater satisfaction amongst people receiving care and among staff • Improved understanding and expectations of an ASM approach


2.1 RDNS Active Service Model Implementation The RDNS Active Service Model Implementation Project was initiated in 2010/11 to identify and implement a service delivery model that ensures a ‘wellness’ and ‘active ageing’ approach to care. In order to achieve this, activities were focused upon incorporating ASM principles into existing models of HACC service delivery as well as exploring new and innovative models, utilising an ASM approach.

2.1.1 Project outcomes and objectives At initiation, the project was focused on achieving the following outcomes:

• Systems and processes that enable RDNS staff to optimise a person’s/carer’s autonomy and improve their capacity.

• Ensure new work practices e.g. intake and initial needs identification, holistic assessment and care planning are developed and adopted by RDNS staff.

• Enhanced stakeholder communication, leading to a positive environment for implementing project initiatives that meet customer requirements.

• Explore and identify opportunities for RDNS to partner with other HACC services in relation to facilitating an individual’s outcomes and goals of care.

Project objectives were developed as follows, to support the desired outcomes: • Achieving workforce engagement and organisation change through active involvement of

staff. • Identifying specific practice changes that will promote person centred care and achieve a

person’s identified goals. • Developing models of service delivery that provide a responsive and efficient service, and

identify capacity building potential for a person and carers, concentrating initially on the Dementia Model of Care and a Leg Ulcer Prevention Program.

• Ensuring implementation of the ASM Project contributes to the achievement of RDNS’ Strategic Objectives.

• Integrating an ASM approach into new service opportunities. • Evaluating the ASM Implementation Project and making recommendations concerning

ongoing holistic and person centred care initiatives across RDNS.

The project approach actively involved clinical staff in the identification, development and implementation of ASM initiatives. This approach was guided by Prince2 project management methodology.

A project initiation document and project plan was developed and included twelve work packages or key areas of work. Some broadly covered communication, human resources, staff training and development, review of policies and procedures and evaluation. Other work packages were more specific including review of the RDNS admission model, implementation of the HACC assessment service and partnership development with other HACC services. There were also work packages covering three key areas of clinical practice, including medicines management, wound management and development and implementation of a dementia model of care.


2.1.2 Activities implemented The key activities implemented under the ASM project involved the following:

1. Achieving workforce engagement and organisation change through active involvement of staff.

A Project Team was established comprising initially of a Project Coordinator. Project governance was also established and included forming of an ASM Project Board with representation from senior management and a Supplier Panel. The ASM Project Board provided the approval and guidance to ensure project objectives were achieved. Advice and support was also provided from the Supplier Panel, an ASM Steering Committee and Clinical Working Groups. A range of management and clinical staff were represented on the ASM Steering Committee whilst the working groups were comprised of representatives from each site, District Nurse Liaison and the Customer Service Centre. ASM champions were also appointed at each site and other program areas to support practice change at an operational level.

The ASM Project Coordinator conducted multiple ‘ASM Road Shows’ to every RDNS site and most divisions across RDNS. An ASM promotional poster was developed and displayed across the organisation, encouraging staff to access additional information. An ASM webpage was also created on the RDNS intranet with information and resources for staff to access. Resources included a plain English ASM statement which was developed to assist staff in understanding this approach, and over one hundred ASM reflective practice case studies written by staff. A ‘Frequently Asked Questions’ section was also available on this site where staff could post ASM related questions and seek a response from ASM Steering Group members. A communications plan was developed and implemented which included these initiatives among others.

2. Identifying specific practice changes to promote person centred care and achieve a person’s identified goals.

Nursing staff were required to use an ‘ASM program code’ to capture statistics on the number of people they were engaging in an ASM approach to care. The RDNS Institute facilitated access to an ASM champion trained in Motivational Interviewing. Approximately 200 staff have completed the Motivational Interviewing education and whilst the impact of this training has not been formally evaluated, anecdotally, staff indicate a greater understanding of motivational interviewing techniques. All RDNS in-service training courses have been updated to include an ASM overlay.

An electronic ‘Initial Needs Screening’ tool has been developed and piloted, underpinned by the ASM principles, involving the Customer Service Centre, District Nurse Liaison and two support sites. The tool provides a dependency score enabling admissions to be prioritised. RDNS completed the pilot of this tool in September 2012 and further work will occur in order to support implementation of the tool to screen all HACC admissions. Similarly, the general assessment tool has been reviewed and a new holistic assessment tool developed and piloted with plans for this tool to be implemented for all future HACC admissions. This tool is consistent with the HACC assessment service guidelines and requirements of a Living at Home Assessment which applies an ASM approach to assessment and care planning.


3. Developing models of service delivery that provide a responsive and efficient service, and identify capacity building potential for a person and carers, concentrating initially on the Dementia Model of Care, the Leg Ulcer Prevention Program and Medicines Management.

Dementia Model of Care

The RDNS Dementia Model of Care was fully implemented across the organisation in 2012. This is a best practice Model for people with dementia or a cognitive impairment, who receive home based nursing care. Using an ASM approach to care, the model is effective in promoting early intervention, maintaining independence and appropriate and timely referrals. An example of this is forward planning regarding the impact of change in the person’s condition and involving and preparing family and carers to manage these changes. Outputs included provision of a standardised best practice model for dementia care, an electronic assessment tool, clinical guidelines, carer support strategies and an electronic Services Directory. This work resulted in a shift in practice, whereby formal and informal support strategies for carers of people with dementia were introduced.

Leg Ulcer Prevention Program (LUPP)

RDNS has implemented the Leg Ulcer Management Program (LUPP), an innovative education program for people with venous leg ulcers, using a multimedia approach, across Victorian sites. LUPP utilises multimedia, including DVD and traditional written education materials, activities for the person involved and staff, which is facilitated and monitored by nursing staff. It is designed around key elements which influence healing of venous leg ulcers and optimising prevention of ulcer reoccurrence. The program aims for improving a person’s knowledge, adoption of healthy behaviours, self-management practices, increased use of best practice compression bandaging and engagement of the person and nurse in health promotion activities. The program was developed by the RDNS Institute and evaluated in a pilot study in 2010. Following the pilot study, LUPP was implemented under the ASM program as standard practice which was evidence based. Audits of uptake of LUPP as standard practice are intended. Further research is now underway to build upon the LUPP concept with development of a Skin Awareness Program (SAP) and e-learning package.

Medicines Management Project

The ASM Medicines Management (MM) Project has provided clinical staff with education and training in strategies to promote people’s functional capacity with safe self administration of medicines underpinned by ASM principles. Included is the development and implementation of a unique set of Medicines Reminder Cards, in six languages, soon to be nine. A major focus of this project has been to expand the sphere of practice of community care aides (CCAs) to further assist people with medicines. As well, the RDNS Home Medicines Review request process has been revised in consultation with key stakeholders in the Medicines Management Reference Group. Work is ongoing around sustaining clinical competencies and the ASM approach towards medicines management. The challenge remains to measure the impact of an ASM approach on episodes of care associated with medicines management through interpreting client care data and staff coding practices. The project is ongoing throughout 2013.


4. Ensuring implementation of the ASM Project contributes to the achievement of RDNS strategic objectives.

The ASM approach supports and contributes to the RDNS strategic plan and goal to ‘strengthen core business’. The ASM model of care is a quality improvement initiative that focuses upon delivering effective community care services that benefit people in supporting them to improve or maintain independence and wellness.

5. Integrating an ASM approach into new service opportunities.

An ASM approach has been integrated into the following activities: • Induction and orientation of new staff • Staff performance appraisals • Most staff education in service programs • Policies & procedures that support ASM implementation • Client Services Managers (CSMs) continuing to explore opportunities for integration of

service delivery with other HACC Assessment Service (HAS) providers • Underpinning the Broadband Enabled Innovation Project which supports medicines

management via video conferencing telecommunications and the National Broadband Network to appropriate people

6. Evaluating the ASM Project and making recommendations with regard to ongoing holistic and person centred care initiatives across RDNS.

Evaluation activities included implementation of a pre and post Staff Satisfaction Survey across the organisation in December 2010 and January 2012 respectively. Other activities have included monitoring of recruitment of people to the ASM program code over the course of implementation and review of incidents and complaints from people on the ASM program code. ASM related indicators have also been integrated into organisational quality improvement audits and the RDNS Client Satisfaction Survey. People on the ASM program were also included among the random sample for the Client Satisfaction Survey to allow for comparison of the results within the sample.


2.1.3 Stage of ASM implementation The development of this report follows two and half years of implementation of the ASM approach to nursing care for people receiving RDNS HACC services (Victorian sites and programs).

Now in the third year, the ASM implementation remains focused upon sustainability of the approach as ‘business as usual’ more broadly, and in particular, the continued application of ASM approaches to assessment and care planning as part of RDNS’ HACC assessment service role.

The implementation process at RDNS has been strategically managed, coordinated and guided by a Project Coordinator and a Project Board, involving all areas of the organisation. This has been essential to ensure momentum, manage the flow of information and coordinate responses. Staff have been directly involved in discussion of issues and challenges. Changes to service delivery have not been immediate, although staff have been encouraged to reflect on areas requiring review or change, as well as identify strengths of current practice. Managers across the organisation have led, and are expected to continue to lead, the change and ensure sustainability within their workplace environment.

Multiple changes have been implemented with the introduction of the ASM. These demonstrate significant commitment at senior management level. Key areas of support include: promoting the ASM concepts at the governance level and gaining support and authorisation; training for staff, and implementing initiatives including the Dementia Model of Care, Leg Ulcer Prevention Program and Medicines Management Project. RDNS has used ‘group approaches’ where appropriate, to ensure staff engagement. We have used change management strategies to embed the model including staff engagement, harnessing support, articulating goals, identifying accountabilities and team development. The project has resulted in increased capabilities in regards to the ASM approach and considerable progress towards changes being embedded across the organisation.

These change management activities and the executive level of support for them suggest that RDNS is already at Stage 2 of the three outcomes areas of progress conceptualised by the Department of Health (2010 pg. 4). There is also early indication of achievement of Stage 3 outcomes (improved HACC service delivery and better outcomes for clients).2 Examples include improved models of care (e.g. Dementia Model of Care, Leg Ulcer Prevention Program), new holistic assessment tools and ASM case studies which demonstrate better outcomes for clients.

These concepts are explored further in this report when discussing the use of theoretical models to explain RDNS’ systematic and strategic approach to transitioning towards an Active Service Model of care.

2 Stage 1 Outcomes: HACC funded agencies have increased knowledge about the application of an ASM approach and have increased commitment to implementing an ASM approach Stage 2 Outcomes: HACC agencies have started to implement an effective ASM approach systematically in practice. Stage 3 Outcomes: Improved HACC Service delivery and better outcomes for clients.


2.1.4 Other studies of implementing similar approaches Several other programs have adopted comparable models of care to the Victorian Active Service Model approach. Other similar concepts include ‘independence or wellness programs’ such as in Western Australia (WA), ‘restorative care ‘ in the USA and ‘re-ablement’ or ‘enablement’ in the UK.

Models of ‘Homecare Re-ablement’ in the UK have been developed and implemented by each Council and are underpinned by national policy from the Ministry of Health. The focus in service delivery is on ‘doing with’ rather than ‘doing for’ and time limited interventions. Significant variation in these models of care has resulted from the flexibility afforded Councils to implement the policy in ways that suit local requirements. Evaluation has shown that re-ablement programs resulted in reductions in the need for ongoing care in comparison to usual care (Glendinning et al., 2010).

Development of restorative approaches to home and community care in the USA has been limited, as funding tends to be by individuals and private health insurance funds. Despite this, a number of large scale research projects have been undertaken to evaluate the effectiveness of a more restorative approach (Tinetti et al., 2002).

In New Zealand (NZ), there is a comprehensive system of home care provision at low cost to eligible citizens across the country. Community care assessments are undertaken by government-funded teams, who then put forward detailed recommendations and funding towards a specific package of care to privately run service providers. The system is currently coordinated by each district health board. Several new developments with a more ‘restorative’ emphasis are under way within the NZ home care system. This includes recent improvements in assessment tools, training in more restorative methods for staff at all levels, development of new funding models to provide an incentive for a more restorative model, and development of new types of services oriented around social goals (Ministry of Health New Zealand 2006).

The HIP program has been evaluated using a non-randomised controlled trial. This study demonstrated that clients who received a restorative home care program would have better outcomes than clients receiving usual home care.

Both the WA Silver Chain and the UK programs have targeted relatively low dependency clients, who are referred at the point of entry to home care services. Following the completion of the program, clients are then referred for ongoing “standard” HACC services if required.

The Silver Chain ‘Home Independence Program’ (HIP) in Western Australia was developed as an early intervention programme directed at optimising functioning, preventing or delaying further functional decline, promoting healthy ageing and encouraging the self-management of chronic diseases. It is designed to be targeted at individuals when they are first referred for home care services or at existing home care clients who request an increase in level or amount of service, with the expressed intention of minimising the individual’s need for ongoing support services (Lewin et al., 2006).


Common elements involved in the enablement programs mentioned include:

• A multidisciplinary team comprised of a combination of allied health staff and home care agency staff

• Comprehensive assessment (face to face and in the person’s home) • A combination of interventions incorporating both functional and social goals • Time-limited duration

The WA state government has funded the roll-out of a broad-based training package within a range of existing home care providers outlining the principles of restorative care. The Wellness Approach to Community Homecare or WATCH (O’Connell, 2006) has now been formally recognised as a key priority for the WA HACC system. This approach encourages HACC services to work with people to retain or regain skills and prevent loss of independence. Evaluation of the Wellness Approach found most HACC service providers supported the philosophy of care and that sound progress was being made with implementation. Barriers identified included complexity of Wellness paperwork, lack of change management resources and a need to tailor the program for special needs and rural populations. This approach is distinct from a restorative or enablement model, in that it is proposed as an underlying philosophical approach to providing services which reinforces and supports each person’s level of independence.

In Victoria, the Department of Health has similarly adopted the Active Service Model more broadly as a quality improvement initiative to underpin the delivery of all HACC services. Pilot projects were formally evaluated (focusing upon different models or areas of ASM practice) to assist in the development of the Active Service Model and explore associated implementation issues. An implementation plan was developed by the Department based upon a detailed literature review and discussion paper and significant consultation with the sector, service users and carers. HACC funded agencies in Victoria, like RDNS are now working towards an ASM approach through implementation of their own ASM plans.

The literature suggests a restorative home care service may be of benefit to older people, and may improve the ability of HACC services to support people to live independently in the community. It is unclear however, from the present literature which components are integral to achieving positive outcomes or the most appropriate assessment approach, staff mix, program duration or whether or not such an approach can be integrated more broadly into home and community care services, as is the approach in Victoria.

Learnings from the UK suggest that regardless of the structure, programs that have been most successful have involved substantial efforts to re-train care staff with new skills and a new model of practice as well as considerable re-organisation of the service. Those that have simply re-named services and have not involved re-training and re-structure have not been successful (Pilkington 2006).


2.2 Evaluation Overview The Department of Health approached RDNS to undertake an evaluation of impacts of the RDNS Active Service Model Implementation Project to inform planning for the evaluation of the ASM program state wide.

A project brief scoping the evaluation was prepared by RDNS in collaboration with the Aged Care Branch, which was approved by the Victorian and Commonwealth Governments. The evaluation commenced in November 2012, with the purpose of determining the extent to which ASM principles have been translated into practice across RDNS HACC services and of what benefit this has been to people receiving services and the organisation. A key aim was to identify barriers and enablers associated with implementing the ASM approach to care.

The key objectives for the evaluation were:

1. To collaborate with the Department of Health and establish appropriate governance structures to monitor the project’s progress and reflect on outcomes

2. To develop and use agreed quantitative and qualitative methodologies, tools and indicators to measure ASM related outcomes for people receiving RDNS HACC services

3. To collect, collate, analyse and interpret data consistent with the agreed methodologies 4. To develop a final report describing the major themes and issues regarding translation of

ASM principles into practice and their policy and program implications 5. To report on the extent to which the implementation has demonstrated an improvement in

people’s independence or wellness

The outcomes expected from the project included: • Demonstrated progress towards translation of translation ASM principles into practice as

part of a person centred approach to care • Contribution to the evidence base for further implementation of the ASM model • Strengthening of the collaborative relationship between RDNS and the Department of

Health

The expected benefits of the evaluation were: • Development of appropriate measures of translating ASM principles into practice • Demonstrated evidence of the extent of integration of ASM principles into practice • Identification of barriers, limitations and learnings associated with implementation of the

ASM approach to care

2.2.1 Scope of the evaluation The scope of the evaluation was restricted to mainly qualitative methods focused upon information that could be extracted from a review of a random sample of RDNS care records, ASM reflective practice case studies and client service data.


It was agreed that the random sample for the care record audit be drawn from people receiving RDNS HACC services with an ASM program code and compared to a sample of clients receiving usual care. The sampling methodology is explained in more detail in 3.2.

People receiving services and their carers were not included directly in the data collection due to fixed timelines and concerns about limitations of this approach and ethical considerations. To overcome this, it was considered that RDNS staff could serve as proxies for understanding the perceptions and experiences that people and their carers may have concerning ASM care approaches. A focus group discussion with nursing staff was conducted for this reason and to also verify and test findings from the client record audit and analysis of case studies.

Despite development and implementation of an organisational Client Satisfaction Survey incorporating ASM related indicators and benchmarking, a decision was made to not include this specifically in the scope of the evaluation. This was due to a lack of opportunity to influence the ASM indicators being investigated. However, it was agreed that results of any significance would be shared.

Whilst the methodology included development of a client profile, it was not considered in scope to include visit data or develop a visit profile due to concerns over data quality and cleansing and exceeding set project timelines. However, some semi-quantitative analysis of the record audit data was included to indicate the average length of stay associated with the sampled records.

It was not within the scope of the project to consult with or collect data involving other HACC services. Nor was the project to explore sector wide or system impacts or benefits. However, if such information were to be identified, it would be documented and shared.

2.2.2 Limitations Whilst the approach to implementation of the ASM model within RDNS has been focused upon change management strategies to bring about practice improvements, challenges exist with the capacity to effectively identify and measure changes in professional practice.

Work is still underway concerning the introduction of a new intake and screening tool, holistic assessment tool and updated care planning documentation. For this reason, interpretation of the data and findings presented in this report should be made with some acknowledgement of limitations in these areas. Care documentation currently has not yet been modified to facilitate recording of assessment information, nursing care plans and progress notes in a format that demonstrates an ASM approach to the fullest.

Despite this, the professional practice of RDNS staff and supporting policies, processes and systems were well established and to some extent were already consistent with aspects of an ASM approach to care. To this end, identification and measurement of ASM progress and impacts should recognise both the strengthening of existing practices as well as introduction of new ones.


2.2.3 Main evaluation questions As the purpose of the evaluation was to determine the extent to which ASM principles have been translated into practice and of what benefit this has been to a person’s outcomes, the ASM principles were used to guide the development of the survey instruments involved in the evaluation activities.

Table 1 identifies examples of practice for each of the ASM principles which have been incorporated into the survey instruments developed for the case study analysis, file audit and staff focus group.

Table 1: ASM principles and examples of practice

ASM Principle Examples of practice

People wish to remain autonomous

• Involved in making decisions about their life/care and priorities

People have the potential to improve their capacity

• Improvement or maintenance of functional ability • Focus on strengths/abilities and not just deficits/needs • What people ‘can do’ as well as what they ‘cannot do’ • Supports independence – to manage activities of daily living • Improve confidence and motivation to manage aspects of /all care • Wellness promotion – both functional and social goals/actions

People’s needs should be viewed in a holistic way

• Holistic needs (not just presenting needs) are considered in conversation with a person at assessment, in care planning and throughout care delivery

HACC services should be organised around the person and his or her carer, that is, the person should not be slotted into existing services (flexible and responsive)

• Individualised approach adopted • Respect for person/diversity (including special needs)/personal

preferences • Involved in decisions & care planning • Evidence of getting to know person (beyond diagnosis) • Support to identify goals • Flexible service – sensitive to a person’s needs and values; provides

choice; service provided at times which suit the person and organised around the person

A person’s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and family; support workers and between service providers

• Communication • Interdisciplinary practices • Referral (including e-referral)


3. Methodology A mixed methods approach was adopted for the evaluation. This included a predominantly qualitative focus to the data collection and analysis with some semi-quantitative analysis of findings. A collaborative research methodology was utilised, involving both RDNS and Department of Health staff in an action learning process throughout the research journey. This methodology and process was employed to ensure that the research produced credible findings to inform policy development and state wide evaluation planning of the ASM approach to care.

3.1 Data collection and analysis The methodology of the evaluation included:

1. Analysis of ASM case studies of reflective practice generated by RDNS staff over the previous two years of ASM implementation (n=109)

2. File audit involving analysis of a sample of RDNS HACC ASM coded client records and comparison to a sample of client records receiving usual care. These were reviewed to assess the extent to which ASM principles were embedded in RDNS’ nursing approach reflected in:

a. use of more person centred ASM language b. identification of a person’s expressed ‘personal’ goals (as distinct from clinical care

goals) c. achievement/non-achievement of goals

A survey instrument was developed for the audit. The number of audits was determined following a small sample audit and the nature of the information found.

3. A focus group discussion with RDNS staff was conducted to reflect on staff learnings and insights and assist with interpretation and verification of findings from the case study analysis and file audit. RDNS staff served as proxies for understanding the perceptions and experiences of people receiving services and their carers concerning ASM care approaches.

4. Service data was extracted and analysed for a client profile comparing ASM coded HACC clients and HACC clients receiving usual care on measures including number and proportion, main condition and main intervention.

A final report was prepared following completion of data collection and analysis. This report summarises the themes and issues arising from the file audit, case study analysis, staff focus group and an analysis of profile data. A draft of the final report was reviewed by the Project Management Group prior to its completion.


3.2 Sampling methodology An ASM program code was introduced at the commencement of the ASM implementation at RDNS. This was to assist staff to identify people that had potential for adopting this new approach to care and enable monitoring of staff uptake of the program. Since the ASM program commencement, around 25% of people receiving RDNS HACC services have been allocated to the ASM program code. It was expected that as the approach became embedded into staff practice, and became ‘business as usual’, coding of people to the ASM program would no longer be required.

The sampling methodology for the evaluation made use of the ASM program code to identify a sample of people that were flagged with an ASM approach. The primary objective of using the ASM program code in the sampling methodology was to investigate the extent to which an ASM approach was implemented by staff with people they identified as suitable for this approach. However, sampling also included HACC clients receiving usual care to determine the extent to which an ASM approach to care was adopted as ‘business as usual’ or alternatively could have been adopted.

Finally, there were no exclusions in the sampling methodology, such as people receiving palliative care or people with dementia.

3.3 Care record audit process, data recording and analysis The care record audit was conducted from a random sample of discharged records, with episodes of care during the ASM implementation period (commencing July 2010 to the present).

The majority of records sampled in the audit included those with an episode coded under the ‘ASM program’ and a smaller number that were not. A larger proportion of ASM coded records made up the audit sample, as the primary focus of the evaluation was to determine ASM related outcomes. The inclusion of people’s records who received usual care was to provide a comparison to see to what extent ASM principles and practice had possibly translated into a ‘business as usual’ approach.

Two master lists of unit record (UR) numbers were compiled from reporting systems linked with the client management database. One list had care records with an ASM program code and the other with usual care. From these lists, records were randomly selected. Records that were not available to be audited due to being located at sites or because they had current episodes of care were excluded and replaced by others randomly chosen from the appropriate master lists.

An audit tool was developed and reviewed by the project team and then created in Survey Monkey to assist with data collection, collation and analysis. Survey questions were structured using a care pathway framework. The key phases of the pathway included referral, intake and screening, assessment, care planning, service delivery, review and discharge. Questions were developed within this framework focusing upon identifying practical evidence of ASM principles.

The audits were conducted by a single researcher with no prior knowledge of which records were coded with an ASM program code (electronic identifier). It was hoped this method would limit any measurement bias. The audit process included reviewing both paper based and electronic components of the care record.


A total of 90 audits was conducted and entered into Survey Monkey. Of these audits, 61 were identified with an ASM program code and 29 were identified as usual care.

Upon completion of the audits the data was extracted from Survey Monkey into a reporting format. The data and findings are discussed further in the next section. Refer to the appendix for the record audit schedule.

3.4 Case study review, data recording and analysis Over 100 ASM case studies have been written by staff across each of the RDNS support sites to encourage nursing staff to reflect on their practice and the ASM principles and approach. A common template was developed to guide staff to reflect upon the demonstration of key ASM principles and outcomes for a particular person. Staff were randomly selected at each site to write a case study. These were submitted by each site, each quarter over the three year implementation period. For this reason the case studies have been classified into years 1, 2 or 3 for the purpose of further analysis.

The completed case studies were published on the RDNS intranet site (ASM webpage) to enable sharing of these reflections. Published case studies were de-identified so that a person’s and staff details were removed.

The analysis of the case studies was undertaken using a survey tool developed to identify practical examples of demonstration of ASM principles, changes in or strengthening of practice and identification of outcomes for both people receiving services and the organisation.

A total of 81 case studies from the available 109 were reviewed by a single researcher. The case studies were classified by year, type of nursing care provided and whether or not a person had a carer involved in their care. Each case study was analysed using the survey instrument. Content meeting the survey instrument was extracted and collated onto an excel spreadsheet from which further coding and analysis and aggregation of data was undertaken, to highlight qualitative themes and semi-quantitative findings.

3.5 Client profile data extraction, review and analysis

Data was extracted from the client management database to compile a client profile comparing ASM coded HACC clients and HACC clients receiving usual care on a range of measures. These included number of clients, age, gender, country of birth status, carer status, primary diagnosis and main nursing intervention. The data reporting period for the profile was from 1st July 2011 to 31st December 2012.


3.6 Staff focus group, recruitment, schedule and analysis The focus group discussion was undertaken at an RDNS site and was approximately 2 hours in duration. The discussion was led by a facilitator with support from the project leader. There were nine participants involved who were recruited from a cross section of RDNS nursing staff and sites and programs.

Other considerations in the recruitment of participants included representation of staff that had been involved in ASM activities such as the Leg Ulcer Prevention Program (LUPP), Dementia Model of Care, and Medicines Management, assessment tool review or ASM training.

An overview of the purpose of the discussion and the questions being explored was circulated to participants prior to the session. A focus group interview schedule was developed by the project team with input from the Project Management Group and facilitator. Whilst the schedule guided the discussion, prompts and probing questions were used where necessary to clarify or follow up a line of discussion. Refer to the appendix for the focus group schedule.

An audio recording was made of the discussion with verbal consent of participants. Notes were transcribed by the research officer. Responses were then grouped and labelled or coded into categories from which further analysis and interpretation was drawn.


4. Evaluation results

This section of the report provides an initial brief description of general findings (4.1), including an overview of the uptake of the program by service users and staff and of the ASM client profile. Section 4.2 describes detailed findings reported against the purpose of the evaluation as set out in the Project Brief (noted earlier), namely:

i. determining the extent to which ASM principles have been translated into practice, and ii. assessing the benefits to individuals concerning improved independence and wellness and

benefits to the organisation with respect to nursing practices.

This section also includes detailed findings about barriers and enablers associated with the implementation of ASM approaches.

4.1 General findings

4.1.1 ASM program uptake by service users and staff The ASM approach was promoted to both new service users as well as existing (those who had received an episode of care prior to the ASM program introduction). Two thirds of the audited records were for new service users and one third (34%) had episodes of care both prior to and also after the introduction of the ASM program. The majority of these records were for people nominated on the ASM program (22 out of 31 records). The ASM case studies analysed suggested motivation towards independence in life or with self care was a common enabling factor for people embracing an ASM approach.

From a staff point of view, offering the ASM approach to existing service users raised possible issues for managing expectations of people and carers that are more aligned to a dependency model of care. This was raised by staff as a key barrier in the focus group discussion.

Furthermore, staff in the focus group suggested that the ASM approach tended to be embraced by people (new or existing service users) who are more active in the community and want to return to their former activities or levels of independence. Staff remarked that younger aged people (e.g. 60 to 80 years) tend to have this culture more so than those of older ages (e.g. 80+ years).

With respect to the extent to which the ASM approach was embraced by staff, one of the key means used for monitoring this was their use of the ASM program code. Since the introduction of the ASM program code to monitor staff uptake of the program, 11% of people were allocated to the program in the first year, which increased to 26% in the second year of implementation. The ASM client profile indicates that 21% of people were allocated to the program over the 18 months from July 2011 to December 2012.

Use of the code by staff seems to plateau at around 20% of people into the second year of program implementation. Precisely why this occurred is unclear. One possible explanation could be that staff required more education around the use of the code when implementing an ASM approach (a


theme which recurred in focus group discussions). An alternative explanation could be that, as the ASM approach increasingly became ‘business as usual’ for all people receiving services, staff no longer saw the need to allocate an ASM code.

Both of the above explanations suggest important learnings. In the initial stages of introducing an ASM approach it is important that staff be educated about the importance of using the code to specify that the new approach is being adopted. As the new approach becomes more embedded staff can be advised that the use of the code is no longer required. Use of an ASM code therefore can be seen as a facilitator for prompting staff to think in ASM terms when the approach is first being introduced.

4.1.2 ASM Client Profile Age distribution The age distribution of ASM clients is similar proportionally to the age distribution of all RDNS clients. Somewhat higher proportions of ASM clients were noted among people aged 71-85 years, but were lower amongst those aged 86+ years. Statistical analysis of results of an RDNS Client Satisfaction Survey revealed that people who received the ASM model of care were younger (54% aged <80 years) than people not on the ASM program (41% aged <80 years), a difference that was statistically significant [χ2(1)=9.38, p<0.01]. Gender A higher proportion of ASM clients were female compared to male (3,366 or 57.8% compared to 2,461 or 42.2%). There were however more males on the ASM program at a younger age (61-75 years). This trend was reversed amongst clients aged 76+ years. The greater involvement of women at older ages as opposed to men is consistent with the fact that women tend to live longer than men. Non-English speaking countries Of ASM clients, 2,094 were from non-English speaking countries, compared to 3,732 from English speaking countries. These figures represent 22% of all non-English speaking people compared to 21% of English speaking people receiving RDNS HACC services. In other words, ethnicity is not a factor which excludes people from participating in an ASM approach. Carer availability The proportion of people that had a carer (either resident or not) was similar for ASM clients (38%) and clients receiving usual care (37%). A higher proportion of ASM clients however, did not require a carer (30%), compared to 24% of clients with usual care. This suggests that the characteristics of this group would place them at the independence end of the ‘independence/dependence continuum’. In this context the ASM provides a means for them to either maintain independence or return to independence following an episode of care. Similarly, the proportion of ASM clients that lived alone without a carer (16%) was somewhat higher than usual care clients (12%). These data suggest that approximately 40% of people in a home care


context have access to a carer. However, people oriented towards an ASM approach may not require a carer if a nurse can assist them to self manage their care alone or in partnership with interdisciplinary health and homecare professionals. Primary diagnosis The number of people with a urinary incontinence diagnosis ranked highest among both ASM clients and usual care clients. Diabetes mellitus ranked second among ASM clients and fifth among usual care clients. The number and percentage of people with a diagnosis of diabetes mellitus was higher among the ASM clients, compared to usual care clients (630 or 8.4% and 556 or 2.5% respectively). This seems to be consistent with the greater focus on self management of diabetes. Beyond examination of primary diagnoses however, it is not uncommon for people receiving RDNS HACC services to have complex health needs and significant co-morbidities. That said, there is still scope for people to take up self care approaches consistent with the ASM principles, such as goal setting and access to holistic care supports as and when required. Treatment requested Wound management and medicines management were the most common types of nursing care provided to both ASM and usual care clients. This was evident in the results of the care record audit and case study analysis. Of treatment provided, medicines management, diabetes and continence management were all higher proportionally among ASM clients compared to usual care clients. Wound management, however was provided for a higher proportion of usual care clients. These differences were greatest in the results of the care record audit which indicated 62% of usual care clients received wound management, compared to 28% of ASM clients in the sample. Given the small sample size, these figures should be considered with caution. However, it is possible that technical aspects of wound care that require the expertise of a nurse limit the opportunity for people or carers to be independent with their wound care. Goal of care The goals of care in use originate from nursing minimum data set reporting indicators which predate ASM. A nursing goal of care is allocated by nurses to people as part of the assessment and admission process and is reviewed upon reassessment and discharge. ASM clients are comparable to all RDNS clients against the key goals of care, particularly those allocated a goal of ‘complete recovery’.

However, a higher proportion of ASM clients (25%) were allocated a goal of ‘incomplete recovery/ rehab to level where ongoing services not needed’, compared to all RDNS clients (17%). This may suggest that nurses using an ASM approach were more attuned to identifying a client’s potential to improve their capacity for self care.

4.1.3 Average length of stay The average length of stay (LOS) or episode duration calculated from the audited care records indicates ASM clients in the sample had a marginally shorter length of stay (LOS = 34 days) compared


to the usual care clients (LOS=36 days). (This was reduced to a mean of 31 days for ASM clients, upon removal of outliers). These data suggest that of discharged clients, ASM clients tended to be discharged sooner than usual care clients. However, further investigation is required to determine a more precise visit profile as it was outside the scope of this evaluation. Variations to length of stay could be expected however, when taking into account that some people require ongoing care (and are not discharged). Other visit indicators such as frequency of visits and the type of care/support delivered during each visit would require consideration for this sub group of clients.

4.2 Detailed Findings

4.2.1 Translation of ASM principles into practice

Audit

A very small number of ASM coded records (10) suggested little evidence of an ASM approach being taken. Of these, only five records indicated that there was actually some potential to undertake an ASM approach. Limiting factors included unexpected admissions to acute care or residential care placement and limitations posed by a person’s health condition (e.g. advanced dementia or arthritis limiting dexterity/mobility and capacity for self care). However, it was suggested in the focus group that allocation of the ASM program code by some staff was not a reliable indicator that an ASM approach had been put in practice.

Of significance, several usual care client records reviewed in the audit showed clear evidence of an ASM approach and positive outcomes for the person’s independence, despite not being allocated to the ASM program code.

Case studies

The majority of case studies provided evidence of more than one ASM principle being translated into practice by RDNS nurses when working with people. Most case studies revealed nursing practice informed by at least two (42% of cases) or three (33% of cases) of the ASM principles. Nursing practice informed by only one ASM principle was evident in approximately 15% of the case studies. No case studies demonstrated all five of the principles in practice. Table 2 summarises the number and percentage of case studies that reflected practice of one or more ASM principles.

Table 2: Number and percentage of case studies demonstrating ASM principles

Number of ASM principles demonstrated Number (%) of case studies

1 Principle 15 (18%)

2 Principles 34 (42%)

3 Principles 27 (33%)

4 Principles 2 (3%)

5 Principles 0


The following table ranks the ASM principles identified in the case studies from most to least common.

Table 3: Ranking of ASM principles by evidence in the number and percentage of case studies

ASM Principle Number (%) of case studies

A person’s needs are best met where there are strong partnerships and collaborative working relationships

51 (63%)

People have the potential to improve their capacity

48 (59%)

Person centred care (flexible and responsive) 29 (35.8%)

People’s needs should be viewed in a holistic way 24 (29.5%)

People wish to remain autonomous 23 (28%)

Focus group

Staff in the focus group were asked to rate the extent to which the ASM principles had been applied in practice across the organisation along a scale from one representing ‘not at all’ to five being to a ‘large extent’. The ratings by staff are discussed separately under each of the ASM principles.

4.2.1.1 Autonomy

Audit

Results suggest evidence of client involvement in care planning and decision making is proportionally higher among ASM clients (52%) compared to usual care clients (41%) in the audit.

Client involvement in ongoing discussions about issues and decisions about care, however, is evidenced more in the overall sample (69%) as well as among usual care clients (76%) versus 60% for ASM clients. Carer and family involvement in ongoing care was comparable for over half of the ASM and usual care clients.

This ASM principle is about recognising and respecting people’s wish to remain autonomous, that is - to be involved in making decisions about their life, care and priorities. Maintaining autonomy has a positive effect on both people’s quality of life and their ability to manage day to day. Self-efficacy is the measure of a person’s ability to set tasks and achieve goals. A person’s sense of self-efficacy can play a major role in how they approach goals, tasks, and challenges.


Case studies

Reflections by staff suggest that a small group of clients may be unable to participate fully in setting goals (e.g. clients with cognitive impairment). They can nevertheless be assisted towards achieving more independence within their capacity. Some case studies indicated staff made it their goal ‘to encourage independence’.

“A man with a history of being ‘fiercely independent’, despite advancing dementia was educated to self administer insulin with prompting. It was possible to determine what aspects of care he could remain independent in, with support from his wife (carer) who gained confidence with his care”

Focus group

With respect to the ASM autonomy principle, focus group members generally rated its application at three on the Likert scale, which equates to a neutral perspective about its application in practice. Typical perspectives expressed were as follows:

“Almost everyone doesn’t like the thought of losing independence, but a lot of people are also in a very dependency type model, and so they have expectations and wish people to do for them rather than do it themselves’ and ‘families may also think this – that mum or dad is of a certain age and he/she is entitled to have visiting nurses care for him/her’.

‘There are people that don’t have the capacity to make the decisions about trying to improve what they can do, yet they believe they have’.

4.2.1.2 Capacity building

This ASM principle is about identifying people’s potential to improve their capacity. It is about

Audit

Almost 70% of the ASM coded records indicated evidence of the person or their carer, usually family members, taking over some if not all aspects of care. In some instances where the person or their carer was already proving independent with care, the role of the nurse was to provide additional information and supports or guidance without ‘taking over’ care. In this way, the ASM approach was about maintaining or building a person’s and carer’s independence and ‘doing with, not for’.

This ASM principle is about identifying people’s potential to improve their capacity. It is about improvement or maintenance of functional ability by focusing upon a persons’ strengths and abilities as well as their needs. It entails supporting a person to manage their activities of daily living, and improving their confidence and motivation to manage aspects of or all of their care. From a wellness promotion perspective it would include physical function as well as mental and social wellbeing goals and actions. The starting point is that all HACC clients have the capacity to improve their functioning and wellbeing across all domains. The aim is to ensure every opportunity is afforded to a person to be involved in daily activities, and that their connection with their community is actively supported.


Changes in nurse intervention which supported improving independence were also evident in a significant proportion of the sample, being somewhat higher among the ASM audits (59%), but not by much (51.5% usual care). This often reflected the journey of a person or their carer towards independence. Often visits entailed the nurse providing initial education, followed by encouragement, prompting and supervision or monitoring. As a person’s and carer’s confidence and abilities increased, often the frequency of nurse visits were reduced, followed by eventual discharge.

Review of progress is important in order to build capacity and independence. This was evidenced fairly consistently in the audited records, less formally from visit to visit rather than as part of a planned review. Once again this practice was more evidenced among a higher proportion of ASM records (69%) than among usual care records (58.5%). Comparable results were shown across the sample regarding evidence of planning for discharge, which rated fairly high.

Case studies

Staff identification of ‘a person’s potential to improve capacity’ was indicated in around two thirds of the case studies reviewed.

A number of case studies demonstrated clients returning to full independence or at least some independence with aspects of their care given appropriate capacity building assistance. This indicates that clients may not necessarily become fully independent but are often able to participate in some aspects of their care.

‘One gentleman’s goal was to be independent in applying compression stockings, without the support of his son. Nursing staff acknowledged that his chronic condition would require ongoing nurse intervention however, he could become independent in some aspects of his care, and he “wanted to be able to do as much as possible for himself”. Staff worked with him to determine what areas of care he could do for himself and what was important for him to achieve to feel less dependent, particularly upon his son. Eventually he became independent with the application and removal of compression stockings. This reduced pressure on his son who was his non-resident carer, to assist daily with this task’.

Changing practice from a purely task oriented administration of care, to more of a focus upon education, encouragement and support was strongly reflected across the case studies.

Focus group

With respect to the ASM capacity building principle, focus group members rated its application as either three (neutral) or four (applied to a certain extent) on the Likert scale. Remarks illustrating these perspectives included:

“staff confidence and ability to work with people using an ASM approach tends to vary, with some staff being really good, but others struggle with it”

“some staff may not have picked up on the full message of goal setting and changes in independence or clients doing more for themselves. They think it’s only about achieving full independence”


4.2.1.3 Holistic view of peoples’ needs and care Audit Evidence of holistic needs considered beyond the referred need was somewhat limited to the scope or completeness of the general assessment tool in the audited records. This tended to vary. Some records indicated rich information provided in the referral or in progress notes, particularly when the person was well known to RDNS. The data also suggests a greater focus on physical abilities and function, more so than social and mental health areas.

There was no strong evidence that new needs were identified and discussed with the person or their carer. However, this does not mean that new needs were entirely absent. Rather it suggests they were not identified or discussed during the care journey.

Evidence of carer and family needs being identified was not high across the sample. As carer availability was not determined with a specific question in the survey instrument, the interpretation of these results is limited. It was clear however that some people in the sample lacked either family or carer supports.

Case studies

The case studies often revealed nurses considering and discussing the holistic needs of a person. Examples range from addressing people’s physical activity with hydrotherapy classes, to their transport needs using the community bus as well as attending to people’s social wellbeing by linking them into planned activity groups.

This ASM principle is about viewing peoples’ needs in a holistic way, focusing upon the person as a ‘whole’. Holistic care looks at an individual’s over-all physical, mental, spiritual, and emotional well-being and is respectful of their autonomy or right to self determination. Independence is not limited to physical functioning but extends to social and psychological functioning and choices.

“Mr Y whose wife had passed away six months prior would forget his medicines and often not prepare meals for himself. Staff addressed his needs holistically, initially monitoring self administration of medicines, and then moving onto work with him on diabetes management, eating, weight loss and exercise, with the Diabetes CNC and physiotherapist. He had indicated that he had put on weight which worsened his arthritis so he wanted to be able to climb the steps to his house without pain or discomfort. The initial visits were to check that he was managing to use the Webster pack and could administer his own medicines. The Diabetes CNC reinforced blood glucose level (BGL) testing and eating regularly. As he did not like the idea of Meals on Wheels, a 'healthy eating' course at the Community health centre was suggested. The Physiotherapist recommended strengthening exercises for him which would help him lose weight. After a few days practice, he was soon able to check his BGLs himself. He followed up and joined the healthy eating course, where he learnt about a local walking group and joined this. He lost 3 kg and was able to reduce his medications. He was able to walk up the house steps without pain or discomfort and was discharged independent in diabetes management.“


Focus group

With respect to the ASM principle of taking an holistic view of a person’s needs and care, focus group members rated its application as three (neutral) on the Likert scale. Typical perspectives in this regard were:

“there’s some inconsistency in holistic practice day to day, however for assessment and review this is done better”

4.2.1.4 Person centred care (flexible and responsive)

Audit

The audited records showed that goals were usually expressed as clinical or nursing goals of care rather than person-centred goals. The use of clinical rather than person-centred language was evident across all forms of documentation within the care record - from referral information, through assessment tools to care plans. Sometimes language used by nurses in care documentation was inconsistent with an ASM approach. For example, descriptions of a person as ‘compliant’ or ‘not compliant’ suggests labelling of clients in negative clinical terms rather than collaborating with them to enhance their personal independence and wellbeing.

Similarly, goals framed in terms of physical, social or mental health outcomes were also not evident. As stated earlier in this report, the nature of current care documentation, particularly care plans, limits the possibility for nurses documenting goals in this way.

There is some evidence of nurses getting to know the person beyond the diagnosis or referred need. This was indicated in a higher proportion of the ASM clients (31%) compared to the usual care clients (17%).

Evidence of identification and consideration of diversity characteristics and special needs, at both screening and assessment was proportionally higher among the ASM clients compared to the usual care clients. Most instances identified included language barriers and need for interpreters and some personal preferences for care.

Continuity of care was comparable for both the ASM and usual care clients, across the sample. In some records the same staff were providing care to the same person throughout the care journey. In other cases different visiting nurses were involved with the same person and consistently followed that person’s care plan requirements.

This principle concerns the focus of service provision so that it is person centred. It emphasises that care should be flexible and responsive based on the goals of the individual (and his or her carer) in their own environment, as opposed to services that provide a standard program of care for all people.


As a further demonstration of this person-centred approach, there was evidence of flexible scheduling of visits around a person’s appointments, usual routines, social activities and care needs for the majority of the people in the sample. Among ASM clients this proportion was 57% as compared to 44% of usual care clients.

Case studies

Fifty two of the case studies identified person-centred goals whereas 29 did not. Case studies that indicated staff tried to get to know the person beyond their clinical or referred need had more person-centred goals identified.

‘Staff reinforced developing a goal that was motivating for Mrs P, returning her to walking and volunteer work which she enjoyed. The care plan strategies supported this through a range of mechanisms as well as identifying alternative strategies to overcome pain, as she did not wish to take pain medication.’

Analysis of people’s goals revealed that they were predominantly focused upon ‘independence regarding care’ (n=40), and a smaller number on ‘social health’ outcomes (n=12) e.g. walking routines, remaining at home, and returning to work. These goals reflected more of a personal aim rather than a clinical focus.

Of the case studies analysed, evidence of person-centred goals increased from year to year, being present in 16% of year 1 case studies, progressing to 40% and 43% of year 2 and year 3 case studies respectively.

Focus group

With respect to the ASM principle of taking a person-centred approach (flexible and responsive), focus group members rated its application as being applied to a limited extent (two) on the Likert scale. Different perspectives in this regard were:

“there is limited flexibility from an access point of view….tend to just to slot people into services due to limited service capacity”

“often, RDNS responds to referrals (e.g. from ACAS) …. that do not progress to care provision because people don’t feel they need the service at that point in time”

4.2.1.5 Working Collaboratively and in Partnership

The expertise and options to meet a person’s needs and preferences can often be located in more than one organisation. A person’s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and family, support workers and between service providers. Improving the interaction and collaboration between services enables individuals to maximise their opportunities to achieve their goals.


Audit

Progress notes in around half of the ASM coded records indicated often regular discussions with the person, carer and family members either face to face or via telephone, involving aspects of care.

There was a strong indication of working collaboratively with other services evidenced by the level of communication in the majority of audited records, particularly for ASM clients. This suggests this practice may have been strengthened through an ASM approach, which emphasises working collaboratively as a key underpinning principle.

Very few outgoing referrals were made in the records sampled. The audit tool was however limited with respect to the information captured concerning referrals. In some instances, records indicated either the person or their carer declined consent for referral to other services for assistance.

Case studies

Evidence of working collaboratively with people and their carers is relatively well developed throughout the case studies. Whilst a number of the case studies did reflect upon on working in collaboration with a range of professionals, (nurses, social workers, occupational therapists, council HACC workers etc) this practice may require further development.

Case studies were limited with respect to staff reflections for suggesting how they could improve their practice of working collaboratively. In one example, the staff member reflected upon working with a council to provide appropriate social support visits.

Focus group

With respect to the ASM principle of working collaboratively and in partnership with people, their carers and other professionals and services, focus group members rated its application as being a four (to a certain extent) on the Likert scale. Typical perspectives shared were:

“new holistic assessment tool is more user friendly in asking people about services and supports they are receiving – to know this information from the beginning”

“lack of knowledge of roles … more interdisciplinary practice needed internally and externally”

4.2.2 Benefits to the Individual and Organisation

The above assessment of translation of ASM principles into practice has revealed that the principles of capacity building and working collaboratively have been applied up to a certain extent (four out of five on the Likert scale). The principles of autonomy and holistic care have been applied in a relatively neutral fashion (three out of five on the Likert scale). These findings suggest that effectively implementing the principles of capacity building and working collaboratively with the person, their carer and other services provide key starting points for implementing the remaining principles. Staff feedback suggests that progress is being made towards application of the remaining


principles. There is still, however, some work needed on application of the person centred principle, seen in the focus group as only applied to a limited extent – two on the Likert scale.

The translation of these ASM principles into practice as noted above, whilst still in progress, is nevertheless yielding significant benefits at the individual and organisational levels. These are noted in detail here including case studies as appropriate.

4.2.2.1 Individual Achievement of personal goals (where stated), and improvements in capacity to self manage were evident for a number of people across the audited care records and demonstrated in the case study reflections.

Benefits for the individual person (or client) included:

• Increased satisfaction from managing care independently and seeing improvement in one’s own condition

• Motivation to continue with care and address other areas of health and wellness (including social health)

• Increased opportunities for social engagement with greater independence in managing one’s condition

• Less restriction on activities, with increased ability to go out without waiting for the nurse • Increased social engagement and enjoyment gained from participating in activities • Improved feelings of being ‘in control’ of one’s health condition and life in general • Reduced anxiety • Generally feeling happier and healthier • Improved self confidence • Sense of personal achievement and ‘pride’ at having either participated in care or achieved

goals or both • Satisfaction of having input into care • Increased confidence in capacity of community services to address personal needs in an

integrated way

It was common for carers to increase their confidence, with the education and support of the nurse. This in turn often reduced stress for carers. One case study noted a client was willing to accept assistance from their carer, when previously they had been reluctant, which strengthened their relationship. In other instances, family members were encouraged to participate more in the care of their loved ones. Often family members expressed relief that people were coping better with their care as a result of the strategies put in place.


The following case studies illustrate some of the benefits discussed.

Case study: Much happier and feeling safe

‘Mr X is much more accepting of community services, and anxiety levels have reduced along with crisis management episodes. He is able to take his medications as directed and his BGLs are stable. He doesn’t miss any appointments now and is more socially active with less episodes of depression. He reports being much happier and feels safe knowing he has the supports available he can rely on’.

Case study: A new lease on life…

‘Mrs Y has a 'new lease on life' since moving to the retirement village, instigates all her own medical appointments and reviews, confident again using public transport… started walking to local shops, became a member of the social committee at the village. She hopes to take responsibility for her medications with support of the nurse and not have to wait at home for the nurse to visit’.

Case study: Feeling completely empowered

‘Mrs A became completely independent in bowel management and feels empowered by the opportunity to improve her capacity and learn to manage her own bowels. She has increased self-esteem and belief in her ability to manage’.

Case study: Life has improved ‘Mr D became self caring with his stoma care. His skin improved, frequency of pouch changing decreased, requiring less washing, so he had more energy ... and now he is attending the occasional social activity. He is independent with ordering and collecting his own supplies. He has increased confidence in his ability to manage his care. His life has improved and he is less anxious about venturing out into the world’.

4.2.2.2 Organisation

A key benefit for RDNS as an organisation was the development of staff capability to work with clients – ‘by your side’. That is, translation of ASM principles into nursing practice helped focus staff on identifying a person’s potential to participate in their own care and possibly becoming independent with their care. This greater focus on enabling self- efficacy was often reflected upon by staff in their case studies. In particular, staff noted the benefit of developing motivational skills including gentle encouragement and perseverance to support people over time to consider taking initial steps in managing their own care and wellness.

On the other hand, this evaluation revealed that staff tend to focus on themselves much less than they do on clients. Opportunities for reflective practice therefore yielded few reflections on how the


ASM approach impacted on staff satisfaction with the performance of their own role. In those instances where staff did make comments, however, an ASM approach was seen as informing a more satisfying approach to working with clients, carers and other home care professionals.

The data suggest that an ASM approach to care, when effectively implemented can lead to a reduction in visits during the episode of care and possibly earlier planned discharge. In terms of episode length, findings presented earlier from the care record audit indicate an ASM approach can lead to a marginally shorter length of stay.

The benefit to RDNS, however, is not only associated with demand management but also with actively promoting the empowerment of people and improving their quality of life rather than creating further decline through a dependency model of care.

Case study: English as a second language is no barrier

“Mr P wished for his wife to attend to his care at home post hospital discharge. English was his second language and he was reluctant to accept RDNS services. Discharge planning had not considered education prior to him going home. The RDNS Liaison nurse working collaboratively discussed Mr P’s needs with him and his wife and a range of hospital staff with the aid of an interpreter. This helped with understanding Mr P’s needs and arranging appropriate supports as per his wishes.

Mr P’s daily routine was accommodated with visits scheduled around other appointments. He commented that the RDNS non-visit days were his 'respite days'. Visits were conducted by RDNS to provide support and education. This reduced the strain on his wife who was his carer. Following the education, Mrs P was happy at being part of her husband’s care and felt more confident in managing her husband at home. Positive feedback from Mr P and his wife, was that they were 'feeling in control’.

Although the initial referral was for daily visits, RDNS coordinated care with other services requiring only 2nd daily visits. Visits slowly reduced to twice weekly.”

Case study: ASM approach overcomes overwhelming complex health needs

“Mrs D was discharged home from hospital requiring stoma care and education following an extended hospital stay. She had poor mobility and impaired manual dexterity which limited Mrs D’s ability to attend her own ADLs and stoma care. Her complex health needs overwhelmed her to the point she feared she may need to enter residential care as she was worried about her ability to manage at home alone. Despite this, she desperately wanted to remain independent at home, manage her care and ADLs and reengage with social activities.

Staff considered her holistic needs, both her nursing care needs and need to reengage with social activities and remain independent at home. The focus of her care was to educate and support Mrs D to self manage and slowly increase her participation with her care as she improved her dexterity and confidence. Mrs D was educated to self manage her stoma care and troubleshoot any potential leakage problems when she went out socially. She was able to identify good self care practices. She also regained her independence with ADLs and mobility, following extensive physiotherapy. She was eventually discharged following a reduction in visits upon being able to manage her own care.” RDNS Active Service Model Evaluation Final Report Page | 38

The above findings on benefits reveal in brief that at the individual level an ASM approach better empowers people and their carers to realise an improved quality of life. This is achieved by making people partners in their own care. At the organisational level, an ASM approach helps to align nursing practice with a restorative focus on working with, not for the person. Findings to date suggest it may help to free up resources as a result of reducing the number of visits involved in an episode of care. Further work on researching visit profiles should provide stronger evidence as to whether these benefits can in fact be realised.

4.2.3 Enablers and barriers In this part of the report we detail our findings in relation to factors which enabled of hindered uptake of the ASM approach. In each case we provide at least one detailed example of how these factors were demonstrated in practical terms.

Case study: Able to achieve some independence despite dementia and failing memory

“Mrs C was an 86 year old Italian lay who lived on her own. She was referred to RDNS by her GP for assistance with twice daily insulin administration and blood glucose level (BGL) monitoring. She had a diagnosis of dementia and scored poorly on the MMSE for memory recall.

Assessment revealed Mrs C had previously been independent with her own care, but lately had struggled with managing her BGL readings and on occasions not remembering the correct dose or forgetting whether she had already taken her insulin. This placed her at serious risk of adverse medicines events. She was very keen to continue to manage her own care, and still had the manual dexterity to maintain some level of independence. Mrs C also had a supportive family who were able to assist when possible.

RDNS visits were put in place to supervise Mrs C attending to her own care. A locked box was used however to prevent her from double dosing. Mrs C’s family also agreed to supervise her on the weekends.

An ASM approach supported 'tailoring of the care to suit Mrs C’s needs, who despite failing memory was able to achieve some level of independence, with minimal formal community supports.”


4.2.3.1 Enablers

Personal motivation

The most commonly identified enabler was where the person was clearly motivated to be independent in self care. This was generally the case if they were independent with daily tasks other than their health need or had previously been independent with performing self management of care either prior to a hospital stay or prior to a period of declining health.

Carer support

Carer involvement and support were also significant enablers. Specific remarks by the nurses in their case studies included:

Focus group insight

“If a person had been very active in the community or had previously been independent with their own care, they embrace the active service model because they want to get on with living.”

‘the carer assisted in setting up equipment needed for the care’ ‘Caring partner willing to take on a supervisory role’ ‘the carer had been watching the care on initial visits so knew what was involved’ ‘the carer had work experience with care procedures and had commenced education whilst still in hospital and was keen to take on this role.’ ‘the carer had been assisting in wound care, and the couple were very active and not requiring other services’ ‘the carer was very involved in the care and willing to learn’

Case study: Confidence to self administer insulin

“Mrs C is an active, alert and socially engaged 90 year old with good cognition and understanding of her health needs, however she was anxious about commencing insulin and the impact of this on her life. Her nurse, working collaboratively with her GP to assist with insulin management, developed a care plan to promote independence with injections under supervision. The nurse provided education and support to Mrs C until she felt comfortable to inject her insulin unsupervised. Mrs C became confident to self administer her insulin, with minimal disruption to her usual life. As a result, she was very happy with her current blood glucose levels, feeling much better physically and emotionally, knowing she is looking after herself and her diabetes.”


Incremental approach to building capacity

Breaking down achievement of goals into smaller steps demonstrated the value of assisting people to build their confidence first and then progress towards a larger goal. In this way, encouraging people to make small changes often resulted in significant impacts on a person’s quality of life.

Supportive structured programs

Programs that are structured and are targeted were seen by staff as an enabler for practicing an ASM approach. Specific examples included the Leg Ulcer Prevention Program (LUPP), dementia and wound interest groups and the Broadband Innovation Enabled Project. Case studies were also seen as supportive and structured activities that allowed staff to reflect on how ASM principles were being applied in particular sites, although staff felt there was limited time to access these case studies on the intranet so their value as a shared learning tool is somewhat limited.

Case study: Steps to confidence and contentment

One gentleman with Schizophrenia and Agoraphobia was visited by RDNS for medicines supervision. He led a very impoverished life, living in a housing commission unit and rarely ventured out. His case manager and carer were first involved in educating him on how to collect his own medicines from the pharmacy. This personal achievement encouraged the nurse to involve him more in taking his medicines, which he eventually managed to the point of being able to self administer on weekends from a dosette aid.

Small steps at addressing isolation were then achieved with encouragement for him to sit outside for half an hour each day in the sun. This led to sitting with others, and short walks each week, and eventually joining into a food bank social activity. This 'gave him a real sense of personal achievement ... made him feel he was part of the high rise community....and now is being greeted by other residents....and seems a more confident and contented man'.

Focus group insight

“Some individual staff who have tended to practice by creating dependencies have changed through having the structure of an ASM program – questioning and reflection has helped them”

Case study: Leg Ulcer Prevention Program (LUPP)

‘LUPP education program was possible in the home providing a more relaxed learning environment… assists with improving confidence with care of leg ulcer and is “helpful in understanding of leg ulcers and prevention”

“…person watched independently and initiated discussion with visiting nurse”

“…person is an active participant in LUPP and the wound healing is evidence of this”


Holistic approach and supporting tools

New holistic assessment tools were suggested as supporting an holistic approach to screening and assessment. Visiting nurses reported that people who have been screened with the Initial Needs Screening tool are well informed of why the nurse is coming to visit. Staff also reported that the holistic assessment tool provides more opportunity for a conversational style covering a broad range of domains.

Supportive roles

The key support roles of Care Managers and ASM Champions were highlighted as being important in the day to day support of nursing staff and in the overall implementation of ASM. These support roles were appointed at each site.

Case study: The value of a Care Manager

“Mrs P, a long standing client, was resistant to the idea of participating in her stoma care. It was in her words “unimaginable”. Her primary nurse discussed this blocker to ASM implementation for Mrs P with the Site manager and Care manager. These staff helped develop a care plan for discussion with Mrs P, who subsequently agreed to trialling the plan on the basis that small changes could help her enjoy a better quality of life (including family outings and attendance at church). The Care manager monitored progress arising from visits by the nurse to demonstrate self care approaches. Gradually Mrs P began to participate more in her care. Consequently her family could take her interstate for a family gathering during which time Mrs P managed her care independently. RDNS continues to visit Mrs P who now participates willingly in her care.” Case study: The value of a Champion “In working with Mr B, one staff member mentioned how discussing the situation with the ASM champion helped her to gain confidence in dealing with the carer's resistance to participating in the Mr B’s care. The carer, once supported became confident in assisting Mr B and overseeing his care.”

Focus group insight

“New Cognition Assessment Tool enables the nurse to find out about the person, what their interests are, what’s important to them, who their supports are….it’s a much more holistic assessment and gives a better idea of what the client is capable of doing.”

Focus group insight

“The Care managers role was to support and guide us, support teamwork and promote discussion and reflection on what’s working and what’s not.”


4.2.3.2 Barriers Common barriers identified can be categorised as either related to the person, or the carer or external factors or a combination of the above.

Complex and unstable health

The nature of a person’s health condition often limited potential for improvements in capacity and independence. This was the most common of the personal barriers. It was often accompanied by a reluctance to participate in care and a lack of motivation or a sense of being overwhelmed by care needs. Staff suggested that advanced dementia and cognitive impairment posed barriers to people participating in goal setting and self care. There were instances however, where these were overcome.

Fear and anxiety

For some people a visit from a nurse is part of their routine and social contact, something they do not wish to lose. On the other hand some people were initially anxious or resistant to the idea of nurse visits because they feared they would have to wait for the nurse and this would limit their independence.

Case study: Residential care placement avoided through ASM approach

“Mrs S had been assessed by ACAS as suitable for low level care and her son was insisting she move to care. She had cases of falls and hypos [low blood sugar levels] and her MMSE score indicated declining memory. Re-establishing a routine for Mrs S’ post- rehab with medications and diabetes management stabilised her. The progress she made enabled the nurse to discuss trialling further steps towards independence. With improvements in cognition and self management of her diabetes complications, staff discussed trialling self administration of medicines with her. This involved a series of progressive steps consistent with an ASM approach. A subsequent reassessment of Mrs S by ACAS found she was no longer deemed as requiring residential care placement. Assessment also revealed that her MMSE score had also improved dramatically.”

Focus group insight

“If they are an elderly person that sits at home waiting for the family to visit once a week, they would much rather the nurse coming to visit 7 days a week because that’s their social outlet. They are lonely and they don’t feel like they need to learn something, that’s why the nurse comes…. In theory its better for them to be accessing a social support program or activity but they don’t want this.”


Case study: Flexible and responsive visits allay fears about limited independence

“Mr B and wife felt burdened by work commitments and caring responsibilities associated with their disabled son. Mr B had been self managing his leg ulcers for some time with involvement of his GP. However, he wanted guidance on better self management. He approached RDNS about this. A schedule of regular weekly evening visits on an agreed day at an agreed time was put in place to ensure the primary nurse could provide continuity of care. He and his wife were also given information on wound management techniques to enable them to undertake daily dressings. He had envisaged that RDNS would “take over his care and visit every day” but is now able to make the most of his limited free time rather than wait for nurse visits.”

Entitlement mentality

In some cases people’s and family expectations are that services should be providing the care and in other cases people state they are entitled to services after paying taxes all their life.

Carer strain and resistance

Carer related barriers included carer strain and sometimes carer resistance to promotion of a person’s self care. Sometimes carers are not able to participate in care and have their own health problems.

Audit

“Person discharged at request of daughter because she "is paying for RDNS to visit and RNs are not supervising (witnessing) taking meds from Webster pack". Person however had progressed to self administration prior to nurse visit.”

Focus group insight

“Expectations with ASM are for family to support and take on care responsibilities. We should question if this is appropriate as family dynamics may be diverse and this may not be the most appropriate option”.

Case study: Wife supported to continue care without stress

“Mr T was referred to RDNS for a hygiene assessment by the Council, and was already seen by RDNS for catheter care. He wanted his wife to continue his care however she was unable, due to her own health concerns and having difficulty. The nurse determined what he could do for himself and that additional equipment and aides may be helpful. Referrals to the OT and physiotherapist and ACAS were made. On follow up, necessary equipment had been placed in the home and his wife was able to continue the care without stress on her back. Mr T also accepted a Community Care Package to assist him and his wife with other areas.”


Lack of ASM approach across continuum of care

Hospitals not promoting independence and not providing education to support an ASM approach was a consistent theme raised in the data. This extended to poor communication with discharge planning concerning an ASM approach. Without the consistent involvement of RDNS Liaison staff, hospital staff often demonstrated little understanding of RDNS’ role and of ASM. Often families and carers are given incorrect information e.g. ‘the district nurse will visit and do everything for you’. Similar views of GPs and case managers were expressed in the data. Insufficient hours as part of a package of care, to allow more time for education other than direct care hours, was also highlighted.

Resource constraints

A recurring barrier identified by staff is that additional time is not available to implement the ASM approach effectively. It was suggested that incorporating an ASM approach for someone to take on their own care often takes twice as long, however timeframes for visits and care units did not allow this. The consequence is that staff can become ‘task oriented’ due to workload pressures and continuity of an ASM approach to care is at risk.

Staff in the focus group reflected that despite acknowledging long term gain from spending time with people to support their improvement, the reality is pressures from resource management and cut backs limit this approach. It was also suggested by staff that people and sometimes staff perceive these changes to be only about cost cutting.

Tensions between an ASM approach and managing clinical risk and quality

Some instances highlighted a tension between the management of clinical risk and quality care with promoting ASM outcomes. One case study highlights use of securing medicines to prevent the client double dosing with her medicines due to failing memory. Whilst another case study highlighted that securing medicines was an impediment to another client visiting family and friends. In the latter case this impacted on the client’s autonomy, but was a key enabler in the former case study to the client achieving better management of her medicines.

Medicines management complexities

A range of medicines management related issues are highlighted in the data including use of different generic medicines by pharmacies, different pharmacies involvement, medication orders not matching what is administered by the person and often complex medicine regimes. These issues

Case study: Hospital not commencing education “Although capable of managing own insulin and BGLs in hospital, upon discharge Mr H was 'deemed to be reliant on community services' and HITH attended twice daily to administer insulin.” In another case, ‘the hospital had not instigated any diabetes education for the person or family”


often contribute to greater confusion limiting people being able to manage their medicines. However nurses often overcame this through putting in place a range of mechanisms to support the person.

Case conferences for ASM approaches vs. ‘at risk clients’

It was suggested in the focus group discussion that there is a tendency to only case conference people when they are heading towards ‘crisis’, rather than for applying an ASM approach of managing a person’s care. It was felt that site to site cultures on this did vary, suggestive of inconsistent practice. Logistics of setting up case conferences were cited as being difficult due to busy workloads. Strategies suggested to work around this included using phone teleconference and email communications to keep everyone involved and informed.

Care documentation not supportive

Staff felt that current care documentation is limited in being able to capture what is happening in practice. Current care plan templates do not have an ASM component or section. Staff felt that including such a section labelled ‘ASM’ would highlight this to visiting staff. This reflects what has been raised earlier in this report concerning the limitations of the evaluation methodology and review of care record documentation.

Knowledge, skill and practice gaps

Gaps in knowledge were suggested in the data related to some staff not receiving education related to the ASM program. Also lack of knowledge of other professional roles e.g. the social worker were highlighted. This was thought to contribute to a lack in interdisciplinary practices both internally and externally. Other nurse practices that were not supportive of an ASM approach were nurses that tended to be task oriented, taking over and taking control rather than allowing the person to trial independence.

Self determined discontinuation

For either physiological or choice reasons meant that in a number of instances, unexpected admissions to acute care or placement into residential care occurred. This impacted on achievement of care goals and occurred despite any ASM approaches to care that were planned or had been put in place.


4.3 Using models of change to explain the ASM journey

4.3.1 Models of change Several models of change have been reviewed to assist with understanding and framing the concepts of change in relation to an ASM approach. Three key models are discussed further here in an ASM context.

The first of these is Prochaska and DiClemente’s model of Stages of Change in promoting health behaviour changes. The model specifies five stages each with its own processes and activities associated with transforming people’s health behaviours. The first stage is pre-contemplation which typically involves consciousness raising – asking people to imagine a new way of behaving. The second involves contemplation – getting people to re-evaluate their existing behaviours. The third involves preparation – getting people to plan for how they might actually change their behaviour. The fourth stage entails action – coordinating social supports and relationships to reinforce steps towards desired behaviours. The final stage is maintenance – using reviews and prompts to maintain “self-efficacy” (Prochaska & DiClemente 1982).

The next model is Bridges’ model of the Three Stages of Transition. Bridges’ model proposes three phases for managing staff transitions from one way of doing things to another. This model describes the first phase as one where people let go of established practices as a means of preparing taking up a new approach to their professional practice. Bridges recognises that this often leaves people in a disorienting neutral zone (the second phase of transition). The neutral zone is the most difficult part of managing a transition as it is characterised by stress, anxiety, and people feeling overloaded and overwhelmed by the new ways which seem to threaten the old ways. Equally, the neutral zone can be a creative time when people rebuild their professional identify around a positive metaphor that sums up the new approach. The final phase is described by Bridges as ‘launching a new beginning’. Staff are clearer on the purpose and vision for the new approach. They are involved in its planning and implementation and progress is reinforced through quick wins and celebrations of success (Bridges 2003).

The final model is Kotter’s model which sets out Eight Stages for Creating Major Change. Each step acknowledges a key principle relating to people’s response and approach to change, and addresses risks that threaten success.

In detail these are: 1. Establishing a sense of urgency – helps others to see the need for change, identifying

strengths, weaknesses, opportunities and threats and how to deal with potential risks 2. Creating the guiding coalition – ensure that the group guiding change includes leadership

skills, credibility, communication and analytical skills; build teams and influential guiding coalitions and get these groups working together as a team

3. Developing a vision and strategy – clarify what will be different and how this will happen with creation of a vision, getting the vision and strategies right to achieve this


4. Communicating the change vision – ensure people understand and accept the change vision, communicate this constantly (communication strategy) and modelled by guiding coalition

5. Empowering broad-based action – remove barriers and encourage risk taking and alter systems and structured that undermine the change vision

6. Generating short term wins – plan for and create visible, unambiguous successes (short term wins) and improvements in performance and recognize and reward people who have made this possible

7. Consolidating gains and producing more change – consolidate improvements and sustain momentum for change; use increasing credibility to change systems, structures and policies that don’t fit the change vision and effort; involve people who can implement the change vision and reinvigorate the process with new projects, themes and change agents

8. Anchoring new approaches in the culture – hold onto the new ways and make sure they succeed until they become part of the culture; create better performance through a client outcomes focus and better leadership and management; articulate the connections between new behaviours and organisational success; develop leadership and plan succession (Kotter 2003).

These models have proved to be useful for describing how RDNS staff have worked with clients, carers and other service providers to achieve stage one, two and three outcomes expected of HACC services when implementing an ASM approach.3 Each of these models is described here to show their explanatory value.

4.3.2 Stages of change (applying the Prochaska model)

Personal level In an ASM context Prochaska’s model of Stages of Change provides a useful means for describing the stages that people go through with respect to health behaviour change. The model specifies five stages on a journey from pre-contemplation to self-efficacy. This model effectively describes the journey that ASM clients make to achieve greater independence and autonomy.

In each of these stages, the nurse uses an ASM approach to assist the person in changing the health behaviours so that they assume greater degrees of participation in their own care i.e. self-efficacy.

Stage 1: Pre-contemplation – this involves raising the consciousness or awareness of a person about a given concern, ‘planting the seed’. In an ASM context the nurse facilitates pre-contemplation by conversing with the person and their carer about the possibility and benefits of greater autonomy and managing their health and wellbeing.

3 Stage 1 Outcomes: HACC funded agencies have increased knowledge about the application of an ASM approach and have increased commitment to implementing an ASM approach Stage 2 Outcomes: HACC agencies have started to implement an effective ASM approach systematically in practice. Stage 3 Outcomes: Improved HACC Service delivery and better outcomes for clients.


Stage 2: Contemplation –as a standard practice the nurse would leave relevant brochures about the RDNS services and how they aim to work with clients to maximise their independence as “food for thought”. At this stage the admitting nurse meets with the person and discusses what they want to achieve from their care and what it will take to achieve this. This is when the unimaginable is clearly being imagined. A care plan is commenced.

Stage 3: Preparation – This is where the primary nurse completes any assessments and the care plan which is signed off by the client. Once completed the plan then provides the basis for implementing the care and support services required to help the client achieve their personal goals.

Stage 4: Action – Supportive actions by the nurse and other service providers are implemented as soon as the care plan is signed off. The client and carer are involved in a regular process of review of support services and their appropriateness or otherwise depending on progress. The person is supported with education, encouragement, aids and equipment if appropriate and collaboration with other services. Supports are oriented towards step by step improvement of a person’s capacities to manage their care and engage in social activities.

Stage 5: Maintenance – During this stage, clients and their carers are helped to continue their self care journey through regular support arrangements involving monitoring or supervision. Regular discussions help people maintain confidence and solve problems that might hinder their continued independence.

Organisational level Prochaska’s model can be adapted to describe the stages through which an organisation changes the way it supports people to maximise their independence.

Stage 1: Pre-contemplation – Department of Health undertook a literature review and facilitated consultative forums with stakeholders including RDNS about an Active Service Model, a new approach to promoting greater independence in an aged care context. A discussion paper was circulated and RDNS responded by making a submission in support of the approach. However the submission noted concerns about the suitability of the approach for all clients e.g. clients with dementia. In other words, DH provided the pre-contemplation prompt to organisations such as RDNS to consider the relevance of ASM approaches for its operations.

Stage 2: Contemplation – The DH now formulated its state wide ASM Implementation Plan and shared this with stakeholders including RDNS. This plan specified the three stage outcomes as measures of progress for implementation of the ASM approach and achievement of its benefits. RDNS responded to the plan by developing its own implementation plan using the ASM Prepare Process outlined by DH.

Stage 3: Preparation – Using its implementation plan RDNS now developed a project initiation document (PID), which is a strategic project design, management, implementation and monitoring tool that RDNS uses to manage its strategic projects. The PID contained detailed work packages representing key activities associated with applying ASM to nursing practice with clients and carers. These work packages included such matters as communications, human resources, training and education, clinical practice models and evaluation. These provided the basis for systematic, strategic


and staged actions to ensure the ASM approach was implemented effectively with leadership support and appropriate resources.

Stage 4: Action – RDNS proceeded to implement its strategic project plans. RDNS and DH agreed that implementation be rolled out over a two year period initially, and later extended to a three year timeframe. During this stage RDNS and DH agreed that an evaluation would help to generate learnings about enablers and barriers to translating ASM into practice.

Stage 5: Maintenance – through regular staff meetings involving primary nurses, care managers and ASM champions, staff were encouraged to continuously reflect on and improve their ASM practice. Regular conversations between nurses, clients, carers and service providers also helped to review and monitor progress.

4.3.3 Transitioning to an ASM approach (applying the Bridges model) As noted above implementing the ASM approach at RDNS involved helping staff to transition from an “old way” (in Bridges’ terms) of working for clients to a “new way” of working with clients. Bridges’ model helps to explain how that transition has been achieved.

During the first part of the transition, staff had to be convinced to let go, to acknowledge losses and pain and to be shown how they would benefit from working in the new ASM model of care. The ASM Prepare process helped those staff that were involved with this exercise to manage the transition. The tool enabled selected staff to engage in discussions aimed at comparing their current practices with a future state of practice informed by ASM principles. Staff were encouraged to talk about what they needed to transition to an ASM model of care. The aim of these discussions was to create a coalition of pro-ASM staff who could foster engagement with the ASM vision among wider groups of staff across RDNS.

The second phase of transition involved RDNS managing its staff through what Bridges describes as the neutral zone. As the ASM approach was implemented, staff experienced a mix of negative reactions and concerns on the one hand and a sense of positive and creative possibilities on the other. On the negative side some staff felt that ASM was all about cost cutting, getting people off the books and managing demand for services. On the positive side, other staff saw ASM as affirmation of the way they had been working for several years. They saw it as putting a name to the way in which they work to enhance the independence and wellness of their clients. The metaphor of ASM being about ‘working with people’ rather than for them was grasped as a means of energising this empowerment approach to community home nursing.

RDNS’ ASM project leaders consciously sought to work with these two dimensions when implementing the ASM approach. Staff concerns and anxieties were acknowledged and these helped to inform discussions about resources and training required so that the positive benefits of the new approach could be realised.

The third phase according to Bridges is the ‘launching a new beginning’, where a purpose and vision is clarified and communicated, a plan is developed involving all staff and is published. With this, the


new beginning is reinforced by consistency, quick wins, symbols of the new identity and celebration of successes.

RDNS sees itself as being partially in this phase as it continues to work through and beyond the neutral zone. Bridges’ third phase does however help to characterise what is required if the new beginning of ASM implementation is to be realised fully. RDNS recognised that a strategic and systematic approach would be required to achieve this, and this is where Kotter’s model of change helps to explain further the journey that RDNS has taken.

4.3.4 A systematic and strategic approach to change using ASM (applying the Kotter model) From the outset RDNS has taken a systematic and strategic approach to managing the implementation of an ASM approach across the organisation. Kotters’ eight stage model for creating major change is helpful for understanding how RDNS has managed this process. Stage 1: Establishing a sense of urgency - Consistent with the Kotter model RDNS began its implementation journey by establishing a sense of urgency. Its management communicated the new DH vision to client services staff as well as the RDNS Institute and management generally. The DH discussion paper and other resources were used to review existing practice and identified opportunities and resource requirements with respect to the ASM approach. Stage 2: Creating the guiding coalition – A Project Board consisting of senior executives in the organisation was established. This board guided the development of a team led by a project manager to ensure RDNS had the relevant human resources to get people working together. A steering committee and clinical working groups were established and the ASM champions were appointed at each site. Stage 3: Developing a vision and strategy – as noted above RDNS used the DH plan to articulate its own strategic plan for implementing ASM throughout RDNS. This strategic document provided the basis for each site preparing its own operational plans to ensure that the strategic plan was implemented consistently and systematically. These plans also allowed site managers to clarify their resource requirements and to monitor progress. Stage 4: Communicating the change vision – A communication plan was developed and this facilitated understanding and acceptance of the new ASM vision for RDNS. RDNS used the DH state wide ASM communications toolkit to review and refine its own ASM communication strategy. Stage 5: Empowering broad-based action – The RDNS Institute which had responsibility for clinical staff training and development ran an ASM overlay into all in-service training programs. Induction and orientation programs were also given an ASM overlay. This process ensured staff were empowered with the necessary skills and perspectives to translate ASM principles into their professional practice. As well, staff at sites were encouraged to engage in reflective practice by writing case studies of their dealings with clients using this approach. The ASM champion site


representatives provided the avenue for staff to feedback issues and concerns for consideration at the site and the broader Clinical Working Groups. Stage 6: Generating short term wins – Staff used their case studies to discuss their successes and these were used as a means for celebrating short term wins. Equally they enabled staff to identify areas where performance could be improved so clients could make further progress towards greater independence and wellness. Stage 7: Consolidating gains and producing more change – RDNS consulted with the Department of Health about the value of consolidating the gains achieved to date and providing the basis for extending and deepening change, and agreed an evaluation would assist this. An evaluation project was therefore developed to capture learnings about enablers and barriers and to develop considered recommendations about further changes to RDNS systems, structures and policies, which could provide guidance to other stakeholders when implementing ASM approaches. Stage 8: Anchoring new approaches in the culture – RDNS has used its experience with DH in trialling implementation of ASM to deepen its commitment to restorative and empowerment models of care in the home care and nursing sectors. ASM principles focused on autonomy and collaborative, holistic care have informed RDNS strategic visioning and branding. RDNS’ new ASM – informed approach is summed up through the phrase ‘RDNS by your side’. In these ways the new approach is becoming anchored in the organisations culture.


5. Conclusion and Recommendations

5.1 Implications for translating ASM principles into practice

Overall, the findings suggest some progress in the translation of ASM principles into RDNS practice, with positive outcomes associated with improvements in peoples’ ability to manage their own care and achievement of partial, if not full independence. Clear benefits for RDNS clients and carers are evident in social and emotional as well as physical health terms. In RDNS experience, the benefits of an ASM approach can be demonstrated in a HACC community nursing context, when the primary focus of care is clinical intervention. The recommendations in this section while focused mainly on RDNS never the less could be applicable more broadly.

5.1.1 Understanding the Rationale for an ASM approach

There is a misconception among clients and some staff that an ASM approach is simply about cost cutting and resource management, at the risk of diminishing the underlying principles of ‘active ageing’ and wellness. An ASM approach has also been interpreted by some staff to mean people should be supported to ‘full independence’ and discharged ‘off the books’. In reality however, it is not possible for everyone to be able to achieve full independence. This is perhaps why it has been incorrectly suggested that an ASM approach is inappropriate for people if they cannot achieve full independence. The intent of an ASM approach is however, that people are supported to achieve a level of independence that is within their capacity.

Recommendation 1: ‘Refresher’ education should be provided to staff about the rationale for the ASM approach, its key principles and components and strategies for applying these in practice. Prior to this education being offered, the ASM education overlay included in orientation and in-service programs should be reviewed. Ensure content remains consistent with the ASM principles.

In this context, it is valid from an ASM perspective to provide continuing care to support the person to live independently within the community. Whilst the message in ASM education delivered to RDNS staff in face to face sessions was thought to be clear, either not all staff received this education or some have applied a narrow interpretation to its meaning.

Recommendation 2: Education offered should be made more accessible to staff through the provision of alternatives other than traditional face to face methods. In addition, provision for appropriate follow up support and reflective practice opportunities should be encouraged to promote discussion and applied learning.


5.1.2 Holistic view of a person’s needs and person centred care

Further effort is required to support staff to take a more holistic view of a person’s needs and provide flexible and responsive care and support. Whilst improvements in a person’s health and physical functional capacity are necessary, this is not sufficient alone for achieving a broader approach to wellness, as is intended through an ASM approach to care. Having people participate in their care is an important first step for building confidence and improvements in capacity to self manage. However, socially isolated people should be encouraged and supported to connect to opportunities for community involvement and developing social relationships. Often a person’s goals are framed by their interests and desires and what is important to them, beyond being defined purely by their health related needs or concerns. Establishing goals that are more person-centred than clinically focused provides more motivation to the person and may assist with building greater social connections.

Recommendation 3:

Continue to make improvements to care documentation and supporting processes for referral and care coordination using the HACC Assessment Service guidelines. This should include refinement of holistic assessment tools and care plans to reflect person centred goals and actions that focus on physical, social and mental health and wellbeing outcomes.4

5.1.3 Collaboration

There is recognition that ASM involves an holistic care approach involving collaboration between a range of health and allied health professionals, council workers and family carers. However, a shared culture of ‘interdisciplinary practice’ in the HACC sector remains underdeveloped.

Recommendation 4:

Improve opportunities for promoting a culture of collaboration with a focus on interdisciplinary practices, for example, secondary consultations and case conferences. This could be done through the Department of Health supporting the gathering and sharing of knowledge and practice about ASM collaboration as part of HACC service system development. RDNS and other organisations continue to participate in regional forums such as ASM alliances for these purposes.

Recommendation 5:

At the agency level including RDNS, staff should adopt case conferences for development of appropriate ASM approaches when coordinating care for complex clients making use of teleconferences and email communications to keep everyone involved and informed.

4 Strengthening assessment and care planning: A guide for HACC assessment services in Victoria, Department of Health 2010.


5.1.4 Paradigm shift – dependency to independence A paradigm shift is required – from a dependency model (reliance on services generally) to an enablement model (of person centred goal achievement). This has implications for nurses and their practice, family and carers and referrers in the way they understand their role. It also affects how they shape expectations about the person’s journey towards personal independence and wellbeing. It is clear that not all nurses have made this shift. Some are following ASM actions in care plans, others are not. This is in part due to workload pressures and resource constraints. It may however also reflect gaps in staff understanding and knowledge.

Recommendation 6:

Promote successes and learnings of an ASM approach to staff, clients, family and carers and other health and community services to show that ASM principles positively enable people to achieve greater levels of independence and wellness, provided that the approach is tailored to each client’s specific situation. Education programs can be used for this purpose, as can sharing of stories through other media and channels.

Recommendation 7:

Review indicators of dependency for consideration of more strength based indicators of capacity that are better aligned to an ASM approach.

5.1.5 Continuity of care

Continuity of care from hospital to home is also an important theme. In some instances, people discharged from hospital are perceived (by hospital staff) as unable to manage in the community despite possibly demonstrating capacity in hospital. Without the consistent involvement of RDNS Liaison staff, education of clients and carers about ASM principles does not always occur. There is also resistance by some health and community professionals, including General Practitioners and Case Managers to work within an ASM continuum of care.

Recommendation 8:

Continuity of philosophy of an ASM approach across the continuum of care should be supported where possible to link hospital based initiatives e.g. ‘Improving Care for Older People’ with ASM and similar initiatives in home and community care settings.

5.1.6 Importance of labelling of ASM

Staff felt that this label was helpful as it highlighted the key concepts around the approach and kept them focused upon this. Without it, they suggested the approach could lose its meaning if it were to become ‘business as usual’. Coding by staff of people with an ASM approach was initially helpful to monitor staff uptake of the approach, however further guidelines are needed around the continued use of the coding, if coding is to continue. Translation of some ASM principles into practice in the care records of people without an ASM code suggests the code may no longer be required. It is


evident that the code has served its purpose to raise awareness of the ASM approach to care and encourage and monitor staff uptake of the approach.

Recommendation 9:

The label of Active Service Model should be maintained as a positive metaphor for promoting uptake of enablement, restorative, person centred approaches.

Recommendation 10:

The requirement for staff to use the ASM program code should be discontinued altogether. If not, then coding guidelines for sustained use of the code, including guidance on when to discharge people from the program, indicating reasons for success or failure of the approach should be developed and promoted.

5.1.7 Dementia and ASM care assumptions

In the early conceptualising of an ASM approach, people with dementia may not have been considered to be applicable for an ASM approach to care. Findings from case studies and focus group discussions in this evaluation however suggest that a dementia diagnosis should not be used to rule out a person’s suitability for an ASM approach. Provided appropriate supports, prompts and monitoring are put in place, people with dementia or failing memory can be enabled to achieve some independence (as demonstrated by the case studies on pg. 37 and 42).

Recommendation 11:

Staff should consider creative means for goal setting with people with advanced dementia and cognitive impairment. This will facilitate consideration of the supports required to enable those people to participate in goal setting and self care, to the greatest extent possible. Use of person centred approaches such as life story could be used in the ways suggested in the Department of Health Strengthening assessment and care planning: Dementia Practice Guidelines for HACC assessment services (2012).

5.1.8 ASM approaches for specific types of nursing care

A set of ‘how to’ guidelines have been developed that could be helpful not only for nurses in applying an ASM approach to nursing care, but also for other health and community professionals to understand what an ASM approach means in the clinical context of HACC community nursing. Possible guidelines for an ASM approach to specific types of nursing care are detailed further in the appendix.

Recommendation 12:

ASM approaches for specific types of nursing care are promoted to improve understanding of an ASM approach in the clinical context of HACC community nursing (see appendix).


5.2 Evaluation Methodology and Learnings Further recommendations are made concerning learnings associated with the evaluation methodology for organisations to consider in planning their own evaluation of ASM approaches to care and how similar methods may be applied.

5.2.1 Evaluation design

A mixed method evaluation approach employing a predominantly qualitative design with some semi-quantitative analysis was useful for gathering and analysing data to increase the validity and reliability of the evaluation. Triangulation involving use of multiple methods enabled comparison of results from the audit survey, focus group and case study analysis in particular. This was useful to determine common or similar themes. The qualitative focus drew out themes and their relationships and highlighted practical examples to demonstrate evidence of translation of ASM principles into practice.

5.2.2 Learnings associated with methods used

The case studies although used as a reflective practice tool by staff during ASM implementation, provided a valuable record over time for in depth qualitative analysis. They revealed important considerations and understandings, which when considered with other evaluation data enabled broader themes and recommendations to be made. Furthermore, the practical examples the case studies provided were drawn upon in formulation of the guidelines for ASM approaches to specific nursing care.

The file audit evidenced demonstration of ASM principles to a limited extent by what was noted in client record progress notes, but perhaps not as well in other forms of documentation in the client record. This was limited as changes to client record documentation had not yet been completed, confirming a constraint that was identified at project planning. It is anticipated that once proposed changes to the documentation are complete, this will enable improved measurement of an ASM approach. The data collected for this report has been baselined against which progress can be compared. Further refinement of the audit tool for broader use by other HACC organisations has also been completed.

The focus group conducted with staff provided an opportunity to validate and clarify information and obtain a better understanding of enablers and barriers to an ASM approach.

Preparation of the ASM client profile was useful for forming a better understanding of client characteristics that staff adopted the ASM approach with. The profile was also useful for making comparisons to the semi-quantitative data drawn from the case studies and file audit. This helped as a means of triangulation to determine the representativeness or otherwise of client characteristics portrayed in the audited records and case studies.


Analysis highlighted some language used by staff in client records and even case studies, may not be consistent with an ASM approach. For example use of the term ‘compliant’ or ‘non-compliant’ was not uncommon. This can imply judgement and possibly a lack of active, collaborative decision making that takes into account the client’s individual preferences and priorities, underpinning the key ASM principle of autonomy. This is suggestive that a shift is perhaps still required in these areas from an ‘old paradigm’ of community nursing, to a ‘new paradigm’. Staff education and training concerning preferred ASM language and meanings would support this shift. Examples of preferred ASM language have been adapted from a Diabetes Australia resource, ‘Position Statement – A new language for diabetes’, may be useful to support such a shift (refer to appendix).

5.2.3 Challenges

Challenges existed with the capacity to adequately measure professional practice change. Other limitations included the subjective nature of the data analysis and representativeness of the sample. Attempts to address this were made prior to the commencement of the audit with project team meetings and pre-audits to clarify these elements and processes.

Survey instrument errors in the file audit may have introduced some measurement bias and inaccuracies. This was compounded by IT issues using the online Survey Monkey software, necessitating duplication of data entry and data cleansing. The time it took to complete the file audits was underestimated, as was the complexity of the audit process reviewing RDNS client records, which are partly electronic and partly paper based. The sampling methodology was limited to accessing only discharged client records for ethical reasons, making it impossible to compare to clients receiving ongoing RDNS services.

Recommendation 13:

A mixed method evaluation approach with a qualitative focus is helpful in drawing out themes and relationships and provides practical examples to demonstrate evidence of translation of ASM principles into practice.

Recommendation 14:

Survey instruments and measures developed and used in this evaluation may be useful for other organisations to adapt and use as appropriate to their context (see appendix).

5.3 Other specific recommendations (for RDNS) To ensure ASM practice is continued in a consistent and effective manner the following recommendations are made specifically for the RDNS ASM implementation:

i. Complete initiatives currently underway to improve care documentation for capturing person centred goals and holistic practice. In particular, this requires changes to existing care plan documentation and client management systems.

ii. Link performance management and development requirements to reflective practice of ASM including history audits and ASM case study development. Encourage and support this


practice through allocation of continuing professional development (CPD) points to reflective activity.

iii. Review client self management policy and case conferencing policy to ensure ASM approaches and strategies are included in case conferencing activities where appropriate

iv. Encourage continued discussion and reflection at team meetings about ASM approaches for complex clients

v. Disseminate evaluation findings and learnings to staff and guidelines for ASM practice vi. Support interdisciplinary practices (both internally and externally) to improve

communication, referral and knowledge about other professionals and services and what is available for clients e.g. secondary consultations, joint assessments and case conferences.

vii. Explore opportunities for further funding to conduct research and evaluation for determining an ASM visit profile e.g. including length of stay, visit duration and frequency of visits. This will assist in understanding the impacts and challenges of an ASM approach concerning resource allocation and demand management.

5.4 Conclusion The findings suggest that an ASM approach can be implemented across HACC organisations using the sort of systematic transition and change management strategies that RDNS has used. ASM approaches demonstrate how a range of health and community professionals can be involved in designing and delivering holistic support to maximise the independence and wellness of HACC clients.


6. References

Australian Institute for Primary Care, (2008) The Active Service Model: A conceptual and empirical review of recent Australian and International literature (1996-2007), LaTrobe University, Melbourne 2008

Bridges, W. (2003) Managing Transitions: Making the Most of Change. Nicholas Brealey Publishing, USA

DiClemente, C.C., & Prochaska, J.O.(1982) Self change and therapy change of smoking behaviour: A comparison of processes of change in cessation and maintenance. Addictive Behaviour. &: 133-142.

Glendinning, C., Jones, K., Baxter, K., Rabiee, P., Curtis, L., Wilde, A., Arksey, H. and Forder, J. (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal study), Social Policy Research Unit, University of York, York.

King AI, Parsons M, Robinson E, Jörgensen D. (2012) Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health Soc Care Community. Jul;20(4):365-74.

Kotter, J. (2003) Leading Change. Harvard Business School Press, Massachusetts, USA

Lewin, G., Vandermeulen, S., & Coster, C. (2006). Programs to Promote Independence at Home: How Effective Are They? Perth, Western Australia: Silver Chain.

Ministry of Health (New Zealand) (2006) ASPIRE: Assessment of Services Promoting Independence & Recovery in Elders, The University of Auckland

Pilkington (2006) Homecare Re-ablement Workstream – Executive Summary and Discussion Document, Care Services Efficiency Delivery, UK

Tinetti, M. E., Baker, D., Gallo, W. T., Nanda, A., Charpentier, P., & O'Leary, J. (2002). Evaluation of restorative care vs. usual care for older adults receiving an acute episode of home care. Journal of American Medical Association, 287, 2098-2105.

UnitingCare Ageing NSW ACT, (2008) Background Paper: Wellness and Restorative Model of Care Project

Victorian Government Department of Health, Strengthening assessment and care planning: Dementia Practice Guidelines for HACC assessment services, Melbourne 2012

Victorian Government Department of Health, Victorian HACC Active Service Model Implementation Plan 2009-2011, Melbourne 2010


http://www.ncbi.nlm.nih.gov/pubmed?term=King%20AI%5BAuthor%5D&cauthor=true&cauthor_uid=22106952

http://www.ncbi.nlm.nih.gov/pubmed?term=Parsons%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22106952

http://www.ncbi.nlm.nih.gov/pubmed?term=Robinson%20E%5BAuthor%5D&cauthor=true&cauthor_uid=22106952

http://www.ncbi.nlm.nih.gov/pubmed?term=J%C3%B6rgensen%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22106952

http://www.ncbi.nlm.nih.gov/pubmed/22106952

Appendix 1: Client Record Audit Tool (ASM evaluation)

RDNS ASM Evaluation Project – Client Record Audit Tool

Client UR: Auditor: Audit date:

Admission date: Discharge date: Episodes of care pre-Nov 2010? Yes No

Nursing care need: Wound management Diabetes management Medications management Other (specify)

Client pathway

Criteria Present Yes/No Audit Comments (include examples from record if appropriate)

Referral

1. Referral source eg. GP, PAC ,Council, ACAS

2. Referral mode e.g. SCTT, phone, fax, self-referral

3. Evidence of personal goals in referral information e.g personal preferences/things important to client

4. Evidence of follow-up or clarifying referral information e.g. medication authorisation

Intake & screening (see Camillus – assessments – CSC/DNL Initial needs

5. Was an Initial Needs Screening (INS) tool completed?

6. If yes Frankston or Springvale client?


screening tool)

7. Evidence of carer/family needs acknowledged

8. Evidence that diversity characteristics and special needs are considered e.g. what is important to the client

Assessment

9. Evidence of getting to know person (beyond diagnosis/referral need) e.g. life circumstances or things of importance to client

10. Evidence of carer/family involvement e.g. discussion with carer/family

11. Evidence of holistic needs identified e.g. beyond referred/presenting need - Physical/Social/Mental health

Physical : Social: Mental health:

12. Evidence of identifying relevant client abilities & strengths (what they can do) i.e. in addition to functional Ax e.g. Physical/Social/Mental health

Physical: Social: Mental health:

13. Evidence of carer/family needs and issues being identified e.g. carer strain, own health concerns, support needs

14. Evidence of diversity characteristics considered e.g. use of interpreter, other language information, ethno specific or Aboriginal support worker consulted

Care planning

15. Evidence of client involvement in care planning & decision making e.g. options discussed and prioritised with client

16. Evidence of carer/family involvement e.g. discussion with carer/family


17. Evidence of client expressed ‘personal’ goals vs clinical care or service delivery goals e.g. client desire to improve to attend social activity, independence in specific area

18. Evidence of goals focusing on: - Physical - Social - Mental health

Physical: Social: Mental health:

19. Evidence of appropriate actions to reach goals e.g. actions provide steps towards reaching goals

20. Evidence of respect for cultural or personal preferences and beliefs related to diversity and special needs e.g. customs, beliefs about care provision

21. What was the ‘nursing goal of care’ e.g. Camillus discharge screen Well person for preventative/maintenance health promotion program Person will make a complete recovery Person will not make a complete recovery, but will rehab to a state where formal on-going service is no longer required Person has a long term care need and the goal is aimed at ongoing support to maintain at home Person in end-stage of illness the goal is aimed at support to stay at home in comfort and dignity and facilitation of choice of where to die Person is unable to remain at home for extended period and goal is aimed at institutionalisation at a planned and appropriate time For assessment only/not applicable

22. Evidence of support or encouragement to improve confidence/motivation and undertake aspects of care e.g. non- judgemental language, education

23. Evidence of goals/actions for carer health and wellbeing (if applicable) e.g need for respite, health check, financial support


Service delivery

24. Evidence client involved in ongoing discussion about issues and decisions about care e.g. discussed with client, options and choice provided

25. Evidence of carer/family involvement e.g. discussed with carer/family

26. Evidence of flexible service provision eg timing of visits around client/carer lifestyle e.g. timing of visits negotiated

27. Evidence of continuity of care e.g. of care plan actions by different staff

28. Evidence of new needs identified and discussed with client/carer e.g. documented discussions/ actions to address

29. Evidence of support, encouragement or education to client/carer to improve confidence/motivation and undertake aspects of care e.g. non-judgemental, coaching, building capacity in steps

30. Evidence of changes in nurse intervention (shift from ‘doing for’ to ‘doing with’), change in visit frequency e.g. providing care shifting to educating and monitoring, visits reduce over time

31. Evidence of client/carer taking over some or all aspects of care with support of staff e.g. ordering supplies, attempts at applying own treatment or taking own medication

32. Evidence of communication with other services

33. Evidence of referral to other services e.g. SCTT, phone, fax


Review

34. Evidence of review of progress and clients/carers needs (eg updates to Ax tool & care plan) e.g. planned review

Discharge/ transition

35. Was the clients/carer personal goal achieved/partially achieved/not achieved

Achieved Not achieved Partially achieved

36. Was the nursing goal of care achieved/partially achieved/not achieved Achieved Not achieved Partially achieved

37. Evidence of planning for appropriate discharge

38. Evidence of involvement of carer/family

39. Evidence of communication with other services

40. Evidence of referral to other services

41. Referral mode (if applicable) (phone, SCTT, fax, self referral) General 42. If there is no evidence of an ASM approach for this client, was there

potential to enhance the client’s independence or wellbeing with an ASM approach?

43. In what areas could an ASM approach have been taken e.g. physical/functional goals; social participation; mental health

44. Summary statement about audit findings


Appendix 2: ASM Reflective Practice Case Studies – Analysis Template Descriptive Information Region/ Site

Year of case study (Year 1,2 or 3) Type of care/treatment provided Overview of case study (2-3 lines including nursing care requested/provided) Carer involved

1. Does the case study demonstrate identification of client goals (person centred)?

2. ASM principles demonstrated – describe any drivers for change in these areas or

approach

3. What were enablers/barriers to practice (if any highlighted or discussed)?

4. How did staff change or strengthen practice?

5. What did staff do differently?

6. Was there a benefit to the client?

7. What outcomes were there for the organisation (if any described)?

8. What does the case study reflection suggest about staff understanding and practice of ASM? (eg use of ASM language and demonstration of understanding and practice)

9. Are there any unexpected outcomes that are highlighted?

Comment Describe Describe Describe Describe Describe Describe Comment Comment


Appendix 3: ASM Staff focus group – Questions and prompts schedule

1. What do you generally believe is the rationale for the introduction of the ASM approach to care?

2. For each ASM principle, rate the extent to which you think the principle has been applied in practice at RDNS: (using the following scale)

5 =Large extent 4 = Certain extent 3 = Not sure 2 = Limited extent 1 = Not at all Principles:

i. People wish to remain autonomous

Prompt - people are actively involved in setting goals and making decisions about their care/life ii. People have the potential to improve their capacity

Prompt – support to maintain or regain independence in daily activities iii. People’s needs should be viewed in a holistic way

Prompt – focus is upon physical and mental health - social connections are important to maintain wellness

iv. HACC services should be organised around the person and his or her carer, that is, the person should not be slotted into existing services

Prompt – services are timely and flexible and support people to reach their goals v. A person’s needs are best met where there are strong partnerships and collaborative working

relationships between the person, their carers and family, support workers and between service providers.

Prompt - working together effectively

3. What do you see as the enablers and barriers or challenges to working within an ASM approach? 4. What strategies could you suggest in adapting an ASM approach to be of more benefit?

5. How confident are you in working with people to improve their independence and wellness using an ASM approach?

6. In your experience, how satisfied do you think people we provide services to are with the ASM approach to care?

7. How satisfied do you think carers and family members are with an ASM approach to care?

8. How satisfied are you with the ASM approach? What is it that is satisfying? Does it make a difference to your role?

9. How do you think the ASM approach has influenced relationships between clients, carers, staff and other services?

10. If you had a magic wand, what would assist implementing an ASM approach when working with GPs, hospitals and other services?

11. Of people that we deliver services to, who do you think benefits most from an ASM approach to care? Who benefits the least?

12. What other learnings can you reflect upon from your experience about applying an ASM approach to care?


Appendix 4: Examples of preferred ASM language (Adapted from ‘Position Statement – A new language for diabetes’ by Diabetes Australia)

Avoid Use Rationale Sufferer, client, disabled person

Person with [condition] Avoid defining the person by their condition eg diabetic. Labelling in this way defines the person by the condition. Patient implies the person is a passive recipient of care rather than active in own self-care. Patients are people, and people are individuals, with their own preferences, priorities and lives beyond their condition.

Disease Condition Disease has negative connotations Normal [person, levels, weight]

People without ‘condition’, target, optimal, healthy or unhealthy weight

Using ‘normal’ to refer to people without a condition implies people with the condition are ‘abnormal’. Similarly levels relating to measurements of vital signs or health indicators if outside normal are ‘abnormal’

Describing the person as.... ‘uncooperative, non-compliant’

Words that describe outcomes or behaviours rather than the person

Describing the person rather than the behaviour implies the behaviour cannot change. Labelling by health professionals may suggest that they have given up. A collaborative approach is necessary to support behaviour change.

Poor or good [relevant behaviour]

Stable, optimal, within the target range, high or low

Poor or good infers a moral judgement about the outcome. Judgement and criticism is not supportive. An individual’s efforts need to be acknowledged regardless of the outcome.

Control Manage, influence Many factors may influence a person’s health condition and many of these may be outside of the person’s control (e.g hormones, illness, stress, other medications). Striving for something that cannot be achieved can create feelings of guilt, despair and frustration. Need to acknowledge that the person may be able to ‘influence’ their condition but not expect that it can ever be truly ‘controlled’

Should, should not, have to, can’t, must , must not

You could consider.... You could try.... Consider the following options.... You could choose to.....

Giving instructions about what a person can and cant do implies that you know better, and that they are uncooperative if they don’t follow instructions. Suggesting options emphasises the individual’s choices, and autonomy that the person is responsible for his or her own health

Failed .... failing to Did not....Has not....Does not.... Implies lack of achievement, ineffective effort or lack of effort, and perhaps disappointment by the person using the term. Often better to avoid judgements about facts.

Compliance/ non-compliance....adherence/ non-adherence

Words that describe collaborative goal –setting

Implies a lack of involvement in decision making and the person is uncooperative or irresponsible. Active, collaborative decision making is required, taking into account the individual’s preferences and priorities.

Tests, testing Checking, monitoring, self-monitoring Tests may imply success or failure. Treating the client Managing ‘condition’

Mentoring Coaching

Implies something done to the person rather than the condition and ignores the active role of the person with the condition. Managing ‘condition’ enables the person to actively engage in decision making and management of their own condition


Appendix 5: Guidelines for an ASM approach to nursing care

Guidelines for an ASM approach to Medicines Management The following guidelines are suggested in relation to medicines management and are evidence based, originating from the RDNS ASM Medicines Management Project.

Medicines assessment is recommended when a person:

• Has difficulty self-managing their medicines • Is on more than five medicines daily • Has had significant change to their medicines regime • Has medicines prescribed by more than one doctor.

Medicines assessment should also identify a person’s:

• Beliefs, values and expectations regarding medicines (motivation, expectations, feelings, confidence to be involved in managing medicines)

• Medicines regime and any concerns (check medicines match authorisation and dose administration aide (DAA)

• Level of carer support • Relationship with doctor and pharmacist • Goals for the person and carer • Literacy and language preference for health information • understanding of and capability for self administering (person or carer) • Use of reminder and other devices to support medicines administration to minimise risk

errors • Correct use of technical equipment or procedures associated with administration of

medicines via different routes • Storage of medicines • Cognition – specifically orientation to time and place • allergies and adverse reactions to medicines • self management of medicines capability.

Recommended care planning will vary according to a person or carer’s assessed ability to self administer medicines.

The following example provides care planning considerations recommended from the RDNS ASM Medicines Management Project, Medicines Care Pathway.

For the person who is able to self administer medicines from a pharmacy filled DAA with ‘assistance’ or ‘prompting’ from a suitably qualified care worker, where there is no family carer involved.


• Confirm and reconcile list of current medicines (including non-prescribed vitamins and supplements) with medical authorization. Determine person’s understanding of same.

• Check suitability of DAA • Check for safe storage arrangements • Clarify arrangements with pharmacy including obtaining script renewals • Provide National Prescribing Scheme (NPS) medicines fact sheets as appropriate, including

translations in desired language • Provide prompt cards (English or translated version) if required • Provide information on use of reminder and other devices to support medicines

administration to minimise risk errors • Referral to other agency and/ or contact numbers for further advice if required • Short term monitoring (2-4 weeks if a new system is in place) • Conduct Mini Mental State Examination (MMSE) or a Roland University Dementia

Assessment Scale (RUDAS) to determine cognition

Other ASM strategies suggested in the data being used with success include:

• Assisting people to stabilise their health condition through establishing a routine with their medicines

• Investing time with trialling a step by step approach to educating and supporting a person to progressively self administer medicines (e.g. relaxing practice of securing medicines, nurse monitoring of person self administering medicines, visits a little later to allow person time to self administer, reduced visits after a period of monitoring of competence, encouragement to self administer on certain days, then possibly entire weekends or perhaps PM medicines)

• Active involvement strategies including having carers attend the pharmacy with person to show them how to collect their medicines

• Promoting family and carer involvement in supporting the administration of medicines, including obtaining and renewing prescriptions

• Discussing medicines regime with the doctor to change dosage if appropriate (e.g. from twice to once daily)

• Assessing the relative risk associated with the type of medication a person is using, be they low, moderate or high alert medicines in relation to safe adherence.

Guidelines for an ASM approach to Dementia Management

• For people with dementia, particularly advanced dementia, it is important to get to know the person and their life context for understanding what might be important for them now regarding their present and future care. Some people may be unable to participate fully in goal setting but may nevertheless have a history of being fiercely independent. This may give some indication that they may wish to maintain independence as much as possible.

• Promote continued client autonomy by involving carers where possible in the person’s care and by determining what aspects of care they can support. This is just as relevant for someone with dementia as it is for a person with any other health condition.


• Take a collaborative approach to person’s needs involving them, their family and other health professionals.

• Consider what education and supports are appropriate to encourage people with dementia to self administer medicines with appropriate prompting.

• Tailor the care to suit the needs of the person, and the level of independence they can achieve within their capacity.

• Consider the impact of carer strain including daily chores and the often constant supervision required of a person with dementia when determining the type and level of supports that may be appropriate.

• Refer to a range of other services with consent of the person and carer. • Deliver education at a pace that is manageable for the person and carer and helps them

develop confidence in their abilities. Support the journey to greater independence in steps. • Continue support visits to provide encouragement and advice regarding any problems

arising. • Provide reassurance to the person and carer that access to nurses is available when needed. • For people with dementia that are still fairly active and independent, consider alternatives

to a lock box for medicines management. This may limit the person’s ability to visit family and friends and take medicines with them. (Note: strategies for medicines management may also be applicable to the person with dementia, depending on the level of cognitive impairment).

• Discuss with the family the level of their involvement in the person’s care. Explore their ability to take over aspects of care such as weekend medicines supervision, support with assistance of DAA and organising Webster packs with pharmacies.

Guidelines for an ASM approach to Wound Management

• Determine the range of other needs a person may have, other than the wound, as other areas may also impact on wound healing (e.g. consider pain, nutrition, management of chronic conditions, appropriate footwear)

• Discuss with the person the role of the nurse to initially stabilise the wound and involving the person and carer in assessment and development of a care plan to progressively educate the person or carer on continuing wound care.

• Discuss short and long term goals in this context • Work with other professionals including the Wound CNC, GP and person’s family to develop

a care plan with appropriate strategies • Consistent with the care plan, encourage the person to learn self care and address any issues

with support from RDNS Wound Clinical Nurse Consultant (CNC) • Follow up with case managers and personal care workers to have them also encourage and

support the person to consider self-care • Enable a collaborative approach to a person’s needs through a joint visit with an allied

health professional (e.g. community health podiatrist and primary nurse)


• Improve communication and understanding of roles and review of care processes through development of a SCTT care coordination plan early in the care episode

• Liaise with case managers to discuss a person’s needs • Encourage the person to use the Leg Ulcer Prevention Program, if appropriate, and initiate

discussion about education • Encourage the person to participate in aspects of wound care (e.g. remove dressing, wash

leg and apply soak prior to nurse visit. Prompt with a phone call from the nurse half hour prior to visit)

• Observe person or carer performing care and provide positive reinforcement and encouragement

• Support carer if appropriate to mimic supervisory role of the nurse in relation to the person’s self care wound technique

• Work with the person to develop an appropriate dressing technique and use of appropriate dressings

• Problem solve ways the person can attend their own wound care. This can involve establishing if a person has the manual dexterity, flexibility and can use aids appropriate (e.g. mirror) so they can position themselves to see and reach the wound.

• Consider dressing products that are easier for the person to use and require fewer changes • Encourage further education and practices which aid wound healing (e.g. diabetes self

management, fluid intake, motivation to increase regular exercise and improve blood circulation)

• Support person to become independent with application of compression stockings and care of skin in wound healing process

• Encourage the person to order their own wound supplies • Refer person as required to other health professionals to support education and self

management (e.g. specialists and diabetes educator, dietitian to assist with diet and weight management, podiatrist for follow up post wound healing to advise on correct footwear)

• Discuss risks of reoccurrence of wounds (e.g. leg ulcers if chronic conditions are not managed)

• Offer the person visits at home or appointments at site wound clinics if the person has transport

• Track healing progress through taking photos of the wound or tracings to encourage and motivate both the person and staff

• Amend visits to a weekly wound review when the person is capable of dressing the wound themselves

• Address pain management through contact with the GP to review medicines as appropriate. Shorter acting analgesics may be appropriate to consider before dressing changes if the person’s pain is a concern.

• Consider a multidisciplinary review at a wound clinic if appropriate, involving a Wound CNC and other health professionals (e.g. Diabetes CNC, community health podiatrist)


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