Figures from the Australian Bureau of Statistics show that life expectancy is now 80 years for males and 84 years for females. Those aged 65 can expect another 19 to 22 years of life. The incidence of co-morbidity rises with age and the cost of aged care, though much debated, will increase significantly in the coming years.
Despite the increasing numbers in residential aged care facilities, most patients prefer to remain at home as long as possible. Since this is also less expensive than residential care, it is the preferred option by all parties. The issue for health authorities is how to maintain these patients at home despite their medical problems and general frailty.
The Department of Veterans Affairs (DVA) is in a unique position in the Australian health care system. It is responsible for all medical costs of Gold Card holders, irrespective of whether these arise in the primary or secondary sector. As such it is interested in programs that improve quality of life and reduce global expenditure.
The DVA Coordinated Veterans’ Care Program (CVC Program) commenced on 1 May 2011. The CVC Program:-
- uses a proactive approach to improve the management of participants’ chronic diseases and quality of care
- involves a care team of a general practitioner (GP) plus a nurse coordinator who work with the participant (and their carer if applicable) to manage their ongoing care
- provides new payments to GPs for initial and ongoing care
The program has proven popular in the Northern Rivers with 20 practices taking part to date. The program is flexible permitting either community nurses or practice nurses to act as the care co-ordinator. The vast majority of North Coast surgeries use their own practice nurses in this role as it simplifies communication between members of the care team.
The program is primarily directed at those Gold Card Holders at high risk of hospitalisation. Those with CCF, IHD, COPD, pneumonia and diabetes are specifically targeted. Sixty percent of Gold Card holders have at least one of these diseases. However, the best predictor of future hospital admission is past repeated admissions.
The DVA has identified about 600 patients in the Northern Rivers who are at risk and have sent letters to both Veterans and their GPs. So far 260 veterans have been enrolled in the program with over 70% being in the target group. The numbers are higher again on the Tweed. Nationally over 22 thousand Gold Card Holders and 4,700 GPs are participating in the program.
DVA is exploring further ways to maintain these at risk patients in their home. Home telemonitoring has been trialled in a variety of settings around the world for over twenty years. Studies to date have had mixed results but the technology and the community's familiarity with IT have changed markedly, particularly in the last three years.
Following the change in government the In-Home Telemonitoring for Veteran's trial has been extended to areas outside the National Broadband Network footprint. Practices in the Northern Rivers and Tweed Valley are now eligible to participate. The program will use videoconferencing and in-home monitoring devices to check on parameters such as weight, pulse, blood pressure and glucose. Veteran's will need to commence or continue a CVC program. The trial will end in June 2015.
The DVA is conducting information evenings next Monday, 17 February 2014 on the Tweed and Tuesday, 18 February 2014 in the Northern Rivers. GPs, nurses and practice staff from interested practices are all invited to attend.