Welcome to Best care for older people everywhere - The toolkit (The toolkit). The toolkit has been developed to assist health services identify tools and resources that can assist them in improving care for older people in hospital and throughout the patient's journey through the care continuum.

The toolkit forms part of the Victorian implementation of the Council of Australian Governments Long Stay Older Patients (COAG LSOP) initiative. As part of this initiative, older people are defined as those aged 65 years or more and Aboriginal or Torres Strait Islanders aged 45 years or more. Further information about Victoria's approach is available at www.health.vic.gov.au/older and in the Policy background section.

The aim of The toolkit is to assist clinical staff to minimise the functional decline of older people in hospital.

Functional decline is a reduced ability to perform activities of daily living, due to a decrease in physical or cognitive functioning [1]. The reason for the focus on functional decline is the high percentage of older patients (34-50 per cent) who experience functional decline in hospitals.

Functional decline can occur as early as day two of hospitalisation. In 30 per cent of hospitalised older persons, functional decline is unrelated to their primary diagnosis. At three months post discharge only 50 per cent recover from functional decline. This can adversely affect a patient's choice of discharge destination from hospital and their ability to return to their preferred setting [1].

Many interdependent problems, including under-nutrition, falls, skin tears, pressure ulcers, delirium and depression, can be prevented or minimised during hospital admission. This can reduce an older person's length of stay in hospital, thereby further minimising the risk of functional decline and leading to improved independence on discharge.

Why should I be concerned about functional decline in older people?

Older people are the main clientele of Victorian hospitals

Although people aged over 70 years comprise less than 13 per cent of the Victorian population (ABS, 2002), they account for almost half of hospital bed usage (Department of Sustainability and Environment, 2003). More than 46 per cent of multi-day patient stays are for patients aged over 70 years. The majority of this hospital usage is for appropriate acute and sub-acute care. A very small proportion of hospital stays by older people in Victoria are due to people waiting for residential aged care beds. (In a Victorian hospital bed census conducted in June 2005, only 367 people were waiting for residential care, a 40 per cent reduction from the 2001 census).

The Victorian population is ageing

From 2003-21, the Victorian population is predicted to increase by 19 per cent. However, during that same period, the proportion of people aged 70-84 years and 85 years and over is expected to increase by 59 per cent and 74 per cent, respectively. As the population ages, we can expect to see greater numbers of older people in Victorian hospitals. Hospital use increases with age, as older people are more likely to suffer from chronic illnesses and experience acute health problems, such as heart attacks, falls and fractures.

Hospitals can be dangerous for older people

Some of the problems that older people experience in hospital include:

• Under-nutrition and dehydration - due to patients' inability to manage their meals and drinks independently, unfamiliar or unpalatable hospital food, missed meals due to conflicting appointments or interrupted meals, reduced appetite due to illness or lack of activity.
• Decreased mobility and loss of independence - due to patients staying in bed, lack of incidental activity, illness or impairment.
• Pressure injuries - due to poor mobility or lack of circulation.
• Incontinence - due to lack of mobility, poor orientation to bathroom, lack of access to bathrooms, use of continence aids, constipation or effects of medication.
• Falls - due to impairment, environmental hazards or poor orientation.
• Delirium - due to infection, sleep deprivation, immobility, dehydration, pre-existing cognitive impairment or medication.
• Medication errors - due to taking incorrect medication, incorrect dosages or medication side effects.
• Depression - due to ill health, loss of function or poor recovery.

These problems occur in addition to the patients' presenting conditions. They can impede recovery, increase length of stay and lead to reduced functioning, not only when compared to pre-morbid functioning, but when compared to a person's functioning on admission to hospital.

What can I do to reduce functional decline in older people?

As clinicians working in a hospital we can make a difference. What we do, or don't do, will affect an older person's likelihood of functional decline. A key thing we can do is to be person-centred in our practice. Put simply, this means treating older people with respect and as equal partners in the health care relationship. We need to listen to the older person, take time to get to know them and engage with them as an equal.

There are some very practical things we can do. For example, ensure that every patient is oriented to the ward environment so they:

• know how to get to the bathroom.
• have a call bell within reach.
• know where the nurses' station is.
• know where to go for meals, if dining in a dining room.

Patients may need to be reminded on more than one occasion.

Encourage incidental activity and independence

It is very important that older people are kept as mobile and independent as possible whilst in hospital as this will help to reduce falls, improve appetite, reduce muscle deterioration and reduce the risk of pressure ulcers.

Encourage self-care

It is important to encourage older people to do as much as possible for themselves. Personal activities of daily living that can be maintained in hospital include showering, dressing, shaving and applying make-up. These activities not only promote independence but help patients to maintain their dignity and encourage them to participate in other activities.

Encourage hydration

Adequate hydration is very important in reducing the risk of infections, delirium and incontinence. Ensure fluids are:

• Palatable to the patient.
• Replenished regularly.
• Within reach, and the patient can refill their glass or get help to do so.

Ensure adequate nutrition

Adequate nutrition is important to reduce the risk of functional decline. Ensure:

• Food is palatable to patients.
• Patients have adequate set up and access to their food.
• Patients have enough time to eat.
• Distractions at mealtime are reduced.

Monitor skin integrity and take steps to prevent pressure areas and skin tears, such as:

• Avoid using soap.
• Encourage patient to remain as mobile as possible (see above under activity and self-care).

These are just some of the things you can do. There are more tips on reducing patients' risk of functional decline in The toolkit.

How was The toolkit developed?

Policy

In November 2003, the Victorian Government launched the Improving Care for Older People (IC4OP) policy (see www.health.vic.gov.au/older). The objectives of the policy were to:

• Better understand older peoples' health care needs.
• Improve integration of care.
• Adopt a strong, person-centred approach.

The IC4OP initiative was the main vehicle for implementation of the IC4OP policy. Substantial achievements by Victorian health services as a result of the IC4OP initiative can be found at www.health.vic.gov.au/subacute. Towards the end of IC4OP, funding was received from the COAG LSOP initiative for 2006-10. It aims to prevent people reaching a 35-day stay in hospital and divert the potential requirement for a residential aged care placement.

The COAG LSOP funding provided Victoria with the opportunity to continue to build on the existing IC4OP and Hospital Admission Risk Program (HARP) initiatives. Victoria's implementation of COAG LSOP has focused on improving the capacity of health services to provide more appropriate care for long-stay older patients in public hospitals and, where possible, reduce avoidable or premature admissions of older people to hospitals. In the event that a hospital admission is required, improved care would focus on minimising the functional decline of older people.

Evidence base

The Health Care of Older Australians Standing Committee (HCOASC), has developed a number of key resources that aim to support improved care of older people. The resources, available at www.health.vic.gov.au/acute-agedcare, have contributed to the information contained within this toolkit, in particular, the 2004 Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings www.health.vic.gov. au/acute-agedcare/functional-decline-manual.pdf.

In preparation for development of The toolkit, the department engaged the authors of the Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings, the Clinical Epidemiology and Health Service Evaluation Unit at Melbourne Health, to provide an update of the resource. Published in 2007, this resource can also be found on the acute aged care website above.

The Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings, and updated version, identify the following areas of functional decline: cognition (which includes delirium, dementia and depression); mobility, vigour and self-care; continence; nutrition; and skin integrity. Three additional domains were identified for inclusion in this toolkit due to their potential impact on the functional decline and quality of care of older people: assessment, person-centred practice and medication.

While the resources provide evidence-based guidelines, a need was identified for a resource that could provide practical, user-friendly tools to assist staff working in hospitals to minimise functional decline in older people. The toolkit aims to provide a 'how to' approach to accompany the information in the resource, make it more accessible to clinicians working in hospitals and support the transfer of evidence-based guidelines into practice.

Development of The toolkit commenced in July 2007, with ten health services appointed as lead agencies for a specific domain under the umbrella of minimising functional decline of older patients in hospital settings. Each lead agency worked in conjunction with at least two partner agencies, and a regional representative, (refer Table 1) to identify or develop resources within their domain.

COAG LSOP The toolkit domain teams

Domain	Lead agency	Partner agencie	Regional partner
Assessment	Western Health	Alfred Health1 Northern Health	Loddon Mallee
Skin integrity	Eastern Health	Austin Health Alfred Health
Continence	Austin Health	Eastern Health Southern Health	Hume
Person-centred practice	Northern Health	Southern Health Latrobe Regional Hospital
Mobility, vigour and self-care	Peninsula Health	Austin Health Eastern Health	Gippsland
Nutrition	Alfred Health	Melbourne Health Peninsula Health
Delirium	Melbourne Health	St Vincent's Health Western Health	Barwon South West
Dementia	Ballarat Health	Barwon Health St Vincent's Health Western Health
Depression	Southern Health	Calvary Healthcare Bethlehem Melbourne Health	Grampians
Medication	St Vincent's Health	Werribee Mercy Northern Health Peninsula Health

1 Formally Bayside Health

Each domain team conducted a literature and resource review to explore resources and tools available in their domain area. They then field tested the resources and tools in one, or more, parts of their own and their partners' health services and decided which tools should be included in The toolkit.

The National Ageing Research Institute (NARI) provided ongoing support for health services, developed the framework and compiled The toolkit.

Who should use The toolkit?

The toolkit can be used by anyone interested in improving the care of older people in hospital settings. It can be used in different ways by clinicians, team leaders and people with organisation-wide responsibilities.

Clinicians can use The toolkit as a stand-alone resource that will give them a 'how to' guide to minimising functional decline in older people.

Team leaders, quality managers and project officers can use The toolkit to introduce or evaluate practices and processes within their team, ward or hospital.

Although the focus is mainly on acute and sub-acute hospital care, some of the tools and resources may be applicable to pre-admission, community or residential care settings.

How can I use The toolkit?

Each domain has a representative symbol used to indicate where further information can be found within another domain. The domains, symbols and relevant sections and information are outlined below.

The toolkit domain symbols

Section	Symbol	Domain		Section	Symbol	Domain
1		Person-centred practice		7		Dementia
2		Assessment		8		Depression
3		Mobility, vigour and self-care		9		Continence
4		Nutrition		10		Medication
5		Cognition		11		Skin integrity
6		Delirium
Each section contains: Five tips (main things to remember) about the domain that you might like to use as a starting point. Information about the domain. Why the domain is important. How to identify problems in the domain area. How to prevent these problems from occurring. How to manage them if they do occur, including strategies for patients and their families or carers. What needs to be considered for discharge. An illustrative case study.				Symbols for further information, resources or tools Further reading or reference Information for families or carers Resource or tool Training or educational resource

Within each of these sections, other symbols indicate where further information can be located, as shown in the following table.

Embedded within The toolkit are links to relevant tools or resources. The link will take you to a Resource review which contains relevant information about the resource or tool including:

• name and setting
• who it is to be used by
• who it is to be used for
• structure of the tool
• availability and cost
• field testing results if applicable
• applicability in rural settings
• person-centred principles
• training requirements
• administration
• data collection and analysis
• psychometric properties
• strengths and limitations
• further reading and references.

The actual resource or tool is located within the Resource review, under 'Availability and cost'.

Some tools have a field-testing template, also embedded in the review. This has been completed for tools and resources that were developed by the domain leads as part of this project. These include information about how the tool was tested and the main findings.

Copies of some resources or tools are not included in The toolkit due to copyright or other issues. Refer to the resource reviews for information on how these can be obtained.

Implementation of The toolkit

Recommended steps for the successful implementation of The toolkit are in this section of this document. Although there are many ways to approach implementation, with no one way considered correct, the approach outlined in the following section is based on The 'how to' guide. Turning knowledge into practice in the care of older people, developed by Project Health. Project Health was commissioned by the HCOASC, and the project led by the Victorian Government, to develop a resource that could guide implementation of the HCOASC knowledge resources in clinical practice.

The 'how to' guide has been developed for governments and health services, at both the organisational and team levels, highlighting that a range of activities are required to support implementation. The 'how to' guide. Turning knowledge into practice in the care of older people can be found with the HCOASC resources at www.health.vic.gov.au/acute-agedcare.

For The toolkit implementation, health services:

• Do not have to use all the tools and resources available in The toolkit.
• Should not look to The toolkit as the only source of tools and resources available.

Networking with other health services is recommended and the sharing of other tools and resources is encouraged.

Steps for successful implementation of this toolkit

The following steps on how to use The toolkit have been adapted from the HCOASC resource, The 'how to' guide. Turning knowledge into practice in the care of older people available at www.health.vic.gov.au/acute-agedcare

The five steps for successful implementation of The toolkit are:

1. Define

Project definition phase involves identifying the 'area of interest' or potential problem area. This is when to ask 'What do we want to achieve?'.

All quality improvement projects begin with the question 'What are we trying to accomplish?'. This involves identifying an 'area of interest', which, depending on your setting and your patient or client population, could be as broad as 'improving the care of older people', or it could be as specific as 'the prevention of falls of older people in hospital' or 'the introduction of a process to reduce post operative delirium'.

So how do you actually decide where to start in improving care for older people?

If there are no clear priorities for addressing the care of older people in your organisation, or if there seem to be conflicting priorities, a formal group exercise called Quality Impact Analysis can be useful.

This is a brainstorming type activity, which enables a structured consideration of the potential problems and opportunities for improvement. As with all brainstorming activities, it is important that you involve relevant stakeholders in this activity to avoid bias.

Based on a list of problems or potential quality initiatives, as well as supporting data, copies of the relevant knowledge resources and other inputs, the group may be asked to identify:

• Five things that are done frequently in relation to the care of older people.
• Five things that involve risk for older people.
• Five things that are of concern to staff or clients in relation to the management of older people.

Participants are then asked to score each item based on the frequency, risk level and general level of concern. Scoring may be, for example, from one to three, where one equals low frequency, risk or concern, and three equals high frequency, risk or concern. The highest scoring topics should indicate the priority of topics for attention and should be confirmed with appropriate data. The activity may be adapted to address a range of other criteria, such as cost or clinical effectiveness.

2. Diagnose

There are several steps to consider in diagnosing priority areas for implementation:

Baseline data collection and identification of gaps in service provision

• Some domains contain audit tools to help diagnose the current status of care. These audit tools can be used to collect baseline data and assess gaps in service provision.
• Other methods to identify priority areas include complaints data, consumer reference groups, incident reports, key performance indicators, clinical indicators and opinions of staff.
• The toolkit can be used to implement a number of domains across the continuum of care or a targeted approach can be used to identify one specific issue in one specific ward.

Prioritise guideline recommendations

• It is important to identify a starting point for implementation.
• The starting point should be an area in which there is good support, adequate resources and in which visible gains can be achieved. Early successes will help generate further support for more complex and risky implementation.
• Diagnosing the current status of the health service will help identify priorities.
• As the domains are interdependent, sustained implementation of one domain will lead to improvements in other domains.

Identify facilitators

• It is important to identify and utilise facilitators in implementation.
• Quality committees are important resources to approach. They have expertise and resources that can assist in implementation.
• Senior staff and clinical leaders can also be beneficial to implementation.

Identify barriers

• It is important to recognise that there will be barriers to implementation.
• Potential barriers to implementation should be identified early in planning and strategies developed to overcome them.
• Barriers related to infrastructure can be challenging to overcome.

Plan for sustainability

• It is important to plan for ongoing sustainability of changes.
• Refer to the Sustain section for how to incorporate sustainability into planning.

Plan for evaluation

• It is important to plan to evaluate the implementation from the beginning. Evaluation data can be used to demonstrate uptake and sustainability and generate support for the implementation.
• Refer to the Measure impact section for further evaluation methods.

Assess costs

• Implementation may have associated costs.
• It is important to research and estimate costs and benefits to provide reasons for undertaking the implementation.

3. Intervene

• The toolkit provides the resources to use during the implementation phase.
• Select and adapt the resources best suited to the needs of your health service.

Every resource does not need to be implemented to be successful and improve care.

4. Measure impact

• Your health service may have developed performance indicators that can be used to measure performance.
• Any baseline data can also be collected again to compare the results pre and post implementation. This may include complaints data, consumer reference groups, incident reports, key performance indicators, clinical indicators and opinions of staff.

5. Sustain

There are many strategies to build sustainability into the proposed changes.

Redesigning systems

• Redesigning systems that support implementation is a powerful way to build in sustainability.
• Adjusting systems that support implementation provides a solid support for ongoing sustainability.
• Redesigning systems can be a large and complex task, requiring support from many different stakeholders.

Documentation

• Appropriate documentation is necessary to measure implementation and sustainability.
• Documentation can act as both a reference and a communication tool. It also can help in training and education and measuring the impact of changes.

Measurement

• It is important to include transparent measures to monitor implementation.
• Regularly record and establish a feedback protocol. This will allow staff to monitor their progress and see how implementation is changing the care they provide.

Training and education

• For ongoing sustainability, it is necessary to provide adequate training for staff and service users to effectively use, and benefit from, implementation. This may need to include both initial and refresher training and ensure training is available for new staff.

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