The overall goal of the Kare programme trial which ran in 2016 for a total of 1,186 patients, was to reduce hospitalisations for older adults, delay aged residential care placements and demonstrate improved health outcomes for patients participating in the trial.
Eight GP practices on the Hibiscus Coast enrolled patients in the trial, these were people living in the community aged 75 and over and Maori and Pacific people aged 65 and over, who had been identified as frail or high risk of hospitalisation.
By 2030 in West and North Auckland, the number of people aged 75 years and older is expected to increase by 59%.
The role of the Gerontology Nurse Specialist (GNS) was the development of a range of tools to support general practise, to carry out a comprehensive assessment, consider care planning, build knowledge and understanding of geriatric issues and develop training, processes and systems to be implemented.
I’ve known people and I’ve journeyed with them, you get to help them as they reach that end point and that’s a process I really quite enjoy. The research has shown we’ve actually reduced hospitalisations and placement to aged residential care.Susan Williamson, Kare Nurse, Whangaparāoa Family Doctors
Statistically significant improvements
- patients knowledge of their conditions and treatments
- ability to cope
- management of symptoms
- adherence to treatment
- number of falls
- “concerning pain”
- reported anxiety & depression
- understanding their medication
- use of medicine blister packs
- mortality during the first year of patients being involved in the pilot
- age related residential care admission
Based on the success of the pilot programme a detailed business case has been presented to the Waitematā DHB Board proposing an initial three year rollout to 60% of Waitematā DHB’s higher need older patients with one third of the DHB’s general practises trained in providing the Kare model.
The 8 practices involved in the pilot continue to implement the Kare model providing comprehensive proactive care to over 1,100 older patients.
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