Recognising the signs of decline
In recent months, I have been assisting providers in the area of clinical governance, which is a relatively new concept not only in aged care but also in healthcare. It emerged in the late 1990s and involves a systematic approach to managing and improving the quality of clinical care provision.
A recent report from the WA Coroner into the death of a home care package client emphasised the importance of staff recognising a change in a client’s condition to ensure that appropriate care can be provided.
The coroner highlighted the need for care plans to be regularly reviewed and updated when a change in condition occurs,
and for providers to clearly document the roles and responsibilities of family members and friends in care planning and ongoing reviews.
For staff to recognise the need for a review by an Aged Care Assessment Team, Regional Assessment Service or other health professional, it is necessary to first understand what a deterioration in an older person’s condition may look like.
A decline in a person’s physical or cognitive functioning can occur rapidly following an unexpected event such as a fall or illness or over an extended period of time.
The User Guide: ACAT Guidance Framework for Home Care Package Level outlines the following domains of care:
- psychological, and
By reviewing this document providers can become familiar with how clients are assessed for home care packages and can use it as a resource for assessing changes in a person’s needs. The framework has domains, categories and descriptors, which can guide staff when reviewing clients.
Another valuable resource is the Best practice approaches to minimise functional decline in the older person across the acute, subacute and residential aged care settings, developed by the Clinical Epidemiology and Health Services Evaluation Unit at Melbourne Health.
This resource identifies the following useful domains:
- cognition and emotional health
- mobility, vigour and self-care
- nutrition, and
- skin integrity.
The guidelines describe the strength of the research evidence supporting each recommended intervention and management strategy to prevent functional decline. Both documents should assist providers to identify and respond to a change in a client’s condition.
The proposed new personal care/clinical care standard in the draft single Aged Care Quality Framework outlines the following requirements:
- clinical care is best practice
- connected and comprehensive care with strong networks and timely referrals to other services
- end-of-life care that is compassionate and consistent with consumer-directed principles
- changes in function, capacity or physical condition are recognised and responded to in a timely manner
- identification and management of high impact or high-prevalence risks to the consumer, for example falls, choking, medication misadventure, delirium, pain, pressure injuries, malnutrition and dehydration
- infection prevention and control
- antimicrobial stewardship to detect the emergence of antimicrobial resistant infections.
The standard requires the workforce to be able to recognise and respond to sudden or unexpected deterioration of a consumer’s condition. The proposed framework states this requirement was included because there was “evidence that warning signs of clinical deterioration are not always identified or acted on appropriately.”
In addition, the document states: “Early identification of deterioration may improve outcomes for the consumer and lessen the degree of intervention that is needed in the future.”
So, what are the lessons here for providers?
1. Ensure you have a clinical governance framework in place
2. Introduce a system for flagging changes in a person’s clinical condition
3. Work with clients and their family and friends to identify changes in a person’s condition or function early
4. Ensure adequate documentation is present in a client’s file pertaining to clinical care
5. Provide education to staff about how to identify and recognise changes in condition and to report or refer to others.