......the Aussie approach

A visitor to Australia will see interesting modern cities, efficient societal infrastructure, beautiful and varied landscapes, incredible wildlife.

Kookaburra and kangaroo are frequently seen but a kangaroo is not just a kangaroo; there are over 50 species including big reds, eastern greys, western greys, whipped tail wallaby, quokka and musky rat kangaroo. Neither is Intermediate Care just Intermediate Care.

In understanding the Australian scene, it is important to be aware of Australia’s history. The early pioneers settled in separate, remote areas of a large continent, developing different political processes and virtually separate countries. The decision to form a Federation of States was made on 1st January 1901. The Centenary of the Federation of the Commonwealth took place in 2001. Australia is seen overseas as a unified country, which it is in a global and sporting context, but internally the states work with separate parliamentary systems; different political groups are in power and have different political health agendas. This is coordinated by the Commonwealth Health Minister and the State Health Ministers at the Australian Health Ministers Advisory Council (AHMAC). Certain aspects of health care delivery are Commonwealth funded while others are funded by the State’s budget.

In Aged Care, the Commonwealth supports “the care” of older people through nursing homes, hostels, community aged care packages, Home Aged Care Services and the Aged Care Assessment Teams/Service (ACAT - ACAS). ACAS are the gateway to accessing the services and perform Case Management function. The States provide “treatment” services to older people through hospital services including geriatric medicine. Some provide acute health care to older people on the same hospital site as mainstream secondary health services. Others have a more sub-acute approach; often the hospitals will be on separate sites. The service delivery is therefore dependent upon the style of geriatric medicine encouraged within the State. This affects the need for Intermediate Care.

Intermediate Care in Australia has been subject to the same discussions as that in the UK, in that Intermediate, Interim, Transitional, Step-Down Care are often used synonymously but describe different components of service to complete the spectrum of health care services needed to maintain older people’s health and care in the community. Thus there is confusion over nomenclature and service style.

The Spectrum
Services that have moved towards the acute end of the spectrum, need a sub-acute style of unit delivering “rehabilitation” with a multi-disciplinary team aiming to help people recover and return to their own home. With the sub-acute style of geriatric medicine, the need is for a care whilst waiting for a permanent hostel or nursing home to be found. The latter has tended to be the usual model within Queensland and is called Interim Care.

The AHMAC has a reference group working on the interface of aged and acute care that is currently seeking feedback on definitions of Sub-Acute Care and Transition Care.

Sub-Acute
Sub-acute care is goal orientated, individualised, inter-disciplinary care that aims to help people regain function and return them to their usual place of residence. It is available to patients of acute facilities on a short term basis, either as an inpatient or on an ambulatory basis. Sub-acute patients generally require an assessment or supervision of their care plan by a specialist medical consultant (geriatric medicine), up to 2-4 hours per day of therapy services e.g. physiotherapy, occupational therapy, access to ancilliary or diagnostic services such as laboratory, radiology, pharmacy, nutrition.

Transition
Transition care comprises a lower intensity of services for people who are either awaiting placement or require more time to recuperate, no longer in need of high level nursing/consultant care/intensive therapy, but who may still benefit from low level therapy and support. Transitional care recipients are generally those discharged from an acute facility and having been assessed by the Aged Care Assessment Service. Transition care aims to maintain physical and cognitive function with up to 2-4 hours per week of therapy. Care can be provided either in the facility or in the community and can be overseen by a General Practitioner1.

The over-arching principle is to have the right patient in the right place at the right time at the right cost. A study of these issues is currently being undertaken by the AHMAC as a national survey of hospital geriatric services. A previous study was performed in 1992 and will allow for comparison and service planning2.

Intermediate care, Aussie style, namely sub-acute and transition care, will be more like the kookaburra than the kangaroo, less variants, with the intermittent flashes of brilliance.3

A more detailed paper on intermediate care, Aussie style, may be published to www.bgsnet.org soon.

Dr P Goldstraw
BGS Member: Australia

Acknowledgments and Disclaimer
My thanks to the Australian Society of Geriatric Medicine (ASGM) Secretariat, to colleagues in Queensland and around Australia who have provided formal and informal information. Views expressed here amount to a personal opinion and does not represent the views of the ASGM.

References
1. ASGM Newsletter December 2002
2. Gray L. Professor of Geriatric Medicine, University of Queensland, Personal Communication.
3. Simpson & Day. Field Guide to Birds of Australia. The Blue Winged Kookaburra of Queensland, Northern Territory and Western Australia has a brilliant blue flash on the wing.