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could provide a disincentive to a person
presenting for early diagnosis and treatment.
"We shouldn't be as scared as we are
about people with early dementia and
cognitive impairment continuing to drive
because the statistics around harm to
others are really not there," says Professor
Joseph Ibrahim from Monash University's
Department of Forensic Medicine and a
consultant physician in geriatric medicine.
He says it's important that health
professionals adopt an individualised
approach to a person driving with dementia
and thoughtfully weigh up a number of
factors and competing interests, including
a person's capability, their need for driving
and what the consequences are if they stop.
"Health prof e ssionals need to look at
the balance of how importan t is driv ing
to that person's life and what's the risk in
those spe cific circumstances - not a one-
s iz e - fits-all approach."
A person's risk is not static and
so an individual's abilities should be
continually reassessed and monitored as
their condition progresses to ensure their
ongoing safety, says Ibrahim.
Alzheimer's Australia says deciding to
limit when and where a person drives may be
an appropriate stage in the decision process
for some people with early dementia
While the temptation may be to take a
precautionary approach and stop everyone
with dementia from driving, Ibrahim says such
an approach fails to take into account the
quality of life impacts on the person with early
dementia and a person's right to mobility.
"Doctors and health professionals in
general like to minimise risk and keep their
patients safe, and so they think that it is
safer to stop someone from driving without
thinking of the consequences that has on a
person's life," he says.
Telling a person to stop driving may lead
to significant social isolation, depression
and negatively impact on self-esteem, says
Knowing when to
hand in the keys
people with dementia will require significant emotional and practical
ort during the process of giving up driving, and caregivers should be
ed to begin a conversation as early as possible. LINDA BELARDI reports.
Ibrahim. It also places a significant burden
on informal carers, he says.
Dr Jacqueline Liddle, occupational
therapist and postdoctoral research fellow
with the School of Health and Rehabilitation
Sciences at the University of Queensland,
says driving can form a significant part of an
older person's identity and that attachment
to driving can make losing the ability to
drive particularly distressing.
As part of her research into the
experiences of older people going through
this transition, she asked them what
driving meant to them. "For some it's a very
convenient and familiar way of getting from
A to B, but for other people it is part of
them. It was their entry into adulthood. It
was part of their job or family holidays.
"Some people showed me pictures of the
cars they have had or their empty garage or
an old licence. Driving was a symbol of their
independence," Liddle says.
Ibrahim says complicating the decision-
making process further is the lack of a simple
objective test that medical professionals
can use to reliably distinguish between safe
and unsafe drivers. Relying on the subjective
judgments of medical professionals leads
to variable outcomes, with some people
stopping driving too soon and others too late.
On-road driving assessments can also be
very expensive, especially for rural drivers,
and there is a shortage of specialised
occupational therapists to conduct them.
In an article published in Injury Prevention
in June, Ibrahim and colleagues from
Monash University and Ballarat Health
Services argue that rural drivers in the
early stages of dementia should be allowed
to drive with a greater level of cognitive
impairment than those in urban centres.
The controversial proposal seeks to
recognise the likely lower crash risk in rural
areas due to reduced vehicle and pedestrian
traffic, and the higher health and social
costs of stopping driving.
"What is being proposed is a risk
management approach that accepts a degree
of risk in exchange for enhanced benefits for
the individual and their family," they write.
All the dimensions of the individual
must be taken into account and decisions
should be evidence-based and not
discriminate simply because of the
presence of old age or disease, it says.
ACCEPTING SOME RISK
Ibrahim points to the issue of alcohol and
driving as an example of society's tolerance
for some level of risk on the road and says
the same principles should apply for drivers
with early stage dementia.
"People drink alcohol and drive, and
as a society we have drawn the line at a
blood alcohol limit of 0.05. ... We have in a
sense accepted that risk but we have never
actually said it out loud."
Ibrahim says no one is arguing that
people with severe dementia should be
on the road. However, for those with mild
dementia who are still functioning well,
removing their right to drive can have
significant impacts on the person that are
not proportional to the level of risk posed
to themselves and the community.
SUPPORTING EACH STEP
Liddle, who has studied the needs of
people with dementia and their carers
as they stop driving, says the transition
to giving up driving is often r d
Man y people often exp e r ience a 'crisis
stage' as their co ndition progresse s
a nd require help with p r oblem solving ,
resolving fa mily conflict and preventing
social isolation, she say s. Grief support
also helps individuals cope with the loss
of driving and the emotional toll on the
person and their family.
There is also the need for caregiver
support as the process can go on for
many years and some carers said they felt
exhausted by the end, she says.
Ibrahim says it's important to begin
a discussion early and forward plan the
transition to becoming a passenger.
I n addition to p roviding valuabl e
co m m unity transport options, Liddle
say s community aged car e provid e r s
have an important role to play role in
notici ng when o lder pe ople need support
hat a person with
need to stop driving at
wever, what is less clear is
me might be.
epted many individuals
a can continue to drive
research has shown that
ehicle collisions due to
ementia is equivalent to
age without dementia.
tralia says a diagnosis
from getting behind the
does not determine
ty to drive," says the
ng policy statement.
s individual driving
experience a different
f impairment as their
lso warns that any
en a diagnosis of
oval of a driver's licence
also the hea
or carer first r
remove the ne
client folders and 700 transition meetings with clients. PresCare
coordinators visited around 600 clients as they transitioned them to
CDC, with almost half the client base requiring repeat consultations
due to the complexity of the changes involved. In many cases families
of the client participated in the discussions as well, something that
PresCare encourages as they believe strongly in helping keep seniors
connected to their families and their communities as they age.
PresCare engaged with global advisory firm KPMG to provide
direct support to transition and transform their business through
this project. KPMG team members worked actively with PresCare
resources to facilitate training, develop marketing content, design the
new business processes, and support software transition work. KPMG
has extensive experience in aged care, so were well equipped to
provide this support. PresCare also used its wholly owned IT provider
and expert in the health and aged care space, Surecom, which was
instrumental in developing the IP to enable PresCare to simplify the
collation and reporting of data and streamline processes.
"We invested a sign ificant amo unt of time and resources in
making sure that what we were do ing was being do ne as efficiently
as possible, t hat our clients receiv ed what they needed, when they
need ed and in the right way," Skel ton says. "We looked at what we
were c urrentl y delivering and com pared that to wh at our clients
n e e ded going forward."
He says the challenge for staff in adopting this new client
management procedure was to accept that the government had
changed the rules. "This is the way of the future and it was necessary
to explain the shift from a medical model to a sales-directed model.
"Our cli ents h a ve been r e asonably recepti ve to u nderstanding
that the user- pay s concept is very different to what the
go vernment prev iously provided, despite t he complexity and detail
involv ed. What has cha nged here is tha t people have an i nput into
what they want going forward. So for us it is about understanding
what they want now and in the future."
In March thi s year, Pre sCare set about c r eating this
transfor mat ion project to facili tate th e move from the o ld way
of block fundi ng to s e lf-di rected care. A comb ination of
ap proaches w a s adopted and in cluded empl oy ing new staff
speci a lists in CDC and retraining s upp ort staff, care co ordinators
a nd field staff. Collabo r ation w a s key to the su ccess of the project,
whi ch involv e d engagi ng with staff at all levels of th e organisation
via various channels including meetings,
emai l, i ntranet and newsletters.
Skelton says the project was a h uge
exercise in impro ving and fine-tun ing
internal and external communications
fo r both staff and clients w ith in their
community care business. Along with
im provements in communic ation, training
for field staff was a priority and was
con ducted in two-day blocks. He was
particularly impre ssed with how resilient
PresCare's people were, especially when
g iven all the right tools, and al so their
dedication to t he wellbeing and happiness
of their c lients.
Each cli e nt was asked what they wa nted
and what they felt t heir care would look
like i n the f uture.
More than ha lf (55 per cen t) reques ted
domestic or person a l care services , other
pri orities were foo d, nursing and allied
health s ervices such a s podiatr y and
ph ysiotherapy. Conversations w ith cl ients
will continue on a regular basis, every
si x months or yearly dependin g on
individual r e quirements .
NEW IT SYSTEMS IN PLACE
B usiness intell igence (B I) has been a b ig
f oc us for PresCar e too, particularly whe n
it co m e s to de livering information abo ut
cl ients, how packages are b e ing ut ilised
and managed , what client s are being
ch arged a nd the services they are using.
"Ensuring that all the information from
different parts of the business and different
data management syste ms is readily
availab le and can be brought together in
easy-to-follow repo r t s," Skelton says.
PresCare, one of Queens land's largest aged care providers,
embarked on a massive operation to inform cl ients
and change t he way staff i nteracted under CDC . The
orga ni sation u sed its in-h ouse specialist IT company for the
technology component a nd introduced new systems an d proces ses
to ensure i t cont in ues to delive r quality servi ces.
PresCare c hief executive offic er Greg Skelton say s implemen t in g
CDC was a d r iver for not only change but also growth . " What we
have d one is bring in a totally new manage ment process ac r oss the
whole organisati on with respect to stakeholder engagement," says
Skelton. "Wi t h the change from delivering bloc k funding to having
clie nts determine the ir o wn needs, it is our fie ld staff who will be
The introduction of Consumer Directed Care (CDC) has sparked a transformation of
leading aged care provider PresCare. Chief executive officer GREG SKELTON spoke
to KYMBERLY MARTIN about these changes to its business management model.
at the f r ontline when it comes to having
dialogue with cl ients.
"This has changed our operating
model forever. We invested si g nificant
project resources in looking at th e way we
interacted with our clien t s and our peopl e ,
and the processes that were needed to
improve that. In other words, it was about
ensuring we foll ow our clients throughout
their agei ng journey with PresCare."
Part of this undertaking involved the
distribution of 11,500 brochures, 750
PresCare's investment in CDC
aaa community care review | 23
22 | AUGUST 2015
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