Novel co-designed service to support health and wellbeing of older carers of older people: A study protocol.

Older carers will attend a multidisciplinary Carer Health and Wellbeing Service (CHWS) - the intervention - which is staffed by a social worker, psychologist, physiotherapist and occupational therapist. Interventions will be tailored to the carers' self-prioritised needs, based on an initial screening tool (the Carer Support Needs Assessment Tool (CSNAT). Interventions will be determined to address the prioritised health and wellbeing needs of the carer. Interventions may be delivered by the CHWS staff, or if not available through the Service staff, will be referred to external service providers (for example for management of a carer prioritised need by health professionals not involved in the Service, e.g. dietitian; podiatrist; sleep disorders clinic). An episode of care for carers will be 6 months, although this may be extended if required by some carers. The service is operating at one of the Peninsula Health sites (Frankston, Victoria, Australia). Interventions will be determined through shared decision-making between the carer and their primary contact CHWS staff member and will be informed by the carer-prioritised needs (CSNAT and other needs), and assessment findings. Depending on the areas of expertise and capacity of CHWS staff relative to the prioritised carer needs, some interventions will be delivered by CHWS staff, while other interventions may require referral to other practitioners or services, within or external to Peninsula Health. Carers will be encouraged to continue other health and wellbeing strategies they may be undertaking at the time of attending the CHWS. INTERVENTIONS PROVIDED BY THE CHWS OR REFERRALS TO OTHER PRACTITIONERS OR SERVICES Following intake assessments at the CHWS, an initial individualised intervention plan will be developed with the carer. This plan will be reviewed regularly to ensure interventions are adapted if necessary to meet changing needs. Interventions will be individualised to the carer and may be changed over time through ongoing shared decision-making between the carer and the CHWS staff, depending on progress and possibly changing needs. The CHWS staff will follow up with the carer to support implementation of one or more intervention options that are within their scope of practice to deliver, through provision of information or resources, through direct intervention provision (e.g. if the Primary Contact is a physiotherapist, and the carer has strength or fitness needs, they may be provided with a tailored home exercise program or participate in a CHWS-based group exercise program), or through other actions as required. There will be broad flexibility in the type and nature of intervention/s that will be initiated in the first instance, including whether the intervention is delivered by CHWS staff, whether it involves referral to an external service/provider/practitioner, and its mode of delivery (face-to-face, online, or hybrid). If assessments indicate the need for medical review for the carer, they will be informed of this, and with their consent, provided with a letter to their medical practitioner outlining assessment findings, planned interventions, and reasons for recommending a medical review. One or more intervention options will be determined through shared decision making between the carer and the clinican to address one or more of the carer prioritised needs from the CSNAT. Possible options for interventions could include the following (although this is not an exhaustive list): - Social Worker - counselling, group sessions, advocacy, sessions focused on navigating changing relationships or care planning. - Clinical Psychologist - psychoeducation, cognitive behavioural therapy, grief counselling, and sessions focused on interventions related to symptoms of anxiety and/or depression. - Occupational Therapist - relaxation, mindfulness and stress management techniques, energy conservation techniques, sleep management strategies, manual handling training and assistive technology to support the carer at home. - Physiotherapist - exercise programs (including tailored home-based, group-based, supervised 1:1 sessions, or other as needed), physical activity advice and support, manual handling training, and mobility/gait aid as needed. OTHER INTERVENTIONS PROVIDED THROUGH THE CWHS (IN ADDITION TO THOSE OUTLINED ABOVE): Staff will have a range of publicly available information resources to provide to carers, or for carers to search through a structured online portal. While much of the information resources will be focused on carer health and wellbeing, some are also related to improving the carers’ understanding of the care recipient’s specific health condition/s, possible prognosis, and what to expect and prepare for. Where indicated, carers may be referred to their or their care recipient’s medical practitioner for further details of the care recipient’s status and prognosis. The CHWS staff will run intermittent education sessions to support carers (may be online, face-to-face, or hybrid; initial aim to run these each 3 months), and/or link carers to other existing programs available within the community/other organisations, to address commonly identified issues that may benefit from a group education approach. Opportunities for carer peer support (through face-to-face or online) will be provided. MONITORING INTERVENTION ACTIVITY AND ADHERENCE During or after each session with a participant, staff will document interventions provided, self-reported adherence to interventions, factors influencing limited adherence, and any changes to improve adherence by participants. CHWS STAFF TEAM DISCUSSION AND COMMUNICATION WITH MEDICAL PRACTITIONERS AND OTHER SERVICE PROVIDERS: After a carer’s initial appointment or after their 6 month (end of episode of care) assessment, and at other times as required, the CHWS team will meet to discuss identified needs, intervention plan, outcome/s and other relevant issues. On these occasions, a letter from the CHWS Primary staff contact will be sent to the carer’s general practitioner (or other service provider, as recommended by the carer) outlining the CHWS staff assessment findings, intervention plan/s, and after the 6 month assessment – outcomes of the intervention and ongoing plans. SUBSEQUENT APPOINTMENTS AND EPISODE OF CARE: CHWS staff may schedule face-to-face, phone or online appointments with carers to follow up on aspects of interventions or activities after the first appointment, at a frequency and duration that is mutually agreed upon between the carer and the staff member (frequency and duration will be documented). Carer involvement with the CHWS will last an average of 6 months (episode of care), from initial contact to final assessment, with a standard episode of care being six months duration, from the time of completion of the initial assessments. The decision regarding discharge timing will be made by the CHWS Primary contact staff member and the carer. Although it is anticipated that the standard episode of care will be six months, carers with ongoing needs being actively addressed by the CHWS or who have added one or more extra interventions during the 6 month period may opt to continue with the Service beyond the 6 month mark. In these cases, the six month assessment will be undertaken as planned; and a discharge assessment will take place when later discharge occurs. Those who complete an episode of care with the CHWS can be re-referred if their circumstances change, or new issues arise. For situations where the person being cared for transitions from home to residential care (for permanent care, not for respite care), or in situations where a care-recipient passes away during the episode of care for the carer, the carer will have the option to continue with CHWS support (with review to determine if needs have changed), or to cease involvement with the CHWS (with re-assessment at this time point if this is acceptable to the carer).