A new research paper from the Office of the Royal Commission into Aged Care Quality and Safety asks the question Does the quality of residential aged care vary with residents’ financial means?
The paper compares indicators of quality of care between facilities receiving a high level of government support (i.e. where residents are, on average, less affluent) with those receiving lower levels of government support (i.e. where residents are, on average, more affluent).
It finds that people in facilities with more affluent residents receive more minutes of care, experience fewer assaults and are also less likely to be chronic opioid users or subject to physical restraint. Residents of these facilities also have lower hospital or emergency department readmission rates.
Below Jennifer Doggett provides some extracts and key findings from this paper (with minor edits), which will be used by the Royal Commission to inform its final report, due on 26 February 2021.
The Office of the Royal Commission into Aged Care Quality and Safety writes:
Funding of residential aged care is currently structured so that a resident’s financial means do not affect the total payment received by their aged care provider to give personal and clinical care.
Residents contribute a proportion of the fees, based on their financial means, with the Government contributing the remainder.
In theory this should mean that aged care providers receive the same level of payment for residents with the same level of need. However, there is some scope for other types of payments to vary with resident’s financial means and these could potentially impact on quality of care.
For example, more affluent residents can pay for extra and/or additional services offered by the aged care provider such as upgraded hotel-type services and other services beyond the minimum care requirements. An approved provider may use these sources of revenue to fund a higher quality of care for residents.
This study used both qualitative and quantitative methods to investigate whether quality of care varies with residents’ financial means.
The qualitative investigation involved a review of the submissions made to the Royal Commission and the comments by focus group participants in Ipsos’s study They look after you.
The quantitative investigation involved using quality of care indicators to see if there were statistically significant differences in the results for groups of facilities. Facilities were grouped according to the percentage of residents that have all or some of their accommodation costs paid by the Australian Government (in the aged care system these residents are described as ‘supported’). Facilities were also grouped according to whether they receive revenue for extra services.
The topic was investigated initially by reviewing public submissions to the Royal Commission and the views expressed by the public in a series of focus groups. In the public submissions from or about people with lower financial means, older people with low financial means saw themselves (or were seen) as having less choice and being more at risk of financial stress when making decisions in times of crisis.
But otherwise these submissions describe issues which are common for people in the Australian aged care system, regardless of their financial means. Focus group participants believed people with greater financial means are more easily able to find a comfortable aged care facility and a higher quality of service.
The topic was then investigated using quality indicator data from across the aged care system. Facilities were grouped based on the share of residents ‘supported’ (meaning their accommodation was partially or fully paid by the Australian Government) and whether the facilities receive revenue for extra and/or additional services (‘extra services’ for brevity) which is more common among facilities with low shares of supported residents. A small number of the quality indicators showed statistically significant differences between these groups of facilities but the large majority did not.
The main statistically significant differences (p<0.05) found in the analysis were:
- Care minutes—Residents in facilities with less than 30% of supported residents received more allied health and lifestyle care minutes on average than facilities with 50% or more supported residents. Also, residents in facilities with extra service revenue received more care time overall and for most staff types. Staff expenditure had similar patterns.
The data on care minutes and staff expenditure was not adjusted to take into account the complexity of residents’ care needs at the facility level which might partially or fully explain the differences. In addition, because there is a correlation between extra service status and lower numbers of supported residents, it is possible that the differences are driven by the fees paid by residents for extra services, rather than being evidence of financially disadvantaged residents receiving lower quality care.
- Assaults—The number of total assaults and serious physical assaults were higher on average in the facilities with 50% or more supported residents than in those with less than 30%. However, the number of sexual assaults were higher in facilities offering extra services.
- Mandatory indicators—The use of physical restraints was higher on average in the facilities with 50% or more supported residents than in those with less than 30%. The use of physical restraints was also higher in facilities without extra service revenue than in those with extra service revenue. However, facilities with extra services had higher rates of stage 1 pressure injuries.
- Clinical indicators—The number of chronic opioid users was higher on average in facilities with 50% or more supported residents than in facilities with less than 30% or 30–39% supported residents. Facilities with 50% or more supported residents also had higher hospital or emergency department readmission rates for long-term residents.
These results were produced using quality indicator data at the facility level. Quality indicators for individual residents are not widely available in the current aged care system. The paper suggests that the development of these indicators would be useful to enable researchers and policy makers to continue research such as this and help ensure all residents receive a high quality of care in the future.