Research identifies the immense challenges for aged care reform, as well as the pressing need for change

Introduction by Croakey: A commitment to address the crisis in aged care was the centrepiece of the Labor Government’s pre-election policy platform. Recently, Minister for Aged Care Anika Wells re-emphasised this commitment when announcing that the Aged Care and Other Legislation Amendment (Royal Commission Response) Bill 2022 was the first piece of legislation passed by the new parliament.

The latest edition of Australian Health Review puts a focus on aged care, highlighting the breadth of challenges facing the Government in responding to the 148 recommendations made by the Royal Commission into Aged Care Quality and Safety (ACRC).

Issues include the tight budgetary environment, widespread workforce shortages, poor coordination between healthcare sectors and a lax regulatory framework that has allowed profits to come before quality care.

Growing demand is also a huge issue, with one paper estimating that in NSW alone, a new 50-bed facility will be required every week from 2020 to 2029 to meet predicted demand, reports Croakey editor Jennifer Doggett in an overview below of the new publications.

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Jennifer Doggett writes:

In the editorial for the Australian Health Review, Editor-in-Chief Dr Sonĵ Hall notes that “there is much to be celebrated emanating from the Royal Commission into Aged Care Quality and Safety’s Final Report, ‘Care, Dignity and Respect’”, and stresses the significance of the new Aged Care Act that puts the older person first and enshrines their rights.

Key reform goals outlined by the ACRC report include a more integrated system and quicker assessments, to free up acute care beds and prevent older people languishing in hospital rather than being in their homes.

It also outlines some of the main reform goals needed achieve these aims, including cultural change, increased workforce numbers, funding sustainability, better regulatory systems, accountable, transparent leadership and improve clinical governance processes.

These are complex issues which do not have simple solutions. The articles discussed below cover different aspects of the ACRC recommendations and make an important contribution to the current reform process.

While they have different approaches, a common thread across these papers is the need to address the two main barriers to the successful implementation of the ACRC recommendations: an inadequate aged care workforce and a lack of coordination between residential aged care facilities (RACFs) and other sectors of the health and aged care systems.

Medicare-funded mental health services

Residents in RACFs have a particular vulnerability to psychological illness, due to a range of factors including issues associated with moving from their former homes, complex physical needs and (in some cases) the onset of dementia.

Recent research demonstrated that over 57 percent of residential aged care residents in Australia have at least one psychological disorder, most commonly depression (46.2%), anxiety (14.9%) or psychosis (9.7%).

Despite this, a paper by a team of researchers led by Dr Monica Cations, South Australian Health and Medical Research Institute, has found that people in RACFs are currently significantly under-served by mental healthcare.

Less than three percent of residents with a mental health condition in the cohort studied accessed funding subsidies for mental health services provided by GPs, psychiatrists, or allied health professionals. In contrast, around 10 percent of the general population (all ages) accessed a Medicare-subsidised mental health service during the same period.

The paper cites other Australian research showing people with depression in residential aged care are far less likely to be referred for non- pharmacological therapies than drug therapies, and that less than 10 percent of residents with an anxiety disorder receive psychological treatment.

These findings are particularly problematic given the strong evidence base for the benefits of mental healthcare for people in RACFs, including a range of studies demonstrating that older people with psychological illness benefit from psychiatric, psychological, and other treatments, including multidisciplinary case management, cognitive behavioural therapy, and problem-solving therapy.

Underlying factors

The study identifies some key factors underlying the low rate of mental healthcare being accessed by people in RACFs, including:

• Low psychological literacy among both residents and workers in RACFs
• Insufficient infrastructure and skilled staff within RACFs to identify and treat the mental health needs of residents (fewer than 60 percent of residential aged care facilities reported employing at least one skilled worker in mental health in the most recent Australian Aged Care Workforce Census)
• A widespread misbelief that people with dementia cannot benefit from non-pharmacological therapies.
• The costs of transport involved in receiving care (of the professional to the facility or the resident to the professional)
• Previous restrictions on people living in RACFs receiving some Medicare-subsidised mental health services.

Short and longer term measures

The paper discusses recent short-term investments in meeting the need for mental health support services in residential aged care settings.

For example, in 2019, the 31 Australian Primary Health Networks were awarded $82.5 million over four years to provide mental health support in these settings. However, the authors argue that the implementation of this initiative has been slow and variable, servicing only three percent of the intended population of residents with mental health disorders in its first two years.

The ACRC report makes a number of recommendations for improving mental health services in RACFs, including increased funding for specialist in-reach mental health service provision, availability of subsidies for a GP-administered mental health assessment and treatment plan for all residents within two months of facility entry, and widened eligibility for psychology items for residents.

This paper provides some important background on the current poor state of Medicare-funded mental health care in RACFs and analyses the barriers to increasing uptake that will need to be addressed if these recommendations are to be successfully implemented.

Minimum staff time standard for nursing homes

The ACRC report contained long overdue recommendations for legislated minimum staff time standards in nursing homes, based on evidence that insufficient numbers, as well as in the skills mix, of staff in Australian nursing homes causes neglect and harm.

Using a five-star rating system developed in the US, the ACRC found that almost 60 percent of Australian nursing homes have unacceptably low staffing levels (one- or two-star ratings). Approximately 73 percent of Australian nursing homes have staffing levels and skills mixes rated between one and three stars.

The Commission used this rating system to underpin recommendations for Australian minimum staff time standards, including that from 1 July 2021 nursing homes should provide a minimum of 200 minutes of care to each resident every day, including at least 40 minutes of Registered Nurse (RN) care (3 star rating), increasing to increase to at least 215 minutes, including at least 44 minutes RN time, from 1 July 2024 (4 star rating).

The former Coalition Government agreed to legislate the three-star standard but delayed its implementation to 1 October 2023, with no clear commitment to requiring improvements beyond this date.

The current Labor Government went to the last federal election with a commitment to deliver nurses in aged care facilities 24/7 and the recent legislation passed by parliament introduces a requirement for this to be in place by 1 July 2023.

An inadequate response

In a paper analysing these recommendations and the response from the former Coalition Government, Dr Micah D. J. Peters and Casey Marnie from the Australian Nursing and Midwifery Federation (ANMF) and University of South Australia, along with Annie Butler, Federal Secretary, ANMF, criticise both the ACRC’s recommendation for minimum time standards and the former Government’s limited response, arguing that the recommendations would add only 20 minutes more of care, including four minute of RN care.

In addition, they identify a number of critical problems with the approach being taken to increasing nursing levels in RACFs. These include:

• the standards are based on the US rating system designed to inform consumers, not a contextually appropriate (i.e. Australian) assessment of residents’ staffing needs
• it is not clear whether minutes relate to staff being ‘engaged by the provider’ (as worded) or to provide actual resident care
• the ‘average resident’ is undefined, which could lead to people with higher needs not being catered for
• there is no distinction made between enrolled nurse (EN) and personal care worker (PCW) roles which disincentivises the employment of ENs and devalues EN contributions
• the temporary exemptions to skill mix requirements, but not staff numbers, risks erosion of RN and EN roles, particularly in regional and remote areas
• providers are permitted to select a skills mix appropriate to the home’s model of care but without requirements that this model of care be evidence based or suitable for residents’ needs
• aspiring to below best practice perpetuates the ethos of ‘good enough’, which contradicts the Commission’s aims.

The authors argue that the objective of staffing nursing homes appropriately should not be to achieve ‘absolute efficiency’, but to ensure that staff work safely, provide person-centred care, develop meaningful relationships with residents and can provide unrushed, dignified care.

They do not believe that the current recommendations provide a roadmap to best practice care or can deliver the transformative reforms that Australia’s nursing home residents and staff deserve.

A staged approach

Along with the call for a 24/7 RN presence (now adopted by the Labor Government), the authors recommend that the minimum time standard should start off higher and be gradually raised so that by mid-2026 close to the equivalent of a best practice five-star rating is achieved.

The delay in achieving this rating is in recognition that best practice care cannot be achieved immediately due to workforce shortages (particularly RNs), attraction and retention challenges and funding model deficiencies.

The authors state that these two reforms would underpin overall improved system and staff outcomes, such as improved recruitment and retention, workplace safety and staff satisfaction by ensuring time to provide respectful, person-centred care.

Emergency department presentations

Patients presenting to hospital emergency departments (EDs) from RACFs are a vulnerable and increasingly important patient group due to the aging population in general and more specifically, the higher rates of complex medical comorbidities, frailty and cognitive impairment in this population.

As a result, patients from RACFs have higher rates of ED presentations, more repeat visits, and are more prone to hospital-acquired complications and higher in-patient mortality.

The intersection between RACFs and EDs therefore presents important opportunities to re-examine how care can be better coordinated across the healthcare continuum in order to reduce ED presentations and hospital admissions where possible with more integrated approaches in primary care settings.

An Australian first

A research project on this issue, conducted by Sally Yin, Dr Jennifer Paratz and Dr Michelle Cottrell from the Royal Brisbane and Women’s Hospital and University of Queensland, was the first Australian study to use state-wide linkage of data to examine patterns of ED presentations of patients from RACFs and the associated 30-day all-cause mortality.

The study aimed to characterise presentations and outcomes of patients presenting to an ED from RACFs and is the largest such study undertaken to date in Australia.

Overall the study highlighted some key patterns of ED presentations from RACF patients, with the most common presentations classified as injury, respiratory and cardiovascular diagnostic categories. It found a re-presentation rate within 30 days of 20.61 percent. The overall 30-day mortality rate was 15.44 percent.

The higher re-admission rate in this population compared to the same age groups in the general ED population (around five percent) suggested to the authors that opportunities exist to improve access to clinical care in RACFs.

They also identified that the higher mortality associated with pro-longed ED length of stay indicated the need for strategies aimed at improving patient flow in this cohort, given that the complex care needs and co-morbidities of this population often make them particularly vulnerable in overcrowded EDs (especially important in the current COVID-19 environment).

Strategies to improve clinical care

The paper discusses previous attempts to improve the provision of primary care within RACFs, citing the following examples of successful small-scale programs:

• a pre-post controlled study of the Health in the Nursing Home program in Queensland found that increasing RACF staffing capacity in providing acute interventions, such as wound management, reduced ED admissions from RACFs by 7.1 percent.
• a large-scale regional Aged Care Emergency program in NSW reduced ED visit rates from RACFs by 20 percent, reduced hospital admissions by 21 percent and reduced 30-day hospital re-admission from 12 percent to 10 percent.

The success of programs such as these suggested to the authors that opportunities may exist to improve coordination between hospitals, RACFs and other care providers such as Geriatrics Outreach Services, Hospital in the Home and allied health providers.

A key focus of this coordinated should be to avoid re-admission when more clinically appropriate options are available, given that re-admission within 30 days was associated with higher mortality. Earlier identification of deterioration and a focus on those with risk factors for ED presentations, such as increased age, complex care needs, polypharmacy and delirium history, may also help to reduce hospital re-admissions.

The article also discusses the importance of Advance Care Planning, including timely discussion of patients’ goals of care, which can reduce presentations to EDs from RACFs if appropriate palliative care, in accordance with patient preferences and resources available, can be delivered in the patient’s facility.

Currently many patients from RACFs do not have advance care planning documentation or an Advance Care Directive and, when they do, it often lacks adequate information required to provide care in full accordance with the patient’s wishes.

Barriers to action

Key barriers to achieving better coordination of care for people in RACFs are discussed in the article including the following:

• the split in responsibilities for healthcare and aged care across Australian and State and Territory Governments
• insufficient access to allied health care in RACFs, including mental health workers, occupational therapists, physiotherapists, speech pathologists and dietitians
• underlying issues associated with understaffing, inadequate staffing skills mix and training, high turnover and insufficient workforce remuneration, including for general practitioners.

Gaps in residential aged care in NSW

The ACRC report described widespread system failure and highlighted the extended waiting times that older Australians were experiencing in accessing appropriate care.

This reflected earlier findings from the Productivity Commission which noted that, in 2018, the median wait to enter RACFs after being deemed eligible was 152 days. This represented an increase of 44.8 percent from the 105-day wait in 2016–17.

This paper, by medical students Adam Austin and Thomas Moss and Thomas-Hoang Le (University of Newcastle) with Associate Professor Stuart Wark also from the University of New England, reports on a secondary data analysis of the provision of residential aged care in NSW using existing datasets including predicted population data from 2019 to 2029 linked to corresponding geographic zones.

The analysis found a significant current shortfall in the provision of RAC in NSW and indications that this problem will worsen substantially over time, with flow-on impacts for the health sector.

Findings include:

• NSW fell below target for RAC services by 1,084.8 operational places in 2019
• By 2024 an inflection point will be reached where demand across all RACFs exceeds the 2019 supply of operational places
• Significant variability was seen, which could lead older Australians to relocate away from an area they consider their community to gain access to the services they require. Evidence suggests that relocation from an existing home can be associated with a significant sense of exile and loss, as well as depression and anxiety; these effects are amplified for Indigenous peoples
• By 2029, state-wide demand for the 2019 supply is projected at 135.6 percent
• Although operational places are also expected to grow, if growth is at the rate achieved over the previous decade, it will only result in 54.8 percent of the additional places required by 2029, thus further stressing the existing community care system and resulting in pressure on the general medical and health sectors to address shortfalls in services.

Overall, the authors calculated that one new 50-bed facility will be required every week, in NSW alone, from 2020 to 2029 to meet predicted demand.

In 2019, the establishment costs of a single new residential care bed were estimated at $325 000, which equates to an additional $8.4 billion investment in physical infrastructure for NSW to meet its target by 2029. To put this figure into context, $60 million in government-funded capital grants was allocated nationally in the 2018–19 financial year.

Improving waiting times for residential aged care is critically important in order to address increasing demand driven by our ageing population.

This paper discusses the medical and health implications for both individuals and their informal carers of this shortfall in the provision of RAC for the NSW population. These include medical complications and negative outcomes for older patients, including premature decline in cognitive function, inappropriate hospitalisations and early death.

The impact on families is also discussed, including the increased burden on informal carers, when they believed that their family members were not receiving an adequate level of care. This results in increased stress and anxiety, negatively affecting individuals’ mental health.

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See here for Croakey’s archive of stories on aged care.