Introduction by Croakey: Australia is set to pass another grim milestone of 6,000 COVID-19 deaths in residential aged care facilities.
Yet despite the clear ongoing risk of COVID-19 to residents, and urging in the past from groups like the Royal Australian College of GPs and the Older Persons Advocacy Network (OPAN), more than a third of eligible residents may have missed out on a vaccination this year.
Croakey editor Jennifer Doggett has dug into the numbers and found multiple barriers to protecting one of the most at-risk groups in our community.
These range from difficulties accessing or compiling accurate data on vaccinations and infections and the lack of a systematic and coordinated approach to delivering primary healthcare and preventive health services to residents in aged care.
While some additional funding was provided in the most recent Federal Budget for GPs to provide services in age care facilities, this funding is unlikely to address the underlying structural barriers which are leaving one of the most at-risk groups in the community under-protected from COVID-19.
Jennifer Doggett writes:
According to government data, 455 residents of aged care facilities around Australia were confirmed to have COVID-19 as at 16 August.
We know that people living in residential aged care facilities (RACFs) are at a high risk of adverse outcomes from COVID-19 and that vaccination is the most effective measure to reduce this risk.
Therefore, it would be reasonable to assume that all efforts would have been made to ensure these residents would be fully vaccinated.
But according to the latest data from the government, this does not appear to be the case.
Advice from the Australian Technical Advisory Group on Immunisation (ATAGI) recommends “a 2023 COVID-19 vaccine booster dose for all adults aged 65 years and over, if their last COVID-19 vaccine dose or confirmed infection (whichever is the most recent) was 6 months ago or longer, and regardless of the number of prior doses received.”
However, the Department of Health and Aged Care’s data indicate that just under two-thirds of eligible residents in aged care facilities have received a vaccination this year.
According to these figures, around a third of aged care residents are currently not fully vaccinated and therefore at significantly higher (and preventable risk) if they catch COVID-19.
Given the inability of the aged care sector to prevent outbreaks in facilities (last week 106 were reported to government) the risk of infection is not insignificant.
This is concerning given that we are now three and a half years into the pandemic and almost 6,000 people in aged care facilities have already died of COVID-19.
Policy framework
Government policy in this area seems clear.
The National COVID-19 Health Management Plan states that the Australian Government’s commitment to prioritising care and support to people at risk will be delivered through “supporting high levels of vaccination among people at risk of severe COVID-19 or death and workers in settings with increased risk of outbreaks occurring (for example, residential aged care homes and disability care facilities)”.
The National Plan also emphasises that the priority for vaccination “continues to be ensuring Australians maintain their full recommended vaccination status, particularly those who are most at risk of severe illness from COVID-19”.
However, eight months on from the release of this plan, with less than two-thirds of aged care residents vaccinated, it appears that that there are problems with its implementation.
Roles and responsibilities
It’s not clear where the problems lie but one issue may be the lack of clear delineation of responsibility for vaccine provision, with RACFs, GPs, Primary Health Networks (PHNs) and third party providers all potentially playing a role.
The National Plan states that the responsibility for monitoring vaccine status and assisting residents to access vaccines lies with aged care facilities and responsibility for providing vaccines lies with primary health care providers.
“Aged care homes are expected to monitor the COVID-19 vaccination status of residents and assist them or care recipients to access additional doses through primary care providers,” the plan states.
There are good reasons why primary health care providers, in particular the GPs who are already visiting facilities and treating patients, are best placed to provide vaccines.
These GPs already know the residents and their medical histories and have established relationships with the facilities, in particular with registered nurses (RNs) who can play an important role in working with GPs to provide vaccination services.
Primary health care providers, already working in these communities, should also be significantly cheaper than outside third party contractors.
However, given the large number of unvaccinated or under-vaccinated residents in RACFs, this plan does not appear to be working.
It’s not obvious why this is the case because, in theory, residents of RACFs should be having regular contact with a number of primary health care providers, all of whom could theoretically administer a vaccine.
As well as having access to RNs mandated for specified hours at all RACFs, most residents would also require regular care from GPs and pharmacists and possibly also from allied health providers and medical specialists, such as gerontologists.
There is no recent or comprehensive data on health care services provided to residents in aged care so it is difficult to get a clear picture of whether an overall lack of access to care is a barrier to the provision of COVID-19 vaccines.
The most recent figures on GP services provided to RACF residents from the Australian Institute of Health and Welfare date from 2016-17 and indicate that 92 percent of residents receive at least one GP visit while in a RACF, with an average of two visits per month for long stay residents.
However, evidence provided to the Aged Care Royal Commission indicates that many residents do not have adequate access to medical care.
Along with the facilities and PHC providers, PHNs also have a role to play in assisting facilities to vaccinate their residents.
When RACFs are unable to find a primary care provider able to administer vaccines to residents, they can approach their PHN for help in locating a provider or alternatively arrange for vaccinations through the Vaccine Administration Partners Program (VAPP) which gives access to a panel of providers that can provide tailored in-reach services.
VAPP services were used extensively in the earlier stages of the pandemic and funding is still available for their use but it has not been accessed this year by any facility.
These services have been criticised for the lack of transparency around contracting arrangements and their high cost is likely to be even higher now, given that there are not the economies of scale that existed when overall vaccination rates were very low.
The Health Department told Croakey that it has worked with PHNs to contact all residential aged care homes to ensure they have clear and ready access to vaccinations.
Asked by Croakey about the apparently low rates of vaccinations among RACF residents, the Department did not provide any decisive answers, but cited a number of possible reasons including “high levels of COVID-19 and vaccination fatigue within the community and a lack of consent from residents’ families”.
The spokesperson said the Department is “continuing to reinforce the importance of COVID-19 vaccinations for older Australians, through regular consumer and sector messaging” and working to overcome vaccine refusal by families.
He also stated that the Government is “now focusing on aged care homes with low uptake of eligible residents vaccinated to further understand the barriers to uptake and facilitate resident vaccinations at the earliest opportunity.”
Data issues
One complicating factor underlying the implementation of the vaccine program in RACFs is that there is no single source of data on the vaccine status of residents, which means it is difficult to know whether the Government’s figures are accurate.
The main source of data on vaccinations in Australia is the Australian Immunisation Register (AIR), administered by Services Australia. This database is a record of vaccines given to all people in Australia.
Under the Australian Immunisation Register Act 2015 it is mandatory for all vaccination providers to report to the AIR COVID-19 vaccinations administered on or after 20 February 2021.
Although this database is a comprehensive and accurate record of COVID-19 vaccines provided in the community, it does not include information about whether people receiving vaccines are residents of an aged care facility.
This means that AIR data cannot be used on its own to determine how many residents in aged care facilities have received vaccines.
To do this AIR data needs to be cross-linked with data from other sources such as Medicare, aged care facility record keeping systems and aged care databases.
This is complex as these data sources were developed for different purposes and are not designed to be inter-operable.
Another source of data comes from the aged care facilities, which are supposed to report directly to the Department on the vaccination status of their residents via the My Aged Care Portal (MACP). However, this data is patchy and a number of facilities have not provided any data on vaccinations to the Government this year.
In these cases the Government has no way of knowing whether this is because no residents have been vaccinated, or whether information about their vaccination status is not being recorded and reported.
The Department spokesperson told Croakey: “It is not a requirement for residential aged care providers to report on the 2023 booster vaccination for eligible residents as this data is drawn from the Australian Immunisation Register data collection. As such there is no penalty for aged care providers not reporting the 2023 booster through MACP.”
He added that the Department is working with a small number of facilities that do not have COVID-19 vaccinations recorded for residents in AIR, to understand where this is due to a reporting issue or where a clinic needs to be facilitated.
Even when facilities do their best to provide accurate data, they may not know if their residents have received a vaccine outside of their facility; for example, if a family member took a resident to obtain a vaccination from a GP or clinic in the community. They may also not know if a resident has had COVID-19 in the six months prior to entering the facility.
It’s also difficult for the Government to obtain accurate data on COVID-19 infection rates among RACF residents.
Most infections are now self-diagnosed with RATs and there is no requirement for reporting positive tests to health authorities. Even if someone is treated by a doctor for COVID-19 this may not show up in data readily available to government. This is because treating doctors would typically record a COVID-19 infection in their own clinical information system in free text format in the notes section.
This means that this information is not searchable and is not automatically uploaded into My Heath Record (MHR), which is visible to other care providers and to government.
An event summary, including details of a COVID infection, could be uploaded to a patient’s MHR if a GP thought this was relevant. However, these summaries are also not searchable, so even if a RACF or government official accesses the MHRs of individual patients to look for evidence of a recent COVID-19 infection they would have to manually search the event summaries of each patient to find it.
Another complicating factor is that the residential aged care population is not static. The average stay in an aged care facility for a permanent resident is less than two years and for people in for respite care it is around three weeks.
This means that unless the data is constantly updated it may not be accurate at any point in time.
Looking to the future
Given that we are now three and a half years into the pandemic, it seems problematic that some key requirements for the implementation of a RACF vaccination program based in primary health care are not in place.
These include an understanding of the capacity and limitations of the primary health care workforce to deliver vaccines, accurate and comprehensive data on the vaccine status of residents, and sufficient resourcing in place to ensure providers are appropriately remunerated for their role.
In particular, if GPs are to play a central role in the delivery of the COVID-19 vaccination program, there needs to be ongoing consultation with the sector to ensure the program is designed in a way that optimises GP involvement. This could include consideration of targeted payments, such as the service incentive payments used in other areas of general practice, such as the provision of childhood vaccination.
It is also difficult to successfully deliver a public health program such as vaccination without measurable targets, clearly defined responsibilities, and appropriate ‘carrots and sticks’ for delivering against the program objectives.
None of these appear to be in place, based on information provided in the National Plan and via Croakey’s interactions with the department.
This issue also has broader implications beyond COVID-19 and aged care.
If the Government wants to rely on primary health care to deliver “…wrap-around care for the people who need it most” (as stated in the Strengthening Medicare Taskforce Report) it needs to ensure there is the workforce, resourcing and infrastructure available to support this aim.
The COVID-19 pandemic has provided us with a valuable opportunity to identify the capabilities and limitations of our primary health care sector to play a role in delivering population-wide preventive health care.
The ongoing failure to provide vaccinations in RACFs suggests that our current system is not up to the task. It is important that governments use the learnings from this experience to strengthen our primary health sector to play a greater role in preventive and public health efforts in the future.
Comment from the RACGP
Asked about aged care vaccination concerns, Royal Australian College of GPs President Dr Nicole Higgins provided the following comments:
“It’s vital we do all we can to lift vaccination rates in aged facilities, not only for COVID-19 but also influenza and pneumococcal disease. After more than three years of COVID-19 pandemic, there might be a certain level of complacency at play, and we can’t let that happen.
“We need to get as many boosters in arms as possible, especially those more at risk of severe outcomes from the virus.
“GPs have a key role to play in caring for older people in these facilities, including delivering vaccinations. With greater support, we could do even more, because as things stand there are barriers to GPs extending the scope of their efforts to people living in aged care.
“This year’s federal Budget included $112 million over four years to support GPs in providing care to older people. This is a huge step forward that will make a real difference and, in the years ahead, I hope government will deliver further boosts in investment as numbers in aged care grow. That way GPs can step up their efforts even further and ensure continuity of care for older people right across Australia.”
Read Croakey’s archive of articles on aged care
