Chapter 5 - Funding for residents with special needs
arrangements do not appropriately support the provision of residential aged
care services to older people presenting with special needs including dementia,
residents with challenging behaviours and complex care needs. Funding
arrangements support a standard service response to all needs with some special
needs not being met, such as older people needing mental health care who
experience access restrictions to generic residential aged care.
Residents in aged care facilities with special needs,
including those with dementia, mental illness and requiring palliative care,
require additional services and support. The staff providing for their care
also require skills to ensure that they have the ability to manage complex care
needs. This chapter looks at the care needs of these groups, the findings of
the Hogan Review and current
funding arrangements, including recent Commonwealth initiatives.
The Hogan Review provides a detailed examination of
funding arrangements for residential aged care including special needs groups.
The following is a brief overview.
The Commonwealth provides subsidies to providers of
aged care. Fees are also paid by individuals. The Resident Classification Scale
(RCS) provides the basis on which the subsidies are paid for each resident. The
subsidy is calculated as follows:
- a basic subsidy determined by the resident's
classification under the RCS; plus
- any primary supplements; less
- any reductions in subsidy resulting from the
provision of extra services, adjusted subsidies for government (or formerly
government) owned aged care homes or the receipt of a compensation payment;
- any reduction resulting from income-testing of
residents who entered residential care on or after 1 March 1998; plus
- other supplements, including the pensioner
supplement, the viability supplement and the hardship supplement (which reduces
charges for residents who would otherwise experience financial hardship).
At the time of the Hogan Review, primary supplements
were provided for:
- concessional and assisted residents: for those
who are unable to afford to pay an accommodation bond or charge;
- respite: paid to offset the higher
administration and care costs of respite care;
- charge exempt resident: for those who were in an
aged care facility on 30 September 1997 and who move to another facility
where they would otherwise be eligible to pay an accommodation charge;
- oxygen and enteral feeding: for those requiring
on-going oxygen or enteral feeding;
- payroll tax; and
- transitional resident supplement.
The hardship supplement provides for residents who
experience difficulty in paying for their care. It may be paid for specific
classes of resident or for individuals who apply for a hardship determination.
The Department of Health and Ageing (DoHA)
stated that a significant component of the current RCS focuses on the
additional effort needed to assist people who have problems of cognition or who
need additional care around the management of problem behaviours. Funding for
people with dementia was estimated to be $2.3 billion in 2004-05.
In reporting on the arrangements for funding the care
needs of special needs groups, the Hogan Review stated that it had received
evidence that there were expectations that more complex care would be provided
by aged care facilities. This included complex pain management, palliative
care, wound management, dialysis and tracheotomy care. The Review also noted
that providers questioned the adequacy of the subsidies payable for people with
a range of specific care needs including dementia and stroke and people from
diverse or disadvantaged backgrounds.
The Hogan Review examined the needs for those residents with dementia, those
requiring palliative care, those in remote and rural areas, the elderly
homeless and people from Aboriginal and Torres Strait Islander communities and
culturally and linguistically diverse backgrounds.
The Review supported the approach for basic subsides to
be determined on level of need for care, supplemented by additional payments
for extraordinary care needs that add significantly to the cost of care. The
Recommendation 6 Funding supplements
The arrangements through which supplements are paid for the
provision of oxygen and enteral feeding should be extended to other specific
care needs or medical conditions.
These specific care needs could include:
(a) short-term medical
needs, such as IV therapy, wound management, intensive pain management and
(b) specific care
needs, such as for dementia sufferers exhibiting challenging behaviours or for
residents requiring palliative care; and
(c) care needs of
people from diverse or disadvantaged backgrounds such as the homeless elderly
and indigenous Australians.
The rate of payment of any new supplements should reflect the
incremental increase in the cost of providing the appropriate treatment and/or
level of care.
As part of the 2004-05 Budget, the Commonwealth
announced its response to the recommendations of the Hogan Review. These
include new residential care supplements to be introduced in 2006 'to better
target assistance to people with higher care needs by supporting the provision
of care to people with dementia exhibiting challenging behaviours and people
requiring complex palliative nursing care'. An additional $11.6 million over
the next four years was provided to strengthen culturally appropriate aged care.
It was noted that care needs of people from diverse or disadvantaged backgrounds
are supported by a number of Australian Government programs. The cost of the new supplement 'will
be absorbed from within existing resources'.
The Commonwealth also stated that it considered that
'extending supplements to other conditions or circumstances would add
unnecessary complexity to the payment system and administration'.
Other Commonwealth programs
The Commonwealth also supports a number of programs
which target special needs, particularly people with dementia, including Home
and Community Services, Community Aged Care Packages and Extended Aged Care at
Home packages. A range of targeted dementia services include the Dementia
Education and Support Program, the National Dementia Behaviour Advisory Service,
the Early Stage Dementia Support and Respite Project, Carer Education and
Workforce Training, and Psychogeriatric Care Units.
In January 2005, Australian Health Ministers jointly
agreed to the development of a National Framework for Action on Dementia. The
Framework will 'provide an opportunity to co-ordinate a strategic,
collaborative and cost-effective response to dementia across Australia'.
Consultations with peak bodies, families and carers are to take place to
develop 'a shared national vision for action on dementia'. A national forum
will be held in July 2005. The consultations will lead to the development of a
draft National Framework to be considered by Australian Health Ministers in
The Commonwealth has also made dementia a National
Health Priority with a $320.6 million package over five years targeting better
prevention, treatment and care. In February 2005, funding of $52.2 million over
four years for the first component of the package was announced for additional
research, improved care and early intervention programs. In the 2005-06 Budget
funding of $225.1 million over four years was provided for 2 000 new
dementia-specific Extended Aged Care at Home places. Funding of $25 million
over four years was also provided for dementia training for up to 9 000
residential aged care workers and 7 000 people in the community who come
into contact with people with dementia, such as police, emergency services and
that, in relation to mental health, the National Mental Health Plan 'calls for
improved cooperation between the mental health and aged care sectors to ensure
that Australians experiencing a mental disorder receive the best possible care.
The delivery of mental health services, however, is constitutionally the
responsibility of individual State and Territory Governments'.
The Commonwealth's Ethnic Aged Care Framework seeks to
improve partnerships between aged care providers, culturally and linguistically
diverse communities and the Department of Health and Ageing and ensure that the
special needs of older people from culturally and linguistically diverse
backgrounds are identified and addressed. The Commonwealth also funds the
Partners in Culturally Appropriate Care initiative under the Framework. This
provides funding to organisations in each State and Territory which help to
link culturally diverse communities with aged care providers to develop more
culturally sensitive services and provides cross-cultural training for staff of
residential age care services.
Responses to current funding arrangements
The difficulties of providing residential aged care for
people with special needs are well documented.
The provision of services for the very large, and
growing, number of people with dementia has been a significant problem. There
was evidence that it was difficult to place people with dementia in aged care
facilities which provide adequate levels of care. Witnesses pointed to the lack
of dementia-specific funding and the failure of the RCS to adequately capture
behavioural problems as the causes of the lack of places for those with
dementia. The Office of the Public
Advocate Qld stated:
[The RCS] is seen as not adequately recognising the support
needs of people who have behavioural challenges, especially people with
dementia and psychiatric illnesses. Although many of these people do not have
high levels of personal or nursing care, the intensity in nature of their needs
means that they require more personalised attention because of the impact of
their behaviour on themselves and other residents.
The Australian Society for Geriatric Medicine stated
that current funding arrangements are 'extraordinarily documentation intensive
but fail to generate a useful care plan' and fails to adequately recognise the
resources required for management of behaviours in intermediate stage dementia
care and leads providers to pick and choose patients who are easier and better
reimbursed. They also result in a financial
disincentive for the provision of restorative care and rehabilitation and fail
to provide any incentive to provide medical treatment on site rather than
transfer residents with new medical problems to state funded hospitals. The
Society concluded that:
Appropriate and expert behavioural management, rehabilitation,
illness and injury prevention, and on site acute and sub-acute medical care
would all be cost effective to the Australian community, and preferred by most
residents and their families. Current remuneration of specialized medical
services and organization of public hospital aged care services does not
support the provision of this care within the Residential setting.
The Benevolent Society argued that 'facilities for
people with dementia and disturbed behaviour are structurally under funded and
their operation is dependent on the commitment of organisations to carry heavy
financial losses. This is not sustainable in the long term.'
Witnesses welcomed the new funding supplement. The
Queensland Government stated that the new funding supplement was 'an
acknowledgement that the current RCS does not adequately address the needs of
this growing subset of residents'. The Government went on to comment that the
proposed three level model of basic funding with supplement for special needs
clients 'should encourage providers to take these clients'.
However, some witnesses argued that the additional
funding may not be adequate to meet the care needs of people suffering from
dementia and that careful development of the supplement will be required. ANHECA
for example, commented that residential aged care is experiencing substantial
growth in the number of cases of dementia amongst residents in high and low
care. It is estimated that approximately 60 per cent of residents in
residential care suffer mild to severe dementia. However, ANHECA stated that 'there
has been no work undertaken to consider the real cost of providing residential
services to those with dementia or with behavioural or other difficulties'.
ANHECA recommended that prior to the implementation of
the dementia and palliative care supplement in July 2006, a substantial review
needs to occur regarding the actual cost of providing such services. ANHECA commented
that while the top subsidy payable to a level 1 resident in residential care is
$118 per day, the average payment for an acute sector palliative care service can
be as high as $430 per day:
There is great difficulty reconciling these two quite separate
figures. It is essential therefore, for government to look at the true cost of
providing an effective palliative care program and an effective dementia
program and to incorporate that cost provision within any revised residential
care subsidy framework.
COTA National Seniors argued that for the new measures
to be effect, they need to include incentives for providers to offer quality
dementia care including an improved mix of capital/recurrent funding, appropriate
training for staff caring for people with dementia and support for innovation
in care for people with dementia.
The Tasmanian Government and other witnesses stated
that the new supplements appear to be funded from existing funds and may
therefore divert resources from meeting other needs. The Tasmanian Government
also suggested that the use of supplements needs to be reconsidered in
conjunction with the overall design of a more appropriate funding model. ACS Australia stated:
Currently the proposal is to meet those very high needs by the
redistribution of the existing pool of resources, and that is a source of some
concern to us and our members, that if you do that then there are necessarily
going to be people who are currently receiving services or who would have
received such services into the future who will miss out. In other words, it
could be seen as a form of rationing residential aged care as well as a form of
targeting residential aged care.
Concern was also voiced at the delay in introducing the
proposed new funding model as this will mean that difficulties in funding
places for the elderly with special needs will continue for some time..
Areas of unmet need
Specialised facilities for dementia
There was debate in the evidence as to the need for
dementia specific facilities. Some witnesses commented that dementia is not a
'special needs' any more, and should be incorporated into mainstream care. Other witnesses stated that it was
extremely difficult to care for both the frail elderly and those with dementia
in the same facility:
The situation for many dementia residents in Australia
currently, certainly in Tasmania,
is that they are in integrated models so that someone like me, who manages 74
beds and another 22 transition beds, is trying to manage people with wandering
and sometimes gross behavioural disorders in with residents who are cognitively
capable. That is totally unfair to both those with dementia and those without dementia.
Victorian Association of Health and Extended Care (VAHEC)
stated that only 5 per cent of high care and 6 per cent of low care beds
are dementia specific with the majority of dementia residents being placed in
mainstream residential services. The Association stated that 'whilst the
majority of these services cater extremely well for residents with dementia, it
is obvious their needs can be better responded to and met in dementia specific
It was argued that the lack of purpose built facilities
for people with dementia may result in a number of problems:
- any facility can be labelled dementia specific
whether it is purpose designed for dementia or not. This makes choosing the
correct facility very difficult for carers and service providers;
- organisations wishing to build dementia specific
facilities are unable to easily access best practice guidelines for their
design or functional management;
- the length of stay of older adults in the acute
hospital setting increases because of lack of facilities and creates the
repeated transfer of residents between non purpose built faculties and
increases safety risks for the individual residents, other residents and staff;
- purpose built faculties have no policy or
funding incentives to be utilised for older people with the greatest need for
that specialised environment. Therefore in practise they appear to be utilised
for residents that solve facility management problems rather than the strategic
needs of the older people with dementia.
The Mary Ogilvy Homes
Society commented that while the Commonwealth has provided a funding component
for dementia care, this is only recurrent funding: 'the majority of the
industry would agree that it needs to be carried out in what is known as a
segregated model, and that requires a capital funding stream to build buildings
that are architecturally appropriate for residents with dementia'.
Witnesses also identified a number of other
difficulties in meeting the needs of residents with dementia. These included:
- people with dementia and co-existing psychiatric
illnesses or intellectual disability require additional support and specialised
management which is not always available;
- a need for further education and training
especially in managing challenging behaviours, however, training budgets which
could adequately meet the needs of staff;
- people with dementia who are physically fit
often have difficulty finding appropriate placement. Many facilities are not
equipped to manage people who are stronger and more agile;
- residential facilities have great difficulty in
accessing specialist advice for residents with dementia and very complex needs
and residents are sent to emergency departments unnecessarily;
- the need for alternative placement options where
facilities cannot manage people; and
- lack of a thorough profile of people on
admission, due either to the inappropriateness of the assessment tool or the
desperation to place people.
The ANF Victoria Branch noted that the Ageing in Place
initiative was intended to address the needs of aged care residents with
dementia but it argued that it had not been successful in giving high care
dementia residents access to appropriate nursing and health care. Low care
facilities or hostels do not have access to adequate nursing care as these
facilities are only required to employ registered nurses on a 'casual' or 'call
in basis'. The ANF argued that care in such facilities is not always and concluded
that 'such lack of access to skilled nursing care by high care residents is
Mental health support
There are special needs associated with people with mental
illness or psychiatric disability, and a body of provocative literature has
emerged over the last couple of decades showing that mental illness is commonly
undetected and often poorly managed in residential settings. Some actually put
the figure as high as 90 per cent or more of those in nursing home care or aged
care facilities fulfil criteria for one or more psychiatric disorders in an
environment that often presents significant difficulties for assessment and
Many witnesses pointed to the need for specialised care
for those elderly with mental health problems. Witnesses noted that more people
who are ageing have a mental illness, particularly depression, and moving into
aged care facilities. The Mental Health Co-ordinating Council (MHCC) indicated
to the Committee that its research had found that the ageing process tended to
exacerbate the symptoms of mental illness. This was due to the experience of
multiple losses and increased physical problems associated with ageing. Many
older people with long standing mental illness also experienced isolation and
illness as they had become estranged from family and friends and withdrawn from
UnitingCare indicated that as a result of people with
mental illness accessing the aged care system there was an increasing need for
crisis, acute and specialist psychiatric care. While Baptistcare stated that
the needs of the mentally ill are very different to people who have dementia.
Staff in residential aged care facilities find it
difficult to care for those with severe mental illness. The Office of the
Public Advocate Qld commented that 'many of the staff in aged care facilities
are not knowledgeable about even normal ageing and are not really able to
understand some of the psychological symptoms and behavioural problems
experienced by residents and, because of that, seldom seek appropriate mental
health intervention once a problem is recognised'.
MCHH concurred with the Public Advocate and identified
an urgent need for increased training of staff in aged care facilities in both
the care of people with mental illness and dementia:
The needs of these residents are not currently being met to an
adequate degree. This can cause deterioration in mental state and cognitive
functioning with consequential decline in safety and quality of life.
Additionally, when residents with these conditions are not cared for in an
optimum manner, the resulting disturbances impact negatively on staff and other
residents. This increases distress for residents and staff and contributes to
the ongoing staff shortage.
McKay also commented on the need for
Training is very definitely an issue. You see some facilities
where it is done very well and others where it is not. In the community in
general the level of training seems to be declining, not improving...Whereas 10
years ago you could access people in the community with training, now it is
extremely hard. That exacerbates the problem. You actually can have people
going in to provide respite who actually may make the situation worse rather
than better. This is not across the board. I have to emphasise that there are
still some very good community services as well. But the training makes a huge
ANF Australia stated the key to providing appropriate
care is the education of staff who work in the acute sector and in the
residential sector and the community sector. Education for mental illness 'has
been neglected a little because of the focus on dementia because of the large
numbers that we are going to be looking at of people with dementia. It is a
The need for additional services and funding was
highlighted in evidence. The ANF Victoria Branch stated that additional funding
(around $50 per resident per day) for patients with mental illness is provided
by the Victorian Government to ensure that appropriate care is provided. The
ANF stated that elderly Victorians with mental illness were well service by
access to public nursing homes but 'these homes would not be able to continue
to provide Psychiatric nursing care if they were reliant on Federal funding'.
It was argued that the Commonwealth's failure to
provide supplementary funding for mentally ill residents, undermined the
provision of appropriate care. In addition there is also limited access to
psycho-geriatric services or behavioural management support services. For example, the NSW Aged Care
Alliance noted that there was only one psychogeriatric unit in NSW. In Queensland the Office of the
Public Advocate noted that there was a problem with the provision of non-acute
residential aged care places in Queensland for people with a psychiatric
disability: 'it lags behind most other states, as does acute aged geriatric
area spending as well as mental health spending more broadly. The lack of
specific psychogeriatric services has been cited by the Royal Australian and
New Zealand College of Psychiatrists by their faculty of psychiatry of old
also commented that the design of facilities for those with mental illness was
important. With properly designed facilities for people who have mental illness
or cognitive impairment the demands on staff are reduced, agitation is reduced
and increases the safety for staff and residents.
The homeless elderly are certainly living in our community and
they are doing it very tough. They deserve respect and they deserve to be
treated with dignity. This is a critical time to ensure policy and funding
decisions ensure homeless older people are not forgotten and indeed they, and
those who care for them, should receive the assistance they need to ensure the
highest quality of life.
The elderly homeless are a small group but who, as the Hogan
Review observed, are one of the most difficult groups to place in residential
care. In relation to funding of
their aged care, the Hogan Review noted that 'while the elderly homeless
attract a concessional resident supplement, they generally have no ability to
pay an accommodation bond, compounding the problem of access to mainstream
services'. The Hogan Review commented that given the funding problems of
providing care for the elderly homeless, there are very substantial grounds for
providing for the special needs of the most deprived of the elderly homeless.
The Review's recommendation included extension of the funding supplement to
disadvantaged groups, including the elderly homeless, and targeted capital
assistance to assist those services experiencing exceptional circumstances.
The Commonwealth's response to the Hogan Review did not
include extension of the funding supplement to the homeless and noted that the care
needs of people from diverse or disadvantaged backgrounds are supported by a
number of Commonwealth programs.
As with evidence to the Hogan Review, witnesses pointed
to the special needs of the elderly homeless and the difficulties they face
accessing care. The elderly homeless are predominantly male and access services
at a younger age than others. Generally homeless people or those at risk of
homelessness have poor diets, have multiple health problems, multiple cognitive
problems, are often alcohol dependent and are subject to social isolation.
The homeless lifestyle hastens the ageing process with premature
ageing found in people in their 40s who have been homeless for a number of
years. As a result they may require the intensive services appropriate to older
people, such as HACC, CACP and residential aged care. The Brotherhood of St
Laurence stated that they are often excluded from these services as they do not
meet the age criterion and conventional models do not suit this group.
When residential aged care is required, homeless people
often find it difficult, if not impossible, to access services. CHA stated that
currently, all providers who cater for this group are religious and/or
charitable organisations. St
Bartholomew's noted that the small number of service providers that are willing
to care for this group appeared to be dwindling. Mainstream services 'actively
discriminate against this client group' and are reluctant to accept the elderly
homeless because of their challenging behaviours. For example, many homeless people
have learnt coping behaviours which are not suitable in a normal community
setting and so extra resources are often required to assist and retrain these
people in acceptable behaviours. Homeless people often have poor interpersonal
skills and are suspicious of people they don't know, including service
providers, and it takes a great deal of time, which is not funded, to build up
a relationship of trust. Other areas where homeless people require a different
and intensive level of support include personal care, leisure activities, overcoming
alcohol and/or drug dependency and medical and dental issues. In addition, without the appropriate
resources, the wellbeing of other residents and the occupational health and
safety of staff are at risk.
VAHEC stated that the RCS, even when maximised, does
not reflect the level of care required by people who have been homeless and
stated that 'the intensive care and one-on-one support required by these people
cannot be provided by organisations within the current funding structure'. St Bartholomew's noted that the
Commonwealth had not implemented the Hogan Review's recommendation in relation
to residential care. Witnesses recommended that the Aged Care Act be amended to
include homeless people as a special needs group so that they can become
eligible for Commonwealth funded aged care services. The Brotherhood of St Laurence
I would not see it as an extra stream of funding. I think it is
more about tapping into the funding but creating a special needs group within
the Aged Care Act. I think Professor Hogan
recommended that homeless people be taken into account with special needs funding.
I think the Commonwealth's response was more or less that they saw that as a
state government responsibility and that it was already being well catered for.
We would strongly argue that it is not being catered for at all and that there
is a need for a funding stream for homeless people.
Ageing with disabilities
We know there are lots of adults with a disability who are now
into their 50s and 60s, and parents who are in their 80s who have been caring
for their loved one for over, in some cases, five decades. This is a very big
cohort and I think that good collaboration between the states and the
Commonwealth will be critical in terms of determining how this current unmet
need will be addressed.
NCOSS noted that at present 11 per cent (30 200)
of those aged 45-64 and 4 per cent (13 000) of those aged 65 or over
with severe or profound core activity restrictions report an early onset
disability (i.e. acquired before age 18). It is anticipated that there will be
an increasing number of people with an early onset or longstanding disability
who are ageing. Between 2000 and 2006, the total number of people with a severe
or profound core activity restriction is expected to increase by 11.6 per cent
(137 600 people).
Witnesses argued that people ageing with disabilities
requires specific and considered responses from all levels of government to
meet their needs. ACROD focussed on the need for improved linkages between
Our view is that the response from governments to this
development, this growing interface between ageing and disability, has been
inadequate. Much of the policy effort at government level, it seems to me, in
these human service areas where demand exceeds supply of services, goes into
restricting entry, erecting barriers – setting restrictive eligibility criteria
– rather than focusing on improving pathways and improving linkages between
sectors. The result is an ineffective and inefficient interface between the two
For example, it was stated that ACAT teams make
assessments where they are largely unaware of the supports and services offered
by the disability sector. A
further example was that of the provision of aids and equipment. ACROD noted
that the responsibilities for the provision of aids and equipment are divided
across government departments and between the Commonwealth and the States:
...with the Continence Aids Assistance Scheme, the federal
Department of Health and Ageing provides that for people in a rationed way; provides
that for people who are under 65 or over 65 if they continue to work for eight
hours a week or more, but when a person turns 65 and they have continence
issues...They then become ineligible for that scheme and they have to then find
an equivalent scheme funded by their state government.
That creates uncertainty and anxiety for them and I think is an
inefficient and ineffective way of doing it. There has been enough research now
that shows that, as a whole, the current schemes leave significant gaps, are
inefficient and are fragmented.
ACROD proposed that the states, Commonwealth and relevant
non-government organisations could come together and develop a coordinated or
centralised system which could ensure that there was equitable and available
aids and equipment for people which, in the long term, would allow people to
remain independent and so reduce the pressure on more formal services.
In addition, it was argued that not only is funding not
keeping pace with the increased demand for service, but also 'the funding
formulae and administrative arrangements that govern the aged care and
disability service systems seem to assume that a person is either disabled or
aged, but cannot be both'. Like other witnesses, ACROD recommended that a
person with a disability who is ageing should have simultaneous access to both
aged care and disability service systems and funding streams, according to
their need. However, ACROD noted:
...people who may have been long-term residents in state funded
group homes – they may be people with an intellectual disability – and that is
their home and has been their home for many years. When they age, because they
are in a state administered and state funded group home, they are denied access
to services that other people have access to; services such as community
nursing, palliative care, dementia support and so on. This effectively denies
them the right to age in place, which is a right that is increasingly expected
by the general community.
Baptistcare provided information on problems with
service provision to a group of aged residents (some in their seventies) with
disabilities in a residential facility in Perth.
As it had to relocate the group from a facility which could no longer provide
for their needs, it sought Community Aged Care Packages as a possible solution:
We saw this as a possible solution that we might be able to work
towards as we endeavour to relocate these people. We made an approach to the
state government here, with whom we are working, and they in turn made an approach
to the Commonwealth office here. We were not at the meeting, but the response
that we were given was that there appears to be little scope in the Aged Care
Act for the two bodies to work together to come up with a solution that may see
something like that being a new initiative within an existing program. So that
is an example we had towards the end of last year which I put to Minister
Bishop as an opportunity that maybe her department could have a look at.
Baptistcare concluded that 'there is an opportunity for
Community Aged Care Packages to go out to people who are currently living
either in the community or, perhaps, in a facility such as the one we have.
That would address their immediate needs and let them remain where they are
rather than relocate them'.
The Greenacres Association commented that there were
concerns about ageing people with a disability who have been living in the
community and working in business enterprise. Greenacres stated that:
- there is an inability to secure the appropriate
supports and services that they require to remain living a meaningful live in
the community as they age;
- there is a lack of, and uncertainty about,
service provision makes it difficult, if not impossible for these people and
their supports to plan for the future; and
- services for ageing people with a disability
must be sufficiently flexible to meet their diverse needs and must take account
of changes in those needs as they further age.
The Greenacres Association noted that the people with
disability they cared for had been supported for most, if not all their lives
and 'would not cope without support (at least initially) in generic services,
and the generic service participants were not keen to integrate with people
with a disability'. Therefore effective transition programs and services are
essential as a person with a disability reaches the age of retirement and
eligibility for aged care services.
ACROD stated that transition from employment to retirement needed to be gradual
so that the person had time to adapt to change. Initially the supported
employee should receive a mix of non-employment activities and employment.
ACROD stated that this requires movement from Commonwealth funded services to
appropriate day activities funded by the States or Territories and aged care
services funded by the Commonwealth: 'in theory bureaucratic and jurisdictional
boundaries should not impede this, but, in practice, the boundaries are often
The Greenacres Association also stated that the
Commonwealth's 'Assistance for Business Services' provides for access to a
personal case manager to support those retiring from a business service.
However, Greenacres commented that:
In theory this sounds fantastic, but the reality is that that
there are not services out there for these people to access. In the Wollongong
area alone there was not a single appropriate service available until the NSW
Department of Ageing Disability and Home Care funded the Retirement Options
Greenacres provided the Committee with details of its
ageing service, Greenacres Retirement Options (GRO). This service provides a
centre based day program for eligible individuals. The service offers a variety
of activities both at the centre and in the community. Assistance for each
activity is provided, the average being one GRO staff member to five retirees
(or less). Priority is given to those individuals over the age of 55 that are
retiring from a business service or have already retired and living with a
family member. Retirees that live with a parent carer have the highest
priority. Greenacres commented that this type of services is ground-breaking
and the first of its kind in Australia.
The Department of Family and Community Affairs (FaCS) stated
that the issue of people ageing with disabilities was a concern:
Certainly the issue of people with lifelong disabilities who are
ageing is a growing concern to us. It is in some ways a relatively new
phenomenon. We are not accustomed to having large numbers of people with
disabilities live to such an age, where they would be regarded in the
traditional sense as potential aged care clients.
The Department went on to note that 20 years ago there were
only a handful of older people with down syndrome. Now there are over
1 000 people in Australia
who are aged with down syndrome. The Department commented:
We are clearly starting to face very real issues at that older
age nexus. I admit that it is not something in the disability world that a
great deal of attention has been paid to in the past. Increasingly we are doing
that but I would still come back to my earlier point that it is really a case
of the appropriate expertise and appropriate kinds of support, rather than
trying to look at how a mix of services might go into the one service. I am
happy to accept that there are needs for improvement in the services.
The Department of Health and Ageing commented that it
and FaCS 'have been working on, including through a small number of pilots
under the aged care innovative pool, to test that issue of the increasing
ageing needs being overlaid on disability needs'. The Innovative Pool offered flexible
aged care places to the States and Territories and other aged care providers,
for time limited pilots to trial new models of service delivery at the
disability services/aged care interface. Two specific categories for people
with a disability were targeted, the first being for people with disabilities
who are ageing. Six projects have been approved in this category for 2002-03 and
a further three for 2003-04. These projects are all providing additional aged
care services for people with disabilities who are ageing in disability
supported accommodation settings.
ACROD supported this development and stated:
That is very good and I know that those pilots are subject to
evaluation this year. I would hope that, subject to that evaluation, they not
only continue but that the principle of combined funding and joint funding that
is established by those pilots can be more broadly applied...It is a very
promising development, because it involves cooperation between Commonwealth and
state and sensibly involves shared funding. The clientele that are being
provided with the service in those pilots have mixed needs and some of those
needs derive from life-long disability and others derive from the fact that
they are growing old. It makes sense, from a policy point of view, for both
levels of government to be involved.
In regard to the provision of age related services to
those ageing in supported accommodation, FaCS stated that it is government
policy that Community Aged Care Packages are not available to people in
subsidised residential care and that:
The disability residential care services or the accommodation
support services are very similar in principle at least to many other residential
services. We would expect that the organisations running those services will be
meeting the needs of the people that they are providing services for. It is
difficult for me to think through why there would be a need for, or an
expectation that – say for our colleagues in the Department of Health and
Ageing but in health and aged care services generally – aged care services of
any kind would be provided to somebody who is already in a residential care
service and presumably having their residential care needs met.
FaCS further commented that it was discussing the growing
number of issues around people with disabilities living in residential care
services who are developing conditions traditionally associated with ageing,
such as Alzheimer's dementia, where there is again a growing recognition that
those services do not necessarily have the expertise and the experience in
As part of our current round of Commonwealth-state arrangements
there are a couple of parts within that where we have agreed with the state
governments that there are areas of expertise which are needed and that is
something that we are discussing with our colleagues in Health and Ageing.
I think it is going a bit far in that environment to suggest
that there is a service model which should be provided. We certainly recognise
there are areas where greater expertise is needed and state governments are
working increasingly with Health and Ageing officers in the states to do that,
but I do not think there is a situation at this stage where it is appropriate
for two models of service or two accommodation support services to be provided
to a person in the one residential setting. I agree with the need but I am not
convinced there is a need for services from two agencies to go to that one
The discussion in this chapter briefly canvasses a
number of significant issues. Solutions to these issues must be found to ensure
that adequate aged care is provided to all those in aged care facilities. The
Committee considers that if the Commonwealth takes on the care of those in aged
care, the Commonwealth is responsible for the total care of that person and the
provision of all services. It must ensure that all matters pertaining to a
person accommodated in an aged care facility are taken into account and the
appropriate services are provided whether they arise from a condition related
to ageing or a pre-existing condition such as a mental health problem or they
arise from lifestyle such as homelessness.
In relation to the supplementary funding for dementia,
while this is a welcome initiative, the Committee considers that it is not
appropriate that these funds are drawn away from other programs. The costs of
dementia and palliative care needs are increasing as are all costs in
residential aged care. Funding the supplement should be provided in addition to
that already provided. The Committee also considers that an appropriate review
of the additional costs of providing care for those with dementia and those
needing palliative care should be undertaken to ensure the funding supplement
is sufficient to provide adequate care.
The Committee also notes that dementia is now a Commonwealth
National Health Priority and that Australian Health Ministers have jointly
agreed to the development of a National Framework for Action on Dementia. The
Committee considers that this is a significant opportunity for ensuring that
the increasing numbers of older Australians who are suffering from dementia
receive adequate care and that they and their families are able to access a
range of accommodation and care options.
5.62 That the supplementary
funding for aged care for residents with dementia be provided for by additional
funding and not funding from within the current budget.
5.63 The Committee recognises that the Australian Health Ministers have
jointly agreed to the development of a National Framework for Action on
Dementia and that the Commonwealth has recognised dementia's significance with
a $320.6 million package of support over five
years. The Committee recommends that all jurisdications work together with
providers and consumers to expedite the finalisation and implementation of the
Framework to assist all dementia sufferers.
5.64 That the Commonwealth undertake a review of the
additional costs of providing care for those with dementia and those needing
palliative care to ensure that the new funding supplement will be sufficient to
provide adequate care.
Mental illness is a major health concern in the
community. Evidence points to the exacerbation of mental illness with ageing.
The elderly with mental health illness or psychiatric disability require
additional and specialised care. They must have access to adequate
accommodation and support options. In order for this to occur, the Committee
considers that the funding supplement should be extended to services providing
care for older people with mental illness. In addition, the Committee considers
that a review of the provision of psychogeriatric services and the
effectiveness of psychogeriatric care units needs to be undertaken.
The Committee also considers that there is a need to
increase the training of the aged care workforce to ensure that mental illness
in the elderly is recognised and that there is a skilled workforce to meet the
needs of elderly people with mental illness.
5.67 That the Commonwealth
establish a funding supplement for residents in residential aged care who have
additional needs arising from mental illness.
5.68 That the Commonwealth
investigate the provision of psychogeriatric services and the effectiveness of
psychogeriatric care units.
5.69 That the Commonwealth
provide targeted funding for the education of the aged care workforce caring
for people with mental illness.
The Committee considers that while the elderly homeless
are a small group, they require additional services to ensure that they receive
appropriate aged care. The Committee is therefore disappointed that the
Commonwealth has not provided a funding supplement for the elderly homeless.
The Committee considers that the Commonwealth should reconsider this decision.
5.71 That the Commonwealth
establish a funding supplement for residents in residential aged care who have
additional needs arising from homelessness.
The number of people ageing with a disability is growing
and they will need to access quality aged care services. While it is
acknowledged that the Commonwealth is aware of this problem, the Committee is
concerned that the barriers between the jurisdictions and within jurisdictions
may impede the development and provision of services for those ageing with a
Those working in the disability sector have built up
the skills and resource base to assist those with disabilities. To these must
now be added the skills and resources of the aged care sector. Without an
understanding of both disability and ageing those ageing with a disability will
not receive an optimum level of care.
The Committee considers a specific and focussed
response is required.
5.75 That the Commonwealth
respond to the growing needs of people ageing with disabilities by consulting
with the States and Territories and stakeholders to identify ways to improve
access by people ageing with a disability to appropriate aged care services
including service provision in supported accommodation.
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