The fundamental purpose of the regulatory framework for aged care is to create an environment to support the delivery of appropriate standards of accommodation, personal and clinical care to the residents of residential aged care facilities (RACFs). The purpose of this inquiry, as articulated in the Terms of Reference, is to investigate how effective the aged care regulatory framework is in achieving that objective.
The aged care regulatory framework does not operate in isolation to impact the quality standards of aged care service delivery. Two key factors which also impact the quality of aged care, are the funding environment and the aged care sector's interactions with the health care sector.
This chapter explores how RACFs interact with external health care sectors and whether additional amendments to regulation or funding mechanisms are required to ensure that the person is placed at the centre of service delivery.
As outlined in previous chapters, the committee is defining clinical care as health care provided by a health professional, while medical care is the health care provided by a medical practitioner, often a General Practitioner (GP).
Integration with primary health and acute care
Leading Age Services Australia told the committee that the siloed approach to primary health, acute care, aged care and social services needs to be broken down into a person-centred 'ageing well' system:
That view would then see supports for older people as they age around preventative health, around support for ageing well...Then when they do require clinical care or support, whether that be in their home or at a doctor's surgery or hospital or a residential care facility, that is made available to them. So the system doesn't create barriers for access.
These arguments for better integration between the aged care and the primary health and acute care sectors are not new. The 2009 report by the National Health and Hospitals Reform Commission, A healthier future for all Australians, made recommendations for national access targets for the health system and recommended that aged care be included in reporting on 'the continuum of health services'. The report went on to make recommendations to better integrate the health and aged care systems.
In its 2018 report, A matter of care, the Aged Care Workforce Strategy Taskforce (Aged Care Taskforce) developed 14 recommended actions, one of which was 'Strategic action 9: Strengthening the interface between aged care and primary/acute care' because 'integration of these systems could be achieved by taking a population health approach, which structures care systems around the needs of consumers rather than around available funding'.
The Aged Care Taskforce stated that to achieve better integration, there needs to be 'a frank discussion across the social and health care industries and all levels of government about how to restructure care and design more flexible funding mechanisms that support consumers to transition more easily between Commonwealth, state and privately funded services'.
The Aged Care Taskforce made many specific recommendations on actions to achieve the goal of better integration and overall recommended the establishment of Social Care Networks, potentially to be operated by the existing Primary Health Networks (PHNs) to achieve these aims.
Role of PHNs
PHNs are the central regional point for funding, planning and commissioning of primary health services in a local area with a view to better integration and coordination of the health system. This is supposed to include better coordination and integration between the health and aged care sectors.
PHNs have already taken some steps to promote better integration between the health and aged care sectors. PHNs have recently been tasked with the co-design and delivery of psychological services within RACFs, but there is still capacity for PHNs to take on a broader role in establishing networks between health practitioners and RACFs. The Department of Health (Department) notes that aged care is one of the six key priority areas for targeted work by PHNs.
The Western Queensland PHN considers that PHNs have a role in supporting better integration and linkage across and between the aged care sector, primary health and acute hospital sector, the Aboriginal Community Controlled health sector, the National Disability Insurance Scheme, non-governmental organisations and the social care sector.
South Western Sydney PHN noted that at a high level, the PHN can liaise with RACFs to ensure that there is appropriate clinical data exchange and communication between the clinician and the RACF. Chapter two highlighted a project undertaken by a PHN in Queensland to integrate My Health Record into the health record keeping system of a RACF provider.
South Western Sydney PHN identified practical ways that it could assist to facilitate better interaction between primary care and RACFs:
[W]e would help advise facilities about what would make clinical care in the facility easier—basic things like having dedicated consulting spaces; coordinating records, so that GPs can use the records, and making the records more user-friendly; working with a registered nurse on site; doing a session with patients, so they are easier to find and easier to follow, rather than leaving the GP to their own devices to find the patients.
As outlined earlier in this chapter, the Aged Care Taskforce suggested that this role could be taken further with the establishment of Social Care Networks to 'better assess local aged and disability care service demands' and improve service coordination. The Aged Care Taskforce suggested that this role could be added to the scope that PHNs already have, or a separate body could be established to work in concert with PHNs.
Issues with current delivery of medical care
Submitters and witnesses raised a number of concerns about the current quality of medical care being delivered to RACF residents, further highlighting the need for better integration with the primary health care sector.
RACFs are funded under the Aged Care Funding Instrument (ACFI) to provide accommodation and personal care, as well as some clinical care. However, as RACF residents are predominantly people with complex health care needs, they often require a great deal of clinical care beyond day-to-day nursing care.
As with other areas of clinical care in the aged care context, there are distinctly opposing views on whether medical care is an issue the aged care regulatory frameworks should be considering at all, given that RACF providers do not provide medical care under the ACFI. As outlined in chapter two, RACF providers also argue that as they are not responsible for the standards of medical care, the standards of medical care should not be a matter for the aged care regulatory framework.
However, the Australian Commission on Safety and Quality in Health Care (Health Care Commission) submitted that RACF providers have a non-delegable duty of care to residents to protect the resident from harm. This duty of care would extend to external medical services provided on‑site in RACFs.
The Health Care Commission told the committee:
The providers know this, so the fact that they're saying that they're not responsible for medical care or even posing these questions to you I find nothing short of remarkable. They can't hide behind an individual medical doctor's prescribing or treatment practices...when it's frequently the aged-care institution instigating the request for medical care.
Furthermore, Leading Age Services Australia submitted that under the Aged Care Act 1997 (Cth) the RACF provider is ultimately responsible for the overall care of the care recipient, although RACF providers responsibility for the quality of care delivered by visiting health professionals 'has not been tested and remains a grey area'.
The Terms of Reference for this inquiry clearly provide scope to investigate how effective the aged care regulatory framework is for ensuring proper medical care standards are maintained and practised. The disagreement over the lines of responsibility for the provision of medical care in the RACF environment would indicate that the regulatory framework is not doing that well, if at all.
Older Persons Advocacy Network noted that the Clinical Governance Framework, outlined in Standard 8 of the Single quality framework, does not include accountability arrangements with visiting professionals to ensure that a facility can demand an appropriate standard of care. Brisbane South PHN informed the committee that a clear process for the accountability of visiting providers, such as GPs, was necessary.
The Australian Medical Association (AMA) submitted that medical practitioners are not provided with adequate access to their patients. The AMA has recommended the standards be amended to explicitly incorporate an 'access to medical care' standard to ensure that residents' medical needs are met by qualified medical practitioners.
However, the Chief Medical Officer of the Department noted that Medicare evidence suggests that RACF residents receive 'good' medical review via GP visits 23 times per year, but challenges still exist in getting urgent care when a person deteriorates.
The AMA cited a survey conducted in 2017 which found that one in three GPs planned to cut back or end visits to RACFs within the next two years due to inadequate Medicare fees and a lack of suitably trained and experienced nurses in RACFs.
The South Western Sydney PHN reported similar issues, with GPs in its catchment area reporting they are progressively moving away from regular visits to RACFs due to logistical challenges, lack of appropriate consultation space and the availability of skilled staff, particularly RNs, to carry out prescribed treatments in RACFs.
The Australian College of Nurse Practitioners submitted a similar view, stating that visiting medical staff often do not report poor standards of care, where their directives are not followed and clinical issues are not reported early.
Bupa has met the challenge of limited external GPs being willing to treat RACF residents by establishing an in-house GP service. The AMA discussed the provision of medical care through an on-site GP, raising concerns that this may take choice away from the patient and would impose on the GP 'an employer-employee relationship rather than having someone coming in from the outside who's able to provide independent eyes looking at the care of a patient'.
By contrast, the Australian College of Nursing pointed out that locating GPs in RACFs would enable them to 'be much more sensitive to the nuances of how the day works, where the person is and where they want to see them'.
The National Health and Hospitals Reform Commission recommended that 'funding be provided for use by residential aged care providers to make arrangements with primary health care providers and geriatricians to provide visiting sessional and on-call medical care to residents of aged care homes'.
Allied health care
Allied Health Professions Australia told the committee that the work of allied health professionals is not valued by RACFs and that this leads to a lack of continuity of care and declining function among residents. However, Allied Health Professions Australia considered that the current funding model was the primary cause of RACFs' current approach to allied health care.
Submitters pointed out that a number of recent reviews of the ACFI had noted the lack of support for allied health services and the effect this has had on care recipients.
In its report, A matter of care, the Aged Care Taskforce noted that there are a number of factors that all combine to limit the availability of allied health services in an RACF. These include the limited number of allied health services and the types of services that are subsidised under the Medicare Benefits Schedule, combined with the level of subsidy and the requirement for referral by a GP. Each factor would need to be addressed in order to increase the prevalence of allied health services in RACFs.
The Aged Care Taskforce also noted that there is significant confusion about what services should be funded by RACFs and what services must be privately funded by the care recipient.
The integration of externally developed care plans into RACF services was a matter raised by submitters and witnesses as an area that could be improved.
Before a recipient is admitted to a RACF, they must first be assessed by an Aged Care Assessment Team which considers the person's medical, physical, psychiatric, psychological and social needs to determine their eligibility and suitability for aged care services. The Australian Law Reform Commission noted that assessment is one way the Commonwealth seeks to ensure that the limited number of aged care places go to people who need them most. These assessments are not currently used to develop a care plan for the care recipient.
The committee was advised that when a care recipient enters a RACF, their GP, who usually provides the lead in coordinating care, often does not follow the person when they enter residential aged care. Instead, the care recipient may see a number of different GPs, limiting their continuity of care.
The South Western Sydney PHN explained that developing a care plan for each resident could assist in the coordination of clinical care and add to the systems that are already available through the My Health Record system.
The Department advised the committee that there is a long-term vision to ensure interoperability between My Aged Care and My Health Record. However, that interoperability is not yet available.
The Australian and New Zealand Society for Geriatric Medicine told the committee that a care plan developed for a RACF care participant needs to be comprehensive so that an appropriate clinical team can be wrapped around the person:
The overwhelming importance is linking any outcomes of assessment with a management plan... It's actually about wrapping a team of health professionals and personal care workers around the individual with appropriate clinical supervision, with appropriate scope of practice and with appropriate clinical governance.
These care plans can become even more important as a person moves towards the end of their lives. As noted in chapter two, palliative care is an important issue in RACFs and it is important that the needs and wishes of patients are respected as they enter the final stages of their life.
Submitters and witnesses to the inquiry noted that currently some people, especially those who suffer from dementia are receiving low quality care at the end of their lives. Alzheimer's Australia advised that advance care planning at the time of diagnosis can allow people with dementia to express their preferences about their end-of-life care.
The AMA noted that most Australians want to die in their own homes, which may include a RACF. Advanced care directives or advanced care plans should be used to promote high quality patient-centred care in a way that is collaborative between the patient and the health care team. The AMA told the committee that this needs to be supported by all RACFs:
RACFs need supporting policies in place that allows the generation of clear advanced care plans appropriate for the RACF setting, that are taken seriously and reviewed regularly.
The committee concurs with the view of Leading Age Services Australia, that while parts of aged care legislation appear to confer ultimate responsibility for the care of a RACF resident on the RACF provider, there is a lack of clarity or real-world testing of this position. However, the committee strongly agrees with the position put forward by the Aged Care Guild in a previous chapter, that residents and their families don't care about jurisdictional issues or legal funding arrangements. They just want person-centred care that is appropriate to their needs.
If the goal of the new Single Aged Care Quality Framework is to provide that person-centred care, then a key change to service delivery must surely be to end the siloed approach where not only the care delivery is fragmented, but responsibility for overall care quality is avoided by the services closest to our frail elderly Australians.
The committee considers that there may be a broader role for PHNs in creating linkages between RACFs and the broader health sector to ensure that the appropriate care is wrapped around the care recipient. PHNs already have a role in coordinating clinical services and that experience in coordinating services in their local areas makes PHNs well-placed to identify and coordinate Social Care Networks to benefit the RACF resident.
Care plans are important to ensure that RACF residents receive coordinated care. The committee recognises that care would be less fragmented and more clinically appropriate if each RACF resident had a care plan and there were requirements on RACFs to enable residents to review, discuss and amend their care plans to reflect the care they want and need.
The committee is concerned about the evidence it heard regarding the lack of access to GPs in RACFs and believes this is an issue that needs addressing as a matter of urgency, given the increase in acuity of residents and their need for medical care.
The overall matrix of aged care funding is an issue of great contention. Some argue there has been a reduction in 'real dollar' funding, while others argue that overall funding has either been maintained or increased. This report will not seek to make comment on past funding decisions, but will look to recommendations being made on where to go from here. The committee is also cognisant that while funding fundamentally impacts the quality of clinical care in RACFs, it has only limited relevance to the Terms of Reference for this inquiry.
The Aged Care Guild described the complexity of care funding and that it often reduces without reference to any improvements in treatments for health conditions:
Take the example of an individual with a level of Parkinson's and with an arthritic knee. On one day they might be eligible for about $60 or $62 a day of the ACFI funding for care to support them. Overnight—bang!—someone with that exact same clinical assessment would be eligible for $48 in care support. Exactly one year later, overnight— bang!—they're eligible for $16 of care support. In that time—if you think about the system and the system being in balance—there were no medical advancements that made it easier to treat Parkinson's disease or arthritis. There were no model-of-care advancements, as far as I'm aware of, that made it easier or more expedient to treat those issues. They were as complex as before but the resources there to support them were significantly less so that is an impact at a care level, and providers have to work out then how they are going to deal with that.
The Aged Care Guild also pointed out that the different funding streams often meant that larger organisations were able to cross subsidise funding from accommodation and lifestyle streams to top up care funding arrangements, which is 'good because we should continue to provide care but it is bad at the same time if it covers up the care funding issue that is in the industry'.
The New South Wales (NSW) Nurses and Midwives' Association made a contrasting point, informing the committee that although aged care did require more funding 'we need to also examine how those funds are spent and utilised and look at the clinical governance around aged care. There's no use throwing good money at aged-care services for it to go straight into shareholders' coffers or for that not to be spent in an accountable way'. The NSW Nurses and Midwives' Association went on to recommend that increased funding should be tied to the best interest of RACF residents, shown through an audit trail, with some funding allocated specifically to safe staffing.
Queensland Nurses and Midwives' Union (QNMU) submitted that the total RACF profit in 2018 was $1 billion, and therefore the sector has capacity to invest in improving quality standards.
The Department told the committee that the recently announced additional $320 million funding for RACFs will not be specifically targeted to service delivery, but will be part of the normal subsidies that providers receive with the 'expectation' that the increased subsidies will be spent on improved care delivery.
The Aged Care Guild pointed to the lack of work done to undertake a comprehensive study on the funding needed to deliver a certain level of aged care, and said that aged care works backwards by developing its care model based on funding availability, rather than developing the funding model based on care needs.
Bupa also pointed to the overall lack of funding under the ACFI, and noted the indexation freeze, and said this issue is threatening the sustainability of the sector and reduces the capacity to provide high quality care to residents, and increases the chances of transfers to the more costly hospital environment.
Leading Age Services Australia pointed to the A matter of care report by the Aged Care Taskforce which outlined that there is a gap between the output of what is considered an appropriate level of care and the input of the direct care hours per resident per day. The funding to fill that gap was costed at $3.5 billion per year.
The Australian College of Nursing also raised the same funding gap and agreed it needed to be filled, but also pointed to aged care funding beyond the ACFI, such as the major refurbishment supplement, as an option for RACFs to improve infrastructure to make services more viable.
Allied Health Professions Australia made a similar observation, and pointed to 'the failures of the current funding structures to support maintenance of clinical care standards.' Allied Health Professions Australia told the committee that funding appropriate access to allied health services would provide a better return on investment through greater mobility, reduced falls risks and more humane and effective management of challenging behaviours.
The AMA made similar comments on Medicare funding for GPs, noting that Medicare is fixed on face-to-face consultations, while psychiatry and psychology has certain tele-health options which would be 'very suitable' options for aged care.
QNMU submitted that there is a financial disincentive for RACF providers to assess residents' capacity to self-administer medications, and recommended that the ACFI should provide some degree of funding to providers for assessments, and for residents who do require assistance in taking medications.
The Aged Care Taskforce suggested 'industry, individual organisations, employees and their representatives collaborate to foster a community dialogue on how to secure the funding needed to provide aged care services'.
Dementia Australia discussed funding arrangements in the context of whether aged care funding arrangements established market-based competition that can drive quality improvements through consumer choice. Dementia Australia told the committee that minimal regulation only works well to underpin individualised care when coupled with a true consumer driven market, because the market competitiveness is what drives competition and consumer choice.
Dementia Australia told the committee that 'the aged care market is not market driven, nor are the mechanisms of transparency and comparability here for consumers to vote with their feet'. Dementia Australia further recommended that should Australia's aged care system move to a co-contribution system, then there should be 'the appropriate level of transparency and tools to be able to make informed decisions about where they want to go and where they want to put their dollar'.
Funding is not an issue that is explicitly covered by the Terms of Reference for this inquiry, but the committee acknowledges it is a fundamental driver of the quality of care in aged care services. Without adequate funding, there can be no adequate levels of staff, which leads to an inability to deliver quality services.
The committee is of the view that the quality of clinical and medical care in aged care services is not of a consistent standard that any reasonable person would accept. The committee is further of the view that issues of funding and the overall viability of the aged care sector are inextricably linked to the quality standards of aged care.