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14 Aug 2017

The AMA has submitted its views on the Federal Government’s regulatory activities applying to quality of care in aged care residential facilities.

The Oakden report shed light on a wide range of issues facing aged care. AMA members have reported that the occurrences at the Oakden Older Mental Health Service were not isolated incidents – indicating a problem with the current aged care system.

The proportion of Australians 65 years of age and over is predicted to increase to 18 per cent by 2026. It is also predicted that 900,000 Australians will have dementia by 2050, almost triple the 342,800 recorded in 2015.

It is evident that the health care needs of residents in residential aged care facilities (RACFs) are increasing in complexity.

The majority of Aged Care Funding Instrument (ACFI) assessments indicate a “high” need of care across all three assessment categories (activities of daily living, behaviour, and complex health care). The Government must ensure the sector has the capacity to provide quality care for this growing, more complex, ageing population.

The issues at Oakden were brought to the attention of the Northern Adelaide Local Health Network when a client was admitted to an Emergency Department with significant bruising to his hip. A person’s health status is a significant identifier for the quality of an aged care facility or home service. When serious health issues arise, aged care issues are commonly noticed.

Medical practitioners – whether at the Emergency Department, or consulting patients at an aged care facility – may have a unique opportunity to identify issues with the quality of an aged care home or signs of elder abuse.

Medical practitioners are also the second highest profession Australians trust and should be considered part of the aged care workforce to increase quality of care.

Many points made in the submission have been previously made by the AMA, and they are not newly arising issues in the aged care sector. The AMA has been advocating for some time to ensure medical and nursing care for older Australians, including lodging submissions to the multiple aged care reviews that have occurred recently.

In this submission, the AMA argues that:

  • Medical practitioners should be included as part of the aged care workforce to ensure residents of aged care facilities are receiving quality care;
  • Aged care needs funding for the recruitment and retention of registered nursing staff and carers, specifically trained in dealing with the issues that older people face;
  • The aged care sector needs a contemporary system that embraces information technology infrastructure for patient management;
  • A contemporary IT system for medication management will reduce the risk of polypharmacy, and in turn reduce the likelihood of cognitive impairment, delirium, frailty, falls, and mortality in RACFs;
  • There needs to be clear, specific, and confidential complaints referral pathways in each RACF so information on complaints processes are easily accessible to both residents and staff;
  • There needs to be increased awareness of mental health issues to include funding for appropriate mental health services in the ACFI assessment process; and
  • The aged care system needs an overarching, independent, Aged Care Commissioner who provides a clear, well-communicated, governance hierarchy that brings leadership and accountability to the aged care system.

Many of these issues need to be reflected in specific accreditation standards that have a strong focus on health. In particular, an “access to medical care” standard should be introduced. To receive funding from the Federal Government, an aged care facility must pass accreditation standards that are assessed by the Australian Aged Care Quality Agency.

The AMA recognises that these standards will vary with the introduction of the single set of aged care quality standards, however, there are several required improvements that should be included in the new standards.

For some standards a flexible approach is adequate, as different services have different capabilities and capacities. However, this may lead to inconsistencies between each assessor, or the assessment process not picking up on vital signs of incompetence.

Standards that relate to medical care should not be subject to interpretation to ensure quality care is received. RACFs must be aware of their specific responsibilities.

Residents should have access to, and their medical needs met by, qualified medical practitioners. Rather than vague standards that say RACFs should ensure compliance with all relevant legislation, a medical care standard should reflect aspects of the National Safety and Quality Health Service Standard.

People living in aged care facilities should have access to the same quality health services as other Australians. The AMA has been advised that currently, RACFs (with the exception of facilities that provide acute services) do not have to comply with these standards.

The current policy settings do not support GPs working after hours, neither does it acknowledge the benefits of continuity of care. AMA members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s management plan is not well known. This creates an environment where the default step for RACF staff may be to refer the patient to an ED.

One concept worth considering is an MBS item for phone consultations with a nurse or carer from an RACF to incentivise doctors to be on call after hours. This could in turn increase the number of doctors who make themselves available out of normal business hours and reduce costs in comparison to reimbursing a GP physically-attended consultation. In addition, the care of patients’ regular GP would avoid unnecessary referrals to the ED and the associated triage issues.

AMA members have reported cases where registered nurses are being replaced by junior personal care attendants, and some RACFs do not have any nurses staffed after hours. This presents significant communication difficulties.

A recent survey identified low staffing levels in residential aged care as the main cause of missed care. The Government must ensure that aged care facilities are not restricted due to a workforce shortage. The decline in the proportion of nurses and enrolled nurses needs to be reversed to ensure residents are provided with timely and appropriate clinical care. This is critical to the success of the aged care system.

While the Government’s complaints process is seeing improvements, there also needs to be a focus on the RACF’s internal complaints process. The culture in many RACFs discourages making complaints, and this was especially seen at Oakden – where staff complaints were answered with bullying and harassment from management. The Government needs to ensure that the privacy and confidentiality of both aged care staff and consumers are protected when making a complaint.

Aged care staff should be properly trained on the ethical, medical and legal issues that can arise from using a restraint, and also educated on ways to improve the aged care environment through ensuring a friendly physical space, and through social and staffing structures.

In order for the aged care system to evolve, we must also consider that, like the broader health system, aged care impacts upon State, Territory, and Federal Governments. However, there is a lack of coordination between the levels of jurisdiction. Aged care is the purview of the Commonwealth but when a health complication arises, residents are often transferred to a hospital which is the responsibility of the State or Territory Government. This means that the States often bear a financial cost resulting from issues that arise in a Commonwealth-run aged care environment.

The Australian aged care system is heavily regulated and, with reform underway, regulation may increase over time. Without adequate financial support, guidance, and accountability from the Government, RACFs and other aged care services will continue to struggle to meet these complex regulations.

CHRIS JOHNSON

The full submission can be viewed at: https://ama.com.au/submission/ama-submission-review-commonwealth-government%E2%80%99s-regulatory-activities-applying-quality

 


Published: 14 Aug 2017