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PRIMARY health care for residents of aged-care facilities is fundamentally broken and an entirely new system tailored to their specific needs is required, say leading experts in geriatric and palliative care.
In a letter published in the MJA, Professor Ian Maddocks, emeritus professor of palliative care at Flinders University in Adelaide and 2013 Senior Australian of the Year, said he wanted to see GPs specialising in residential aged care and basing their practices in residential aged care facilities (RACFs). (1)
Professor Maddocks wrote that on-site GPs would be able to provide “consistent availability and comprehensive care” to residents, improving morale of RACF workers, stimulating support from allied health staff and creating a “community care hub”.
“That will maintain communication between hospital, home and the RACF, ensure continuity of care, and it will do much towards mending many current problems”, he wrote.
Associate Professor Craig Whitehead, president of the Australian and New Zealand Society of Geriatric Medicine, supported the general idea of Professor Maddocks’ “community hub” but told MJA InSight that RACF residents “need a different form of health care”.
“The idea exists [among bureaucrats and politicians] that RACFs are just homes. That is clinical nonsense”, Professor Whitehead said.
“From our point of view [as geriatricians] the quality of primary care — and therefore, via referrals, access to specialist care — in RACFs is poor, and the problems with the structure of primary care for people in RACFs are huge.
“The whole structure does not match the clinical reality of the situation.” He said aged care legislation concentrates on accommodation but not health care even though the two were directly linked.
Dr Liz Marles, Royal Australian College of General Practitioners president, said the College’s view was that it was “always best” for elderly patients to continue to see their regular GP.
“We would not want to see [RACF-based GPs] displace the patient’s regular GP”, Dr Marles told MJA InSight.
“We would regard that as a retrograde step. The family GP knows the patient, and may treat their relatives as well, and can deliver appropriate care to that patient.”
Professor Whitehead said the reality was that when an elderly person entered an RACF they usually geographically moved away from their regular GP, estimating that this affected 50%–60% of RACF residents. “There are huge quality-of-handover issues involved in that dislocation”, he said.
Geography was also the driver of service in aged care, Professor Whitehead said. It was often difficult to take RACP residents to the GP and GPs did not want to leave their surgeries to visit patients in RACFs, in part because there was a financial disincentive to do so.
Professor Whitehead said locum services currently provided most of the after-hours primary care at RACFs, or GPs visited RACFs at the end of their working day.
“From my experience … deaths in RACFs often come about because a stretched GP is [seeing RACF residents] at the end of their day and is not able to deal with the complexity of the patient because the facility is not structured to deal with that complexity”, he said.
“That’s not what we want for patients who have the most complex conditions, the most complex medications, as well as end-of-life issues and ethical complications.
“They need to be getting care from good quality GPs who are happy to be there, rather than being sent to hospital to die.”
In his MJA letter Professor Maddocks wrote that many of the problems that beset RACFs could be alleviated if GPs were prepared to specialise in this area, and if extra training in psychogeriatrics and in palliative care was available. He said the main problems included over-prescription of psychotropic drugs, lack of a comprehensive acute and chronic care for residents, underuse of advance directives, poor family support, inappropriate transfers to acute care, poor on-the-job support for staff and inadequate palliative care.
He suggested a single comprehensive diploma program similar to that offered by the Royal Australasian College of Physicians in palliative medicine would be ideal, with consideration of improved remuneration for RACF consultations.
Professor Whitehead told MJA InSight proper preventive primary care in RACFs would do “an enormous amount to reduce hospitalisations” of residents.
“We’re moving the frail people around and their health care needs are not being met. There needs to be a different form of health care.
“It’s a failure of bureaucrats and politicians. This issue doesn’t get the attention it deserves and in the current political climate I doubt that it will”, Professor Whitehead said.
“You get what you pay for.”
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These professors of geriatrics have some valid points but have not been at the ‘coal- face’ to know what it is like.
Our patients almost always ask us to attend them in ACH even though we may be less available than the regular local GP. Because they are afraid during this transition into the new confines of residential care and need our counselling. But when GPs find difficulty in committing to their patients, or the patient’s cognition fails, we should transfer care to the most available GP , if skilled and their families and ACHs allow us.
The Aged Care Panels assisted GPs in coordinating care with ACHs and Hospitals, and trained GPs and Nurses in Aged Care, Advanced care planning and Palliative care. Now the system is chaotic, incoordinated and inefficient since the cessation of the Panels.
As there is less funding now , there are more inexperienced, unskilled staff callng GPs to attend patients for trivia or paperwork for accreditation, and major clinical problems are often ignored.
The Government needs to listen to the concerns of all those working with residents including the personal care attendants.
Our small rural town has a 40 bed nursing home high care unit with attached low care unit. Our GP practice is the only one in town, each doctor has around 10 residents each and visits the home fortnightly to do whatever needs doing. the place is computerized with both medical director and autumn care for the nurses. As we run a 24 hr on call system there are no “inappropriate” transfers to the emergency department 50kms away. Care is good, although the nurses and carers are stressed by the time and funding pressures placed on them. That and the difficulty getting any specialist opinions are the main problems. According to the federal health department nursing homes are funded to transport residents to the nearest hospital, which they in their wisodm view as the base hospital 50 kms away not our small local hospital. Consequently getting residents to attend specialist appointments is difficult if they don’t have relatives to transport them. The ambulance and hospital transport won’t take them as they are in a federal facility. From our doctors’ pespective we are quite happy with the care arrangements at the home. If groups of doctors and nursing homes in the larger centres got their act together and organized themselves better they could do the same, but if if they all want to keep seeing one resident in 10 diferent homes because they are the family doctor, rather than 10 residents in the one home, then the present mess in the larger cities will continue
I became an Aged Care Nurse Practioner because of all the issues mentioned. I have been working full time at a high care RACF for the past 5 years providing rapid access to needed health care. I am authorised to diagnose, prescribe & order tests for all the acute issues wihich face residents in care. I collaborate with the 15 or so GPs who visit the facility who are all happy to take a quick phone call in an acute situation. In this way the resident keeps their own GP which is important & I provide the communication link between the resident, their families & the GP.It’s a great model of care which works well. I also comprehensively review each resident every 3 months & provide that information to the GPs when they visit. In this way their chronic health conditions are reviewed so the best primary health is provided.
I discuss Advance Care Plans with residents on admission so that inappropriate treatment is not given by GPs or locums. The number of avoidable hospital admsisions fell by 89% in my first year of employment & we plan for our residents to die with dignity & peace in the place of their choice which is generally at the facility.
I coordinate all residents’ palliative care & our symptom management is timely & appreciated by families who don’t have to wait until after hours for a GP to visit. Our RACF has a great reputation in our community with GPs often recommending it to their patients because of the superior clinical care given.
Surely it would be more effective for the federal government to financially support NPs in RACFs that to train GPs as suggested by Professor Maddocks? It certaintly works well for our residents.
Many vaild points raised already.
I worked as a medication-review pharmacist in multiple Aged Care facilities for 15 years, and saw a wide spectrum of medical care and in-house systems. I do appreciate the relationship people hold with their ‘long-standing’ GP but also the benefit of a fresh pair of eyes. There is a difference between a doctor being called to see a patient for whom something is clearly ‘wrong’ and a review of a person’s health status (objectively looking for change or disorder), and any discussion of models of care I think needs to clearly recognise the objective of the care episode. The decimation of advanced-level nursing in Aged Care over the years is a tragedy. A model that doesn’t seem to have been mentioned yet is the potential role of aged-care specialist Nurse Practitioners. This is a role that could provide a ‘fresh eyes’ comprehensive review of a person’s health status, a client-centred care plan and specialist advice on (for example) challenging behaviour in dementia, and a degree of governance to ensure that medical and social care needs (as identified with the resident eg AHDs) are being applied. The GP would remain the go-to person for acute/chronic medical care. The NP could provide advanced-level nursing guidance/support to the on-site nursing staff. NPs generally have a close working relationship with geriatricians and an understanding of local referral processes. The need for timely medication-review could be identified by the GP or NP, thus utilising the medication-review process to it’s original intent.
I am a surgeon who regularly visit a nursing home(It so happens one of the clinics I consult in is just next to one)
It is certainly very fulfiling and let one see the patient in a different perspective…eg the patient is no longer 87yo patient referred with a skin cancer for excision – you get to see their past through their photos and treasured posessions. You also have a bit more time to chat with the patients. It gives one too a sense of perspective…and oftern it helps me opt to do more conservative treatment rather than surgery all the time(I know some of my colleagues who do minor plastic surgery may criticize this approach)
You also get to meet the nurses and PCAs doing the wound care after the excisions. You can directly give the instructions rather than via a letter which may not end up being read in a timely manner. You can also tell them to apply the urea cream only to the keratoses etc
It saves a lot of time and effort on the part of the families and nursing home – esp if patient is bed bound! It saves a carer’s time too.
Medical care in RACF is a complex issue. Whilst there is merit in an onsite GP, the quality of this care is only as good as the quality of the doctor. I am a GP and my mother-in-law is a resident in supposedly high quality RACF in another capital city. There is an onsite doctor and residents are strongly encouraged to shift to using that doctor, who is the only doctor in the complex. Unfortunately, over the 4 years that my mother in law has been there, this doctor has consistently made very questionable medical decisions, shown no compassion or interest, won’t initiate any specialist involvement and is busque and avoidant towards family.
An example: The doctor, who was onsite, refused to see my mother in law after she had been found lying on the floor for 24 hours after a fall when she was in the independent living section of the complex. ‘It wasn’t necessary’…Which meant that the diagnosis of her pelvic fracture was delayed by several days. And they refused to send off a urine sample for culture despite the new acute onset of incontinence, delaying the diagnosis of UTI by 2 months until a geriatrician arranged testing. This is geriatrics at its most basic and to fail to deal with these appropriately, when one is the sole doctor in charge, is most alarming.
So, the downside of the onsite doctor is that it can become a small kingdom over which one can rule without appropriate oversight and higher clinical governance. And if you think that is only theoretical, let me remind you that this is a true story unfolding in a ‘good’ capital city based RACF in 2014.
Focussing on the GP fails to appropriately address the other issues that make aged care more complex. I can name a few – inadequate GP payments, insufficient nursing numbers and skills, poorly designed facilities, overemphasis on care plans, charts and other boxes to tick which prevent staff from providing hands on care, lack of technology, no funding for discussions with staff or family away from the residents, removal of telehealth consult rebates for GPs to support specialist consultations, no progress for MBS listing of telehealth consultations from GP rooms to RACFs, unrealistic expectations on the health care system, lack of specialists willing to travel to the facility (why is it only the GP who should do home visits?)…
There is a need to improve care in RACFs but it is a systemic problem. Picking on the GP as the source of poor care is missing the big picture.
All of the players in your article have valid points, some possible partial solutions but avoid the major problem. I provided care single handedly for a 75 bed not for profit nursing home in Launceston 300m from my house for three years. I spent considerable time dealing with meeting the requirements of then DoHA that had very little to do with better patient care and everything to do with protecting the Minister’s backside. PBS prescribing occupied around 3 hours a month on top of rewriting medication charts. The red tape overwhelmed everything.
RACF are the places where a third of men and half the women over 75 die. These institutions are highly regulated, have poor capital support, and lack facilities for appropriate medical care. Patients deteriorate at inconvenient times and families demanded futile actions or unreasonable hospital therapies. Getting any specialist to visit was impossible, there were no advice services for severe behaviour problems and the processes of guardianship were time consuming without remuneration but necessary to do anything to improve the residents comfort and safety.
Blaming GPs for the difficulties and suggesting that a Diploma from the wrong college would help improve care is somewhat of an ivory tower view. RACF medical care is a classic wicked problem. The solutions lie in a realistic expectation from the community, appropriate recognition and support for GPs who do it, better facilities, recognition of the need for highly skilled nursing staff and a more sensible regulatory framework. Given the adversarial nature of the politics of this area, the commercialisation of the RACF industry and familial neglect for some older people, I think we have more hope of seeing pigs fly than reasonable reform.
Another GP’s “should” do more. Very little about the ridiculous financial issues surrounding aged care for which a tradesman would not work. Why dont we have onsite in house specialists within the aged care homes???
Hmmm……
The health system is not equipped to cope with the complexity of aged care, the numbers of aged care residents or the ethics of aged care and advanced health care directives. It is simplistic to think that a GP should be an in house resident medical expert when in my experience finding even a registered Div 1 nurse in these facilities is difficult. We have 3 month trained Certificate in Aged care people trying to do the most enormously complex job with little support. Hospitals do not want an aged care cohort entering its doors with the accompanying complexity of care that cannot be turned around to generate income fast enough. Unless we can do a procedure on it. Our health system or any system is only as strong as its weakest link, and the most vulnerable of our patients will be a the nexus of that weakest link. As yet procedural care on healthy people is the most financially rewarding part of being a Doctor in this age. I’d like to see that well and truly discussed along with the perverse financial incentives that drive our system. Plugging the holes with GP’s (seen as some kind of commodity) is not the answer to a much bigger problem than this might at first seem.
I am running a project on video communication between GPs and residents at RACFs. This is one way to increase accessibility to GP services. We have some practice-based GPs and one GP who is dedicated to providing aged care services and who drives around to several RACFs. In both cases video consultations can be useful. However, we are finding that there are very substantial differences in how the different RACFs are operating, with some having very high staff and management turnover, so it is hard to work with them, either for usual in-person visits, or to introduce a new service by telehealth. It is a little early to say how the project is going to turn out, but I mention this because I think that in trying to solve this problem of service delivery to RACFs it is worthwhile (verging on necessary) to look also at issues inside the RACFs, rather than focusing solely on the availability and capability of the medical workforce.
I work as a pharmacist in aged care undertaking medication reviews. As older people are now able to stay in their own homes for longer with increased availability of community services, those living in aged care usually have higher care needs, chronic medical conditions and multiple comorbidities. In agd care facilties I often see fragmented care with the current system due to multiple prescribers including the GP, specialists, locum doctors and also hospital prescribers (from ED and hospital admissions). Breakdowns in comunication between the prescribers and the facility also occurs. This often leads to polypharmacy and inapporpriate prescribing. If a GP has multiple residents at one facilty they are usually able to visit once a week or more and provide support over the telephone at other times to coordinate the care of each resident. However if a GP only has one resident at a facility often they are unable to schedule regular visits (due to conflicting demands) or need family to bring the resident to the surgery (which can be infrequent). Locums are often used to fill the gap between GP visits. Locums do their best but they are dealing with unfamiliar patients. Compounding these issues care staff are now administering medications from dose administration aids with little understanding of pharmacology. Most facilities have only one division 1 nursing staff on duty to oversee medication administration.
The recent cut to the availability of repeat medication reviews to every 24 months (unless there is a documented clinical need) rather than annually adds to a picture of aged care being “broken”.
An onsite GP would resolve many of these issues. Each GP could cover several facilities across the week.
Reminds me of the old adage he who can does he who can’t teaches and he who can’t teach teachs teachers
Residents die in ACFs because that’s what happens at the end of life not because GPs aren’t trained to delay the inevitable.