Ageism at heart of aged care policy stagnation

“SIGNIFICANT ageism” is at the heart of Australia’s lack of policy direction on the provision of aged care services in Australia, says a leading geriatrician.

“[Older] people are not valued by society,” Associate Professor Craig Whitehead, Regional Clinical Director for Rehabilitation, Aged and Palliative Care at the Southern Adelaide Health Service, told MJA InSight in a podcast this week. “That partly drives why [aged care] is not on policy agendas, why universities don’t talk about it, why [professional groups don’t] necessarily advocate for specialist general practice.

“As a society, we need to think about why we have ended up with these quality of care issues in residential aged care. We have to start recognising that these older people have intrinsic significant value and that value has to be recognised and acted on.”

Professor Whitehead’s comments came as the MJA published findings that older people living in home-like residential aged care facilities reported a better quality of life and fewer hospitalisations than people living in standard, institutionalised care, which dominates Australia’s aged care sector.

The retrospective, cross-sectional analysis reviewed 17 Australian residential aged care facilities (RACFs) in four states. Four facilities provided clustered, domestic models of aged care, and 13 facilities provided standard models of care. All residents in the domestic care facilities had been diagnosed with dementia, whereas 79% of the residents in the standard care had had a dementia diagnosis.

The researchers defined clustered domestic models of care as meeting at least five of the following criteria: small living units with 15 or fewer residents, independently accessible outdoor areas, allocation of care staff to specific living units, meals cooked in units, self-service of meals by residents, and residents’ participation in meal preparation.

Facilities not meeting these criteria were defined as standard models of care.

The researchers found that, after adjusting for patient- and facility-level factors, older people residing in smaller, clustered care reported a better quality of life (adjusted mean EuroQol EQ-5D-5L score difference, 0.107; 95% CI, 0.028–0.186). These residents also had fewer hospitalisations (adjusted rate ratio, 0.32; 95% CI, 0.13–0.79), and fewer emergency department presentations (adjusted rate ratio, 0.27; 95% CI, 0.14–0.53).

Adjusted costs were also lower in the clustered domestic model, the researchers reported, with savings of almost $13 000 per resident. The authors noted, however, that the cross-sectional nature of the study meant that conclusions about the causality of the associations reported could not be drawn.

Speaking in the MJA InSight podcast, lead researcher Professor Maria Crotty said that the research did not consider capital costs and was a snapshot in time, but it did indicate that there was room for innovation in the aged care sector.

“The [Australian] government is spending about $11.5 billion a year on residential aged care, and our feeling is that there is some strength to these models,” she said.

In an accompanying editorial, Professor Joseph Ibrahim, Head of the Health, Law and Ageing Research Unit at Monash University, welcomed the innovative investigation, but wrote that the findings may not apply across Australia’s diverse aged population.

“RACFs must serve the needs and wants of their residents, and this encompasses enabling those who want to go skydiving to do so, as well as providing optimal quality care for people nearing the ends of their lives,” he wrote. “We need approaches that are more proactive in satisfying the individual needs of a diverse range of residents, and must be uncompromising in guaranteeing optimal care and eradicating abuse of this highly vulnerable population.”

Professor Julie Byles, Global Innovation Chair in Responsive Transitions in Health and Ageing at the University of Newcastle, said that it was important to note that all residents in the clustered domestic model had dementia, because about 80% of people with dementia would eventually reside in an RACF.

“[The clustered domestic models of care] are more home-like environments, where it’s like living with a family. The researchers talk here about having access to the outside, sitting down to prepare and eat meals – this is such a normal, naturalised behaviour.”

But in standard, institutionalised care, Professor Byles said, residents were required to learn a new behaviour at a time where it’s “really difficult and probably disturbing”.

Professor Byles said that staff in the smaller care model would also have the opportunity to observe residents more closely and detect changes in their health earlier.

“If you know people better, you are more likely to pick up changes in their health early and before they get to some sort of critical point where they may need transfer to a hospital or ED,” she said.

Dr Stephen Judd, CEO of aged care provider HammondCare, said that his organisation had been building only smaller, domestic-style facilities since 1995.

“Home is where we feel we belong and is an enabling, and not a disabling, environment,” said Mr Hammond in the MJA InSight podcast. “Too many aged care services have what some of the regulatory researchers call a ‘protective disciplinary culture’”.

Dr Judd said that residents in such models were told that they “can’t do this”, “can’t do that”, “can only eat on someone else’s schedule and it’s all for your own good.”

Such restrictions prevented residents from feeling comfortable and that they belonged, said Dr Judd, who also serves on the Advisory Council of the Australian Aged Care Quality Agency.

Professor Ian Cameron, Chair of Rehabilitation Medicine at the University of Sydney, said that he hoped the MJA findings would encourage increased development of RACFs with clustered domestic models of care.

“The number of older people is going to increase enormously as everyone knows, and the number of older people with dementia is going to increase enormously, so there is going to be a need for ongoing investment in facilities. I hope this influences future planning,” said Professor Cameron, who is also an investigator with the National Health and Medical Research Council Partnership Centre on Dealing with Cognitive and Related Functional Decline in Older People, which supported the MJA study.

Professor Cameron said that clustered domestic care models may help to overcome some of the key hurdles in the provision of effective health care in RACFs.

“The current model is broken,” he said. “Potentially, in a facility of 60 residents, you have 40 GPs providing the medical care. That doesn’t work. There is enormous fragmentation.

“Some of the clustered domestic models give residents a choice of a GP, but also include far fewer numbers of GPs providing care. So, the GP knows the residents better, visits more often and is able to provide more appropriate care.”

Professor Whitehead agreed that there were significant barriers to the provision of primary care services in RACFs.

“We need to design a primary care system … that makes it easy for [GPs] to step in to [RACFs] and do the job properly,” he said.

At present, Professor Whitehead said, GPs lacked access to IT and medical notes, and visiting facilities often came at a cost to their practice.

“There are all sorts of reasons why traditional general practice is struggling to engage with the residents in aged care.”

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