Steve Mcfarlan, Director of Aged Psychiatry, Caulfield Hospital (Alfred Health) & Associate Professor of Psychiatry at Monash University, talks about fixing an aged care system that is ‘broken’.
Last week, Alzheimer’s Australia released a report that was highly critical of the way Australia’s aged care sector responds to the needs of dementia suffers and their families.
It’s an issue that demands urgent government attention, with the number of Australians with dementia projected to triple by 2050. In order to meet the projected demand for residential aged care places, Alzheimer’s Australia predicts we will need to add 500 to 1,000 new nursing home beds each month for the next 40 years.
So, how do we begin fixing an aged care system that is so broken?
Successive Commonwealth governments have responded to the ongoing rise in demand for care by placing a greater emphasis on care at home, through Community Aged Care Packages (CACPs packages) and, for those with dementia, Extended Aged Care at Home – Dementia (EACH-D packages). Unfortunately, demand is exceeding supply and waiting lists currently exceed 12 months.
In theory, a package can provide several hours of external support each week, which is tailored to the needs of a person with dementia. In practice, up to half of the funding for such packages is absorbed by “administration costs”. And the packages themselves often fail to meet the specific needs of dementia sufferers.
A key problem is the lack of continuity of care that comes from having a range of different and new carers. From the perspective of a dementia sufferer who has short-term memory impairment and fears change, this can be harmful. I’ve cared for a number of people whose experience of home care packages have led them to cancel the service and struggle on alone.
Those employed by care package providers often lack specific training or skills in dealing with dementia. This clearly needs to change, but will come with significant training costs.
Package providers also need to prioritise continuity of care to individual clients when apportioning duties to their care managers.
More than half of Australian nursing home residents have been diagnosed with dementia, though many more may be undiagnosed. They’re also likely to have other medical and cognitive problems, making them an incredibly complex population to care for.
So it’s worrying that you can attain a qualification to work as a Personal Care Assistant (PCA) in a nursing home by completing just ten hours a week of training, over 12 months. The “dementia competency” component of the course can be satisfied by attending only three six-hour modules.
The vast majority of care in nursing homes is provided by PCAs, rather than registered nurses (RNs), who are much more highly trained (and more expensive to employ).
The Aged Care Act makes no reference to a mandated staff mix within facilities, only that “approved providers are required to maintain an adequate number of appropriately skilled staff to ensure that the care needs of all care recipients are met.”
But solving this problem isn’t as easy as hiring more RNs, who are in short supply. There remain massive disincentives for RNs to pursue careers in aged care, most notably with wage disparity. Public sector nurses doing similar work earn, on average, $168 to $390 more per week than aged care nurses.
RNs working in aged care also face inadequate staffing, excessive workloads, declining standards of care, and requirements for excessive documentation, which makes recruitment and retention difficult. The annual turnover of nursing staff in some facilities can be as high as 90%.
Better remuneration for staff is vital in order to attract, train and retain sufficient numbers of skilled, committed and caring staff to work within nursing homes.
GPs who visit aged care facilities to provide care also face financial disincentives. There are no specific items in the Medicare Benefits Schedule (MBS) to compensate doctors for nursing home visits. Consequently, many GPs choose not to provide this service.
A simple but effective solution is to provide financial incentives for GP nursing home visits that reflect not only travel time, but also the case complexity and extra consultation time that this requires.
We also need to improve doctors’ understanding of dementia management – and this should begin in medical school. In my own institution’s five-year medical course, students spend only four days in a geriatric psychiatry attachment.
Funding for patients with dementia
The current aged care funding model for nursing homes discriminates against those with dementia. Funding is based on each residents’ Aged Care Funding Instrument (ACFI) assessment, which is undertaken when they arrive at the facility. It’s then translated into their ACFI score, on which government payments will be based.
A “behaviour loading” will result in more funding. But “physical behaviours” that might require two or three extra staff members to assist (such as aggression, resistiveness, spitting, kicking, scratching), receive the same weighting as other, less onerous conditions. As a result, facilities can be reluctant to accept residents with high-level behavioural needs.
The Aged Care Funding Instrument should be revised to attract a higher level of subsidy for dementia sufferers with problem behaviours.
Road to reform needs to consider dementia
It’s true, there are political disincentives to address the parlous state of affairs in dementia care: the costs will be high and the payoff won’t occur for may years.
Perhaps that’s why the Productivity Commission’s 2011 report on aged care services makes scant reference to dementia. It advocates for greater choice and consumer empowerment, but so far this hasn’t extended to patients with dementia.
The Commonwealth government can no longer ignore the growing care needs of people with dementia. This year’s budget must set the foundations to develop a strong, well-trained (and better paid) workforce to care for our ageing population.
Image courtesy: We need to rethink our aged care workforce and funding for dementia patients. Alex E Proimos