Redressing quality and safety in aged care

Mandating improved patient-to-staff ratios is only one step required to improve quality and safety for our aged in Australia. Recognising and addressing the issues in our existing model is the next.

Ensuring that personal and clinical care delivered to older persons living in aged-care institutions is high quality, safe and effective is a widely accepted community and societal norm and expectation.

Care for our older citizens has traditionally been delivered in ‘nursing homes’ and, in many settings, this has continued. In recent years there has been a reframing of this towards residential and aged-care facilities (RACFs). The care delivered in nursing homes and RACFs is affected by a range of factors, such as regulations, funding and expertise of the workforce. The enactment of the Aged Care Act 1997 signalled the creation of a new model of aged care through the amalgamation of hostels and nursing homes into RACFs. This transformation moved the funding model of nursing homes from ‘health care’ to ‘social care’, and removed the regulatory and legislative requirement for care to be delivered by qualified registered nurses, with mandatory 24-hour cover in nursing homes.¹

New model creates new issues

The new model resulted in significant changes to the profile of people entering a residential care facility. Individuals who had previously entered low-level care, such as a hostel, now remained in the community. When they eventually entered residential care they were older, with an increased acuity due to complex medical and mental health conditions. The proportion of people in residential aged care with complex health care needs has quadrupled from 13% in 2009 to 61% in 2016, with a drop to 55% in 2017 (reflecting a change to the method of rating).²

By June 2017, people diagnosed with at least one behavioural or mental health condition made up the majority of residents (85%), with half diagnosed with depression (47%) or dementia (52%). Mental health conditions render residents particularly vulnerable, needing specialised support. A recent study found of 141 resident deaths from suicide reported to the coroner, over half (66%) of residents had been diagnosed with depression, and a major life stress, such as deteriorating health, was reported in 80% of residents.

However, researchers were unable to determine if the residents had entered care with depression or whether they had been diagnosed with it subsequently.³ The limited access of residents to skilled allied health, nursing and medical health care professionals means that many of their complex clinical needs, such as wound care and pain relief, and mental health needs, are often unmet.⁴

Response to sustained failure 

Residential care patients with mental illness have been subjected to sustained physical and chemical abuse, and neglect. A landmark case is the South Australian government-run Oakden Older Persons Mental Health facility, closed in September 2017 after an investigation and Senate inquiry unearthed 10 years of neglect of elderly patients with dementia.⁵

Subsequently, increased auditing led to the Commonwealth closing one aged-care service per month.⁶ The legislative and regulatory oversight for care delivered in residential care facilities has comprised the Commonwealth’s Accreditation Standards, with 44 expected outcomes.⁷ These standards have been supplemented by a National Quality Indicator Program (QI Program) that commenced on 1 January 2016.⁸ However, system failures have permitted accreditation of organisations that had been delivering substandard care, such as the Oakden facility.⁵ National accreditation standards have been subject to gaming by substandard service providers and were limited by focusing on provider processes. The QI Program, while an attempt to highlight the consumers’ experience and their quality of life, is limited by voluntary participation of facilities.

In response to these issues, a new single set of standards — the Aged Care Quality Standards — has been developed and, subject to parliamentary processes, from 1 July 2019 will replace the existing Accreditation Standards. These new Standards will apply to all aged-care services, including residential care, home care, flexible care and services under the Commonwealth Home Support Program.⁹ Concurrently, a new Aged Care Quality and Safety Commission will be established, with $106 million to support better facilities, care and standards in aged care.⁶ The Aged Care Quality Standards focus on quality outcomes for consumers rather than provider processes.

Royal commission

Furthermore, in 2018 — seven months after release of the South Australian Independent Commission Against Corruption’s report into Oakden, and after more than 5000 submissions from aged-care consumers, families, carers, aged-care workers, health professionals and providers in the aged-care sector — the government has established the Royal Commission into Aged Care Quality and Safety. ⁶ The Commission’s Terms of Reference were announced in October and include inquiry into the following matters:

1. “the quality of aged care services provided to Australians, the extent to which those services meet the needs of the people accessing them, the extent of substandard care being provided, including mistreatment and all forms of abuse, the causes of any systemic failures, and any actions that should be taken in response;
2. how best to deliver aged care services to:
   1. people with disabilities residing in aged care facilities, including younger people; and
   2. the increasing number of Australians living with dementia,
3. the future challenges and opportunities for delivering accessible, affordable and high quality aged care services,
4. what the Australian Government, aged care industry, Australian families and the wider community can do to strengthen the system of aged care services to ensure that the services provided are of high quality and safe;
5. how to ensure that aged care services are person‑centred, including through allowing people to exercise greater choice, control and independence in relation to their care, and improving engagement with families and carers on care‑related matters;
6. how best to deliver aged care services in a sustainable way;…” ¹⁰

This is the latest in a series of 20 reviews into aged care in 20 years.¹¹ The challenges of the quality and safety of aged care are well-documented. This is perhaps best captured by recent salient remarks by the Australian College of Nursing Chief Executive Officer Adjunct Professor Kylie Ward, who indicates that Australia’s 360,000 aged-care workers are primarily unskilled workers, comprising 75% of the aged-care workforce.¹² The quality and safety of care delivered to older citizens in RACFs will never improve while the workforce is unskilled and lacks professionalisation, and the 2018 Royal Commission into Aged Care Quality represents the opportunity to address this.

Mandating nurse-to-patient ratios, as now occurs in acute care settings, is a critical step in the pursuit of high-quality and safe care of older citizens, and just one of the measures available to the Commissioners of Inquiry. The professionalisation and appropriate resourcing of this sector, together with the (re)recognition of the care provided in RACF as health care, is fundamental to future quality and safety of aged-care services in Australia.

*Professor Ramon Shaban is Clinical Chair and Professor of Infection Prevention and Control at the University of Sydney and Western Sydney Local Health District, within the Susan Wakil School of Nursing and Midwifery and the Marie Bashir Institute for Infectious Diseases and Biosecurity.

^Julie Potter is a Senior Research Officer at the University of Sydney and Western Sydney Local Health District, within the Susan Wakil School of Nursing and Midwifery and the Marie Bashir Institute for Infectious Diseases and Biosecurity.

References

1. Angus J, Nay R. The paradox of the Aged Care Act 1997: the marginalisation of nursing discourse. Nursing Inquiry 2003; 10(2): 130-8.
2. Australian Institute of Health and Welfare. GEN fact sheet 2016-17: People's care needs in aged care. 2018. https://www.gen-agedcaredata.gov.au/www_aihwgen/media/2017-Factsheets/People-s_care_needs_in_aged_care_factsheet_2016%E2%80%9317.pdf (accessed 17 October 2018).
3. Murphy BJ, Bugeja LC, Pilgrim JL, Ibrahim JE. Suicide among nursing home residents in Australia: A national population-based retrospective analysis of medico-legal death investigation information. International Journal of Geriatric Psychiatry 2018; 33(5): 786-96.
4. Phillips J, Currow D, Parker D, Ries N. Australia’s aged care residents are very sick, yet the government doesn’t prioritise medical care. The Conversation. 20 December 2017.
5. Lander B. Oakden: A Shameful Chapter in South Australia’s History. Adelaide, South Australia: Independent Commissioner Against Corruption (ICAC). South Australia; 2018. p. 312.
6. Prime Minister, Minister for Health, Minister for Senior Australians and Aged Care. Media Release: Royal Commission into Aged Care Quality and Safety. In: Health and Social Services, editor. Canberra, Australia: Licensed from the Commonwealth of Australia under a Creative Commons Attribution 4.0 International Licence; 2018.
7. Department of Health: Ageing and Aged Care. Current standards. 09 July 2018 2018. https://agedcare.health.gov.au/quality/current-standards2018.
8. Department of Health: Ageing and Aged Care. Quality indicators. 08 August 2016 2016. https://agedcare.health.gov.au/ensuring-quality/quality-indicators-for-aged-care (accessed 15 October 2018).
9. Department of Health: Ageing and Aged Care. Single set of quality standards - the Aged Care Quality Standards. 10 July 2018 2018. https://agedcare.health.gov.au/quality/single-set-of-aged-care-quality-standards (accessed 17 October 2018).
10. Royal Commission into Aged Care Quality and Safety. Terms of Reference. 2018. https://agedcare.royalcommission.gov.au/Pages/Terms-of-reference.aspx (accessed 17 October 2018).
11. Phillips J, Parker D, Woods M. We've had 20 aged care reviews in 20 years-will the royal commission be any different? The Conversation. 20 September 2018.
12. Ward K. Australian College of Nursing eNewsletter 26 October 2018. Canberra, Australia: Australian College of Nursing; 2018.

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