VCOSS welcomes the opportunity to provide input to the House of Representatives Committee on Health, Aged Care and Sport inquiry into Quality of care in residential aged care in Australia.

VCOSS is the peak body for social and community services in Victoria. Aged care is an area of significant interest and relevance to our membership; not-for-profit services delivered two-thirds of aged care services in 2015-16.[1] With almost a quarter of a million people using Australia’s government-funded aged care services every day, a strong aged care system is important to Australia’s future.

Older Australians deserve a residential aged care system where they are treated with dignity and respect, where their care needs are met, and where they can maintain their autonomy, capacity and wellness as much as possible. The system will need to adapt to meet the changing needs of its resident population. For example, people in residential aged care are getting older, frailer and more likely to be experiencing dementia than in the past. More than half of the residential aged care population now live with dementia.[2]

VCOSS supports an aged care system that helps people live a good life and where they can maintain a sense of control over their life, contributing to overall wellbeing. The current aged care system is beginning to reorient itself towards greater choice and control for residents, through the adoption of person-centred policies and giving older people more control to pick and choose their services, especially “in home” care.

However, this submission draws on VCOSS’ members first hand experiences assisting and supporting older people, their families and carers in the aged care system. Many members reported that older people in residential aged care continue to lack autonomy and control over their lives. Provider policies can act to stifle choice and fail to promote wellness. Staff shortages and poor training can lead to neglect and a failure to provide basic care to older people.

A robust quality framework should be developed to provide strong protections to help prevent harm to people, and ideally to promote high quality service delivery. It should reflect the experiences of residents, by involving them in quality processes.

Recommmmendations

Use better residential aged care models

• Improve data collection, analysis and reporting about the nature of incidents in residential aged care
• Undertake a broader inquiry into alternative models of aged care that support older people’s autonomy and capacity
• Revise the residential aged care funding model to improve equity, support consumer choice, and maximise wellness

Strengthen regulatory frameworks

• Establish a serious incident response scheme requiring providers to report incidents of assault or neglect, the incident investigation outcome and any resulting actions
• Consider strategies to involve residents in accreditation and quality improvement processes, including increasing minimum participation requirements, and better information sharing with residents and families
• Explore alternative methods for seeking feedback from people with dementia or who need other communication mechanisms
• Implement the recommendation of the Australian Law Reform Commission that aged care legislation should regulate the use of restrictive practices in residential aged care
• Appoint a Senior Practitioner to provide leadership, expertise and accountability in the use of restrictive practices in residential aged care.

Help residents exercise choice and enforce their rights

• Publish objective ratings, against national standards, for all residential aged care providers to help people make informed choices
• Incorporate a ‘Trip Advisor’ style review function within the My Aged Care website
• Increase funding for independent advocacy services for older people to provide equal access, including those from rural and regional areas
• Foster an environment where families, friends and community are welcomed into residential aged care facilities

Build a skilled and high quality workforce

• Ensure providers support all residents to undertake advance care planning and appoint a substitute decision-maker
• Introduce staff-to-resident ratios to improve the quality of care provided to older people
• Investigate options for registration of personal care workers

Use better residential aged care models

Understand mistreatment in residential aged care

Recommendation

• Improve data collection, analysis and reporting about the nature of incidents in residential aged care

Several recent reviews have highlighted the abuse and mistreatment of older people in residential aged care facilities across Australia. The Australian Law Reform Commission (ALRC) inquiry into elder abuse heard many instances of abuse by paid care workers and residents, as well as by family members. They included institutional abuse where the “routines, systems and regimes of an institution result in poor or inadequate standards of care… and denies, restricts or curtails the dignity, privacy, choice, independence or fulfilment of individuals.”[3]

VCOSS members also reported many instances of this kind of mistreatment, abuse and neglect in residential aged care. They emphasised the importance of focusing on the spectrum of mistreatment, from indignities (for example the use of infantilising language, referring to residents as ‘naughty girls’) through to serious incidents of assault and deaths. Restrictive practices also remain common, including use of medication as a restraint or behaviour management strategy, especially for people with dementia.

Management policies and culture that focus heavily on avoiding risk can also lead to a loss of choice and autonomy for residents. VCOSS members provided examples of residents being prevented from walking around the facility by themselves or forced to use a walking aid, despite there being no physical or medical need for one.

The extent of mistreatment in residential aged care in Australia is unknown. The available data is likely to be a substantial underestimate. Data from the Aged Care Complaints Commissioner only reflects complaints that are reported, and is only available for broad thematic areas, such as “clinical care”, or “choice and dignity”. No information is available about the number of complaints about particular providers, or how those complaints were resolved.

Organisations like Senior Rights Victoria also collect information about the phone calls they receive to their elder abuse phone line. However, VCOSS members noted that they do not retain information when calls are made anonymously, so again, this data source is likely to be a significant underrepresentation.

Review the model of care

Recommendation

• Undertake a broader inquiry into alternative models of aged care that support older people’s autonomy and capacity

Residential aged care is often the option of last resort for people, who would prefer to remain in their homes. VCOSS members report residents often only enter aged care because they fear becoming a burden to family or carers. At the same time, they fear losing their identity and autonomy.

VCOSS members report the existing model of care is flawed, realising many of the fears expressed by older people. It often fails to provide older people with choice and does little to encourage them to live as full a life as possible.

Australia should undertake a broader investigation into the aged care model, looking at alternative models that could better support older people’s autonomy and capacity.

For example, to address the lack of choice residents can experience in the ‘traditional’ aged care system, some providers are moving to ‘household models,’ where smaller groups of 15-20 residents share their own kitchen and living areas. Residents are in control of their own routines, can help themselves to food at any time rather than waiting for set mealtimes, and work with staff to fill social and leisure time, rather than waiting for pre-planned activities.[4] However, VCOSS members report that adoption of these models are not universal across providers.

A range of other more innovative models are also being explored in Australia and overseas. For example, the Homeshare program based in Melbourne matches older people living in their own home with people willing to provide some care and household maintenance in return for accommodation. A program in the Netherlands has gone further, trialing intergenerational living by offering free accommodation to students within an aged care facility, in return for 30 hours of socialising with the older residents each month.

Other countries are also trialing intergenerational learning, which includes placement of childcare centres within aged care centres.[5] Closer to home, Playgroups Victoria has run playgroups at aged care facilities. Workers report people with dementia become more lucid and engaged chatting with toddlers, and children can learn a lot from engaging with older people. Intergenerational activities show older people that they are valued as individuals that still possess lifelong skills, rather than just being passive recipients of care.

Change the funding model

Recommendation

• Revise the residential aged care funding model to improve equity, support consumer choice, and maximise wellness

VCOSS members reported that the current residential aged care funding model disadvantages some vulnerable older people and risks pushing them into poverty. In particular, the system offers significant incentives for up-front payment, disadvantaging families and older people with low-incomes and without the means to meet high up-front costs.

The funding model can also result in perverse incentives. Necessarily, people requiring higher levels of care receive higher levels of payment. However, there is no incentive to providers to increase people’s strength, confidence and physical condition. In this respect, aged care providers are rewarded when the health and wellbeing of their residents deteriorates, undermining efforts to build a culture that maximises the wellness of residents.

A 2017 review of the residential aged care funding model found it is no longer fit for purpose.[6] The review stated the profile of aged care facilities has changed in the decade since the existing funding instrument was introduced, and it no longer adequately reflects the care needs of residents.

A revised funding model should be based on principles of equity, supporting consumer choice and maximising wellness. The model should also be flexible (enabling people to move more easily between different types of care) and support the specific needs of population groups, including rural and regional communities, Aboriginal and Torres Strait Islander people and people with culturally and linguistically diverse backgrounds.

[1] Department of Health, 2015-16 Report on the operation of the Aged Care Act 1997, 2016.

[2] Dementia Australia, Key facts and statistics, updated January 2018, https://www.dementia.org.au/statistics

[3] ALRC, Elder Abuse – A National Legal Response, pp 110.

[4] Residents feel ‘at home’ with new care approach, https://www.agedcareguide.com.au/talking-aged-care/residents-feel-at-home-with-new-care-approach,

[5] The Conversation, ‘Combining daycare for children and elderly people benefits all generations,’ January 5 2017 https://theconversation.com/combining-daycare-for-children-and-elderly-people-benefits-all-generations-70724

[6] McNamee J, Poulos C, Seraji H et al. Alternative Aged Care Assessment, Classification System and Funding Models Final Report. Australian Health Services Research Institute, University of Wollongong, 2017.