Why is it so hard to organise healthcare for older people in residential aged care facilities in Australia?

Abstract

In the 2020 pandemic of COVID-19, outbreaks occurred in a number of Australian residential aged care facilities (RACF), principally in Victoria. Morbidity and mortality in RACF were significant and at the time of writing 685 of the total 908 deaths due to COVID-19 in Australia occurred in these facilities. Outbreaks in RACF were characterised by confusion of roles, poor quality care and acute workforce deficiencies and resulted in tragic consequences for older people. No level of government nor the providers (owners) of RACF were prepared to accept the responsibility for the outcomes of these outbreaks. It is this lack of accountability for healthcare in residential care that is the major cause of the ongoing crises within RACF. Despite the lack of good quality data concerning the health status of older people in RACF, it appears that these individuals are the sickest and frailest part of the Australian population. There were 213 397 people in RACF on 30 June 2019. Less than 1% of residents did not require assistance in their activities of daily living and 60% were judged to have complex healthcare needs. Over time, the complexity of their healthcare needs seems to have increased, but unfortunately, comprehensive surveys of residents for all health conditions using robust methods are lacking. The Aged Care Funding Instrument, used to determine the level of Commonwealth subsidies for individual residents, relies on recorded diagnoses and may lack validity in determining health conditions. For example, in one survey of 17 RACF, 83% of residents were assessed as having likely cognitive impairment but only 65% had a diagnosis of dementia recorded in their medical records. The provision of good quality healthcare for this vulnerable group with manifest health needs should be a priority. The lack of quality data to determine needs is one problem, but what else has hindered a coordinated response? First, RACF are not healthcare facilities. They are the homes for frail older people, usually providing support and care until death. Nobody wishes to spend their last years living in a hospital ward. Providers have been urged by government, older people and their families to make the environment as home-like as possible. This may explain some of the difficulties with aspects of healthcare such as infection control, but it does not excuse the lack of a coordinated healthcare response. The basis for this inaction lies in the dysfunctional arrangements for funding and ongoing responsibility for healthcare for older people in RACF. The Commonwealth Government is responsible for subsidising personal care and setting standards for RACF. The responsibility for provision of healthcare is less transparent. The Commonwealth Government is responsible for the Medicare system that oversees payments to general practitioners who provide some of the primary care to RACF. The availability of registered nurses, employed by the providers, helps supplement this primary care. The delineation of the roles of these two groups of professionals is unclear with great variability in their coordination and scope of practice. There is a clear need for organisation of healthcare services at the facility level; unfortunately this is often substandard. These healthcare services require considerable allied health inputs, sadly not available in most RACF largely as a result of current funding models. The provision of specialist services is even less coordinated. The Stateorganised healthcare services are responsible for emergency specialist care but non-urgent specialist care, with their associated allied health requirements, generally falls back to the individual resident and their families to organise and fund. The diffuse nature of this accountability over multiple layers of government has been apparent and received criticism for two decades. In this issue of the Internal Medicine Journal, Brownstein and colleagues examine some of the characteristics of healthcare provision at the interface of RACF and State-run healthcare facilities. They examined the course of 149 older frail people who were transferred to hospitals and died there within 24 h. In general, most of the residents presented with an acute and distressing change in their condition and the transfer to acute care was mostly in keeping with their advance care plans, if available. Expert assessment and treatment at the RACF may have prevented some of these transfers, but the vast majority of the transfers to hospital seemed to be appropriate under the circumstances, in concordance with previous research on hospital transfers some years ago. This disjointed healthcare response has historically resulted in major adverse healthcare outcomes that in the hospital system would be treated as sentinel events. Under increasing pressure from the widespread publicity of these adverse events, the Commonwealth L. Flicker is the holder of a MRFF Next Generation Clinical Researchers Practitioner Fellowship 1155669.