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ROYAL COMMISSION: Health care and aged care systems don’t work together

The last hearings for this year of the Royal Commission into Aged Care Quality and Safety, held in Canberra, the Australian Capital Territory (ACT), are focussing on instances of good practice and how that can become systematic in the aged care and health care sectors.

Susan Irvine, Registered Nurse and General Manager of Home Nurse Services, appeared on a panel for the Commission to talk about better practice in aged care. [Source: Aged Care Royal Commission]
Susan Irvine, Registered Nurse and General Manager of Home Nurse Services, appeared on a panel for the Commission to talk about better practice in aged care. [Source: Aged Care Royal Commission]

On the first day of this week’s hearings, a panel of health care and aged care professionals provided their expertise on best practice in health care and aged care.

Sitting on the panel were Dr Troye Wallett, a General Practitioner and Aged Care Consultant for GenWise Healthcare; Dr Paresh Dawda, General Practitioner and Director and Principal of Prestantia Health, and Susan Irvine, a Registered Nurse and General Manager of Home Nurse Services.

Senior Counsel Assisting, Peter Gray QC, started the panel discussion around the current health care system funding for staff.

Mr Gray asks the panel for an ideal funding model while would improve access and quality of primary health care for people in nursing homes.

Mr Dawda suggested a funding program providing a blended remuneration model for supporting the provision of primary health care into residential aged care facilities as a good option for the Australian aged care industry.

“When I look at the complexity of care that’s required within residential aged care, the need for team based care, the need for prevention, the need for comprehensive care, the need for coordination, there’s no doubt in my mind that a blended funding model is the fit for purpose funding model that can help deliver some of those requirements where we need them in aged care,” says Mr Dawda.

Dollar a day funding proposal

Counsel Assisting Gray says the Commission is toying with the idea about whether the Commonwealth should fund a scholarship program to encourage more nurses into the industry.

Ms Irvine says, “We estimate an additional 600 nurse practitioners nationally to support aged medical care in Australia, and certainly a scholarship program would go a long way to supporting that growth of that workforce.”

In her submission to the Commission, she suggested a $1 per day per resident funding stream to be paid through residential aged care facilities to nurse practitioners to help with the retention of nurse practitioners to provide necessary high-level clinical nursing support.

“The dollar a day that [Home Nurse Services] are proposing would supplement the non-billable items that nurse practitioners do within the facility, similar to doctors, we believe,” says Ms Irvine.

“So that goes some way to supporting that upskilling and mentoring that the nurse practitioners do within the facility and we estimate that for every consultation or review that the nurse practitioner is doing with the resident, that it’s anywhere - as a minimum, it’s probably 10 minutes per practitioner that nurse practitioners are communicating and educating the staff in that facility.”

Talking about the importance of multidisciplinary teamwork within aged care, Ms Irvine says, “One of the things that I raise in my statement generally is that over the last 30 years the complexity of care in aged care has significantly increased and most people entering residential aged care in particular with significant comorbidities but a lot of people with dementia and challenging behaviours, mental health and psychoses.

“With the ageing disability sector, we’re getting a lot more complex people with disabilities in general, ageing. And then palliation and end of life management. So I think that that multidisciplinary specialty model is critical to managing the medical care needs of residents in aged care and that advanced clinical practice.”

Dr Dawda added that there needs to be an integration of systems, including record systems, clinical systems and professional systems.

“For a team to work efficiently and effectively requires a number of factors; it requires a shared purpose, it requires trust, it requires communication,” says Dr Dawda.

“A mechanism of building that trust, that communication is to have some clear roles and responsibilities through shared education activities and professional activities around that.”

Other areas for better practice suggested was a clarification of the aged care providers roles in obtaining primary health care for their residents.

Dr Dawda agreed that requirement clarifications would create better practice and believes there is a need for care coordinators within aged care, although he is uncertain where they would sit within the system.

Dr Wallett says the requirement for providers to engage primary health care practices could be problematic and add a burden to the aged care facilities, especially when they are already overburdened.

Additionally, Dr Dawda believes there could be a possible embedding of general practice within the aged care system to result in high performing primary care.

Ms Irvine was also of the same idea, saying a true team care-based approach is the most effective in residential aged care, and clinical care coordinators can be the missing link and can assist the aged care provider, their residents and families in connecting with GPs.

Commissioner Lynelle Briggs AO asked if remuneration was the only way to get GPs into aged care, with Dr Dawda saying it is only part of the issue.

“One of the reasons I do it is not for the remuneration, because of the professional satisfaction it gives me so I think that’s certainly an intrinsic motivator to tap into,” says Dr Dawda.

“I think what puts people off, what the barriers are is the huge volume of non-clinical administrative tasks, faxes toing and froing, messages sort of bouncing around. 

“So I think if some of that non-clinical burden can be systemised and made more efficient and made to be less of a burden, then I think that would incentivise some GPs to do aged care.”

Poor communication between aged care staff and medical professionals

On the second day of the Royal Commission, Jennifer Walton gave direct evidence about her mother’s treatment in aged care and the difficulty navigating between the doctor’s office, the aged care facility and hospitals.

Ms Walton’s mother, Avril Walton, died in May of this year, at the age of 84. She developed dementia in 2012 and had to move into an ACT aged care facility in 2015 after some major health issues, including a hip replacement in 2014.

During her stay in the aged care facility, Mrs Walton continued her ongoing medical treatment and relationship with her GP.

“It was extremely important because Mum first consulted her in 2007 when she came to Canberra so they had already had that length of relationship by that time, so it provided that continuity of care,’ says Ms Walton. 

When Mrs Walton was unable to visit her GP due to deteriorating mobility, her doctor started to visit her within the aged care facility and was quite in-depth when reviewing the aged care notes. The GP would provide her own notes about care or medication to the nurse station.

Attending hospital multiple times after falls would cause a lot of agitation and Ms Walton believes if hospital-like services were provided in nursing homes, there would have been less stress on her mother.

At the end of the evidence, Ms Walton says there seemed to be a lot of miscommunication and conflicting directions from the aged care facility, the doctor, and hospitals, which caused a lot of confusion around the care her mother was receiving.

“So from our experience, having dementia shouldn’t mean that health and aged care systems treat people with any less respect or fail to provide the necessary care to ensure continued wellbeing,” says Ms Walton. 

“That’s just – it shouldn’t be the case. And on our experience, the hospitals were not equipped to deal with situations where people with dementia present with other issues. 

“Continuity of care should be the standard, not the exception and it shouldn’t be a fight to get consistent care across aged care and health settings. They should work together and provide wraparound support for people.”

The Royal Commission hearings will run to the end of this week and are the last hearings for the year, finishing on December 13.

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