IFA Virtual Town Hall Resources 6 November 2020

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Key Resources from Presentation

Resources Australia Aged Care System and Standards
The main government website is: https://www.myagedcare.gov.au /
https://www.agedcareguide.com.au/terms/couples-accommodation

During 2017-18 the Quality Agency conducted 3,099 unannounced assessment contacts: https://agedcarequality.govcms.gov.au/sites/default/files/media/2017-18%20Regulator%20Performance%20Report.pdf

The main website is: https://www.agedcarequality.gov.au/

https://www.gen-agedcaredata.gov.au/www_aihwgen/media/ROACA/2018-19-ROACA.pdf
https://www.gen-agedcaredata.gov.au/www_aihwgen/media/ROACA/ROACA-Summary-2019.pdf
https://www.gen-agedcaredata.gov.au/www_aihwgen/media/ROACA/ROACA-Key-Facts-2019.pdf

The building standards for long-term care, while pretty generic across Australia, are governed by each State administration. Here are the standards for New South Wales.
https://www.priorityhealthcare.com.au/files/Victorian%20Government%20Aged%20Care%20Brief.pdf

Details of the subsidies and supplement payments to all approved providers are here:

https://www.health.gov.au/health-topics/aged-care/providing-aged-care-services/funding-for-aged-care-service-providers/aged-care-subsidies-and-supplements

The above, details both residential care facilities and Home Care Packages where services are delivered into a persons home. There are 4 levels of subsidies based on assessed needs, from $24.07 to $139.70 per day and then there are additional daily supplements in the home care payments. In residential care for a residents with the maximum care needs, the organization irrespective of status (Private or not-for profit), receives a subsidy od approximately $80,161.30 per annum and then there are a few additional payments that can amount to about another $1000 per annum.

Details on how places are allocated and funding support for building is at
https://www.health.gov.au/initiatives-and-programs/residential-aged-care/funding-for-residential-aged-care/allocated-places-and-capital-grants-for-residential-aged-care

Certification of Buildings https://www.anao.gov.au/work/performance-audit/building-certification-residential-aged-care-homes

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Key Resources shared by Participants

• Alberta Association on Gerontology action report
• Reimagining Nursing Homes in the Wake of COVID-19
• Accreditation supports a balanced response to COVID-19 in senior living
• COVAX Welcomes Appointment of Civil Society Representatives
• National Academies – the Quality of Care of Nursing Homes

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Summary

People living in long-term care (LTC) homes in across the globe have been far more likely to die of COVID-19 than the rest of the population. However, the impact of COVID-19 on residents in LTC has varied widely within countries.

The lack of pandemic planning in the sector, outdated building standards, poor staffing practices and the reluctance by government to hold service providers accountable in ensuring quality resident outcomes has contributed significantly to the high death rates in long term care.

Staffing

Many LTC staff, in particular care aides or personal support workers, are under paid and less likely to secure full time positions relative to their counterparts in other sectors of the health care system. As such, staff frequently take on several part-time or casual roles at different LTC homes, which increases the risk of transmission among facilities. Some LTC homes also subcontract out services such as laundry, cleaning and cooking, further increasing transmission risk. In addition, subcontracted staff may have less access to paid sick leave — a critical element in allowing staff to self-isolate when ill. All of this is in line with evidence that staff are the main vectors of Covid-19 transmission in LTC facilities.

Shared rooms

Prior to the COVID-19 pandemic, LTC residents in many countries were more likely to reside in shared rooms. In Ontario where the IFA is headquartered approximately 63% of residents are in shared rooms. Rates of infection associated with the LTC and the health care sectors are lower where facilities have single patient/resident rooms. Shared resident living arrangements are a contributing factor to the spread of Covid-19 and other outbreaks such as influenza in LTC.

In a recent Long-Term Care Staffing Study undertaken by the Ministry of Long-Term Care in Ontario, concerns were heard from a wide range of organizations regarding staffing challenges within the long-term care sector. Addressing these concerns is fundamental to developing a modernized system that delivers safe, quality and resident-centered care, and can meet the growing demands of an ageing population.

Priority Areas for Action

The study itself was broad in scope, reflecting a wide range of inter-related and complex issues. It was impossible to address all of the issues they heard about in one study, with limited time. However they did identify five key priorities for immediate action.

1. The number of staff working in long-term care needs to increase and more funding will be required to achieve that goal
2. The culture of long-term care needs to change – at both the system and individual home level
3. Workload and working conditions must get better, to retain staff and improve the conditions for care
4. Excellence in long-term care requires effective leadership and access to specialized expertise
5. Attract and prepare the right people for employment in long-term care, and provide opportunities for learning and growth

What was not addressed in this report was how a sophisticated quality of care standards framework in itself can ensure appropriate staffing based on the resident care mix and measured against legislated resident outcome standards. Mandated staffing profiles in long term care will never ensure quality of care.

If we compare long term care standards and staffing levels in counties like; the United States, Canada, England, Germany, Norway, and Sweden, reports have found wide variations in both nurse staffing standards and actual staffing levels within and across countries. Although comparisons are difficult to make due to differences in measuring staffing, the vagueness of standards, and limited availability of actual staffing data makes comparisons difficult. Both the standards and staffing levels in most countries (except Norway and Sweden) are lower than that recommended by many experts. Such a discussion is taking place in Canada right now. Only yesterday the government of Ontario announced that it was mandating 4 hours of direct care to each resident in LTC.

Findings from such studies demonstrate the need for further attention to nurse staffing standards and levels in order to assure the quality of nursing home care. A high quality of nursing home care requires adequate levels of competent staff but mandating staffing levels does not ensure quality resident outcomes. A home delivering poor quality of care can not be fixed by staffing alone.

Across the globe in developed countries, Acts and Regulations generally specify some mandatory staffing requirements. These include:

• Administrator: Each home must have an Administrator who is in charge of the home and is responsible for its overall management

• Director of Nursing: Each home must have a DON, who must be a registered nurse.
• Medical Director and Attending Physician: Each home must have a nominated (rarely a full time position) Medical Director and Attending Physician to evaluate and address medical practices, clinical procedures and resident care.
• Registered Nurse: Each home must have at least one registered nurse on duty and present in the home at all times, except as provided for in any regulations.

Building Standards

In Ontario for example the maximum resident home area caters to 32 residents, but the standards do not specify that all must be single rooms. Rooms will have an ensuite or shared washroom that includes a toilet and washbasin. It is not mandated that such washrooms have showering or bathing facilities. Each resident home area with have a tub/bath facility and a shower room. Not a good standard to mitigate infection.

Quality Resident Care

In Australia – Care standards are the same across all facilities irrespective of the state/province where they are located and are federally regulated.

https://www.myagedcare.gov.au/aged-care-quality-standards.

The National Aged Care Mandatory Quality Indicator Program has operated since 1 July 2019. There was a similar quality indicator program in place since the 1997. All Australian Government-subsidised aged care homes must collect and provide quality indicator data to the Department of Health. All homes in Australia are assessed against 4 standards and 44 outcomes with reviews being undertaken by the Australian Aged Care Quality Agency.

Standard 1: Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates. There 9 outcome standard measured.

1.1 Continuous improvement
1.2 Regulatory compliance
1.3 Education and staff development
1.4 Comments and complaints
1.5 Planning and leadership
1.6 Human resource management
1.7 Inventory and equipment
1.8 Information systems
1.9 External services

Standard 2: Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team. There are 17 outcome standards measured.

2.1 Continuous improvement
2.2 Regulatory compliance
2.3 Education and staff development
2.4 Clinical care
2.5 Specialised nursing care needs
2.6 Other health and related services
2.7 Medication management
2.8 Pain management
2.9 Palliative care
2.10 Nutrition and hydration
2.11 Skin care
2.12 Continence management
2.13 Behavioural management
2.14 Mobility, dexterity and rehabilitation
2.15 Oral and dental care
2.16 Sensory loss
2.17 Sleep

Standard 3: Care recipient lifestyle

Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community. There are 10 outcome standards measured.

3.1 Continuous improvement
3.2 Regulatory compliance
3.3 Education and staff development
3.4 Emotional Support
3.5 Independence
3.6 Privacy and dignity
3.7 Leisure interests and activities
3.8 Cultural and spiritual life
3.9 Choice and decision-making
3.10 Care recipient security of tenure and responsibilities

Standard 4: Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and wellfare of care recipients, staff and visitors. There are 8 outcome standards measured.

4.1 Continuous improvement
4.2 Regulatory compliance
4.3 Education and staff development
4.4 Living environment
4.5 Occupational health and safety
4.6 Fire, security and other emergencies
4.7 Infection control
4.8 Catering, cleaning and laundry services

During 2017-18 the Quality Agency conducted 3,099 unannounced assessment contacts. The Quality Agency, nationally, held 87 training courses on accreditation and quality review during 2017-18. The Quality Agency conducted, nationally, 190 compliance education sessions for aged care services that require support to improve performance against the Standards. Of those, 111 were directly related to the regulatory case management activities; these are the services that are directly experiencing compliance issues.

The Quality Agency received 1,954 referrals from the Department of Health and the Aged Care Complaints Commissioner. 1,888 intelligence reports from state government public health units. 964 other information referrals including concerns raised by the public.

In addition, review audits were undertaken where there are reasonable grounds to believe that the standards are not being met. Of the 72 review audits conducted during 2017-18, there were 22 ‘Not to revoke’ decisions, 38 ‘Vary’ decisions, and 12 ‘Revoke’ decisions.

Where there are adverse findings there is a Timetable for Improvement program that allows approved providers of aged care services time to remedy poor performance, unless serious risk to the health and safety of consumers is identified.

There has been much discussion and criticism of the private for profit sector in this debate, however it would not be justified if all sector providers were treated the same in terms or the fees they could charge and the outcomes that they were measured against.

In 2019 some 6% of for-profit residential care facilities failed aged care standards and some of them multiple times. In comparison 5% of not-for-profit and 4% of government facilities failed standards.

More than 1.2 million people received aged care services during 2017–18, with most (77%) receiving support in their home or other community-based settings. Putting this in context, of Australians aged 65 and over in 2017–18:

• 7% accessed residential aged care
• 22% accessed some form of support or care at home
• 71% lived at home without accessing government-subsidised aged care services.

More than 3,000 aged care providers in Australia deliver care through nearly 9,000 services (outlets). The sector comprises private (for-profit) providers alongside community-based and charitable providers, and state and territory and local government providers. The mix of ownership type varies across programs, with the largest proportion of for-profit services in the residential care program (41% of residential aged care places are managed by for-profit providers).

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Types of compliance actions if quality care standards and outcomes are not met

Areas for Improvement – Where a provider doesn’t meet the Aged Care Quality Standards, the Commission can give them a Direction to make improvements. They will check in later to monitor and assess if these have been addressed. The provider must also revise their plan for continuous improvement.

Non-compliance notice – If a provider does not meet requirements and is not providing the care and services required by the law, they may receive a non-compliance notice. The notice indicates there are significant problems that they need to fix. If they don’t take action within the agreed timeframe, they may be given a sanction.

Notice to Agree – Where an aged care home’s non-compliance has resulted in the Commission considering revoking their approval to deliver aged care through a sanction, the Commission may – in certain circumstances – first issue the provider a Notice to Agree (NTA). These circumstances include where:

• the aged care home has failed to give an undertaking to remedy their non-compliance
• the aged care home has failed to comply with an undertaking to remedy their non-compliance
• the aged care home has made submissions in response to a non-compliance notice that are unsatisfactory, or
• the Commissioner is satisfied the provider’s non-compliance poses an immediate and severe risk to the safety, health and well-being of those receiving care.

Sanction – Where there is continued non-compliance, the Commission may impose a sanction.

Some examples of continued non-compliance include:

• a provider who does not remedy the non-compliance within the specified period, or
• where there is an immediate and severe risk to the safety, health or well-being of those receiving care.

A sanction may revoke the provider’s approval to deliver aged care.

One final note that is worth mentioning. As at the end of October in Australia there was a total of 685 deaths in LTC. 655 in the State of Victoria alone. Many states and Territories have none. Interestingly most of the deaths are in non-profit homes. There were 83 residential aged care facilities currently active with COVID-19. 82 of these services are in Victoria and one is in Queensland. Deaths in long-term care represents about 75% of all COVID-19 deaths.

• In 2019, 837 older Australians died from influenza
• In 2020, 28 older Australians have died from influenza to date.

The lower number of deaths in 2020 in the data available to date compared to the same point in 2019 is likely the result of increased influenza immunisation rates, and increased infection control protocols introduced during the COVID-19 pandemic.