Category: Aged Care Funding
Preventable nursing home deaths surge
The Age, Michael Bachelard
Sarah Russell’s mother, Joan, died in a nursing home in September 2015. She believes the death was premature.
“When my mother was engaged, she was terrific. When she was alone and not engaged, she’d suffer anxiety … [and] she would get up and walk,” Dr Russell, a public health researcher, said.
Dr Russell gave up work to look after her, but she could not be there at all times, so she attached a note to her mother’s walking frame to warn the personal care assistants at the aged care facility not to leave her walker within reach.
One day, in the dining room after lunch, they did.
“She got up and walked, fell over. She didn’t break her hip, but she did damage her ribs, and six weeks later she was dead. The GP made the connection between the fall and her decline … I think the fall hastened her death.”
Response from Richard Colbeck’s office via Department of Health.
An Australia Day reflection (2017)
by Ian Anderson and Sarah Russell
Another Australia Day has been and gone demonstrating that our history provokes a range of emotional responses – pride, sorrow, happiness, anger and guilt. The large number of non-Indigenous Australians who attended Invasion/Survival Day rallies around Australia suggests guilt is a common emotional response of non-Indigenous Australians when recalling Australia’s colonial treatment of Aboriginal people.
If you accept – as I do – that the Australian frontier was a violent place and many Aboriginal lives were lost in this violence. Also that Aboriginal Australian suffered because of the loss of livelihood, disease and poverty. Then there is much to provoke a sense of guilt. However, guilt prevents constructive dialogue.
Instead I want an honest conversation between Indigenous and non-Indigenous Australians about our shared past and its consequences. I want to have this conversation in ways that enable us all to address the legacy of the past and create a shared future.
Guilt can be a crippling and paralysing emotion. Guilt doesn’t create the basis for reframing our relationships or enabling us to see new alternative futures together. For some, the fear of guilt becomes a reason to avoid thinking about these confronting truths about Australia’s past.
For those Australians who do not have any historical connection to Australian frontier– such as more recent migrants – guilt seems an even less appropriate response.
Hobart Lord Mayor Sue Hickey brought herself to national attention when she raised concerns about The Museum of Old and New Art’s (MONA) proposal for a Truth and Reconciliation Park. MONA has a long-term vision to transform an industrial site into a cultural precinct at Macquarie point. This proposal includes a precinct that acknowledges Tasmania’s colonial conflict with Indigenous people as well as a Tasmanian Aboriginal history centre. It has the potential to become a national building project with an innovative cultural space that creates new ways for Australians of all backgrounds to reconcile our colonial past.
Sue Hickey said a Truth and Reconciliation Park would create “a guilt ridden” place adding that she “didn’t kill Aborigines”. She received public opprobrium for her comments, particularly from Indigenous Australians. Although her initial comments were clumsy and caused offence, subsequent discussions between Sue Hickey and Tasmania’s Palawa (Aboriginal) were positive. However, the incident illustrates how the fear of guilt can get in the way of conversations about our colonial past.
I am not promoting a naïve dewy-eyed nationalism that glosses over the confronting aspects of our history. If we are going to have a shared future, we need to collectively remember our colonial history. But there may be more productive ways to set the tone for our engagement with our colonial past.
A dialogue about our colonial history underpinned by generosity, empathy, respect and compassion has greater potential for constructive engagement with our colonial history and its legacy. This approach may allow us to acknowledge past suffering whilst at the same time opening up new ways for us to relate to each other and build a shared future. This is a future in which we all belong but in different ways.
Every year we have difficult conversations about the problems associated with choice of the 26th of January to celebrate our Australian nationhood. This year was no different. Australia day honours, BBQs, citizenship ceremonies and invasion day/survival day marches were all held concurrently. Once again, Australia Day – a national day that should bring Indigenous and non-Indigenous together – divided our nation.
A poll published in the Guardian found most Indigenous Australians want the date changed. 26 January is the anniversary of the date in which the First Fleet raised the Union Jack in Sydney Cover in 1788. It is a date that by virtue of its historical symbolism causes pain to Indigenous Australians.
26 January became a public holiday uniformly across all Australian states only in 1994. For many Indigenous Australians it is symbolic of the act of dispossession. Yet we seem unable to have a frank and honest conversation about changing the date. Being dismissive and responding that this is a silly conversation – or that it is “political correctness gone mad” – is not a generous way to bring all Australians into a celebration of our shared collective future. A generous approach to dialogue based on empathy, respect and compassion would seek to find a date to celebrate our nationhood that is inclusive of all Australians.
We need a way to talk about our past that is honest that acknowledges harm both intended and not intended to Indigenous Australians. Perhaps this would be more productive if we were able to move from one based on guilt to one based on emotional engagement that is enabling. That might require us all to shift our approach to each other and acknowledge the multiple cultural traditions. Whoever we are – Indigenous, descendants of settler Australians, migrants or refugees – we all have a stake in our nations future.
Reverse the aged care cuts?
Residential aged care in Australia is big business. The Aged Care Financing Authority estimates the residential aged care sector requires $31 billion of investment over the next decade. To attract investors, the Productivity Commission recommends a competitive market with reduced regulation. Private equity firms, new foreign investors, and superannuation and property real estate investment trusts are entering the residential aged care market in large numbers.
The ‘Living longer living better’ aged care reforms have decreased regulation and introduced a consumer-driven market based system. The irony of this move towards a free market system is that providers rely on government subsidies. The government pays approved providers a ‘residential care subsidy’ for each resident living in an aged care home. The amount for each resident is calculated using the Aged Care Funding Instrument (ACFI). ACFI is used to pay subsidies based on each resident’s level of need. It has three funding categories: Activities of Daily Living, Behaviour and Complex Health Care. Funding in each of these domains is provided at four levels: high, medium, low or zero.
ACFI provides a financial incentive to classify residents as requiring a higher level of care. The provider receives additional subsidies when a resident is reclassified as requiring a higher level of care. However, staff levels rarely change nor are extra services provided to the resident. Where do our taxes go?
Under the current arrangements, the providers do their own assessments for government subsidies. Although politicians and peak bodies may claim that the overwhelming majority of providers are doing the right thing, the ACFI Monthly monitoring reports do not support this claim. It has been reported that one-in-eight of 20,000 ACFI claims audited last year (2014-15) were deemed to be incorrect. This figure is already tracking higher at one-in-seven in 2015-16. The ACFI Expenditure Working Group has been formed to understand the causes of recent growth in residential aged care subsidies.
Michael Pascoe asked: “Where’s the dividing line between systemic fraud and “innocent mistakes” in the aged care sector? It’s somewhere in the hundreds of millions of dollars very-much-for-profit aged care providers have been ripping out of the system by exploiting a flawed funding model – a model that encourages exaggerating care needs and discourages improving the health and independence of individuals”.
The changes to the Aged Care Funding Instrument (ACFI) announced in the federal budget have caused some private providers to worry about their profits. In a letter to managers of aged care homes, Optimum Healthcare Australia estimates the changes to ACFI will result in an average 80-bed aged care home losing $439,000 per year in government subsidies.
Not surprisingly, the peak body representing private providers is asking the government to reverse its decision. Leading Aged Services Australia has launched a campaign: ‘Reverse the Cuts – Fund the Care Australian Seniors Need and Deserve’. In response, Aged Care Matters has begun a reverse campaign: “Cut the greed: Provide the care Australians fund”. When a resident is classified as requiring higher needs, additional resources should be directed towards the resident with higher needs. Aged Care Matters also calls on all providers to stop exaggerating residents’ care needs.
Optimum Healthcare Australia recommends aged care homes re-appraise residents before the January 2017 to ensure funding is “grandfathered”. They recommend residents’ care needs are reassessed “to determine what care they actually need, not just what is reported by carers.” With their assistance, providers will “experience minimal financial impact from the [ACFI] changes”.
Some ACFI coordinators and ACFI consultants describe their role as “generating income for the providers”. An ACFI coordinator for an aged care home with 160 beds told Aged Care Matters that he is “highly stressed as the provider expects the ACFI rate for all residents to be at least $204 per day”. He described the provider for whom he works as “cooking the books” to maximise funding.
ACFI consultants must not only stop exaggerating residents’ care needs, they must also stop reclassifying residents with an illness and care needs that they do not have. Recently, an aged care home falsely claimed a resident had Parkinson’s Disease, and related health deficits, for which the provider claimed a subsidy under ACFI. When his daughter complained to ACFI Compliance Section, she was told that the appraisers “must be able to trust the word of the health care professionals at the aged care facility”.
ACFI is built on an honesty system. In an era of fraudulent behaviour in both pink batts and private colleges, it is clear that profit-based systems that rely on government subsidies cannot rely on honesty. The funding of aged care homes require transparency, scrutiny and accountability. We must all know how the providers spend our taxes.
When a resident in an aged care home is reclassified as requiring a higher level of care, the extra funding should be used to employ more staff or to introduce services such as strength training, music or lifestyle programs that would improve residents’ quality of life. Their care must not be traded on the market like any other commodity.
Dr Sarah Russell is the Principal Researcher at Research Matters and a former Registered Nurse. She is a foundation member of Aged Care Matters.
Published in Online Opinion
Writers’ Block
Optimising aged care funding
Religious, community-based and charitable organisations were once the main providers of residential aged care in Australia. Families could feel reasonably secure that while standards of care would vary, aged care facilities were not motivated by profit. During the past decade, privately owned aged care facilities have grown at twice the rate of those in the non-profit sector. Publicly listed companies are now the fastest growing owners of aged care facilities.
Earlier this year, Bentleys Chartered Accountants reported that profits in the aged care industry rose significantly. Despite the small sample (only 179 aged care homes), their report estimated that net profits jumped 159% in 2015, from $4.14 to $10.71 per resident per day.
The growth in the aged care industry is underpinned not only by our ageing population but also government subsidies. Major aged-care providers such as BUPA, Japara, Regius and Estia receive substantial government subsidies. Estia, for example, received a 10.9% increase in government subsidies during last financial year.
The changes to Aged Care Funding Instrument (ACFI) announced in the recent budget are intended to help curb a predicted $3.8 billion blowout in government subsidies. The changes will save the government $1.2 billion.
The peak bodies that represent providers of residential aged care – Leading Aged Services Australia (LASA), Aged and Community Services Australia (ACSA) and Aged Care Guild – have described these changes as a “budget cut”. The Aged Care Guild complains that the budget is fuelling uncertainty in the industry and could force a rethink on future investment plans.
In an increasingly competitive environment within the aged care sector, peak bodies for providers have successfully lobbied the government for less regulation. The recent Aged Care Roadmap describes “lighter regulation” and a “consumer driven and market based system”. Paradoxically, the providers of aged care homes lobby simultaneously for a decrease in regulation and an increase in government subsidies.
Government subsidies in aged care often serve the interests of the providers more than residents. When a resident is reclassified as requiring a higher level of care, the provider receives more money from the government. However, staff levels rarely change nor are extra services provided to the resident.
Currently, funding for aged care homes is based on a ‘terminal decline model’ rather than ‘restorative care’. The provider receives additional subsidies when a resident declines. There is no financial incentive for providers to introduce services such as strength training or lifestyle programs that would improve residents’ quality of life. Instead, a provider is rewarded for promoting dependency rather than encouraging wellness.
Under the current arrangements, the providers do their own assessments for government subsidies. Many providers employ staff purely to complete the ACFI paperwork. The role of these staff is to generate income for the employers rather than provide care to residents. Some providers employ Aged Care Consultants who specialise in “ACFI optimization”. These Aged Care Consultants promote themselves as specialists who help to maximise funding for the aged care home.
It is not only the for-profit organisations that are making massive profits in residential aged care. Mecwacare, for example, is as a not-for-profit organisation that offers residential aged care. According to its Annual Report, it made a net profit of $3.9M for the year ended 30 June 2015. It purchased a new head office and added a further six Aged Care Homes to its portfolio.
For both the for-profit and not-for profit sector, ACFI documentation appears to have become a creative writing exercise. It has been reported that one in eight claims for government subsidies are incorrect. Whether the blowout is due to false claims for subsidies or the increasing number of high care residents in aged care is unclear.
The federal government recently introduced fines to curb a growing trend of incorrect, or deliberately false, claims for subsidies. Whether a fine of merely $10,800 for providers who repeatedly make false claims will act as a deterrent remains to be seen. Money may speak louder than the coroner.
Coronial inquests into separate deaths at two aged care homes, BUPA Kempsey and Arcare Hampstead in Melbourne, exposed inadequate care, mismanagement and cover-ups in response to complaints. Despite this inadequate care, both BUPA Kempsey and Arcare Hampstead were fully accredited by the regulator, the Aged Care Quality Agency, with perfect scores of 100 per cent in all criteria. Surely this suggests something is wrong with the accreditation processes.
Following the coronial inquiries, both homes were asked to improve their policies and procedures. However, the Aged Care Quality Agency did not change the accreditation processes. The accreditation and outcome standards remain woefully inadequate.
The Australian Aged Care Quality Agency must review the process of accreditation. The accreditation process should play an important role in monitoring the standards of care in all aged care facilities. Given accreditation enables aged care facilities to receive government subsidies, it should not be a rubber stamp.
Aged care homes requires greater scrutiny, accountability and transparency. We need evidence-based information so that we can have informed discussions about how to provide the best possible care for frail, elderly people who live in aged care homes. We need to feel reassured that government subsidies are being used to improve the quality of life of residents, not the pockets of providers.
Dr Sarah Russell is the Principal Researcher at Research Matters and a former Registered Nurse.
Published in Online Opinion
Aged care: Preventable nursing home deaths surge
The Age
Michael Bachelard
29 May 2017
Sarah Russell’s mother, Joan, died in a nursing home in September 2015. She believes the death was premature.
“When my mother was engaged, she was terrific. When she was alone and not engaged, she’d suffer anxiety … [and] she would get up and walk,” Dr Russell, a public health researcher, said.
Dr Russell gave up work to look after her, but she could not be there at all times, so she attached a note to her mother’s walking frame to warn the personal care assistants at the aged care facility not to leave her walker within reach.
One day, in the dining room after lunch, they did.
“She got up and walked, fell over. She didn’t break her hip, but she did damage her ribs, and six weeks later she was dead. The GP made the connection between the fall and her decline … I think the fall hastened her death.”
Dr Russell said the care assistants in Joan Russell’s home were “extremely busy”, but “the other explanation is that there were a lot of people in Mum’s nursing home for whom English was not their first language.
“It’s a real problem, not just for instructions left on a walker, but for communication at all. I don’t know if the person who left the trolley beside my mother was not able to read the instructions or was too busy and forgot.
“We were great friends, my mother and I … It mattered a lot to me that she had the fall.”
Dr Russell received an apology from the facility.
Behind the numbers
Letter, The Age
The federal government cut payments to aged care by $1.2 billion over four to help curb a predicted blowout in costs. Aged care providers are predictably are up in arms. Unfortunately, government subsidies often serves the interests of the providers more than residents.
Under the current arrangements, the providers do their own assessments of residents. When a resident is reclassified as requiring a higher level of care, the provider receives more money from the federal government. However, staffing levels rarely change nor are extra services provided to the resident. One in eight claims are reportedly incorrect.
The Aged Care Funding Instrument is based on residents’ level of care rather than ‘restorative care’. There is no financial incentive for providers to introduce services such as strength training or lifestyle programs that would improve residents’ quality of life.
The funding of aged care homes requires greater scrutiny and transparency to ensure the best possible care for frail, elderly people.
Sarah Russell, Northcote
Pain is real, not a myth
Letter, The Age
It is tragic that older people commit suicide (The Age, 17/1). The National Coronial Inquiry Service estimates that two people over the age of 80 are taking their lives every week. The most common method is hanging.
Ian Hickie suggests older people commit suicide because of myths and negative stereotypes about ageing, pain relief, hospitals and how the health system treats elderly people. Are these myths?
Recently, an elderly woman living in an aged care home died in excruciating pain because no one was suitably qualified on the night shift to administer the prescribed morphine. The woman’s daughter was so traumatised she could not remain at her mother’s bedside to hold her hand.
We do not need motherhood statements about healthy ageing. We need political action to ensure older Australians are valued and receive the quality of health care that they deserve.
Sarah Russell, Northcote