When so much of a resident’s waking hours is spent either at a meal, or thinking of a meal, the meal can either make or break an elderly person’s day.
So why are some aged care providers still offering residents meals they can’t stomach?
It comes down to three key factors: cost-cutting, aged care funding structures that don’t reward good food and mealtime experiences, and residents not being given a voice. And it has a devastating impact on nutrition.
Our research from 2017 found the average food spend in Australian aged care homes was A$6.08 per resident per day. This is the raw food cost for meals and drinks over breakfast, morning tea, lunch, afternoon tea, dinner and supper.
This A$6.08 is almost one-third of the average for older coupled adults living in the community (A$17.25), and less than the average in Australian prisons (A$8.25 per prisoner per day).
Over the time of the study, food spend reduced by A$0.31 per resident per day.
Meanwhile the expenditure on commercial nutrition supplements increased by A$0.50 per resident per day.
Commercial nutrition supplements may be in the form of a powder or liquid to offer additional nutrients. But they can never replace the value of a good meal and mealtime experience.
dementia (because of difficulty swallowing and sensory sensitivities)
a poorly designed dining environment (such as poor acoustics, uncomfortable furniture, inappropriate crockery and table settings)
having too few staff members to help residents eat and drink and/or poor staff training
not supplying modified cutlery and crockery for those who need extra help
not offering residents food they want to eat or offering inadequate food choices.
My soon-to-be-published research shows disatisfaction with the food service significantly influences how much and what residents eat, and therefore contributes to the risk of malnutrition.
Malnutrition impacts all aspects of care and quality of life. It directly contributes to muscle wasting, reduced strength, heart and lung problems, pressure ulcers, delayed wound healing, increased falls risk and poor response to medications, to name a few.
Food supplements, funding and quality control
Reduced food budgets increase the risk of malnutrition but it’s not the only aged care funding issue related to mealtimes.
Aged care providers are increasingly giving oral nutrition supplements to residents with unplanned weight loss. This is a substandard solution that neglects fundamental aspects of malnutrition and quality of life. For instance, if a resident has lost weight as a result of ill-fitting dentures, offering a supplement will not identify and address the initial cause. And it ends up costing more than improving the quality of food and the residents’ mealtime experience.
Our other soon-to-be-published research shows the benefits of replacing supplements with staff training and offering high-quality food in the right mealtime environment. This approach significantly reduced malnutrition (44% over three months), saved money and improved the overall quality of life of residents.
However, aged care funding does not reward quality in food, nutrition and mealtime experience. If a provider does well in these areas, they don’t attract more government funding.
It’s not surprising that organisations under financial pressure naturally focus on aspects that attract funding and often in turn, reduce investment in food.
A research team commissioned by the health department has been investigating how best to change aged care funding. So hopefully we’ll see changes in the future.
Aged care residents are unlikely to voice their opinions – they either won’t or can’t speak out. Unhappy residents often fear retribution about complaining – often choosing to accept current care despite feeling unhappy with it.
We lived in an aged care home. This is what we learned
New Aged Care Quality Standards came into effect on July 1 (I was involved in developing the guidelines to help aged care providers meet these standards).
However, they provide limited guidance for organisations to interpret and make meaningful change when it comes to food, nutrition and mealtime experience. Aged care providers will need extra support to make this happen.
We’ve developed an evidence-based solution, designed with the aged care industry, to address key areas currently holding aged care back. The solution offers tools and identified key areas essential for a happier and more nourishing mealtime.
At the end of 2018, our team lived as residents in an aged care home on and off for three months. As a result of this, and earlier work, we developed three key solutions as part of the Lantern Project:
a food, nutrition and mealtime experience guide for industry with a feedback mechanism for facilities to improve their performance
free monthly meetings for aged care providers and staff to discuss areas affecting food provision
an app that gives staff, residents and providers the chance to share their food experiences. This can be everything from residents rating a meal to staff talking about the dining room or menu. For residents, in particular, this allows them to freely share their experience.
We have built, refined and researched these aspects over the past seven years and are ready to roll them out nationally to help all homes improve aged care food, nutrition and mealtime experience.
The reduction in life span [for people experiencing loneliness] is similar to that caused by smoking 15 cigarettes a day, and it’s greater than the impact on life span of obesity … Look even deeper, and you’ll find loneliness is associated with a greater risk of heart disease, depression, anxiety and dementia.
Research suggests low-income individuals are more likely to experience loneliness. So, too, are people who have a serious mental or physical health condition or have had a serious disruptive event (financial or job loss, illness or injury, or relationship breakdown) in the last couple of years.
The impact of housing tenure on loneliness has received little attention. While recognising that there are no definite associations, we interviewed about 80 older (65-plus) private renters and social housing tenants who depended on the Age Pension for their income. These in-depth interviews indicated that their housing tenure was a critical factor in their risk of experiencing loneliness.
Many older private renters have little disposal income, because the cost of housing uses up much of their income. They also live with the constant possibility that they may be asked to vacate their accommodation. Their limited budgets mean they often end up living in a poorly located property. These features, individually or in combination, create fertile ground for anxiety and loneliness.
Their dire financial situation was often an obstacle to social activities. One interviewee told of how she had to choose between food or breaking her isolation by using public transport.
Well, you sort of think what you can do with $2.50. That’s a loaf of bread type of thing. – Beverley *
A 72-year-old woman living by herself said she could not afford the outings organised by her church.
There’s quite an active social club at the church for over-55s but I can’t go to any of those … Sometimes I think it would be nice to go on something that appeals to me, yes. And they might have an afternoon at somebody’s home and you’re asked to bring a plate [of food]. You see, I couldn’t afford to do that.
Peter, 67 and divorced, had left the workforce prematurely due to ill-health.
I’ve become very isolated. I used to, before I had the hip operation, I used to play tennis and I loved to play tennis … but I really can’t afford it. I’ve found a few clubs that I could go and play in. I’d like to get back to it, but they say, ‘Ah, the fees are this and you pay it annually,’ and I can’t come up with $150 or $200 or whatever.
Lack of money and insecure tenure were sources of enormous distress and anxiety, which further discouraged social contact. Brigette (67) was brutally honest:
You do get depressed and I believe that’s why people suicide … And there have been times when I’ve thought, what is the point to life? I really have thought this can’t go on, you know … I feel sorry for people because it is hard, and once you stay in it’s like crawling out of a slime pit … I have to say, ‘Get up and go out, go up the shops … Pretend you need potatoes or something.’
Not all of the private renters interviewed experienced loneliness. These interviewees usually had strong family ties or had managed to find affordable and secure accommodation.
In sharp contrast, only a small proportion of the social housing tenants interviewed said they were lonely. Almost all were adamant they did not experience loneliness and felt they had strong social ties. Their affordable rent, security of tenure, long-term residence and having neighbours in a similar position meant they could socialise and were not beset by anxiety.
An 85-year-old long-established social housing tenant’s response to the question about loneliness and isolation was typical:
I do like it around here. I know where everything is and I know all the people, especially around these units you know. I know everyone and they know me. I like it around here. This is my home, you know. This is a community, I think. Like I know all the people and we’ve become really good friends. I couldn’t think of being anywhere else. – Kay
Pam, who had been a private renter before being allocated social housing, reflected on how her life had changed:
Well, it is changed because I’m happier and I think I’m healthier and I have a lot of new friends. I also have a lot more people around me for support if anything does happen. If I get sick and if they don’t see me for a few days someone will come and say, ‘Pam, are you OK?’ In private housing there was nobody.
The residualisation of social housing meant some tenants were living in what they perceived to be unbearable conditions. However, they generally were able to deal with their situation. Patricia coped with her very challenging neighbours by going to the local community centre.
No, I hate it [public housing]. I live here [at the community centre] every day. Yes, I’m on the committee here and I do things every day. This is my home, my family. Everybody is friendly with everybody. We have outings and things.
What the interviews indicate is that the housing tenure of age pensioners often plays a fundamental role in whether they are able to escape the experience of loneliness. Older private renters are far more likely to experience loneliness than their counterparts in social housing and that loneliness can be acute.
This year’s budget includes $448.5 to modernise Australia’s Medicare system, by encouraging people with diabetes to sign up to a GP clinic for their care. The clinic will receive a lump sum payment to care for the person over time, rather than a fee each time they see their GP.
The indexation freeze on all GP services on the Medicare Benefits Schedule (MBS) will lift from July 1, 2019, at a cost of $187.2 million. The freeze will be lifted on various X-ray and ultrasound MBS rebates from July 1, 2020.
The budget announces $461 million for youth mental health, including 30 new headspace centres, some of which will be in regional areas. But it does little to address the underlying structural reforms that make it difficult for Australians to access quality and timely mental health care.
In aged care, the government will fund 10,000 home care packages, which have been previously announced, at a cost of $282 million over five years, and will allocate $84 million for carer respite. But long wait times for home care packages remain.
Other announcements include:
$62.2 million over five years to train new rural GPs
$309 million for diagnostic imaging services, including 23 new MRI licences
$331 million over five years for new pharmaceuticals, including high-cost cancer treatments
$107.8 million over seven years for hospitals and facilities including Redland Hospital, Bowen Hospital, Bass Coast Health and Ronald McDonald House
$70.8 million over seven years for regional cancer diagnosis, treatment and therapy centres
$114.5 million from 2020-21 to trial eight mental health facilities for adults
$43.9 million for mental health services for expectant and new parents
$35.7 million over five years for increased dementia and veterans’ home care supplements
$320 million this year as a one-off increase to the basic subsidy for residential aged-care recipients.
Here’s what our health policy experts thought of tonight’s budget announcements.
A hesitant step forward for Medicare
Stephen Duckett, Director, Health Program, Grattan Institute
Medicare funding is slowly creeping into the 21st century. The 19th-century model of individual fees for individual services – suitable for an era when medicine was essentially dealing with episodic conditions – is being supplemented with a new fee to better manage the care of people with diabetes.
The precise details of the new fee – including the annual amount and any descriptors – have not yet been released. But it should encourage practices to move towards a more prevention-oriented approach to chronic disease management, including using practice nurses to call patients to check up on their condition, and using remote monitoring technology.
The budget announcement contained no evaluation strategy for the initiative. The government should produce such a strategy soon.
Support for aged and disability care
Hal Swerissen, Emeritus Professor, La Trobe University, and Fellow, Health Program, Grattan Institute
The budget has short-term measures to address major issues in aged care and disability while we wait for the royal commissions to fix the long-term problems.
The National Disability Insurance Agency (NDIA) is struggling with the huge task of putting the National Disability Insurance Scheme (NDIS) in place.
There has been a major under-spend on the on the scheme. Price caps for services such as therapy and personal care are too low and nearly one-third of services are operating at a loss. The under-spend would have been more if there hadn’t been a last-minute budget decision to significantly increase service caps, at a cost of $850 million.
$528 million dollars has also been announced for a royal commission to look at violence, neglect and abuse of people with disabilities – the most expensive royal commission to date.
There is more funding for aged care. Currently, 130,000 older people are waiting for home care packages – often for a year or more. Nearly half of residential care services are losing money and there are major concerns about quality of care.
The short-term fix is to give residential care $320 million to try to prevent services going under. The budget includes 10,000 previously announced home care packages, at a cost of $282 million, but that still leaves more than 100,000 people waiting.
Little for prevention, Indigenous health and to address disparities
Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney
Preventable diseases and conditions are a key factor in health inequalities and rising health-care costs. The two issues looming large are obesity and its consequences, and the health impacts of climate change.
There is $5.5 million for 2018-19 and 2019-20 for mental health services in areas affected by natural disasters, and $1.1 million over two years for the Health Star rating system – otherwise nothing for primary prevention.
The Treasurer did not mention Closing the Gap in his budget speech, and there is little in the budget for Indigenous health.
Just $5 million over four years is provided in the budget for suicide-prevention initiatives. And the Lowitja Institute receives $10 million for health and medical research.
$6.3 million to continue the development of the Health Data Portal for services funded under the Indigenous Australians Health Program.
Inequalities and disparities
Disadvantaged rural and remote communities will (ultimately) benefit from efforts to boost National Rural Generalist Training Pathway, with $62.2 million provided over four years. This was a 2016 election commitment.
Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University
There are no major changes to public hospital funding arrangements in this year’s budget.
Funding for public hospitals is predicted to increase at between 3.7% and 5.6% over the forward estimates. However, these figures are contingent on the new COAG agreement on health funding between the Commonwealth and states, which is due to be finalised before the end of 2019.
The states will be hoping to wring some more dollars from the federal government given their soaring public hospital admissions and pressure on waiting times.
Government spending on the private health insurance rebate is projected to increase more slowly than premiums at between 1.8% and 3.2% because of indexation arrangements which are gradually reducing the rebate over time.
Smaller targets for mental health
Ian Hickie, Co-Director, Brain and Mind Institute, University of Sydney
Numerous reports and accounts from within the community have noted the flaws in Australia’s mental health system: poor access to quality services, the uneven roll-out of the NDIS, and the lack of accountability for reforming the system.
The next federal government faces major structural challenges in mental health and suicide prevention.
Not surprisingly, this pre-election budget does not directly address these issues. Instead, it focuses on less challenging but worthy targets such as:
continued support for expansion of headspace services for young people ($263m over the next seven years) and additional support for early psychosis services ($110m over four years)
support for workplace-based mental health programs ($15m)
support for new residential care centres for eating disorders ($63m).
A more challenging experiment is the $114.5 committed to eight new walk-in community mental health centres, recognising that access to coordinated, high-quality care that delivers better outcomes remains a national challenge.
Despite the commitment of health minister Greg Hunt to enhanced mental health investments, the total increased spend on these initiatives ($736.6m) is dwarfed by the big new expenditures in Medicare ($6b), improved access to medicines ($40b), public hospitals ($5b) and aged care ($7b).
It will be interesting to see whether mental health reform now receives greater attention during the election campaign. At this stage, neither of the major parties has made it clear that it is ready to deal directly with the complex challenges in mental health and suicide prevention that are unresolved.
New funding for research, but who decides the priorities?
Philip Clarke, Professor of Health Economics, University of Melbourne
The budget contains several funding announcements for research.
The government will establish a Health and Medical Research Office, to help allocate money from the Medical Research Future Fund (MRFF). This will be needed, as the budget papers commit to a further $931 million from the MRFF for:
Clinical trials for rare cancers and rare diseases
Emerging priorities and consumer-driven research
Global health research to tackle antimicrobial resistance and drug-resistant tuberculosis.
In addition, the budget includes:
$70 million for research into type 1 diabetes
a large investment for genomics (although that is a re-announcement of $500 million promised in last year’s budget)
a series of infrastructure grants to individual universities and institutions, such as $10 million to establish the Curtin University Dementia Centre of Excellence.
The government appears to be moving away from allocating medical research funding through existing funding bodies, such as the National Health and Medical Research Council (NHMRC), towards allocating research funds to specific disease areas, and even to individual institutions.
This is a much more direct approach to research funding, but it raises a few important questions. On what basis are these funding decisions being made? And why are some diseases considered priorities to receive funding? There is very little detail to answer these questions.
Australia’s allocation of research funding through the MRFF is diverging from long-held traditions in other countries, such as the United Kingdom, which apply the “Haldane principle”. This involves researchers deciding where research funding is spent, rather than politicians.
* This article has been updated since publication to clarify the 10,000 home care packages have been previously announced.
As the royal commission begins investigating the failures of the residential aged care sector, it is important such a review also considers the broader socio-political factors that have contributed to this crisis.
The commission needs to go beyond the institutional problems at individual aged care facilities, as these are a symptom of a much broader rejection of ageing in society and marginalisation of older people.
Negative stereotyping of older people is reinforced in the media, and this both informs and reflects societal attitudes. In Western society especially, we fear dependency, invisibility and dying. Aged care is a silo of these fears. And until it affects us personally, we ignore it.
How older people are marginalised in society
We have an expiry date in our society. This is not the date we die, but a time when our skills and knowledge are no longer considered to be valid or useful. Our value is largely determined by our economic contributions to society. But for many older people, this is difficult to demonstrate because they’re no longer in the workforce.
The economic impact of societal rejection of ageing is significant. Modelling by Price Waterhouse Cooper indicates that Australia’s gross domestic product would increase by almost 5% if people were supported to work longer. And data from the Australian Bureau of Statistics reveal that many Australians would like to retire later if they could.
Yet, there is evidence that older people are routinely denied work. In 2016, Age Discrimination Commissioner Susan Ryan said there was an urgent need to “tackle the discrimination that forces people out of work years before they want to leave”.
While older people should be supported to work longer if they wish, over half of Australians between the ages of 65 and 80 report a moderate or severe disability, resulting in greater dependency. A 2017 study of late-life dependency published in The Lancet found that, on average, older people will require 24-hour care for 1.3 to 1.9 years of their lives.
However, it is important that older people are not considered redundant in their societal role when dependency increases.
Aged care workers are also undervalued
Residential aged care facilities fulfil an essential role in our society. Yet, our recent ethnographic study in two residential aged care facilities in Victoria shows how this role has been compromised by an under-skilled, under-valued and overworked aged care workforce.
Older people were exposed to a revolving door of anonymous workers, significantly reducing opportunities for teamwork and fostering relationships between staff and residents. In one of the not-for-profit facilities, a single registered nurse was responsible for the care of 73 residents. This contributed to the delegation of an increasing range of tasks to unregistered personal care assistants with minimal training and delays in recognising signs of health deterioration among residents.
A reliance on general practitioners also increased the likelihood of hospital transfer. And hospital transfers can sometimes prove harmful, with previous studies showing that the noisy, fast-paced environment, bright lights and anonymous faces can have a negative impact on residents, particularly those with dementia.
Within the healthcare sector, aged care has the lowest status of all specialty areas amongst nurses and doctors. Recruiting appropriately qualified and skilled people to work in aged care is thus a constant challenge. Australia is expected to increasingly rely on imported labour to staff its aged care sector in the near future.
Ways to fix the system
Encouraging more healthcare professionals to enter the aged care sector will require a multi-pronged approach, starting with finding ways to engender more professional respect for those working in the field.
Greater emphasis also needs to be placed on improving the gerontological expertise of aged care workers. This can be strengthened by prioritising aged care in medical school education and recognising “nursing home” care as a specialist medical area. It is also imperative that personal care assistants receive greater recognition of the roles and duties they perform.
Registration of personal care assistants as third-tier health care professionals is well overdue to ensure better oversight of their training and scope of their practice.
We also need to recognise the importance of human connection in residential aged care facilities. This requires strategies to build better relationships between residents and staff, and developing a formula for more accurate staffing allocations that reflect the real time commitments involved in aged care.
Who bears the ultimate responsibility?
It’s not enough to be shocked by the aged care scandals uncovered by the media and the decision to appoint a royal commission to investigate. We must also make older people, their contributions and end-of-life needs more visible. Increased funding and oversight will only come when we collectively say it’s important.
It is incumbent on us to ensure that residential aged care facilities do not operate as holding bays for the silenced, or wastelands for the discarded, where the occupants are expected to demand nothing and be as little cost to society as possible.
We have an opportunity to reconstruct the delivery of residential aged care. Let’s begin with the end in mind: a society that not only values older people, but values the resources required to provide the care they need and deserve.
There has been no shortage of inquiries into the aged care system over the past few decades. That shocking systemic problems of neglect and abuse remain, as revealed by the ABC’s recent Four Corners expose, highlights the failure of government and industry to act on the recommendations arising from these investigations.
We can only be optimistic that the royal commission into the quality and safety of aged care will help change that. A royal commission will capture the public consciousness in a way other inquiries have not. It will document hundreds, if not thousands, of individual stories. Its proceedings will lead to extensive media coverage, and invite a national conversation. Its recommendations should prove harder for governments to shelve.
But there is no reason for government and industry to wait years for the royal commission to hand down a report. They can act now to make real progress, based on what we know already.
Three months ago the Aged Care Workforce Strategy Taskforce, which I chaired, delivered its report on ways to improve aged care. Based on listening to thousands of people throughout the aged-care sector over nine months, our report outlines 14 areas for action to support Australia’s aged care workforce in their essential role of caring for some of the frailest, most vulnerable members of society.
There is no need to wait on making the changes our report recommends.
By acting immediately, meaningful strategic reform can be implemented within the next three years. It can make a real difference to the quality of aged care well before the royal commission has completed its work.
Fragmented industry needs a unifying code
The aged care industry is fragmented, made up predominantly of small to medium enterprises spread across community, home and residential care settings. It relies on a diverse workforce under pressure from rising expectations and other changes much outside its direct control.
Our report’s central recommendation is the need for the aged care industry to embrace a voluntary code of practice. This code can help focus the minds of care providers on standards, workforce practices and commitments to quality and safety. This in turn will focus attention on the need to attract and retain committed, high-quality staff.
We are pleased the industry has embraced this idea. Industry leaders have also supported initiatives to improve the skills and qualifications the industry demands of its workers.
There is a need for the education and training sector to get on board, ensuring graduates have the skills and knowledge that support safe, quality care.
We need a holistic approach to care
One important finding from our investigation is that those in care, and their families, want a more holistic approach to caring. What they don’t want is narrow “clinical” care, one that treats mental health with a pill or judges a meal just on its calories. Well-designed care needs to consider all aspects of health, as well as cultural needs and aspirations around “living well”.
There are clear funding implications. To provide holistic care requires changing how money is spent, as well as how much.
Simply stated, as a society we have been short-changing the elderly.
That is why our first recommendation is the need for a concerted social change campaign to reframe caring and promote the importance of aged care as a work vocation.
As the report notes, shifting negative attitudes towards ageing, the elderly, death and dying is a social challenge:
It begins with understanding that care for older people is broader than organised, professional care. These factors contribute to the perception that aged care is not a career of first choice. The opportunities that ageing and aged care present in terms of employment, research, contribution to the economy and as a driver for innovation also go largely unrecognised.
The spotlight the royal commission will place on aged care should help provoke some serious social soul searching. We need a national conversation about our attitudes to ageing. We need to recognise the problems besetting the industry are but a subset of a wider attitudinal problem that has undervalued the elderly.
But the royal commission must not be used as an excuse to procrastinate. There are actions now we know we can take. We should take them.
Most older people want to stay at home as long as they can. When this is no longer possible, they move into residential aged care facilities, which become their home. But Australia’s care facilities for the aged are growing in size and becoming less home-like.
Today, more than 200,000 Australians live or stay in residential aged care on any given day. There are around 2,672 such facilities in Australia. This equates to an average of around 75 beds per facility.
Large institutions for people with disability and mental illness, as well as orphaned children, were once commonplace. But now – influenced by the 1960s deinstitutionalisation movement – these have been closed down and replaced with smaller community-based services. In the case of aged care, Australia has gone the opposite way.
Evidence shows that aged care residents have better well-being when given opportunities for self-determination and independence. Internationally, there has been a move towards smaller living units where the design encourages this. These facilities feel more like a home than a hospital.
The World Health Organisation has indicated that such models of care, where residents are also involved in running the facility, have advantages for older people, families, volunteers and care workers, and improve the quality of care.
Around 50% of residents living in aged care facilities have dementia. And research has shown that a higher quality of life for those with dementia is associated with buildings that help them engage with a variety of activities both inside and outside, are familiar, provide a variety of private and community spaces and the amenities and opportunities to take part in domestic activities.
In June 2018, an Australian study found residents with dementia in aged-care facilities that provided a home-like model of care had far better quality of life and fewer hospitalisations than those in more standard facilities. The home-like facilities had up to 15 residents.
The study also found the cost of caring for older people in the smaller facilities was no higher, and in some cases lower, than in institutionalised facilities.
There are some moves in Australia towards smaller aged care services. For example, aged care provider Wintringham has developed services with smaller facilities for older people who are homeless. Wintringham received the Building and Social Housing Foundation World Habitat Award 1997 for Wintringham Port Melbourne Hostel. Its innovative design actively worked against the institutional model.
Bigger and less home-like
Historically, nursing homes in Australia were small facilities, with around 30 beds each, often run as family businesses or provided by not-for-profit organisations. Between 2002 and 2013 the proportion of facilities with more than 60 beds doubled to 48.6%. Financial viability rather than quality of care drove the increase in size.
Today, around 45% of facilities are operated by the private for-profit sector, 40% by religious and charitable organisations, 13% by community-based organisations, 3% by state and territory governments, and less than 1% by local governments.
In 2016, the Australian Institute of Health and Welfare (AIHW) reported that residential care services run by government organisations were more likely to be in small facilities. One-fifth (22%) of places in these facilities are in services with 20 or fewer places. Almost half (49%) of privately-run residential places are found in services with more than 100 places.
All of this means that more older Australians are living out their last days in an institutional environment.
Once larger facilities become the norm, it will be difficult to undo. Capital infrastructure is built to have an average 40-year life, which will lock in the institutional model of aged care.
The built environment matters. The royal commission provides an opportunity to fundamentally critique the institutional model.
Tonight ABC’s Four Corners will air the first of a two-part investigation into the often shocking treatment of the elderly in aged care homes around Australia.
The timing coincides with Prime Minister Scott Morrison’s weekend announcement of a royal commission into Australia’s aged care system. The prime minister said poor standards had led authorities to close one aged centre per month since the Oakden aged mental health home scandal.
South Australia’s Oakden facility closed nearly a year ago, following revelations of abuse and neglect dating back a decade.
While the terms of reference are yet to be determined, the royal commission will likely look into issues already raised by previous inquiries into the sector. These include the changing demands of Australia’s ageing population, staffing ratios, funding levels and the mental health, well-being and safety needs of nursing home residents.
Below are five articles in which our experts have previously explored the complex aspects of Australia’s aged care system, drawing on research which has exposed where the problems are, and have been for some time.
Lack of medical care
Our ageing population, and the focus on helping the elderly stay at home for as long as possible, means by the time people enter aged care they are older and sicker than before. Around half of people living in aged care today have dementia, depression, or another mental health or behavioural condition.
In fact, the proportion of older people requiring high care for complex needs, which includes assistance with all activities of daily living such as eating and bathing, has quadrupled from 13% in 2009 to 61% in 2016.
Yet there is no legal requirement for all aged care facilities to provide 24-hour registered nursing care. In the article below, Jane Phillips, David Currow, Deborah Parker and Nola Ries explore how today’s nursing home residents have minimal access to quality medical care.
Research consistently shows more people want to stay in their own homes as they age. In the 2018-19 budget, the government announced an extra A$1.6 billion over the next four years for an additional 14,000 Home Care Packages. These deliver an agreed set of services to meet the specific needs of aged Australians who want to remain at home.
The government also subsidises a number (currently around 283,000) of residential care places for older people unable to continue living independently.
Aged care subsidies are allocated through a ratio, which aims to provide 113 subsidised care places for every 1,000 people aged 70 and over. This ratio will increase to 125 places for every 1,000 by 2021-22. Within the overall number of places, the government also sets sub-targets for the numbers of Home Care Packages and residential care places.
The government is aiming to amend the ratio in favour of more home care packages. By 2021-22, the target for home care packages will increase from 27 to 45 per 1,000, while the residential target is to reduce from 88 to 78 per 1,000.
But as Professor of Health Economics at University of Technology Sydney, Michael Woods has written, this still won’t be enough to meet demand.
Older Australians living in nursing homes represent one of society’s most vulnerable populations. More than 50% of residents in nursing homes suffer from depression compared to 10-15% of adults of the same age living in the community.
Recent research conducted by Briony Murphy and Professor Joseph Ibrahim from Monash University’s Health Law and Ageing Research Unit, found around 140 Australian nursing-home residents took their own lives between 2000 and 2013.
The authors found nearly 70% of those who took their own life were male, 66% had a diagnosis of depression and nearly 80% were experiencing one or more major life stresses, such as health deterioration. Around 43% were experiencing isolation and loneliness, and nearly 30% had trouble adjusting to life in a nursing home.
The small proportion of adults over 65 living with depression in the community shows that depression is not a normal part of the ageing process… the much larger figure of those suffering depression in nursing homes raises some serious questions.
Stories of abuse and neglect in nursing homes have also highlighted the issue of poor nutrition and oral health. In November 2017, the dire state of this was shown in a report of a nursing home resident in NSW who was found with maggots in her mouth the day before she died.
Researchers have long highlighted people living in aged care have substantially poorer oral health and three times the risk of untreated tooth decay than people living in the community.
Bronwyn Hemsley, Andrew Georgious, Joanne Steel and Susan Balandin collated a list of ways family members can help ensure their loved ones’ oral health is adequately looked after. This includes visiting your family member around mealtimes
…or helping the person to eat… Ask the resident permission to look into her mouth to check if she is swallowing or removing leftover food promptly.
It is no secret people are living longer, thanks to advances in medical technology. Futurist Ray Kurzweil predicts we are approaching a point of breaking even – where for every year lived, science can extend lifespans by at least that much. And more than 80% of Kurzweil’s predictions have so far proved correct.
But length of life and quality of life are not the same thing. For good quality of life as one ages, there must be optimal retirement options. The default is to stay in one’s current home for as long as possible, or downsize. Some will settle into the quiet life of a retirement village on the urban fringes.
Driving the trend are well-heeled baby boomers (those born between 1946 and 1964) who have been using technology at home and work for years. For some, technology has been integral to their lives. And it seems it might be integral to the future of retirement living.
Vertical retirement communities
The chair of the NSW inquiry into retirement villages, Kathryn Greiner, recently recommended integrating designated seniors’ apartments in medium or high-rise residential developments where people of all ages live. Experts have said such retirement communities are the “way of the future”.
But the future is already here, as greater numbers of vertical retirement communities in high-rise apartment buildings are being built in inner-urban areas around Australia. They offer high levels of luxury with ready access to the kinds of amenities inner-city dwellers have grown accustomed to.
High-rise retirement villages would typically be equipped with various smart technologies that connect with the larger technological infrastructure of the city.
Similar to luxury hotel suites, residents would have a spectrum of in-house services and entertainment options presented via internet-connected smart TVs.
Multimedia suites would be there for augmented or virtual reality experiences – travel and education being among them. In-house cinemas would host movie nights.
The way we’re heading, technology-enabled, proactive health management will likely be built into the infrastructure of these retirement villages. It will allow people to stay healthy and live independently at an advanced age, forestalling the time when a move to aged care becomes necessary.
The health-maintenance technology available today means retirees hardly need to leave home for a checkup. Telehealth gives on-demand access to doctors via the internet. Visiting nurses have their role in looking after the elderly at home.
Then there are the dozens of smartphone apps that monitor vital signs, some of which send timely warnings before something becomes a problem.
And while high-rise living may not offer the same access to the outdoors for walking and exercise, technology has other options.
“Exergames” – video games that enable physical activity – are a segment of the computer game industry known to be beneficial to people of all ages, including the elderly. Exergames lend themselves well to vertical communities by not needing much space. They are played either alone or with friends in self-contained virtual environments.
Apart from the physical benefits of exercise, exergames have also been shown to improve mental alertness, balance and coordination, all of which contributes to fewer injuries common to the elderly, such as fractured hips from falling.
Good help is not hard to find now with assistive technologies like Google’s Duplex. These personal assistants fit right into the high-tech home and allow people, wherever they live, to stay independent for longer.
The assistant can keep your diary, make appointments over the phone, buy flowers and have them delivered, turn on the lights, call a taxi and more. Autonomy aids like this could delay the transition to aged care.
High-rise apartments are a thorny issue in suburban neighbourhoods, regardless of who is living in them. There are already some objections to high-rise aged-care facilities. But these mainly come from existing low-rise residents who are not happy to have any high-rise buildings in their neighbourhood.
Some are concerned that high-rise communities will lead to social isolation. Traffic congestion is also a concern.
When managed well in an architectural and town planning sense, vertical communities offer high-quality living while occupying a smaller urban footprint than a hundred detached dwellings. They can help reverse the urban sprawl of Australian cities, which are among the largest and least densely settled in the world. We love our big suburban houses, but they do consume vast tracts of countryside.
People want to live out their days in the freedom of their own home, not in an institution, no matter how benevolent. And it’s in the national interest to relieve pressure on the public health system. Emerging health-optimising technology and vertical communities can enable this. It’s a win-win.