HLCA

2

Learnings From Australia’s Failed Residential Aged Care System: A vision for the Future

Abstract

The following report discusses Australia’s failed residential aged care (RAC) system and the associated poor outcomes of older people. The key factors contributing to this failure are critically analysed and their interconnectedness considered in line with a systems thinking approach. Poor health outcomes and serious adverse events have been found in relation to Australia’s failed RAC system. Inappropriate use of restraint, adverse health events and preventable deaths were found to be systemic within RAC following the well-publicised Royal Commission into Aged Care Quality and Safety. Three key causative factors are discussed. Firstly, an inadequately skilled workforce, understaffing, and overreliance on unskilled workers have contributed to poor care delivery and outcomes. Secondly, insufficient governance and regulation has meant both the commonwealth and RAC providers have failed to meet their accountability to safety and quality standards and have missed opportunities to learn and improve from failures. failures. Lastly, consumer access to healthcare and specialist services have been hindered by funding barriers and poor integration Australia’s broader healthcare system.

Long-term residential care systems are essential in promoting healthy ageing (World Health Organisation, 2021). For older Australia’s whose health prevents them from living at home, the residential aged care (RAC) system delivers 24-hour care and accommodation support. Given the vulnerability of older people, it is important this system can effectively deliver on health outcomes and improve population health. Unfortunately, Australia’s RAC system is widely associated with poor health outcomes. The recent royal commission into aged care revealed restrictive practices, abuse and neglect, and preventable deaths (Ibrahim, 2019). These negative outcomes, and the RAC system as a whole, are influenced by a multitude of stakeholders and contextual factors and their complex interconnectedness. This systems thinking approach, which when applied to future planning of healthcare interventions, can strengthen effectiveness through careful informed design (Savigny & Adam, 2009). The following report critically analyses the failed RAC system, the interrelated contributing factors, lessons learned and recommendations for the future.

System failures

Recent socio-political attention on Australia’s RAC system and the Royal Commission into Aged Care Quality and Safety has highlighted systemic failures in care and safety. The RAC system is widely associated with poor health outcomes for older people, including preventable deaths, inappropriate use of chemical and physical restraints, and instances of abuse and neglect (Ibrahim, 2019). Incidents of premature and preventable deaths in RAC has increased in the past decade, with falls contributing to the majority of these (81%), followed by choking (7.9%) and suicide (4.4%) (Ibrahim et al., 2017). Chemical restraints such as antipsychotics, anti-anxiolytics and antidepressants are frequently overprescribed to manage challenging behaviours, in particular in people living with dementia (Westbury et al., 2019). This is despite overwhelming evidence that chemical restraint is an ineffective behaviour management strategy, and increase the risk of adverse outcomes including falls, cardiovascular events and death (Westbury et al., 2019). Incidents of neglect and abuse of older people in Australia’s RAC system has recently drawn widespread public attention and anger. The Royal Commission highlighted shocking stories of elder abuse in Australia and this trend is seen internationally (Ibrahim, 2019; Myhre et al., 2020). Considered analysis of the factors contributing to these failings is essential for healthcare leaders to learn and improve the system for the future.

Workforce

Adequate staffing levels and skills are essential for RAC to provide best practice care (Bonner et al., 2021). Staffing levels and skill mix directly impact safety and quality outcomes for consumers (Eagar et al., 2020). The RAC workforce has been shown to be inadequate in terms of staffing levels, skill mix and education. Over half of consumers living in RAC are affected by inadequate staffing levels, and Australia rates poorly against international benchmarking (Eagar et al., 2020). Registered healthcare professionals are grossly underrepresented, with nurses comprising 25% and allied health only 1.4% of the workforce (Department of Health, 2017). On average per day, consumers receive 36 minutes of care from qualified nurses and only 8 minutes from allied health professionals, mostly physiotherapists (Eagar et al., 2020). These time constraints hinder organisations from delivering safe quality care.

The inadequacy of current staffing models and the lack of legal mandate on staffing levels and skill mix has contributed to neglect and missed care for RAC consumers (Bonner et al., 2021). While these macro-system factors require a nationwide solution, there is much to learn from the meso-system factors within organisations themselves that have further contributed to care failings. A recent study found a lack of staff skills and competency to be a significant contributing factor to adverse events in RAC (Andersson et al., 2018). Healthcare leaders are accountable for ensuring their teams are adequately skilled to deliver effective care and services and must prioritise the learning and development needs of their workforce. The study also found that inadequate teamwork, documentation and communication contribute to serious adverse events and are interrelated to wider workforce issues (Andersson et al., 2018). Healthcare leaders must address communication and teamwork at an organisational level to help reduce the risks of adverse events.

Governance and Regulation

Governance ensures accountability across healthcare systems and is a key driver of quality and safety (Corkin & Kenny, 2017). The Royal Commission into Aged Care Quality and Safety (2021) found that insufficient governance at both the individual provider level and macro-system level contributed to adverse health outcomes for consumers. There is inconsistency in the quality of governance and leadership skills across RAC providers (Royal Commission into Aged Care Quality and Safety, 2021). Clinicians in management roles often lack additional training in clinical leadership and governance (Dwyer, 2011). From a system thinking perspective, it is clear that this ineffective governance and leadership is related to the underrepresentation of professional clinical staff. Higher up the chain, some executives and boards lack clinical expertise and focus more heavily on financial risk than clinical risk (Royal Commission into Aged Care Quality and Safety, 2021). At a national level, regulation of the RAC system is insufficient, and there is no focus given to learning from adverse events and sharing these learnings to improve care at the system level (Hibbert et al., 2021).

Reflecting on these governance failings offers key learnings for healthcare leaders. Firstly, risk management is a key component of clinical governance. Leaders must ensure effective risk management systems are operational in RAC, as these form a key component of clinical governance (Corkin & Kenny, 2017). Secondly, leaders should work to foster safety cultures and adopt a ‘no-blame’ approach to adverse events, as these help to strengthen healthcare quality (Santa et al., 2018). Organisational culture is an important factor in clinical governance (Australian Commission on Safety and Quality in Health Care, 2017). Lastly, RAC leaders should ensure effective incident management systems are in place to accurately identify safety failures and risks (Australian Commission on Safety and Quality in Health Care, 2017).

Access to Specialist Services

The increasing complexity of healthcare needs in RAC calls for a multidisciplinary team approach, including specialists and allied health (Ibrahim, 2019). However, in reality, these health services are scarce in RAC due to funding (Flicker, 2021). Access to allied health professionals including physiotherapy, occupational therapy, speech pathologists, podiatrists and mental health professionals are severely limited in RAC (Royal Commission into Aged Care Quality and Safety, 2021). Access to specialist services are even worse and are poorly coordinated with state funded services (Flicker, 2021). Compared to their community-dwelling counterparts, people in RAC are less likely to see their GP or access specialist services (Australian Institute of Health and Welfare, 2019), and are less likely to access rehabilitation services (Mitchell et al., 2019). Learnings can be taken from these access inequalities. At a national level, allied health professionals and specialist professions have a responsibility to lobby for improved funding and representation of their services in RAC. Such lobbying has been seen in the recent Royal Commission into Aged Care Quality and Safety (2021). At an organisational level, leaders can learn the importance of building effective partnerships with local community services and providers to enhance multidisciplinary care delivery.

System Future and Recommendations

Demand on the RAC system will increase significantly in the future. This is due largely to Australia’s ageing population and their increasing reliance on RAC services related to an increase in chronic conditions (Karmel et al., 2012). The RAC system, as it currently exists, is not sustainable for the healthcare needs of older Australians into the future. However, the socio-political environment and recent royal commission into aged care provides strong cause for reform. The RAC system must harness this opportunity and address its weaknesses in order to ensure effective healthcare outcomes for older people in the future. The Australian Government has proposed a $17.7b reform package to improve the quality and sustainability of the aged care system (Department of Health, 2021). The five-year plan aims to address workforce and governance issues, along with strengthening the RAC system to improve care quality, safety and suitability for consumer preferences (Department of Health, 2021). A systems thinking approach can be applied to future recommendations of the RAC system. In careful consideration of the interrelated factors contributing to previous failings and lessons learned, the following recommendations are made to improve the RAC system in the future.

Improved Governance and Shared Learning

Healthcare systems rely on effective governance to drive accountability, quality and safety (Corkin & Kenny, 2017). To improve the RAC system for the future, it is recommended that attention be given to strengthening internal capabilities for governance. Indeed, researchers and the royal commission have called for a strengthening of RAC governance as a strategy to reduce preventable harm to aged care residents (Bonner et al., 2021; Hibbert et al., 2021). The RAC system should make use of resources and positive examples from within other sectors of Australia’s healthcare system. For example, in response to inconsistencies in governance across primary and acute healthcare, the Australian Commission on Safety and Quality in Healthcare (2017) devised a framework to improve clinical governance of healthcare systems. This framework addresses five key components of effective governance including leadership, culture, quality improvement systems, clinical performance, environment safety and consumer partnership (Australian Commission on Safety and Quality in Health Care, 2017). At a national level, the RAC system could incorporate this clinical governance framework into legislation and quality standards. At an organisational level, it is recommended that providers work to address each of the five key components in its strategic planning. For example, incident management systems and open disclosure are essential to improve safety and quality improvement systems (Australian Commission on Safety and Quality in Health Care, 2017).

The Royal Commission found that some RAC providers failed to respond to and appropriately investigate adverse events (Hibbert et al., 2021). In Sweden, adverse events in RAC are investigated by both providers and an independent body, and findings are deidentified and published (Andersson et al., 2018). This adds to the knowledge base of causative factors and supports the system to improve quality of care through shared learnings from failures (Andersson et al., 2018). Such approaches to investigation and transparency have been seen to be effective in other systems in healthcare systems such as hospitals in Australia and England, as well as high reliability industries such as aviation (Hibbert et al., 2021). However, the complex relationship between effective governance and the workforce cannot be ignored. Appropriate staffing levels and skills within leadership as well as registered clinical staff will be essential in improving clinical governance at the point of care (Bonner et al., 2021).

Workforce Capability

The future of the RAC system relies on its workforce. The evidence calls for increased staffing levels, skills and capabilities to improve the future of RAC (Bonner et al., 2021; Eagar et al., 2020). However, the current workforce issues are complex and interrelated to legislative and socio-political factors, and therefore require a systems thinking approach to any improvements. The Royal Commission has recommended workforce initiatives to address staffing levels, skill mix, training and retention (Bonner et al., 2021). Firstly, workforce planning should be regularly undertaken to ensure adequate staffing levels to meet increasing demand. To meet international benchmarks for minimum staffing levels as at current demand, the RAC system would require a 37.3% increase in its total workforce, including a 175% increase in allied health professionals (Eagar et al., 2020). Secondly, initiatives must further consider the combination of skill mix in the workforce, including adequate ratios of nursing, allied health and specialist staff. This will be essential to drive positive outcomes in light of the increasingly complex healthcare needs of consumers (Ibrahim, 2019). In recognising this, the Royal Commission has recommended mandated allied health staffing in RAC by 2024, including but not limited to occupational therapists, mental health professionals and pharmacists (Royal Commission into Aged Care Quality and Safety, 2021). Lastly, the system can aim to improve retention through initiatives targeting culture and training. Effective supervisor support for direct care staff can improve the quality of clinical care and reduce workforce turnover (Xerri et al., 2019). It is recommended the RAC system embeds a clinical supervision program for all levels of staff to improve workforce skills and foster a learning culture. Clinical supervision is an approach to professional development where supervisors provide clinical guidance and support to less experienced healthcare professionals (Snowdon et al., 2017). It is associated with more effective care and compliance with evidence-based practice and processes (Snowdon et al., 2017). Healthcare leaders in the system should further work to foster a positive culture that promotes learning, as this a key component in improving care quality and safety in RAC (Wells et al., 2019). Leadership styles and organisational structure in RAC should also be reviewed to move away from traditional medical model authoritative style leadership. This has been shown to be a barrier to safety in attempts to improve team collaboration and move to shared leadership at point of care (Gibb et al., 2016).

Healthy Ageing Services

Funding and service delivery models should be reimagined to encourage health promotion and healthy ageing. The World Health Organisation (2021) calls for healthcare policy and systems to focus on improving the functional ability of older people. Reablement offers one such model of care. A reablement approach aims to improve or maintain function in older people by leveraging an individual’s strengths and residual abilities and modifying the environment (Poulos et al., 2017). If older people in RAC are supported to maintain and improve their functional abilities, then this in turn will reduce the burden of care on the workforce. Evidence calls for such evidence-based approaches to improve person centred care and health outcomes for people living with dementia (Poulos et al., 2017; Rahja et al., 2020). Furthermore, it offers broader societal and economic benefits for the system. A recent cost benefit analysis highlights significant benefits to RAC providers and society, at relatively low cost to providers (Rahja et al., 2020). This initiative will be dependent on the above-mentioned recommendations to improve workforce skills, training and boost levels allied health professionals in the system, who play a key role in reablement of older people.

Conclusion

Australia’s RAC system has failed to provide safe quality care for older people with serious adverse outcomes. Shortfalls in the workforce, governance, regulation, and poor access to specialist services have contributed to these poor health outcomes. Important lessons from these failings provide direction to policy makers and healthcare leaders for the future of RAC. Demand for RAC services will significantly increase with the ageing baby boomer population and an increase in chronic health conditions. The effects of poor governance and regulation highlights the importance of robust accountability processes and continuous improvement. Furthermore, it highlights a key role for the regulatory body to lead system improvements through transparency and shared learnings. The results of an understaffed, under supported and under skilled workforce must be recognised, and leaders should ensure action to boost workforce capability and retention. The increasingly complex needs of older people calls for innovative approaches that promote health and functional ability into older age. This will rely on enhanced multidisciplinary and specialist care, moving away from traditional medical models and into the future. In summary, the failings of Australia’s RAC system have been influenced by a multitude of contextual factors, with analysis of its contributing factors highlighting significant opportunities for improvement into the future.

References

Andersson, Å., Frank, C., Willman, A. M. L., Sandman, P. O., & Hansebo, G. (2018). Factors contributing to serious adverse events in nursing homes. Journal of Clinical Nursing, 27(1-2), e354-e362. https://doi.org/10.1111/jocn.13914

Australian Commission on Safety and Quality in Health Care. (2017). National Model Clinical Governance Framework. Commonwealth of Australia. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-model-clinical-governance-framework

Australian Institute of Health and Welfare. (2019). Interfaces between the aged care and health sytems in Australia: First results. Australian Government. https://www.aihw.gov.au/reports/aged-care/interfaces-between-the-aged-care-and-health-system/contents/summary

Bonner, R., Peters, M. D. J., & Butler, A. (2021). Workforce: The bedrock of aged care reform. Australian Economic Review, 54(2), 285-293. https://doi.org/10.1111/1467-8462.12427

Corkin, D., & Kenny, J. (2017). Quality patient care: Challenges and opportunities. Nursing Management (Harrow, London, England), 24(7), 32-36. https://doi.org/10.7748/nm.2017.e1670

Department of Health. (2017). The aged care workforce, 2016. Commonwealth of Australia. https://www.gen-agedcaredata.gov.au/www.aihwgen/media/Workforce/The-Aged-Care-%09Workforce-2016.pdf

Department of Health. (2021). Australian government response to the final report of the royal commission into aged care quality and safety. Australian Government. https://www.health.gov.au/sites/default/files/documents/2021/05/australian-government-response-to-the-final-report-of-the-royal-commission-into-aged-care-quality-and-safety.pdf

Dwyer, D. (2011). Experiences of registered nurses as managers and leaders in residential aged care facilities: A systematic review. International Journal of Evidence-Based Healthcare, 9(4), 388-402. https://doi.org/10.1111/j.1744-1609.2011.00239.x

Eagar, K., Westera, A., & Kobel, C. (2020). Australian residential aged care is understaffed. Medical Journal of Australia, 212(11), 507-508.e501. https://doi.org/10.5694/mja2.50615

Flicker, L. (2021). Why is it so hard to organise healthcare for older people in residential aged care facilities in Australia? Internal Medicine Journal, 51(1), 11-12. https://doi.org/10.1111/imj.15158

Gibb, H., Freeman, M., Ballantyne, A., & Corlis, M. (2016). TeamCare: Development and evaluation of an evidence based model for supporting safer, quality care delivery to residents in aged care Facilities. Ageing International, 41(2), 117-138. https://doi.org/10.1007/s12126-015-9237-z

Hibbert, P. D., Clay‐Williams, R., Westbrook, J., Reed, R. L., Georgiou, A., Wiles, L. K., Molloy, C. J., & Braithwaite, J. (2021). Reducing preventable harm to residents in aged care: A systems approach. Australasian Journal on Ageing, 40(1), 72-76. https://doi.org/10.1111/ajag.12861

Ibrahim, J. E. (2019). Royal Commission into Aged Care Quality and Safety: The key clinical issues. Medical Journal of Australia, 210(10), 439-441.e431. https://doi.org/10.5694/mja2.50168

Ibrahim, J. E., Bugeja, L., Willoughby, M., Bevan, M., Kipsaina, C., Young, C., Pham, T., & Ranson, D. L. (2017). Premature deaths of nursing home residents: An epidemiological analysis. Medical Journal of Australia, 206(10), 442-447. https://doi.org/10.5694/mja16.00873

Karmel, R., Gibson, D., Anderson, P., Wells, Y., & Duckett, S. (2012). Care trajectories through community and residential aged care services: Disease effects. Ageing and Society, 32(8), 1428-1445. https://doi.org/10.1017/S0144686X11001231

Mitchell, R., Draper, B., Harvey, L., Wadolowski, M., Brodaty, H., & Close, J. (2019). Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged ≥ 65 years living in residential aged care and the community. Osteoporosis International, 30(2), 311-321. https://doi.org/10.1007/s00198-018-4800-6

Myhre, J., Saga, S., Malmedal, W., Ostaszkiewicz, J., & Nakrem, S. (2020). Elder abuse and neglect: An overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect. BMC Health Services Research, 20(1), 199-199. https://doi.org/10.1186/s12913-020-5047-4

Poulos, C. J., Bayer, A., Beaupre, L., Clare, L., Poulos, R. G., Wang, R. H., Zuidema, S., & McGilton, K. S. (2017). A comprehensive approach to reablement in dementia. Alzheimer's & Dementia, 3(3), 450-458. https://doi.org/10.1016/j.trci.2017.06.005

Rahja, M., Nguyen, K. H., Laver, K., Clemson, L., Crotty, M., & Comans, T. (2020). Implementing an evidence‐based dementia care program in the Australian health context: A cost–benefit analysis. Health & Social Care in the Community, 28(6), 2013-2024. https://doi.org/10.1111/hsc.13013

Royal Commission into Aged Care Quality and Safety. (2021). Final report: Care, dignity and respect. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/publications/final-report

Savigny, D. d., & Adam, T. (Eds.). (2009). Systems thinking for health system strengthening. Alliance for Health Policy and Systems Research, WHO. https://www.who.int/iris/bitstream/10665/44204/1/9789241563895_eng.pdf?ua=1.

Snowdon, D. A., Leggat, S. G., & Taylor, N. F. (2017). Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Services Research, 17(1), 786-786. https://doi.org/10.1186/s12913-017-2739-5

Wells, Y., Brooke, E., & Solly, K. N. (2019). Quality and Safety in Aged Care Virtual Issue: What Australian research published in the Australasian Journal on Ageing tells us. Australasian Journal on Ageing, 38(1), E1-E6. https://doi.org/10.1111/ajag.12638

Westbury, J., Gee, P., Ling, T., Kitsos, A., & Peterson, G. (2019). More action needed: Psychotropic prescribing in Australian residential aged care. Australian and New Zealand Journal of Psychiatry, 53(2), 136-147. https://doi.org/10.1177/0004867418758919

World Health Organisation. (2021). Decade of healthy ageing: Baseline report. Summary. World Health Organisation. https://apps.who.int/iris/rest/bitstreams/1348996/retrieve

Xerri, M., Brunetto, Y., & Farr‐Wharton, B. (2019). Support for aged care workers and quality care in Australia: A case of contract failure? Australian Journal of Public Administration, 78(4), 546-561. https://doi.org/10.1111/1467-8500.12379