Nursing home patients

April 2015

FocusNursing home patients

Models of general practitioner services in residential aged care facilities

Volume 44, No.4, April 2015 Pages 176-179

Richard L Reed

Background

Provision of timely and high-quality general practitioner (GP) services to patients in residential aged care facilities (RACFs) is essential for this group of patients as they have high medical needs.

Objective/s

The aim of this article is to describe different models for general practice care for patients in RACFs.

Discussion

Models for general practice services include the Continuity Model, where GPs follow long-term patients; the RACF Panel model, where GPs provide care to several patients in nearby RACFs; the GPs with Special Interest in Residential Aged Care (GPwSI RAC) model, where GPs provide regularly scheduled services to larger groups of patients; the Longitudinal General Practice Team (LGPT) model, where GPs provide team-based care; and RACF-based models of care, where GPs partner with RACFs. Hospital-based models of care have also been developed to provide in-reach services to patients in RACFs during episodes of acute illness. There is limited evidence for which of these models is most effective. Developing and testing different models of general practice care should be a priority.

Provision of timely and high-quality general practitioner (GP) services in Australian residential aged care facilities (RACFs) is essential for this expanding population of at least 170,000 people,1 who have substantial health needs.2,3 There is growing evidence that the current methods of delivering GP services to this population are not optimal, and there are high and rising rates of acute care services use4 and concerns about the quality of services provided.5 People in RACFs aged 65 years and above account for nearly 9% of hospital admissions,6 despite representing only 4% of this age group.7

GPs provide most primary care services on-site in RACFs. However, a survey by Catholic Health Australia (CHA) in 2010 of 90 affiliated RACFs indicated that only half of these facilities provide visiting rooms for GPs.8 A recent Bettering the Evaluation and Care of Health (BEACH) survey,9 conducted in 2012–13, indicated that 53% of GP participants provided care in an RACF in the previous month. This proportion increased by a small amount over the past decade (personal communication, Dr Helena Britt, University of Sydney). However, estimates provided by the Australian Medical Association (AMA) suggest that those who are regularly engaged in residential aged care are considerably fewer at only 21% of GPs.10 Reasons given by GPs for this low participation rate include inadequate remuneration and increased time required to care for this population.3 The Medicare Benefits Scheme (MBS) funds general practice services at the same level as in the GP’s surgery (with an additional call-out fee for travel time). This payment fails to sufficiently account for the high levels of non-contact time,11 including communicating with RACF staff, and makes involvement of other general practice staff such as practice nurses difficult to fund.

On average, GPs provide 17.1 separate MBS services annually when caring for an RACF patient for 1 year.12 Despite this number of services, RACF staff indicate that improved access could result in better care. The CHA survey noted that 54% of homes were struggling with accessing GPs but were able to cope, whereas an additional 15% of respondents reported that the difficulty they experienced in accessing GPs sometimes compromised patient care.8 Additionally, 57% reported GP access problems occasionally resulted in transfer to the hospital, and an additional 18% reported that hospital transfers occurred fairly frequently or regularly.

Optimal delivery of general practice services is best accomplished through planned organisation of clinical services, which are sometimes referred to as models of care. A range of general practice models can be identified. It should be noted that these models of care are not mutually exclusive; nor are all models of care included in this discussion.

The continuity model

Many GPs continue to provide care for their long-term patients after they move to an RACF.  This continuity model is viewed by the RACGP as the preferred model and that it is ‘always best’ for elderly patients to continue to see their regular GP.13

However, the proportion of patients cared for in the continuity model is likely to be lower than is typically assumed. In the previously described CHA survey,8 respondents at 43% of these facilities indicated that most residents (≥70%) need to have alternative arrangements made for general practice care at admission.

Additionally, after entry to these facilities, 55% of homes surveyed reported that most residents (≥70%) had changed within a few months to a GP who has existing patients residing in the home. Lack of continuity of GPs was much greater in the major cities, where only 17% of RACFs reported that most residents (≥70%) continued to receive general practice services from their prior GP. BUPA Aged Care, which operates many RACFs across Australia, states that only 30% of GPs in their facilities continue to provide care to their patients following admission.14

Disadvantages of changing GPs include loss of the long-term relationship and lack of information regarding prior healthcare. However, this may be mitigated by a fresh assessment by a different GP and potentially increased access to healthcare if the new GP is near the RACF. Evidence from the UK suggests having larger numbers of RACF patients at a facility results in more regular visiting by GPs.15 Not all GPs are interested in gaining the special knowledge and expanded skills required for RACF care, such as managing difficult behaviours in dementia or working in a setting where access to diagnostic tests, specialists or equipment is delayed. Additionally, capacity of RACFs to support in-facility services such as palliative care varies widely and knowledge of the skill mix of staff in each facility can contribute to better care.

RAC panel model

Some GPs accept new patients in nearby aged care facilities or see all of the RACF patients for their practice, allowing them to continuously provide care to a number of RACF patients referred to as a panel. Having a sufficiently sized panel allows GP access to the Aged Care Access Incentive (ACAI).16 This practice incentive payment (PIP) is currently worth up to $5000 annually for GPs who provide more than 140 occasions of RACF-identifiable services. On the basis of reported annual rates of general practice services,12 this would require an individual GP panel of 8–12 residents to obtain the full incentive. The additional compensation paid to an individual GP substantially increases funding for a panel of this size; however, once 140 eligible annual services are provided, there is no additional incentive payment. GPs need to be attached to a PIP-eligible (accredited) practice to receive the ACAI.

GPs with special interest in residential aged care (GPwSI RAC)

Some GPs regularly provide scheduled care in RACFs. These GPs tend to cluster their patients in a few facilities where they have established a relationship with RACF administration and staff and have substantial panel sizes. In the UK, these practitioners are referred to as GPs with Special Interest (GPwSI) and there are methods for accreditation, including for older adults.17 These GPwSI are typically very committed to providing aged care, despite the low compensation, and also appreciate the flexibility of working hours. As with many areas of specialisation in general practice, there are concerns raised regarding losses of generalist skills,18 particularly for those who solely provide care in this setting. However, GPwSI RAC are likely to be few in number but could account for care of a substantial number of RACF patients.

Longitudinal general practice team (LGPT) model

Currently there are few incentives for nurses to engage in the support of GPs in their work in RACFs. However, practice nurses have the capacity to enhance and substitute for GPs in this setting. The Australian Medical Association (AMA) and the RACGP wrote a position paper in 2006,19 which promoted a LGPT model that allows the doctor to delegate tasks related to the care of residents of aged care facilities to the general practice nurse (or, on occasion, other team members with clinical training) rather than to staff employed in the RACF. This paper also advocated for changes in MBS payments to facilitate this model.

Nurse practitioners can also provide RACF primary care services in a team-based model.20 However, evidence for this model of care is sparse and a recent systematic review using specified quality criteria was able to identify only two nurse practitioner studies from the USA that met the criteria. These papers were published at least a decade ago.20 The two studies found some improvements in care, including higher family satisfaction and greater attainment of resident-specific goals. The MBS allows for payments for nurse practitioner services in RACFs if engaged in collaborative practice with a medical provider. However, the payments for these services are considerably less than those paid to GPs (eg 57% of a GP standard consultation in 2014) without a supplemental call-out fee. This funding may not cover the costs of provision of these services by nurse practitioners. This low rate of reimbursement will be a substantial barrier to developing integrated GP–nurse practitioner models funded solely from MBS payments.

In a recent position statement, the AMA supports appropriate expansion of the role of nurses within a team-based model of care in RACFs but states that ‘all healthcare provided to older Australians must be coordinated by a medical practitioner familiar with the patient, who provides continuity of, and takes ultimate responsibility for, that care.’21 The AMA also notes that ‘nurse practitioners can only provide care within their scope of practice. Residents will still require access to medical practitioners to provide comprehensive medical care.’21 The Southern Adelaide, Fleurieu, Kangaroo Island Medicare Local has developed an LGPT model using GPwSIs, a practice nurse and a nurse practitioner trainee (Table 1).

Table 1. An example of a longitudinal general practice team (LGPT) model – REACH Aged Care

The Southern Adelaide, Fleurieu and Kangaroo Island (SAFKI) Medicare Local developed the REACH Aged Care in the South Program to support GPs and RACFs in their region.

REACH services included:

  • urgent assessment when a patient’s usual GP was unavailable during regular hours
  • interim coverage for GPs who were on vacation or ill
  • provision of ongoing medical services to RACF patients whose GP was no longer willing to provide care in the RACF.26

This program also worked with facilities to assist with their clinical governance. REACH became a major provider for ongoing care for residents using a GP–nurse team and there was high satisfaction with the services.

Training for nurse practitioners was also provided.

The program was initiated with funding from SA Health but closed in 2014 because of changes to government funding and subsequent changes to the REACH business model.27

RACF-based models of care

Some RACFs have established relationships with specific GPs to take most patients in a facility who lack a GP willing to provide ongoing care. Many of these GPs also provide input into clinical governance. There is a long history of aged care facilities in the USA partnering with primary care doctors as the US federal government mandates that a doctor be involved in RACF governance as part of their accreditation standards. These US RACF medical directors take responsibility for overall clinical care carried out at the facility. They apply their clinical and administrative skills to guide the facility in providing care, help the facility develop and manage quality and safety initiatives, including risk management, and provide information to facility staff and medical practitioners to aid understanding and provision of high-quality care.22 This work is compensated by the facility.

The AMA has released position statements21,23 on the medical care of older adults that are consistent with this approach. These statements recommend that all staff employed in RACFs should be appropriately trained and be involved in continuing educational programs. Regular discussion of patient care issues between the patient’s GP and other providers of care is also recommended. The document states that quality assurance procedures should also be established to facilitate monitoring by medical practitioners of the clinical services provided to residents and recommends retainer arrangements between RACFs and medical practitioners to support this.

Recently BUPA Aged Care has begun employing GPs to work in its facilities in line with this approach (Table 2).

Table 2. An example of a RACF-based model of
care – BUPA Integrated Health Care model

BUPA Aged Care has developed the Integrated Health Care (IHC) model for its RACFs where it employs vocationally registered GPs with a strong interest in geriatric medicine in the aged care setting.27

GPs provide individual services in on-site consulting rooms, which include the capacity to perform simple procedures.

GPs are provided with training as required.

The IHC GP also works with a specialist nurse on-site in providing clinical oversight for clinical care in the facility including the ability to provide leadership and training to nurses to deliver more complex medical care.

The IHC model has been implemented in 20 aged care homes28 and BUPA intends to roll out the model across all of its facilities.

This program is currently being evaluated by the University of Tasmania.

Hospital-based in-reach services

People living in RACFs have high rates of transfer to hospital. A number of programs have been developed to reduce the rate of acute care service use, which are funded by the Australian states and territories that provide these services. These models of care include:

the State of Victoria In-Reach Services,24 which provide a range of medical and nursing services to RACFs to reduce emergency department demand

programs using paramedics25 who visit RACFs to deal with acute problems such as minor suturing or replacing percutaneous endoscopic gastrostomy tubes

Silverchain’s Home Hospital program, which provides hospital level services (eg intravenous antibiotics) in community settings including RACFs.26

These programs show promising results in reduction of acute care services use but often do not address ongoing care issues (eg lack of GP access or quality-of-care issues). These models return the patients to general practice care after a period of high need and do not add to the capability within the general practice.

Conclusion

Several models of general practice care for RACFs are in use in Australia. More comprehensive models such as team or facility-based models have the potential to provide responsive and integrated services but are limited by low rates of reimbursement through the MBS. Historically, the development and evaluation of new models in this sector has relied on supplemental funding from a range of government or private sources and, indeed, the sustainability of models currently in operation is likely to require ongoing subsidy. Those models of care, which promote improvements in general practice services within RACFs, as well as effective involvement of GPs in clinical governance, should be supported. More rigorous evaluations of initiatives in this area would strengthen the case for increased public funding of these models, which is well overdue. The new Primary Health Care Networks (PHNs) would be well placed to support initiatives in this sector.

Key points

  • Several different models for general practice services in RACF exist but all are limited by low levels of reimbursement.
  • The GP panel model provides access to the Aged Care Access Incentive (ACAI), which provides a payment to GPs who maintain a panel of RACF patients and provide a sufficient number of eligible services.
  • New models of RACFs are developing that provide the opportunity for GPs to contribute to clinical governance and quality improvement.

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

Acknowledgement

The author would like to acknowledge assistance of the BEACH team at the Family Medicine Research Centre, University of Sydney, in their analysis of provision of RACF services over time.

References

  1. Australian Institute of Health and Welfare. Residential aged care in Australia 2010–11: a statistical overview. Canberra: AIHW, 2012. Available at www.aihw.gov.au/publication-detail/?id=10737422821 [Accessed 24 September 2014].
  2. O’Halloran J, Britt H, Valenti L. General practitioner consultations at residential aged-care facilities. Med J Aust 2007;187:88–91.
  3. Gadzhanova S, Reed R. Medical services provided by general practitioners in residential aged-care facilities in Australia. Med J Aust 2007;187:92–94.
  4. Hillen JB, Reed RL, Woodman RJ, Law D, Hakendorf PH, Fleming BJ. Hospital admissions from residential aged care facilities to a major public hospital in South Australia (1999-2005). Australas J Ageing 2011;30:202–07.
  5. Looi JC, Macfarlane S. Psychotropic drug use in aged care facilities: a reflection of a systemic problem? Med J Aust 2014;200:13–14.
  6. Australian Institute of Health and Welfare. Movement between hospital and residential aged care 2008–09. Canberra: AIHW, 2013. Available at www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129544618 [Accessed 24 September 2014].
  7. Australian Institute of Health and Welfare. Where do Australian’s older people live? Canberra: AIHW, 2013. Available at www.aihw.gov.au/publication-detail/?id=6442468045&tab=2 [Accessed 25 September 2014].
  8. Catholic Health Australia. Survey of access to general practitioners in residential aged care. 2010. Available at www.cha.org.au/images/policy/Survey of GP Access in Residential Aged Care.pdf [Accessed 24 September 2014].
  9. Britt H, Miller G, Henderson J, et al. General practice activity in Australia 2012–13. Sydney, 2013. Available at hdl.handle.net/2123/9365 [Accessed 24 September 2014].      
  10. Hambleton S. Aged care: three areas in need of support. Financial Review. 2 April 2014.
  11. Australian Medical Association. AMA Aged Care Survey Report. 2012. Available at https://ama.com.au/ama-aged-care-survey-2012 [Accessed 30 September 2014].
  12. Taylor MJ, Edvardsson D, Horey D, Fetherstonhaugh D, Nay R, Swerissen H. General practitioner service provision in residential aged care facilities: 1998–2011. Australas J Ageing 2013;32:56–59.
  13. Swannell C. Aged care ‘broken’. MJA Insight. 7 April 2014.
  14. Hospital and Aged Care. Bupa plans to revolutionise aged care. 2013. Available at www.hospitalandagedcare.com.au/news/bupa-plans-to-revolutionise-aged-care [Accessed 30 January 2015].
  15. Evans G, Grimley Evans J, Lasserson DS. Questionnaire study of the association between patient numbers and regular visiting by general practitioners in care homes. Age Ageing 2012;41:269–72.
  16. Australian Government, Department of Human Services. Practice incentives program: general practitioner aged care access incentive guidelines, September 2013. Available at www.medicareaustralia.gov.au/provider/incentives/pip/files/gp-aged-care-access-incentive-guidelines.pdf [Accessed 30 January 2015].
  17. Royal College of General Practitioners. GP with a Special Interest (GPwSI) accreditation. Available at www.rcgp.org.uk/clinical-and-research/clinical-resources/gp-with-a-special-interest-gpwsi-accreditation.aspx [Accessed 30 September 2014].
  18. Wilkinson D, Dick ML, Askew DA. General practitioners with special interests: risk of a good thing becoming bad? Medical J Aust 2005;183:84–86.
  19. Australian Medical Association and Royal Australian College of General Practitioners. GP Services in residential aged care facilities. 2006. Available at https://ama.com.au/gp-services-residential-aged-care-facilities [Accessed 24 September 2014].
  20. Donald F, Martin-Misener R, Carter N, et al. A systematic review of the effectiveness of advanced practice nurses in long-term care. J Adv Nurs 2013;69:2148–61.
  21. Australian Medical Association. Access to medical care for older Australians. 2012. Available at https://ama.com.au/position-statement/access-medical-care-older-australians-2012 [Accessed 25 September 2014].
  22. American Medical Directors Association. The nursing home medical director: leader and manager. 2011. Available at www.amda.com/governance/whitepapers/A11.cfm [Accessed 25 September 2014].
  23. Australian Medical Association. AMA Position Statement on Care of Older People 1998. Amended 2000 and 2011. Available at https://ama.com.au/position-statement/care-older-people-1998-amended-2000-and-2011 [Accessed 25 September 2014].
  24. Street M, Considine J, Livingston P, Ottmann G, Kent B. In-reach nursing services improve older patient outcomes and access to emergency care. Australas J Ageing 2014; doi: 10.1111/ajag.12137 [Epub ahead of print].
  25. Jensen JL, Travers AH, Bardua DJ, et al. Transport outcomes and dispatch determinants in a paramedic long-term care program: a pilot study. CJEM 2013;15:1–8.
  26. Reed RL, Erny-Albrect K, Oliver-Baxter J, Stanners M, Shelby-James T, Bywood P. Promoting clinical engagement and cross-sector collaboration through changes in workforce, use of technology, and improved business systems. Forrest ACT, 2014. Available at http://dspace2.flinders.edu.au/xmlui/handle/2328/27678 [Accessed 25 September 2014].     
  27. Waterford K. Bupa to employ GPs in aged care homes Australian Medicine. 10 September 2013. Available at https://ama.com.au/ausmed/bupa-employ-gps-aged-care-homes [Accessed 25 September 2014].
  28. BUPA Aged Care. GP Opportunities. Available at http://bupaagedcare.com.au/careers/GP-Opportunities [Accessed 3 October 2014].

Correspondence afp@racgp.org.au

02 June 2015 09:45

Re: Models of general practitioner services in residential aged care facilities

Michael Sosnin

GP

Boronia Medical Centre

Dear Editor,

I was saddened but not surprised to learn that of the 43,400 GPs in Australia(1) only 21% of them regularly attend RACFs,(2) so least 70% of patients entering an RACF will no longer be cared for by their usual GP.

Gordon et al(3) note that 176,816 Australians currently reside in RACFs, therefore those GPs that still attend RACFs each care for an average of 19 residents. If each resident is seen on 17 occasions per year,(2) or once every 3.5 weeks,(3) this equates to six RACF visits each week for these GPs. Despite this workload, Reed notes that the medical needs of many RACF residents remain unmet, hence the emergence of alternative models of care, such as the nurse-based “longitudinal general practice team”.

Reed cites low remuneration, time pressures and lack of visiting (examination) rooms as factors in the low GP attendances. I would include delays in finding staff, patients, medication charts; staff unfamiliar with the patient and cumbersome electronic records. I sympathize with the dedicated nursing staff at these facilities, who face chronic understaffing, high turnover, and increasing bureaucratic pressures. Where possible, I try not to visit during meal times, bath times, hand-overs or after hours. However, I remain frustrated by the wide discrepancies between the RACFs I attend: some without staff qualified to give injections and varying policies regarding prescriptions and medication charts.

So, it’s not surprising that the majority of GPs do not attend RACFs. Many in our overworked profession do no home or after hours visits at all. But the need for these services will only increase in the future - will our loved ones (or indeed, we ourselves) still be looked after by our usual GP?

I have no clear answer, but would simply ask readers to consider this hypothetical situation: if the 4 out of 5 GPs shared the load evenly, each GP would care for approximately 4 patients, rather than 19, which equates to just 1.3 RACF visits per week.

With this suggestion, I do not seek to disparage the good work of GPs working under the RAC panel, or on-site RACF models. The continuity (“cradle to the grave”) model does however, remain the RACGP’s preferred system of RACF care. We risk further de-skilling and losing this traditional domain of general practice if we do not set an example to future generations of GPs.

Dr Michael Sosnin
M.B., B.S., F.R.A.C.G.P.

References

1. Australian Bureau of Statistics. Census of Population and Housing 2011. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features20April+2013 [Accessed 2 June 2015].
2. Reed RL. Models of general practitioner services in residential aged care facilities. Aust Fam Physician 2015;44:176–79.
3. Gordon J, Harrison C, Miller G. General practice encounters with patients living in residential aged care facilities. Aust Fam Physician 2015;44,:173–74.

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