Overview of residential aged care
The lifetime risk of requiring aged care home care in Australia is estimated to be 20% for men and 34% for women.3 Approximately 6% of people aged over 65 years (and 30% of people aged over 85 years) live in RACFs. There are equal proportions of men and women aged 65-74 years; but by age 85 years, residents are predominantly women.4 The residential aged care population includes groups with special needs such as Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, and people with physical and intellectual disabilities.
Residential aged care facilities provide accommodation, personal care and other support services such as pharmacy, allied health, social services, specialist services or respite care. Facilities can be owned and managed by charitable not for profit, private for profit, or government organisations.
Residential aged care is regulated under The Aged Care Act 1997 (Commonwealth) and accredited via the Aged Care Standards and Accreditation Agency.5 There is an expectation of continuous improvement to services, and facilities must be accredited to receive subsidies. The Australian Government Department of Health and Ageing regularly audits facilities and residential care claims.
Facilities provide accommodation and high care and/or low care to eligible older people who are assessed by an Aged Care Assessment Team (ACAT) (Aged Care Assessment Teams are known as Aged Care Assessment Services (ACAS) in Victoria). The Resident Classification Scale (RCS) is used to assess the level of care and support needs of the individual. Based on this, an Australian Government subsidy is paid per resident per day. People entering are income tested with some residents expected to pay additional fees. An accommodation payment may also apply. Overall, there are about 140 000 government subsidised beds comprising 74 000 high care (formerly aged care home care) and 66 000 low care (formerly hostel care).6 Ageing in place facilities enable residents to remain in the same facility as their care needs increase from low to high care.
There are increasing demands for residential care as the population ages, and as informal care by family members becomes a less viable option due to shifting work patterns and higher levels of family mobility.7
The transition into residential care
An older person requiring residential care will usually have had a period of care in their own home. They may or may not progress to requiring residential care. This may occur with a progressive disorder such as dementia (or with an acute event superimposed upon a progressive disorder), with admission occurring at a level of dependence when family and community support services can no longer meet the aged person's needs. Alternatively, the journey may be sudden for a previously independent person with an abrupt onset of disability due to an illness such as a stroke or hip fracture. Here the person and their family experience the shock of rapid changes to their needs and circumstances. They may be confronted by pressure for early hospital discharge. Decisions about future care may be made hastily, during a time of confusion, shock and grief. The care setting that is appropriate for an older person, and that meets his or her particular needs will be assessed by an ACAT.8
The Australian Government publication, 5 steps to entry into residential care provides a resource that assists in understanding what residential care is, what to expect and how to arrange it.
General practitioners play a significant role in supporting patients making the transition into residential care. They may be able to continue providing care, however some GPs do not visit RACFs , and some people need to find a new GP if they enter a facility in another locality. General practitioners can ease the move for the patient and their family by arranging community supports while waiting for a placement, by continuing to provide care in the RACF, by transferring medical records to the chosen GP at a new locality, or by accepting care of a new patient moving into a local facility.
Discussion with the patient and relatives before admission into residential care may include the management and likely course of health conditions, advance care planning, cultural values and family concerns (see Medical assessment of the resident ).
Multidisciplinary health care of residents
Older people in residential aged care are the sickest and frailest subsection of an age group that manifests the highest rates of disability in the Australian population.9 The prevalence of chronic conditions among residents in high care is estimated to be 80% sensory loss, 60% dementia, 40-80% chronic pain, 50% urinary incontinence, 45% sleep disorder, and 30-40% depression. Annually 30% of residents have one or more falls and 7% fracture a hip.10
General principles of quality medical care for persons living in residential aged care (as agreed by the RACGP Silver Book National Task Force) are:
- is of the same standard as applied to the community generally
- respects the rights and responsibilities of residents
- acknowledges the various levels of dependency among residents, including their functional status and capacity to make decisions
- acknowledges groups with special needs such as Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, people with disabilities, and veterans
- includes information, education, and support for relatives/carers/representatives involved with the health care of residents
- meets the specific health and quality of life needs of residents in relation to diagnostic evaluation , disease management, optimising function, symptom control, palliative care, psychosocial and spiritual wellbeing
- is multidisciplinary with collaboration between GPs, residential aged care staff, pharmacists, allied health and specialist service providers
- uses available evidence based clinical and organisational practices
- maintains continuous quality improvement through collaboration and systems development by general practice and residential aged care providers.
The multidisciplinary approach to health care of residents entails GPs working with residents and their relatives/carers/representatives, residential aged care staff, and other primary care and specialist service providers as needed. Assessment information and expertise from each discipline can be shared and used to define issues, set management goals and implement care plans. Teamwork is most effective within a climate that encourages the sharing of information and a spirit of cooperation.
Residential aged care staff
Residential aged care facilities provide residents with accommodation, personal care, including food and support services, health promotion and lifestyle activities, nursing care and allied health services. Services are mainly provided by staff of the facility with extra input when required from other service providers.
Facilities are required to maintain a safe and healthy environment for residents through providing systems and group programs such as infection control procedures, medication management systems, falls prevention programs, and physical and social group activities.
Nurses and personal care attendants (PCAs) provide 24 hour care, and also act as an important communication link with residents, relatives/carers, GPs and other service providers.
Registered nurses provide general nursing care, resident assessment, care planning and monitoring of residents' personal and health care needs. Evidence based tools for nursing assessment and management of common geriatric syndromes in residential aged care are widely used in care planning.11 Registered nurses supervise PCAs and liaise with GPs and other service providers to facilitate health care for residents. They also facilitate the involvement of relatives and carers in residents' care. Registered nurses have responsibility for documentation related to residents' care plans, records and classification of care level, as well as accreditation of the facility.
Enrolled nurses (registered nurse Division 2 in Victoria) also make up the nursing workforce and have a range of responsibilities in care provision. The enrolled nurse is an associate to the registered nurse who demonstrates competence in the provision of patient centred care as specified by the registering authority's licence to practise, educational preparation and context of care.
Core as opposed to minimum enrolled nursing practice requires the enrolled nurse to work under the direction and supervision of the registered nurse as stipulated by the relevant nursing and midwifery registering authority. At all times, the enrolled nurse retains responsibility for his/her actions and remains accountable in providing delegated nursing care. Core enrolled nurse responsibilities in the provision of patient centred nursing care include recognition of normal and abnormal in assessment, intervention, and evaluation of individual health and functional status. The enrolled nurse monitors the impact of nursing care and maintains ongoing communication with the registered nurse regarding the health and functional status of individuals. Core enrolled nurse responsibilities also include providing support and comfort, assisting with activities of daily living to achieve an optimal level of independence, and providing for the emotional needs of individuals. Where state law and organisational policy allows, enrolled nurses may administer prescribed medicines or maintain intravenous fluids, in accordance with their educational preparation.12
Personal care attendants are the largest occupational group in PCAs. While PCAs are not required to possess particular educational qualifications, about 60% of PCAs have a Certificate III, and 6% have a Certificate IV, in aged care.13 Personal care attendants work within organisational guidelines to maintain residents' personal care and daily living activities. They liaise with registered nurses (if available), GPs and other service providers to facilitate health assessment and medical care for residents, particularly in low care facilities.
Support workers in facilities include cooks, activity aids and volunteers who contribute to residents' personal care and activities.
Primary medical care personnel
Primary medical care includes prevention, management of chronic diseases and geriatric syndromes, rehabilitation, palliative care and end of life care. Primary medical care is mainly provided by GPs, their practice staff and locum GPs, working closely with staff of the RACF, the resident, relative/carer and pharmacist, with extra input as required from allied health practitioners and specialist services. Some GPs will attend residents after hours, while many engage a medical deputising service to provide after hours care for patients. Locum GPs attend and treat residents , and provide feedback to their regular GP. General practice staff can facilitate administration of patient records and the use of immunisations, Medicare Benefits Schedule (MBS) items, case conferencing arrangements, and reminder systems for review appointments.
Pharmacists play an important part in the medical care of residents, given that most are prescribed multiple medications and need assistance with administering their medications. The pharmacist's role includes:
- the dispensing and supply of medications
- provision of information and advice
- involvement in medication education for consumers of aged care services and staff
- participation in medication advisory committees
- involvement in relevant quality assurance activities such as regular residential medication management reviews and reference to relevant professional standards.14
Allied health practitioners contribute a range of health services in residential aged care settings as part of multidisciplinary care including: rehabilitation, wound management, palliative care, and assessment following acute hospital admission. Qualified allied health professionals include physiotherapists, pharmacists, psychologists, podiatrists, occupational therapists , speech pathologists, social workers, radiographers, orthotists, optometrists and dieticians.15 Skills of allied health professionals contribute to improved patient outcomes.
Residents periodically require specialist medical services such as acute care, aged care, psychiatry of older age, rehabilitation and palliative care. Services may be provided externally, eg. at a hospital, or as shared care with GPs and staff at the facility.
Acute care may require transfer of residents to hospital, or be provided at the facility (eg. through hospital in the home or aged care teams). Different strategies are being developed to improve communication across the acute/residential care interface, make hospital care more age friendly, and build the capacity of RACFs to treat acute illness and avoid hospitalisation.
Aged care assessment teams and geriatricians may provide GPs with specialist advice on the management of complex clinical conditions commonly encountered in older age, level of care assessments, geriatric assessments of patients at risk of functional decline, and education for GPs and residential aged care staff.16
Psychiatry of older age services may support the care of residents by GPs and RACF staff by providing expertise in the assessment and management of mental disorders including behavioural and psychological symptoms of dementia, depression and mood disorders, and psychosis of older age. Psycho -geriatricians (psychiatrists with specialist training in older age psychiatry), psychiatric nurses and allied health practitioners can provide professional education, patient assessment and management advice, case management, and telepsychiatry in remote areas.
Rehabilitation services are most commonly provided following an acute event such as stroke or hip fracture. Intensive short term programs are also useful for specific problems in residents with gradual decline of function, eg. spasticity, and bed-chair transfer. Restorative care refers to a less intensive form of rehabilitation focussed around activities of daily living.17
Specialist palliative care may be provided in two main ways. Specialist providers may help assess the resident and establish a plan of care with the resident, relative/carer, GP and RACF staff. The GP and RACF staff then provide ongoing care and reassessment. Less commonly, specialist services may be involved for a longer period of ongoing care. In general, all care provided by a specialist palliative care service will be provided in partnership with the primary care provider18 (see Palliative care).
Figure 1 shows a map for integrated residential health care, where residents and their relatives/carers are served by three levels of multidisciplinary health care: residential aged care , primary medical care, and specialist medical care. The map can be used to identify local services and gaps in service provision and access.19
The fourth level (outer layer) represents the wider community and supports for residential medical care, including:
- population demographics, family and social structures and community attitudes
- government funding, regulation and monitoring of residential aged care and health service sectors (federal, state and local level)
- industry peak bodies, unions, employer groups and professional organisations which support providers' conditions, education, standards and practice
- consumer groups, eg. Council on the Ageing (COTA) and the Carers Association which represent older people and their relatives/carers
- nongovernment organisations (NGO), eg. Alzheimer's Association, Continence Foundation which support people with specific conditions.
Divisions of general practice play an important role in supporting GPs and primary health care. As part of the Strengthening Medicare Package, divisions of general practice are funded to establish and operate 'aged care GP panels' aimed at:
- improving access to appropriate medical care for all aged care residents
- increasing participation of GPs in aged care initiatives aimed at improving quality of care
- encouraging GPs and divisions to work more effectively with RACFs.
For further information regarding the Aged Care GP Panels Initiative, please contact your local division of general practice.
Role of residents and their relatives
Residents and their relatives are central in the provision of quality medical care.
The RACGP standard on the 'Rights and needs of patients' requires that GPs treat their patients with confidentiality, privacy and ethical behaviour. Practices that respect these rights maintain confidence in the profession and increase patients' willingness to communicate fully with their doctor.21 It is advisable for GPs to be familiar with the 'Commonwealth Charter of Residents' Rights and Responsibilities', as well as the advocacy services and complaints resolution processes in their state or territory. The charter includes privacy, dignity, safety, maintenance of independence, control over decision making, and the right of access to advocacy and a complaints procedure.
Patients'rights do not diminish when they move into a RACF, regardless of their physical or mental frailty or ability to exercise or fully appreciate their rights. There is also an accompanying responsibility to ensure that a person exercising their individual rights does not affect the individual rights of others, including those providing care.
Federal and state advocacy services can be accessed via a toll free number (1800 700 600) available under the National Aged Care Advocacy Program (NACAP). NACAP advisory services are available free of charge. In some situations, GPs may choose to act as an advocate for the welfare of residents.
Residents or their representatives have the right to complain if care recipients believe they are not receiving adequate care, or are dissatisfied with their living conditions or medical treatment. It is desirable for GPs to ensure that residents' issues or concerns are addressed and resolved. Achieving a satisfactory outcome involves effective communication between the GP and other service providers , resident, facility staff, family and carers. Most RACFs will have a complaints mechanism in place to resolve disputes. If a complaint cannot be resolved informally, alternative strategies are available. A Complaints Resolution Scheme is available and is overseen by a Commissioner for Complaints.
Control over decision making
Residents have the right to accept or refuse any proposed medical treatment. However, many residents have difficulty understanding a medical treatment or conveying consent due to cognitive impairment or communication difficulties. The high prevalence of cognitive impairment has implications for gathering information in the assessment of residents, for discussing and deciding treatment, and for providing care. It also highlights the important role that relatives, carers and representatives play in the medical care of residents. Some residents will have full autonomy and be in a position to meaningfully have their privacy and control completely protected. However, most residents will need to have family (and/or others) help with providing information and making decisions; some may need decisions made for them. It is recommended, wherever possible, that when a person enters residential aged care, the appointment of an authorised representative and advance care planning occur in anticipation of future changes that may occur in the resident's health and/or capacity to make decisions. It is important for GPs to be familiar with the relevant federal and state requirements in relation to authorised representatives and advance care plans (see Advance care planning). Irrespective of legal requirements, it is advisable to discuss any proposed treatment with the resident's family or carer to avoid any misunderstanding or disagreements , as family members or carers may hold different views.
Privacy and confidentiality of health information
The RACGP provides guidelines regarding the management of health information in private medical practice.22 Information regarding the health of individuals collected by medical and other health practitioners has been treated as confidential for as long as health professions have existed and has been reinforced by common law. In many countries, the privacy and confidentiality of information, including health information, has been codified in statute law. In Australia, information privacy in the commonwealth public sector was codified in the Commonwealth Government Privacy Act 1988. Similar legislation has been passed in most states and territories. Private health service providers, including GPs and residential aged care providers, are required to abide by the National Privacy Principles in the Privacy Act (Health Amendment) 2000 when collecting, using, disclosing and storing health information. This means that residents of RACFs :
- have more choice and control over their information
- should be told what happens to their health information
- should be told why and when a health service provider may need to share information, for example to ensure they receive quality treatment and care from another provider
- can ask to see what is in their health record and, if they think it is wrong, ask for it to be corrected.
Under privacy laws, it is important that RACF staff ensure the consent form used on admission allows for residents' health information to be disclosed to all relevant service providers (see Tools 10). This allows residents to receive continuity of medical care, eg. by locum doctors, ambulance crews or hospital emergency staff. Where residents lack capacity to consent, there may be another person authorised to exercise their rights in relation to their health information. Where there is no authorised representative, the Commonwealth guidelines on privacy in the private health sector permit use and disclosure by the health service. Such use and disclosure must comply with the National Privacy Principles and also consider the health service providers' professional and ethical obligations, having regards to current accepted practices. Where practicable, residents should be advised when information is to be shared. In some specific situations such as case conferences, residents may choose to withhold specific information held by their GP from other care providers.