Can consumer directed care work in residential aged care? And what would it look like? Australian Ageing Agenda investigates.
In Sunny Hill Nursing Home in Illinois in the US, aged care residents play a critical role in the hiring of new care staff. In fact, the three-to-six-member resident committee has the power to veto any prospective candidate in the final interview stage.
The residents have input into the interview questions that are asked and tell the prospective candidate what residents would expect of them if they were hired.
Management says the involvement of a trained resident committee, often made up of residents with past experience in hiring staff, sends a clear message that residents are decision-makers, whose opinions are respected.
The initiative at Sunny Hill is part of the organisation’s consumer directed care model that aims to pass greater choice and control to residents.
Since the 1990s, nursing homes across the US have joined a grassroots movement away from institutional provider-driven models to consumer-led models that emphasise autonomy, flexibility and resident rights, known as the ‘culture change’ movement.
New conversation in Australia
While this movement in the US has been underway for 20 years, in Australia the conversation around consumer-led approaches in residential care is just getting started.
At a policy level, the Living Longer Living Better reforms announced by the former Labor government in 2012 included for the first time a commitment to pilot CDC in residential care. Despite this initial interest from government, a trial ultimately failed to get off the ground.
This year, CDC in residential care is one of the confirmed areas of focus for the South Australia Innovation Hub Trial, giving the concept renewed attention in the sector, especially in relation to reforming regulation.
In speaking to a range of providers and commentators, most agree that CDC in residential will require a very different approach to CDC in home care.
The congregate care setting, shared costs and group rosters make the application of individual budgets in a residential environment impractical. Many argue that new terminology may also be required to better reflect the uniqueness of the residential care environment and the models to be developed. The concept of CDC in residential care is further complicated by the vulnerability and frailty of residents.
Ian Hardy, CEO of Helping Hand in South Australia, says there are a number of ways residential care providers can, within existing policy structures, begin to adopt a more resident-directed approach. For example, residents and families can collectively have a greater say in how services are designed and delivered and in the look and feel of facilities, he tells Australian Ageing Agenda.
“The idea of co-design or co-production in residential care might tell us interesting things about residents’ preferences for lifestyle activities, menu design, dining arrangements and dining times. It might also be used to hear from residents about the design of buildings to help the sector evolve its building approaches over time in ways that perhaps better reflect what residents really want.”
Hardy says encouraging the continuation of family involvement in residential care and facilitating the use of a resident’s own resources to top-up existing services will also be increasingly important in the future.
“Another area of great potential is for the sector’s thinking about staff and staffing to become much more interprofessional so that there is less hierarchy and a more integrated approach to care and support,” he says.
Rethinking the deficit-model
A more consumer-directed and focussed approach in residential care will require a move away from the current deficit model that is entrenched in many facilities, says Carrie Hayter, an industry consultant who supports providers to implement personalised care services.
“One of the things that the social model brings is looking at the person in their entirety, and even if they are coming to the end of their life, it’s about that person living out every moment of their life to the fullest capability that they can. If you don’t look at the social side and purely focus on the medical, then you lose the essence of who is the person you are caring for and their story.”
She says the cultural change facing many providers will be significant.
“People think CDC is all about individualised budgets, but it’s actually a spectrum of concepts and I think for residential aged care, providers need to start with understanding the person, their supports and structuring the support around them… There are massive cultural shifts that need to happen both within the way agencies think about older people, work with older people and their allies and support their staff to think differently.”
Building close relationships with residents and identifying strengths and goals will be critical, Hayter says.
From that foundation, other elements of choice and control can be offered to residents such as personalising a resident’s daily routine, encouraging resident-led lifestyle activities and offering the choice to purchase items such as meals externally. Other, more radical ideas might include allowing residents to choose who they live with or facilitating the choice of a preferred staff member, including allowing a community care worker to transition with a person once they enter residential care, says Hayter.
Growth in cluster model
Hayter says one of the major barriers to the implementation of CDC approaches in residential care is the financial incentive for providers to build bigger facilities. “Facilities with 80 to 100 beds are just too big to make it consumer-directed,” she says.
“We need to look at deinstitutionalising care by having much smaller accommodation living arrangements and even smaller groupings of people.”
One way providers have sought to achieve this without compromising their viability is by setting up small clusters of residents within facilities that are matched together according to shared interests and backgrounds.
Benetas is one organisation that has adopted a cluster model as a way of encouraging a more homelike environment.
“Most residential homes are simply not built to support CDC because they are structured around clinical models rather than facilitating environments of choice,” says Benetas CEO Sandra Hills.
“We are doing a lot of work to come up with new building designs that adopt a cluster model of eight to 10 residents as part of a person-centred approach. This also means putting some of the back-of-house operations like catering and laundry out of sight.”
As part of the Benetas model, residents are also assigned to specific carers to increase familiarity and promote continuity of care.
Person-focussed care systems
In a broader policy context, Hardy says CDC in residential care can also be thought of as setting up care systems that are truly person-focussed. For example, he says an older person’s currently siloed health, transport and housing entitlements should be brought together to maximise care and support for individuals.
Fundamental structural change to the aged care system should also be considered to facilitate greater consumer choice and flexibility, he says.
Hardy says a single assessment and funding mechanism which covers all forms of care is increasingly common internationally, was a recommendation of the Hogan Pricing Review of Aged Care in 2004 and the principles of flexible consumer access to services were articulated in the Productivity Commission’s Caring for Older Australians report in 2011.
A single system would be simpler and would allow consumers to receive their care entitlement in their preferred setting (at home, in residential care, or other accommodation such as a retirement village).
“The impact of a single assessment and funding approach over time would be to shape the total care system in ways which reflected the preferences and purchasing power of the individual,” says Hardy.
He says Australia would benefit from understanding how the operation of a market system has affected the distribution and responsiveness of residential care sectors in countries such as Japan and Germany that have adopted a single care system.
Hayter agrees that unbundling care and accommodation subsidies in residential aged care is necessary to provide consumers with greater flexibility.
A quality of life focus
Hills says residential care in the future will have a much stronger emphasis on promoting a quality experience of ageing and that quality of life measures will be just as important as clinical outcomes.
To move in this direction, Benetas is developing a quality experience indictor through the US-based Centre for Quality Leadership, which will measure aspects such a resident’s engagement with their community and support networks, their overall wellbeing and how they are encouraged and supported to make decisions.
An extended version of this report appears in the current issue of AAA magazine (July-August).
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