Providers need to reconsider their priorities

To achieve the goals of independence and staying at home, there is no greater evidence than for the inclusion of allied health and exercise therapy in reforms, writes Dr Tim Henwood.

While the terms reablement and restoration have received varied definitions, specific to older adults they imply employing a person-centred approach to improving an individual’s wellbeing and independence.

At Southern Cross Care (SA, NT & Vic) Health & Wellness we have embraced an innovative, evidence-based model of care to offer clients a holistic pathway to better wellbeing and independence. A client’s comprehensively assessed physical and mental health needs are aligned to their person-centred goals and discussed at a multidisciplinary case conference activity that then plans with the client their best health pathway.

For some, this may be engagement with a range of allied health professionals to manage their complex needs, and for others it may be just one-to-one exercise physiology. The aim is always the same: for the client to achieve their goals through meaningful physical, social and mental health engagement activities and for them to graduate into ongoing group exercise participation for the maintenance of their health gains.

For older adults, the value of allied health and exercise therapy participation is irrefutable. A simple Pubmed search using the term “benefits + exercise + older adults’’ reveals greater than 16,000 peer-reviewed publications supporting the benefits of participation. While there are many variations within these studies – population, age, type of exercise and participation intensity and frequency – the underlying message is always the same: participation makes people better.

“Providers must be directed towards the integration of reablement and restorative service.”

As an ex-academic, a number of my publications are included among these 16,000 and they all consistently report a large – greater than 40 per cent – increase in muscle strength and function following exercise participation. However, it is my work in my current role that speaks the greatest volumes. Because we have translated this evidence to practice, and show – on average – 45 per cent improvements in functional wellbeing for clients in as short as eight weeks when they participate in holistic, multidisciplinary reablement and restorative programs that culminate in regular exercise.

Even with this evidence, sedentary behaviour continues to be prominent among older Australians. It is also the largest driver of poor and declining health nationally in this population. Less than 20 per cent of all older adults engage in physical activity at levels sufficient to maintain or improve their health.

While there are many barriers to physical activity participation for older adults, it does not help that the majority of aged care providers are prioritising care – domestic assistance and personal care – equipment like walking aids, mobility scooters and toilet raisers and home modifications such as rails over preventative, reablement or restorative services.

StewartBrown and the Department of Health’s report – 2020 Home Care Provider Survey – found allied health and exercise therapy so underutilised in the aged care space that it is described as a “specialised service”. It accounted for only 2 per cent of all home care package spending. Breaking this down, we see that more than four-and a- half home care package hours a fortnight are dedicated to domestic assistance and personal care, and less than 10 minutes to allied health and exercise therapy.

While care services do help people remain in their own homes, they are not a definer of independence and nothing more than a short-term, bandaid solution that still allows physical, social and mental wellbeing to decline.

The Department of Health and Aged Care has promised positive aged care reform to promote the independence of older community-dwelling Australians, and this has become one of the most commonly associated statements to the coming reform. This is reinforced in Minister for Aged Care Anika Wells’ forward in the October 2022 consultation paper A New Program for In-Home Aged Care – Discussion Paper, where she specifically states older people have the right to expect support to live safely at home into their frailer years.

This desire for independence is intrinsically linked to the most raised goal of the older adult, “I want to stay in my own home”. To achieve this goal of both government and individuals, there is no greater evidence than for the inclusion of allied health and exercise therapy in reform.

This need did not go unnoticed during the Royal Commission into Aged Care Quality and Safety, which in Recommendation 36 calls for in-home care to include allied health care. Specifically, it calls for “a level of allied health care appropriate to each person’s needs” from 1 July 2023. And from 1 July 2024, it recommends “that the assessment process for eligibility for care at home identifies any allied health care that an older person needs to restore their physical and mental health to the highest level possible (and maintain it at that level for as long as possible) to maximise their independence and autonomy.”

This need is further backed by the World Health Organisation’s The Global Status Report on Physical Activity 2022, which states “older adults in particular benefit from regular physical activity to maintain physical, social and mental health, delay dementia, prevent falls, and realise the benefits of healthy ageing.”

“For older adults, the value of allied health and exercise therapy participation is irrefutable.”

Similarly, for Grant Thornton’s A model for transformation and governance: The redesign of the aged care sector, which supports the integration of innovative restorative care services to aged care consumers to reverse or slow the decline associated with activities of daily living. Adding these services to a client care plan can delay and remove the need for long-term care and support services, the report finds.

In short, evidence shows us and authority encourages us to integrate reablement and restorative services into client care plans to support wellbeing and independence. However, this remains an underutilised service type among aged care providers. Again, the barriers to participation are significant and include time, access, environment and health literacy, but also there is no strong message guiding the aged care sector to embrace reablement and restorative services.

Whether an historic issue or the provision of reablement appearing too foreign a concept, aged care providers need to reconsider their priorities. Take for example the recent PWC-led review of National Aged Care Mandatory Quality Indicator Program. As published in the project’s Development of quality indicators for in-home aged care – Evidence review summary report, five of the 10 highest ranking quality of care domains are positively impacted by the provision of reablement and restoration services, or, alternatively, negatively impacted when lacking.

These domains cover:

• the consumers’ capability to undertake basic and instrumental activities of daily living
• the prevention and avoidance of falls
• pain that impacts activities of daily living, quality of life, function and overall disability
• planned or unplanned hospitalisation
• the presence of depression, with indicators including level and impact to the client.

Falls are the leading cause of hospitalisation among older adults, with hospitalisation having a number of deleterious cognitive and functional implications for the group. However, numerous research interventions have shown allied health-led exercise participation can positively modify falls occurrence and falls risk as well as hospitalisations. Equally, research shows allied health-led exercise intervention as short as eight weeks can alleviate depression, reduce pains and increase function and quality of life when compared to usual care.

Providers need to embrace reablement and restorative care to adhere to these quality indicators. There exists a unique opportunity to positively modify community aged care – to ensure it does, reform must:

• align to evidence-based practice
• embrace the recommendations of the royal commission.

This will guarantee improved wellbeing and independence among community-dwelling aged care consumers and other older Australians. The catch is, providers must be directed towards the integration of reablement and restorative service. The incorporation and prioritisation of reablement and restorative services into aged care reform will – no doubt – challenge the sector. However, without this, care will continue to be the primary service offering, consumers will continue to experience declining health and the sector will continue to experience avoidable stress.

For aged care reform to ethically meet the needs of consumers and for independence to be an achievable goal for all, aged care providers must be guided to ensure all clients access allied health and exercise therapy reablement and restorative services.

Dr Tim Henwood is group manager health and wellness at Southern Cross Care (SA, NT & VIC)

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