A new call for allied health in aged care

Across the broad aged services spectrum, there is growing awareness and acceptance of the need for greater involvement of the various allied health services. Yet policy and practice barriers remain. Here, Australian Ageing Agenda provides a platform for the leading peak bodies to present their views on the changes required to facilitate access for their members to aged services.

Providing their opinions are:

• Dr Rick Olive, Australian Dental Association
• Anita Hobson-Powell, Exercise & Sports Science Australia
• Rik Dawson, Australian Physiotherapy Association
• Gail Mulcair, Speech Pathology Australia
• David Stokes, the Australian Psychological Society

Dental: ‘Direction and support’

New investments in the training of staff who work in residential facilities, and to the design of the facilities themselves to accommodate visiting professionals are required, writes Dr Rick Olive.

It is well known that the Australian population is ageing, and this will bring many challenges for healthcare service delivery. As people age, they often become less able to care for themselves; have poorer mobility, which affects their ability to access care; and usually have more complicated medical issues requiring more complex care. In some cases, elderly Australians’ physical state can be such that they are no longer able to live independently.

There have been substantial increases in the number of older people who have retained their natural teeth over the last 50 years. Ensuring the dental health of this section of the community, especially those in residential aged care facilities, provides an additional challenge.

Studies have shown that high levels of plaque accumulate on residents’ natural teeth and dentures, which place them at high risk for developing aspiration pneumonia, a commonly occurring event necessitating transfer to an acute care facility. Dislodgement of teeth, fillings and calculus as well as ill-fitting dentures contributes to this problem.

The importance of maintaining good oral health will help minimise the risk of deterioration in the general health of residents and therefore reduce the demand on the public health system. For example, research has shown that with improved oral hygiene interventions, the rate of pneumonia and mortality associated with aspiration pneumonia can be reduced by around 40 per cent.

The ADA recommends that core components in the education and training of all healthcare professionals working in aged and residential care should include the ability to undertake an ‘oral health screen’ as well as provide ‘daily oral hygiene’. This will enable healthcare professionals working in aged care facilities to appropriately monitor residents’ oral health and help them maintain good oral health; potentially reducing the risk of adverse outcomes.

In addition, measures to ensure that appropriate oral healthcare is provided should be incorporated into the standards by which facilities are accredited. These standards must also be extended to require that facilities provide an environment within which dental examinations and treatment can be safely provided by oral health professionals.

Lack of an appropriate type of dental chair, x-ray facilities and other relevant equipment available at residential aged care facilities are significant barriers to providing quality care.

These issues could be addressed if such facilities were incorporated into the design of residential aged care facilities.

This will not occur without direction from governments or support provided to existing facilities. The development of a multi-purpose room that can be utilised by dentists and other visiting healthcare professionals will have significant cost benefits to the health system overall.

From both an oral health and general health perspective, there needs to be additional investments and resources not only towards the training of those healthcare professionals who regularly work within aged care facilities, but also to the design of the facilities themselves to enable visiting healthcare professionals to treat more complex cases.

Accreditation standards not only need to be updated to mandate these requirements, but consideration should also be given towards funding incentives to assist this process of improvement.

These measures will both enable allied health services to support aged care residents in their day-to-day health care needs, as well as ensure that healthcare professionals can effectively and safely perform their work when they are needed.

The ADA’s Policy Statement on Aged Persons and Individuals Unable to Access Dental Clinics can be found at ada.org.au.

Dr Rick Olive is president of the Australian Dental Association.

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Exercise physiology: Overcoming the funding barrier

Policy developers need to appreciate the benefits of exercise for older people and increase equity and access to these services, writes Anita Hobson-Powell.

Accredited exercise physiologists (AEPs) can make a significant contribution to the health, wellbeing and independence of older Australians. As a result the profession is emerging as an essential service within ageing and aged care. However, there are varying levels of understanding within the sector about the role of an AEP in the allied health team which has presented a barrier to more AEP services being delivered in a variety of ageing and age care settings.

Older people in the community and in aged care facilities experience high levels of chronic disease, disability and pain and are at an increased risk of falls and fall related injuries. Most people over 75 years of age will have at least two chronic conditions and nearly half of this cohort will experience a fall in any given 12-month period. AEPs can play a significant role in symptom reduction through treatment and therapy.

An AEP specialises in delivering progressive exercise therapy that is an essential contributor to improved health within the multidisciplinary approach to treatment. There is strong evidence that, even for the very old, resistance training can reverse the progress of sarcopenia (loss of muscle mass). AEP-led exercise therapy also improves strength and balance, and prevents falls.

A raft of evidence supports AEP interventions in reducing the symptomology of chronic conditions, reducing pain and functional disability, and improvements in the individual’s capacity to carry out activities of daily living. These improvements support the increased emphasis in the sector on reablement and restorative care which translates into improved personal dignity and quality of life for individuals.

Exercise is not only a means of getting stronger and fitter but also provides socialisation for isolated individuals, respite and a welcome outing for carers, therapy to remain living at home and a fun activity that people look forward to each week.

The growth of AEPs in the community is also being seen in Home and Community Care funded services. One NSW allied health HACC provider reports that 75 per cent of its total services are exercise physiology. This was driven by high demand across the community for home and centre based falls management and reablement care.

While community services are seeing an increase in AEP service delivery, residential care has not experienced the same growth.

The lack of “clinical exercise therapy” as a recognised pain management therapy and exercise physiology not being listed as an allied health profession under the Aged Care Funding Instrument (ACFI) are the main reasons why the growth has been significantly less than in the community setting.

Older adults with a chronic condition can access AEP services through a team care arrangement under Medicare. However, this only allows for five visits per year which the referring doctor apportions between the allied health team. In many cases, the five visits shared across allied health do not provide the necessary support required to manage an individual with multiple chronic disease states as is the case with many older people.

Policy is already moving towards broader support for reablement services to assist older people with complex health conditions and care needs. Policy developers need to appreciate the benefits of exercise for older people and increase equity and access to these services – to those in the community and those in aged care facilities: in particular for those most in need, older people from low socioeconomic backgrounds and non-self-funded retirees. This could be achieved through provision of additional sessions through the existing team care arrangement funding and revision of the ACFI to include exercise physiology as a funded treatment modality.

As part of the allied health team, AEPs have a significant role to play in improving the health and physical capacity of older people independent of their level of disability or disease. This translates directly into improved dignity and quality of life for older Australians in their twilight years.

Anita Hobson-Powell is executive officer of Exercise & Sports Science Australia.

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Physiotherapy: ‘A greater dialogue’

We would like to provide the sector with knowledge on how physiotherapy can meet the needs of customers and reduce program costs, writes Rik Dawson.

Physiotherapy is an important component of care in residential aged care facilities as well as enabling at risk older people to remain in the community through rehabilitation and restorative care. It is widely acknowledged that adequate levels of physiotherapy can help older Australians improve or maintain optimal function, health and wellbeing.

Physiotherapists can assess and treat a variety of neurological and musculoskeletal disorders as well as effectively work in other areas of rehabilitation including fall and injury risk minimisation, incontinence management and education, prescribing exercise appropriate for the individual, and rehabilitation. Physiotherapists can be part of an effective team by providing manual handling training and risk assessment and reduction enhancing the wellness of the workers within aged care.

Research has shown that by increasing the hours in their physiotherapy program from part time to full time for a 50-bed aged care facility provided a cost saving of $283/bed/year in terms of nursing dollars. It also found that increased physiotherapy support improved resident independence with activities of daily living, reduced staff manual handling risk and enhanced resident psychosocial function.

Specific programs designed by physiotherapists that focus on enhancing an individual’s rehabilitative  potential through the prescription of active and short-term restorative  programs  has been shown to give many benefits to older people living at home.

The recent introduction of the Living Longer Living Better reforms in the home care sector will enable older people living at home for the first time to access restorative physiotherapy. However, the Australian Physiotherapy Association (APA) believes that there are some barriers to this.

Specifically, there are insufficient funds allocated to deliver real change to consumer’s independence and to deliver the health prevention benefits to the aged care system. The APA is also concerned that the community aged care sector does not have the education to support active wellness and restorative care.

The APA has petitioned the government to deliver education to community providers on wellness so that they can give the appropriate support to their consumers. For example, an older person who is having difficulty standing up from their lounge chair may request an electric sit to stand chair. As an unintended consequence, the electric chair will increase their leg weakness and balance causing further functional decline in other transfers. These chairs cost up to $2,000. Research has shown that an appropriate targeted physiotherapy program is a more economical choice and will likely increase leg strength and balance, and independence for all transfers.

The emergence of restorative care in the community sector has highlighted the weakness in the funding mechanism within residential aged care. Not only is it not consumer directed but the Aged Care Funding Instrument (ACFI) is based on funding dependence, not therapy, by creating incentives for funding passive treatments that do not improve function, mobility or independence.

The APA proposes that ACFI be changed to allocate funding to physiotherapy treatment that maximises residents’ functionality and mobility, for example falls prevention and the management of functional incontinence.

The APA would like to open a greater dialogue with the aged care sector by providing the sector with the knowledge on how physiotherapy can meet the needs of their customers and assist aged care programs to reduce costs. I know our members will be happy to make a meeting to talk about our profession. To find your local APA physio please visit our website www.physiotherapy.asn.au.

Rik Dawson is chair of the national gerontology group of the Australian Physiotherapy Association and director of Agewell Physiotherapy.

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Speech pathology: ‘Starting a conversation’

There must also be a change of mindset about the communication needs of ageing Australians, and government alone cannot bring this about, writes Gail Mulcair.

Sadly, both communication and swallowing are vulnerable to the ageing process. A swallowing disorder may affect 50 per cent of seniors in residential care and 100 per cent of people with Alzheimer’s at some point in their disease progression. One Australian study suggests that as many as 70 per cent of aged care residents have a communication disorder, with usually more than one issue impacting on communication.

It is against this backdrop that speech pathologists play an essential part of the team that cares for older Australians.

There is no systematic information available regarding access to speech pathology services in residential facilities. Private speech pathologists working in aged care consistently report that, while they may be asked to assess and manage a person’s swallowing difficulties, referrals for communication assessment or management are rarely received. This is despite recognition by nursing and care staff that participation and social interaction are vital.

This issue relates to the Aged Care Funding Instrument that does not adequately assess communication or acknowledge the profound impact that communication and sensory impairment have on the needs of residents. Even though untreated communication difficulties increase the time, complexity and burden of care, there is inadequate provision of funding or resources for staff to identify or meet residents’ communication abilities or needs. This fails to comply with aged care accreditation standards and best-practice guidelines.

Speech pathologists are rarely employed by aged care providers as staff. Rather, the majority of facilities contract private speech pathology services for assessment and/or management advice for specific residents. This service delivery model represents a significant challenge to best-practice care, which requires a coordinated inter-professional team working together to meet an individual resident’s complex care needs. Services need to be available which reflect a chronic disease management approach, as opposed to only acute and short-term rehabilitation services.

Current community care packages and the ACFI do not adequately recognise communication disorders or enable provision of communication assessment or support (e.g. direct intervention, education, and access to augmentative or alternative modes of communication).

Pursuant to this, we want to see effective strategies applied within aged care settings for creating a communication accessible environment and enhancing communication opportunities. This includes the training of nursing and care staff regarding communication needs, and providing specific information and strategies for individuals with communication disorders and their families.

In our submission to the Australian Senate’s Community Affairs Committee inquiry into the prevalence of different types of communication, we put forward several propositions with regard to the care of older Australians.

In its final report (2 September 2014), the committee recommended an investigation into “the current service delivery model for speech pathology services in aged care residential homes in Australia.”

The committee recommended that following this investigation, “the findings should be considered as part of the federal government’s ongoing aged care reforms”.

We are vigorously pursuing the implementation of all the recommendations arising from the report with government at all levels.

Notwithstanding the committee’s recommendations, there must also be a change of mindset about the communication needs of ageing Australians, and government alone cannot bring this about. It is why, in an endeavour to highlight the extremely low profile of speech pathology and communication services in residential aged care facilities, we have recently released a new video, titled Communication Matters.

The key message of this new video is that with time, creativity and support, communication can be improved for ageing Australians; helping them to connect, to maintain friendships, and to convey basic wants and needs.

We want to start a conversation about making communication a priority for all Australians; irrespective of age, medical condition or place of residence. We are encouraging all providers to show this video to their staff and engage in a dialogue with speech pathologists about how they can contribute to improving the communication skills of their aged care residents.

For further information, visit www.speechpathologyaustralia.org.au.

Gail Mulcair is chief executive officer of Speech Pathology Australia.

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Psychology: Shattering the ‘awesome silence’

If the incidence of depression among seniors was seen in the general community there would be agitation for governments to do something, writes David L Stokes.

According to the Australian Institute of Health and Welfare (AIHW) just over half of all permanent aged care residents have significant symptoms of depression. Of interest, about 45 per cent of people entering residential aged care also had significant symptoms of depression. This suggests that not only are a large percentage of seniors living in the community quite depressed but they seem to get worse after they enter residential aged care.

It has been known for some time that the incidence of depression and anxiety among seniors (50 per cent) is much higher than that in the non-aged care community (around 20 per cent). If this were the case for the general community, there would be agitation for governments to do something about it. Mental health policies for state and federal elections rarely mention mental health and seniors in the same sentence.

What is even more worrying is that, apart from the awesome silence about this issue in the general community, there is a lack of best practice interventions for these mental health issues both in the general community and in residential aged care facilities.

The most common response, particularly in residential aged care, if the issue is treated at all, is to have a GP prescribe some psychoactive medication. This is not best practice for two reasons: firstly, introducing such medication to a person who is already on a number of other medications commonly produces poly-pharmacy problems. Side effects of the medications itself are also common. Secondly, it has been well established that non-pharmacological treatments, such as cognitive behavioural interventions are as, if not more, effective than medications. Given the problems that poly-pharmacy create, these should be the first port of call.

An Australian research study that confirms the validity and importance of these best practice principles was completed by a clinical psychologist Michael Bird in residential aged care facilities in NSW. Michael identified two groups of residents; the first group were provided with a mix of psychosocial interventions tailored to the individual needs of the case with only a minority receiving psychoactive medication.

The second group was treated mainly with medication. Among the first group over the course of the trial, only one patient was hospitalised (for a total of two days) compared with more than 20 per cent (total hospital days 93) of the second group. Drug side effects were reported in 12 cases in the psychosocial group, and in 32 cases in the conventional treatment group – a threefold reduction. Visits by GPs to deal with behavioural problems were reduced by half, an average of 4.5 visits in the psychosocial group, and 9.4 visits in the conventional treatment group. Visits by consultant psycho-geriatricians were also less common, an average of 1.2 visits in the psychosocial group, as against 4.8 visits in the conventional care group. Use of medication declined in the psychosocial group and increased in the control group.

So what can we do to address this problem? We need to provide staffing and resources to assist nursing staff to identify and effectively support residents with depression and/or anxiety; employ or fund expert psychologists to both provide appropriate psychosocial interventions for resident and provide some of the support noted above; and adopt and endorse guidelines about best practice and provide these for GPs to follow among the elderly both in residential facilities and the community as a whole

Australian seniors deserve better, if not best, services.

David Stokes is a clinical neuropsychologist and principal advisor with the Australian Psychological Society.