The Aged Care Revolution

Leon Flicker

National Travelling Fellow AAG Darwin September 2014

Western Australian Centre for Health & Ageing University of WA Royal Perth Hospital

Format of Today’s Talk

• Australia is getting older • Why it is not necessarily a bad thing • Changing clinical care models • Move from residential care to community care • Dominance of chronic neurodegenerative conditions with resultant changes required.

Format of Today’s Talk

? Maximum Life Span What would happen if there is a constant improvement in life expectancy?

Men Women Why Australia's 'ageing timebomb' is fizzing Three Intergenerational reports later • In 2002, 1st intergenerational report projections were apocalyptic. By 40 years Australia’s budget deficit climbs to 5% of GDP.

• Five years later, that figure has shrunk to 3.25% of GDP. (in 2010 down to 2.75%) Hands on the doomsday clock have been wound back...

• What went right was a number of very small things – birth rate increased from 1.6 to 1.7 (not FALL) now reaching 1.9 – Workforce participation rate is now expected to be 57 per cent, instead of 56. • We are living even longer than expected • Even at the time of the first intergenerational report Australia’s aging future wasn’t particularly scary (for one thing our buying power was expected to double). It is likely to get even less scary in the reports to come ……....BUT THE MAJOR RESIDUAL PROBLEM IS FRAILTY Intergenerational Report 2010 Business is Booming!

36 million

Based on FR of 1.9 & Immigration of 0.6% pa

Budget 2007-2008 Format of Today’s Talk

• Australia is getting older • Why it is not necessarily a bad thing • Changing clinical care models • Move from residential care to community care (Driven by RAC subsidies) • Dominance of chronic neurodegenerative conditions with resultant changes required.

Residential aged care (RAC) in Australia The Evolution of the Current System • At the end of the 19th Century there was a move to house the homeless and chronically sick. These were the work houses in many Western countries • By the mid 20th Century these had evolved into State Government funded nursing homes • By the end of the 20th Century the State Governments decided to largely close these & leave funding of RAC to the Federal Government. • By the mid 20th Century many small private hospitals were largely housing older people . • This arose because of female participation in the workforce and most efficient to care for very disabled older people • Since 1963 federal funding has subsidized RAC and in particular private nursing homes. Residential aged care in Australia The Evolution of the Current System (2) • In the ten years between 1963 and 1973 the number of private nursing home beds doubled from 26 per 1000 population aged 65+ to 47 per 1000. • In the 1970s and early 1980’s there was continuing dramatic increase in Federal funding for residential care despite an attempt at controls and this was driven at least partly by inappropriate admissions to such care. • After a series of successful pilot programs in the early 1980s funded by the Commonwealth, but utilising the expertise of regional geriatric teams, a developing system of integrated services began centred around Aged Care Assessment Teams (ACATs). Nursing Home Provision for the Population Aged 70 years and over

Community Care for older people in Australia 1 Home and Community Care • Shared funding State and Federal, minimal gateway • Supposedly not high intensity • Centre-based day care • Transport shopping or appointments • Domestic assistance house cleaning, etc • Personal care – help with bathing, dressing, etc • Home maintenance • Home modification • Nursing care dressing wound, continence advice. • Food delivery

Community Care for older people in Australia 2 Home Care Packages • Federally funded • Meant to be more intensive services • Needs ACAT assessment • Support services – such as washing, house cleaning, etc • Personal services – such as showering, dressing, mobility • Clinical care – nursing, some physiotherapy • 4 levels up to nursing home replacement

• CONSUMER DIRECTED CARE

Access to beds for older people in acute and aged care facilities – This will a problem for at least the next 20 years Trends in the use of hospital beds by older people in Australia: 1993–2002 Gray LC et al, MJA 2004; 181:478 Trends in the use of hospital beds by older people in Australia: 1993–2002 Gray LC et al, MJA 2004; 181:478

More good news! • Average number of hospital bed-days per annum rises from 1.5 days per persons aged 65–69 years old, to 6.3 days per persons aged 85+ • People aged 65+ comprise 13% of population, contribute 35% of hospital admissions and 47% of bed-days. • By 2050, people aged 65+ will be responsible for two-thirds of all hospital bed-days. The Geriatricians Trick – GEM • In 1984, a randomized trial demonstrated the effectiveness of a geriatric evaluation unit was reported. (Rubenstein NEJM). • Since then, numerous other studies and a Cochrane systematic review confirmed the benefits of inpatient geriatric assessment and rehabilitation more likely to be – Alive, in own homes at 6 months, 1.25 (95% CI 1.11 to 1.42), – Decreased rates of institutions 0.79, (95% CI 0.69 to 0.88) – Improved physical and cognitive function • These benefits are mainly apparent when patients are admitted to a dedicated ward area and a specialist multidisciplinary team and not in a general medical ward with a visiting team. • Medication Rationalization is an important component So far • How “free” health care and the subsidization of the community and residential aged care system drove the development of geriatric evaluation and rehabilitation in Australia • Older people belong in hospital when they are acutely sick • Major issues as to how individual services fit together • If individual sectors work harmoniously together it is more cost effective and better outcomes for patients Aged Care An Integrated Service For Older People • Since the mid 1980s Aged Care Assessment Teams have been instrumental in providing a central resource to older people. The development of ACATs has been accompanied by massive increases in the funding for Community Care. • These ACATs, which have SOMETIMES been integrated in regional geriatric services, operate as “gatekeepers” to expensive resource items such as residential care places and “Aged Care Packages”. • They also operate as central referral sources for – Inpatient Assessment acute sector or sub-acute sector – Rehabilitation - • Inpatient, often called subacute care • Outpatient - Day Hospital or Domiciliary – Community Services – Psychogeriatric Services and specialised facilities How did Geriatric Evaluation Management and Rehabilitation evolve into subacute care? 1. State run nursing homes These hospitals became more involved in people who did not reside on these places but were admitted for a shorter period typically < 28 days. 2. Arose directly in a secondary or tertiary hospitals often as a component of a regional geriatric unit • Various state programs followed to try and redistribute resources on a more equitable basis Costs: $A700+ per bed day (about half way between nursing home and acute hospital care) and distinguished by specialist medical care and comprehensive multidisciplinary teams

Subacute care and rehab beds increased in number but decreased on a per capita basis - 2002 Aged Acute Care and Assessment beds by State/Territory

Crisis in Aged Care 1998-2001

• For a number of reasons a sudden and unexpected decrease in the number of residential care places in Australia • Largely a problem in sourcing capital and decreased Federal subsidies • Still have not worked out what is a fair and transparent method of user pays and copayments

A Hospital Census of 65+ • On the 17th April 2002 a hospital census of over 65 year olds took place. The second part was completed for the same set of patients at midnight on 8th May 2002 • Of a total of 617 hospitals around Australia, 611 hospitals returned surveys covering 99.9% of hospital beds in Australia. • 16,104 of the estimated 17,745 patients in hospital were surveyed (1,641 patients were deliberately not surveyed as they were in ICU or other high dependency ward and/or had surgery on the day of the survey).

Proportion of older people for whom another form of care was considered more appropriate Type of care recommended for patients in hospital This has grown even more important Number of Beds in WA Queuing Analogy 285,200 65+ years in 2011 12% of WA • A residential care bed is like a city parking spot • Acute and subacute beds function as the highways (turning most of the people away from the city) • Only 90 parking spots appear each week • Closing residential care beds is like closing down a parking station Length of stay • Opening up new services Res TCP Subacute Acute e.g. TCP opens up a new 3 years 50 days 21 days 5 days lane but if the service avoids residential care then we have bypassed the city

The Future of Subacute Care in Australia • COAG process has prioritized this area for expansion Australian Govt has provided $A500 million and then $A1.6 billion over 8 years to increase services • NB This money will not just provide an increase in bed based services • There is an urgent need to more explicitly define subacute care and provide it on an equitable basis in all parts of Australia

Level 1 Intensive care coordination People with chronic diseases •Care across continuum & complex needs who •Tertiary & secondary prevention frequently use hospital •Comprehensive assessment •Care planning

Level 2 •24 hour advice People with chronic disease & •Specialist and GP care •Self management complex needs who use •Comprehensive discharge hospital or who are at •planning risk of hospitalization

Level 3 Usual Care People with chronic •GP care disease and/ or •Self management •Community services complex needs

Level 4 Primary prevention Whole Population

Levels of chronic and complex care management Hospital at home early discharge Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R There was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased …allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24;) Significantly fewer people allocated to hospital at home were in residential care at follow-up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups. Evidence on cost savings was mixed.

Healthy Australia Accord • Recommends National Access Targets across the continuum of health services including acute care, subacute care and aged care assessment (Already RAC targets) • The second element in redesigning the health system to meet emerging challenges is to connect and integrate health and aged care services for people over the course of their lives. Greater need for Coordination • The interface between subacute care, acute care and RAC will need careful management to prevent duplication and waste. • Similarly the interface between the ambulatory rehabilitation programs (Day Hospital, RITH, domiciliary therapy, community physiotherapy, outpatient therapy...) will also need careful management. • Principle is that there may be many different services but only one case manager per patient and access is streamlined and prioritised on need. • It is now becoming more obvious the major challenge of the future will be to fund and organise ambulatory health care and community supports. Format of Today’s Talk

Projected number of people with dementiaNB: Flat line

Source: Calculations by AIHW based on data from Lobo et al. 2000 and Harvey et al. 2003 Cause of Death in Australia

The postponement of CVS disease and cancer increases the lifetime risk of developing neurodegenerative disorders which are even more heavily age dependent Years of Life Lost by Condition An example which requires this coordinated approach - Patients with dementia How should we manage such patients? 1) Primary prevention 2) Timely assessment 3) Community Support Services 4) Acute inpatient and outpatient management of comorbidity including early advanced directives 5) Efficient and compassionate transition to residential care 6) Specialized and efficient personal and health care in residential care including palliative care

What is happening to the incidence of dementia?

• There are really no recent studies. • There has been a 25% reduction in age-adjusted stroke death rates in the USA and Australia most likely due to a decreased incidence • Similarly, age-adjusted female hip fracture incidence decreased between 1995 and 2005 by about 25%, continues to decrease and has very little to do with osteoporosis treatments. Towfighi A, et al Therapeutic milestone: stroke declines from the second to the third leading. Stroke 2010 ; 41 : 499, Islam MS, Anderson CS, Hankey GJ, et al. Trends in incidence and outcome of stroke in Perth.. Stroke 2008 ; 39 : 776 – 82 Brauer CA, et al. Incidence and mortality of hip fractures in the United States. JAMA 2009 ; 302 : 1573 – 9 . Exercise training increases size of hippocampus and improves memory (2010)

Erickson et al www.pnas.org/cgi/doi/ 10.1073/pnas.101595 0108

Early or Timely Diagnosis? • A diagnosis should be made as soon as possible in every individual case - Driven by personal and professional experiences of delays in access to diagnosis and support. • Currently no high quality evidence that diagnosis before the usual point of clinical presentation leads to long term improvements for people with dementia and their families. “policy cart before the research horse.” • “Early” versus “screening” • Potential harms of premature diagnosis – Diversion of resources from activities of proven value – Misclassification of substantial numbers of people – Overdiagnosis and overtreatment – Raising levels of anxiety in the population, particularly among older people. Delirium ? Precursor to dementia

• Clouded state of consciousness • Problems in sustaining attention • Sensory misperceptions • Disturbed thinking • Hyper and hypo activity with disturbance in sleep wake cycle • Onset is rapid • Condition fluctuates People with Dementia and Hospitals The problem is Comorbidity (Draper et al 2011) • Dementia was the principal diagnosis for 6% of hospital admissions of people with dementia. • The most common principal diagnoses for those stays were lower respiratory tract infections (8%), fractured femur (6%), urinary tract infections (6%), head injury (3%) and stroke (3%). • Patients with dementia spent longer in hospital (17 days) than those without dementia (9 days). • Differences in length of stays were even more pronounced among younger patients. A Shared Care Model for Dementia • Assume an average ACAT region services 100,000 Australians. In that catchment about 114 GPs. (2 in NT) • There will be approximately 1350 people with dementia. • Each GP would have on average 12 people with dementia to look after (assuming a survival of 5 years) ~ 2 new people with dementia per year • The memory service would have to be able to provide diagnostic services for ~250 new cases per year and provide support to GPs for the others including 400 people in residential care. IS THIS SO HARD?