Apa Aged Care Survey 2009

Transcription

1 Apa Aged Care Survey 2009

2 FOREWORD The Australian Physiotherapy Association (APA) advocates for equitable access to quality physiotherapy and optimal health care for all Australians and is committed to ensuring that government policy decisions do not adversely affect the delivery of physiotherapy within our communities. Gerontology Physiotherapy Australia (GPA) is a national group of the APA whose philosophy of care is centred on maximising functional ability, which physiotherapists strongly promote in the residential aged care sector. The introduction of the Aged Care Funding Instrument (ACFI) by the Federal Government has been of great concern to Gerontology Physiotherapy Australia since its proposal in In response to these concerns the APA undertook a survey to gauge the level of physiotherapy provided to clients in residential aged care facilities (RACFs). The first survey in 2007 established important benchmarks of the level of physiotherapy service delivery prior to the introduction of the ACFI. The 2009 survey discussed in this report establishes what the effect of the introduction of the ACFI has been on the provision of physiotherapy services in our aged care facilities. Patrick Maher APA President Shylie Mackintosh Chair Gerontology Physiotherapy Australia ABN NATIONAL OFFICE PO Box 437, Hawthorn BC, VIC 3122 Level 1, 1175 Toorak Road, VIC 3124 Tel: (03) Fax: (03) national.office@physiotherapy.asn.au 1

3 Acknowledgements Authors: Paula Johnson (Senior Policy Officer, APA National Office), Shylie Mackintosh, Chair, Gerontology Physiotherapy Australia and Jane Louis, Gerontology Physiotherapy Australia. The APA wishes to acknowledge the work of the members of Gerontology Physiotherapy Australia, and the APA members who completed the survey. First published 2010 Copyright Australian Physiotherapy Association 2009 This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the APA. Australian Physiotherapy Association PO Box 437, Hawthorn BC Victoria 3122 Phone Fax national.office@physiotherapy.asn.au Web site: 2

4 EXECUTIVE SUMMARY Key findings from the report Optimal pain management has been compromised since the introduction of the Aged Care Funding Instrument (ACFI) Exercise programs in most facilities have either decreased or failed to expand since the introduction of the ACFI A significant proportion of physical therapy is delivered by staff members who are not appropriately qualified or experienced There is a poor rate of uptake of Medicare items for physiotherapy services There appears to have been a decline in the ratio of physiotherapists to residents within residential aged care facilities (RACF) The survey indicates that there has been an increase in the number of unpaid hours worked by physiotherapists since the introduction of the ACFI Half of the physiotherapists surveyed believe that the therapy needs of residents in RACFs are not adequately met Just under half of the physiotherapists surveyed believed that optimum levels of mobility and dexterity were not achieved for all residents, meaning that nearly half of all RACFs are not fully meeting accreditation standards. Elderly residents of RACFs need sufficient care to maintain wellbeing and the best possible level of mobility. The Australian Physiotherapy Association believes that the ACFI review scheduled for must urgently address the problems identified in this report, to ensure that Australia s aged care residents receive the most appropriate level of treatment from skilled practitioners. 3

5 INTRODUCTION It is now well established that Australia has an ageing population with the number of people aged 65 or more projected to double within thirty years. As a consequence, residential aged care facilities (RACFs) and the care requirements of older people have become a high priority for Australia. Previous funding for residential care was based upon the Resident Classification Scale (RCS); however, in 2008 the Aged Care Funding Instrument (ACFI) replaced the RCS. Funding under the ACFI system targets the individual resident s care needs rather than focusing on the care delivered. OVERVIEW The ACFI is a resource allocation instrument that uses the assessment of core care needs as a basis for allocating funding (Department of Health and Ageing, 2009). The ACFI was produced to replace the RCS. In 2002 a review of the previous RCS funding model took place and determined that care assessment and documentation were driven by ensuring maximum funding for an RACF. The ACFI was intended to function very differently to the RCS. The ACFI focuses funding on dependency (need for care) and thus, the ACFI does not explicitly or implicitly prescribe particular health care interventions (including allied health services and therapies) to maximise mobility and dexterity. According to the Department of Health and Ageing (DoHA), it was designed to be simpler, shorter and easier to use than the RCS and intended to streamline and simplify the funding system so that aged care homes spend less time on paperwork and more time providing care. This new funding model was implemented on 20 March 2008, it did not negate the responsibility of aged care providers to provide care planning and care intervention programs, however ongoing care documentation which was required to secure funding under the RCS is not required for the ACFI. As outlined in the ACFI User Guide, 12 care needs questions are used to determine the level of care necessary for the individual and thus the funding requirement (DoHA, 2009). With the ACFI, the number of funding categories for basic care has been reduced from eight to three, which are outlined below. Activities of Daily Living (ratings on Nutrition, Mobility, Personal Hygiene, Toileting and Continence questions are utilised to determine the level of the basic subsidy) Behaviour Supplement (ratings on Cognitive Skills, Wandering, Verbal Behaviour, Physical Behaviour and Depression questions are utilised to determine the behaviour supplement) Complex Health Care Supplement (ratings on Medication and Complex Health Care Procedure questions are utilised to determine the complex health care supplement). The amount of each of these that is payable in respect of a particular resident depends on the ratings (A, B, C or D) for each of the ACFI questions (1 12). Diagnostic information about mental and behavioural disorders and other medical conditions is also collected. 4

6 THE CASE FOR REVIEW The Australian Physiotherapy Association (APA) has voiced concerns to the Federal Government since the ACFI pilot in Concerns were raised when a number of aged care facilities indicated that there would be a reduction of the level of physiotherapy available to the residents once the ACFI was introduced. APA members expressed alarm about the potential impact on residents and standards of care in RACFs. In particular, members were concerned that the proposed funding instrument may encourage premature dependency to maximise the facility s funding. The Department of Health and Ageing (DoHA) assured the APA that if this was to occur it would be a breach of Accreditation Standards. The Accreditation Standards state that residents must be referred to appropriate health specialists in accordance with the resident s needs and preferences. The Standards do not explicitly state that the services the resident needs must be provided for low care residents. For these reasons the APA conducted a survey with physiotherapists working in RACFs in 2007 to determine the baseline level of physiotherapy service prior to the introduction of ACFI and then a second survey in 2009, to evaluate current trends in the care of residents, in particular the impact (if any) the ACFI has on physiotherapy services in RACFs. METHODOLGY Sampling The second survey was conducted online from 29 May 2009 through to 24 July All members of the APA s Gerontology Physiotherapy Australia (GPA) and Physiotherapy Business Australia (PBA) were invited, via , to participate in the survey and encouraged to forward the survey to other physiotherapists working in RACFs who may not be members of these groups. Data Analysis and Reporting After the closing date (24 July 2009) of the online survey the raw data was downloaded to Microsoft Excel. After cleaning, the data was then pooled and analysed descriptively, with comparison to the previous survey in Survey Design The survey was developed by the APA s Senior Policy Officer in consultation with its executive management team and the GPA Committee. The survey was composed of a series of closed questions, mostly with Likert scale response categories, as well as a number of open ended sections inviting comments. The instrument was converted to an online tool which could be accessed via a link through the ed survey invitation. 5

7 RESULTS In 2009, responses were received from 206 physiotherapists, compared to 157 in The number of responses varies for different questions, as it was not compulsory to respond to all questions in the survey. Table 1: Employment Status in RACFs (204 respondents) Number Percentage Change since 2007 Ongoing, permanent 81 40% +3% Contract employment % 0% Other* 12 6% 2% *Of those that answered other, the majority of respondents worked through a consultant/agency/contractor agreement. Table 2: Number of hours of employment per week* (205 respondents) Number Average per facility Change since 2007 Total Number 2, hours per week 0.4 hours per week Paid 2, % 4% Unpaid % +4% *It was assumed that where it was not indicated whether employment was paid/unpaid, that the employment hours were paid. Table 3: Number of physiotherapists employed at RACFs (206 respondents) Number Percentage Change since 2007 One physiotherapist employed % 3% 2 or more physiotherapists employed % +2.5% Table 4: Number of beds in RACFs (205 respondents) Number Average bed per facility Change since 2007 Total Number 21, beds High Care 12,406 57% 3% Low Care 6,761 31% +5% No indication of bed type 2,608 12% 2% Table 5: Since the introduction of the Aged Care Funding Instrument, physiotherapy hours at aged care facilities have (193 respondents) Number Percentage Increased by 10 or more hours per week 8 4% Increased by between 5 & 9 hours per week 15 8% Increased by between 1 & 4 hours per week 45 23% Remained unchanged % Decreased by between 1 and 4 hours per week 4 2% Decreased by between 5 and 9 hours per week 5 3% Decreased by 10 or more hours per week 2 1% 6

8 RESULTS Table 6: Since the introduction of the Aged Care Funding Instrument, physiotherapy assistant hours at aged care facilities have (181 respondents) Number Percentage Increased significantly 9 5% Increased slightly 20 11% Remained unchanged % Decreased slightly 16 9% Decreased significantly 17 9% Ceased completely 3 2% Table 7: Assuming that all clients require physiotherapy care in the RACF setting, in a normal week the amount of time spent with clients in a clinical setting was (195 Respondents) Average time spent per client per week 5 minutes 4.45 minutes Range 2 seconds 27.8 minutes 24 seconds 30 minutes Table 8: In a normal week the amount of time spent discussing care plans with staff was (202 respondents) Average percentage of weekly hours spent on care-planning per week 25% +10% Maximum time 100% 0% Minimum time 0% 0% Table 9: Proportion of physiotherapy services carried out by non physiotherapy staff (193 respondents) 2009* Average 37% Maximum response 0% Minimum response 100% * No data was collected in 2007 Table 10: The number of hours per week that non physiotherapist staff members undertake tasks that are most appropriately undertaken by a physiotherapist) Number Percentage Change since 2007 Less than 1 hour per week 51 26% +7% 1 2 hours per week 32 17% 0% 3 4 hours per week 34 18% 0% 5 hours or more per week 76 39% 7% 7

9 RESULTS Table 11: The facility uses Medicare funding for allied health (139 respondents) Number Percentage Change since 2007 Yes 55 30% +10% No % 10% Table 12: If the facility did not use Medicare items, the primary barrier to their use is thought to be (159 responses; individuals could choose more Number Percentage Change since 2007 than one response) Doctors are too busy to contribute to care plans 43 27% +2% RACF staff are not aware of Medicare funding 40 25% 0% Doctors are not prepared to contribute to care plans 32 20% 3% Medicare system is too hard to understand 16 10% +1% Other 28 18% 0% Table 13: Since the introduction of the Aged Care Funding Instrument, on average, the number of hours per week that are spent on delivering electrotherapy and massage for pain relief have (193 respondents) Number Percentage Increased by 10 or more hours per week 8 4% Increased by between 5 and 9 hours per week 15 8% Increased by between 1 and 4 hours per week 45 23% Remained unchanged % Decreased by between 1 and 4 hours per week 4 2% Decreased by between 5 and 9 hours per week 5 3% Decreased by 10 or more hours per week 2 1% Table 14: Since the introduction of the Aged Care Funding Instrument, exercise programs at aged care facilities have (181 respondents) Number Percentage Increased significantly 6 3% Increased slightly 20 11% Remained unchanged 94 52% Decreased slightly 31 17% Decreased significantly 27 15% Ceased completely 3 2% 8

10 RESULTS Table 15: Physiotherapists are valued (193 respondents) Number Percentage Change since 2007 Strongly agree 75 39% 3% Agree 85 44% +5% Neutral 17 9% 3% Disagree 12 6% +1% Strongly disagree 4 2% 0 % Table 16: Physiotherapists are able to practise as autonomous practitioners and their professional opinion is respected* (193 respondents) Number Percentage Strongly agree 67 35% Agree 93 48% Neutral 18 9% Disagree 9 5% Strongly disagree 6 3% * No data was collected in 2007 Table 17: Every client in this RACF receives the physiotherapy treatment they require from a qualified physiotherapist (193 respondents) Number Percentage Change since 2007 Strongly agree 17 9% +6% Agree 41 21% +4% Neutral 28 15% +1% Disagree 78 40% 1% Strongly disagree 30 16% 9% Table 18: Clients therapy needs are adequately met in the RACF (193 respondents) Number Percentage Change since 2007 Strongly agree 12 6% +4% Agree 53 28% +4% Neutral 31 16% 4% Disagree 72 37% 3% Strongly disagree 25 13% 1% 9

11 RESULTS Table 19: Clinical consultation time is adequate for residents (193 respondents) Number Percentage Change since 2007 Strongly agree 18 9% +5% Agree 52 27% 1% Neutral 26 13% 2% Disagree 75 39% 0% Strongly disagree 22 11% 3% Table 20: Generally, communication is good between physiotherapist and other RACF staff regarding client care planning (192 respondents) Number Percentage Change since 2007 Strongly agree 64 33% +3% Agree 94 49% +1% Neutral 20 10% 7% Disagree 13 7% +3% Strongly disagree 2 1% 0% Table 21: Physiotherapists have adequate input into the planning and implementation of resident care* (193 respondents) Number Percentage Strongly agree 41 21% Agree 90 47% Neutral 26 13% Disagree 29 15% Strongly disagree 7 4% * No data was collected in 2007 Table 22: The Aged Care Funding Instrument has compromised evidence based practice in the management of pain* (193 respondents) Number Percentage Strongly agree 62 32% Agree 53 27% Neutral 56 29% Disagree 19 10% Strongly disagree 3 2% * No data was collected in

12 RESULTS Table 23: Optimum levels of mobility and dexterity are achieved for all residents (Accreditation Standard 2.14) (193 respondents) Number Percentage Strongly agree 17 9% Agree 55 28% Neutral 36 19% Disagree 66 34% Strongly disagree 19 10% * No data was collected in 2007 Table 24: The biggest problem faced by the provision of physiotherapy to residents of RACFs was (134 respondents) Number Percentage Lack of funding for physiotherapy 43 32% Lack of physiotherapist hours 29 22% Low value placed on physiotherapy 19 14% Lack of freedom to exercise clinical discretion due to funding tool Lack of exercise programs (falls prevention, balance, mobility) 8 6% 7 5% High administration requirements 7 5% Other 21 16% Table 25: Changes physiotherapists would like to see over the next 2 years in their RACFs are (142 respondents) Number Percentage Increased hours for physiotherapists 32 23% More emphasis on the funding and provision of exercise programs for balance and mobility The introduction of physiotherapy assistants or increased hours for physiotherapy assistants 24 17% 24 17% Increased staffing (nursing, carers) 7 5% Promotion of independence 6 4% Increased compliance with care plans 6 4% Utilisation of Extended Primary Care programs/ Medicare benefits 5 4% Equipment/ improved facilities 5 4% No change needed 5 4% Lowered administrative requirements 4 3% More government support for aged care 3 2% Other 21 15% 11

13 DISCUSSION Physiotherapy treatment in aged care facilities The results indicate that there may have been a decline in physiotherapists working hours in RACFs, with an average decline of just under half an hour (12.1 hours per week down from 12.5 hours per week in 2007) (Table 2). This is despite an apparent rise in the average number of beds per facility (106 beds per facility up from 92 in 2007) (Table 4). The 12.1 hour average includes unpaid hours worked in facilities, which has increased from 4% of all hours worked to 9%, an indication that the new funding instrument is failing to provide for an adequate physiotherapy presence within RACFs. An issue with response bias may have occurred as physiotherapists who have left the aged care sector were not easily accessible for this survey. No reports of termination of hours in this survey occurred, despite a number of anecdotal reports to the APA. Of major concern in the 2007 survey was the low allocation of clinical physiotherapy time per resident. Data supplied in 2007 indicated that although time was not split evenly between low and high care residents, the minimum time allocated per patient was 24 seconds. Data from the 2009 survey indicates that this situation has intensified, with the minimum time allocated per patient being two seconds, however the average rose slightly to five minutes, and the maximum time allocation fell by just over two minutes at 27.8 mins (Table 7). On average 25% of a physiotherapist s time was spent discussing care plans with staff (Table 8). Physiotherapists concerns about residential aged care Physiotherapists two most significant concerns were the lack of funding for physiotherapy in aged care facilities (32% of respondents) followed closely by the lack of physiotherapist hours (22%) (Table 24). 30% of physiotherapists said that residents received the physiotherapy treatment they needed from a physiotherapist, which represents an increase from However the majority (56%) still felt that patients were not getting the treatment they needed from qualified staff (Table 17). This poses problems for the safety and reliability of treatment for some of the most fragile people in our communities, and remains a problem for physiotherapists in implementing care plans and ordering interventions under the Complex Health Care section of the ACFI. In addition, 51% of physiotherapists believed that the therapy needs of residents in RACFs were not adequately met (Table 18). Adequately met needs are likely to result in decreased dependence on care workers, decreased incidents of falls and increased wellbeing, so it is vital that adequate services are available to residents. The survey showed that the importance of physiotherapy within aged care facilities is well recognised, with 83% of respondents saying that they feel valued within their RACF (Table 15). Yet comments indicate that physiotherapists remain frustrated by inadequate time to see residents in RACFs or to run exercise programs that would help manage pain, reduce falls and improve well being. Pain management in aged care facilities ACFI allocates funding for specific modalities of pain management, and it has been the APA s experience that many physiotherapists feel that this undermines their choice of efficacious pain management modalities. Survey data has supported this anecdotal evidence, with 59% of physiotherapists indicating that the ACFI has compromised their evidence based practice in the management of pain (Table 22). Only 12% disagreed with the statement that ACFI has compromised evidence based practice in the management of pain. 12

14 DISCUSSION Electrotherapies and massage to manage pain (two of the three modalities for which funding is specifically allocated) have increased by 35% within RACFs (Table 13). Given that overall services have decreased in the aged care facilities, this result is concerning, as other active modalities with good evidence to support their use (such as exercise therapy) must have been cut to provide such an increase in the level of passive therapies with little evidence to support their use. Residents mobility and dexterity A total of 44% of respondents believed that optimum levels of mobility and dexterity were not achieved for all residents (Table 23), meaning that in the opinions of those most qualified to assess mobility and dexterity, nearly half of all RACFs were not meeting accreditation standards. One way to assist with the delivery of certain physiotherapy services within RACFs would be to increase the hours of trained physiotherapy assistants (PTA), however the survey found that in 20% of cases, PTA hours have been reduced. In some of these cases, PTA hours have ceased entirely (Table 6). Medicare funding in aged care facilities One of the concerns raised in the 2007 survey was a lack of utilisation of Medicare rebates available for allied health treatment of chronic and complex conditions. This has improved somewhat with 10% more facilities now utilising the items, however the vast majority of RACFs are failing to utilise this funding (70%) (Table 11). The top three reasons cited for this is that doctors were too busy or not prepared to contribute to care plans (47%) and that RACF staff were not aware of the funding (25%) (Table 12). This correlates with GPs claims since the introduction of the Enhanced Primary Care (EPC) program that administrative requirements for the scheme are a disincentive to its use. This finding also suggests that the placing GPs in the role of gatekeeper to allied health services within RACFs is ineffective, and arrangements should be changed to better facilitate access to physiotherapy for residents of RACFs. Other issues that could contribute to decisions not to utilise the items are the relatively few treatments allowed under the scheme in contrast to the long term treatment required for residents of aged care facilities. 13

15 CONCLUSIONS The results of this survey show that there has been a decline in the ratio of physiotherapists and PTAs to residents within RACFs since the introduction of the ACFI. Physiotherapists have also expressed concern about the impact of funding for selective modes of pain management and the subsequent decline in exercise programs that otherwise would have the potential to reduce falls and improve residents mobility and dexterity. The survey found that a significant proportion of physical therapy continues to be delivered by staff members who are not appropriately qualified or experienced. This is problematic on a number of levels, as the quality of such treatment is questionable and has the potential to compromise patient safety. The poor rate of uptake of Medicare items indicates that more needs to be done to encourage GPs and RACF staff to utilise EPC funding. Improvements could include reducing administrative work associated with the items and increasing the number of services available to residents. 14

16 Apa Aged Care Survey 2009 First published 2010 Copyright Australian Physiotherapy Association 2009 This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the APA. Australian Physiotherapy Association PO Box 437, Hawthorn BC Victoria 3122 Phone: Fax: national.office@physiotherapy.asn.au Web site: