Our ref: KTCM-DL. 14 May 2012

Transcription

1 14 May 2012 Our ref: KTCM-DL Keith Tracey-Patte Assistant Secretary Policy and Evaluation Branch Ageing & Aged Care Division GPO Box 9848 Canberra ACT 2601 Dear Keith Re: Aged Care Funding Instrument revision I am writing with regards to the revision of the Aged Care Funding Instrument (ACFI). As the APA has been excluded from any recent discussions on the revision to ACFI, we are concerned about the potential implications that may arise from changes to ACFI that can affect the care provided to older Australians and be detrimental to their health and wellbeing. Our members are gravely concerned with rumours that some aged care providers may significantly reduce or altogether remove services provided by physiotherapists should there be changes to ACFI that do not support therapies that reduce pain, and maximise function and independence. Whilst we acknowledge that as revisions to ACFI remain unannounced and the above concerns are driven by speculation within the industry, we need to ensure that any change does not inadvertently reduce the access of aged care residents to physiotherapy. Physiotherapy is a vital component in aged care and one of the key treatments that can optimise function and improve the health of older Australians this is acknowledged by the Productivity Commission in its report Caring for Older Australians. We are fully aware of the issues with the current ACFI model. Some of the changes that were recommended in our earlier submissions to the Department of Health and Ageing (please refer to attachment) are: To help support older Australians gain and maintain independence and in the case of home care (when ACFI will eventually be used for older Australians in the community as proposed in the Living Longer, Living Better package) help them remain and receive care at home, restorative assessment and treatment should be included as a section in the ACFI. This care should encompass o maximising physical functionality o falls and balance o continence especially functional incontinence o pain management No funding levels should dictate the frequency of treatment, other than requiring that they be based on clinical best practice. Treatment options should support the clinical judgement of the most suitably qualified health professional, and should be based on the most up-to-date evidence and guidelines available. The Complex Health Care section should be amended to support the most appropriate clinician s clinical decision, rather than focusing on particular modalities and frequencies.

2 Perverse incentives that currently encourage behaviour leading to further functional decline instead of promoting maintenance of function and mobility must be addressed. An example is when a resident who is slow and requires supervision is placed in a wheelchair as it attracts a higher level of funding and requires less staff time, despite assisted walking being able to improve mobility. We are also acutely aware that there is currently a lack of a rehabilitative or restorative focus in residential aged care where specific physiotherapy interventions are evidenced to improve or maintain function, and we believe this is partly influenced by the existing ACFI funding model. The APA believes that we need to be directly involved with any review of ACFI. As one of the main health professions in the aged care sector, it is crucial that we are able to directly advise points such as the above, as well as ensuring that, as previously mentioned, changes to ACFI does not inadvertently reduce the access of aged care residents to physiotherapy. Please feel free to contact Darren Li, Senior Policy Officer, at (03) or darren.li@physiotherapy.asn.au should you require any clarification or more information about the points made above, or any matters related to the provision of physiotherapy for older Australians. Thank you for your consideration and I look forward to your response. Yours faithfully, Cris Massis Chief Executive Officer

3 Submission to the Review of the Aged Care Funding Instrument Presented to the Department of Health and Ageing April 2010 Authorised by: Patrick Maher President Australian Physiotherapy Association 1/1175 Toorak Rd Camberwell VIC 3124 Phone: (03) Fax: (03)

4 Executive Summary The APA advocates that any aged care system should aim to maximise mobility and functional independence in older people, and that such a system would greatly contribute to improving quality of life for its participants and reduce the burden of care. The APA makes the following recommendations: That the requirement for residents to be reassessed under the ACFI six months after readmission from extended hospital leave be removed. That restorative assessment and treatment be included as a section in the ACFI. Treatment should be available for both low and high care residents. This care should encompass o maximising physical functionality o falls and balance o continence especially functional incontinence o pain management No funding levels should dictate the frequency of treatment, other than requiring that they be based on clinical best practice. Treatment options should support the clinical judgement of the most suitably qualified health professional, and should be based on the most up-to-date evidence and guidelines available. A mechanism should be implemented, that ensures funding for the incorporation of new, evidenced based guidelines as they are released. Funding incentives that are built into the current ACFI that encourage providers to improve and maintain the physical function of residents should be explicit in the ACFI documentation. The Complex Health Care section should be amended to support the most appropriate clinician s clinical decision, rather than focusing on particular modalities and frequencies. Funded pain management modalities should include current modalities such as therapeutic exercise programs supervised by physiotherapists. The ACFI should be changed to reflect the following: Section 2 Mobility should include a mandatory physiotherapy falls assessment (as per the ACSOHC Guidelines). Where clinically indicated, residents should be enrolled in a physiotherapist supervised falls and balance program that is based on current clinical practice guidelines Section 5 Continence should include a physiotherapy assessment to determine suitability for physiotherapy intervention to improve function. Section 12 Complex Health Care should: o define an allied health professional, and the list should be kept up to date o require all staff (other than physiotherapists and medical practitioners) administering heat packs, therapeutic massage or pain management involving technical equipment specifically designed for pain management to have undergone a minimum training requirement specific to the modality being applied. Training must include (but should not be limited to) such areas as: contra-indications; complications; tests required prior to treatment; required warnings; supervision of the resident during application; and familiarity with the APA s guidelines for the clinical use of electrophysical agents. o move the funding criteria away from the focus on duration of treatment. Funding should match the severity of the condition, rather than prescribing treatment categories o require that interventions used are based on the clinical requirements of the resident 2 of 13

5 That the Department of Health and Ageing (DoHA) work with Medicare to ensure that the systems are integrated effectively, and that the mandatory requirement for GP contribution to care plans be removed. Residents of RACFs with a complex condition should be recognised as needing more than five sessions, and should be entitled to additional consultations with specified allied health professionals under the program. That a pool of funding be allocated to people who move from an acute hospital bed to an aged care bed. This funding should be used for rehabilitation for a set period of time. That the ACFI include a mechanism to ensure that incentives are offered to fund implementation of new evidence based guidelines into residential aged care facilities. It is extremely difficult for aged care providers to balance budgets based on medium to long term cost savings and intangible improvements in resident well-being. With slim day to day profit margins, providers find it difficult to invest in therapies which will provide long term cost savings. It is up to the Government of Australia to ensure that care to older people is not focused on maximising dependency in order to maximise funding, but instead focused on prevention of decline, maximisation of function and clinical best practice. If the focus on resident dependence is allowed to continue without an equal focus on the prevention and improvement of ill health, then the burden of Australia s ageing population will soon become unmanageable. This submission provides recommendations that aim to change the focus on dependency to ensure that people who have the potential to improve function are empowered to do so. Australian Physiotherapy Association The Australian Physiotherapy Association (APA) is the peak body representing the interests of Australian physiotherapists and their patients. The APA is a national organisation with state and territory branches and specialty subgroups. The APA corporate structure is one of a company limited by guarantee. The organisation has approximately 12,000 members, some 70 staff and over 300 members in volunteer positions on committees and working parties. The APA is governed by a Board of Directors elected by representatives of all stakeholder groups within the Association. The APA vision is that all Australians will have access to quality physiotherapy, when and where required, to optimise health and wellbeing. The APA has a Platform and Vision for Physiotherapy 2020 and its current submissions are publicly available via the APA website 3 of 13}

6 Introduction The Aged Care Funding Instrument (ACFI) The APA advocates that any aged care system should aim to maximise mobility and functional independence in older people, and that such a system would greatly contribute to improving quality of life for its participants and reduce the burden of care. This submission contains recommendations that the APA believes would help the Australian residential aged care system to achieve these goals. Physiotherapists have been concerned about the effects of the ACFI on residents of Residential Aged Care Facilities (RACF) since the inception of the new funding instrument, and observations of its wide implementation have shown that these concerns remain valid. The Aged Care Funding Instrument (ACFI) is based primarily on the resident s need for care and dependency 1 and does not provide incentives for residential aged care providers ( providers ) to offer interventions that reduce dependency and decline. Instead, it rewards premature increase in functional decline, meaning that residents need more care, more staff and more funding. The APA s concerns continue to revolve around the negative incentives that form the basis of the instrument, namely that maximal dependency is equated with maximal funding, and we believe that there are no effective incentives for providers to focus on improving independence and functionality. These financial incentives steer providers and residents towards unintentional premature disability maximum dependency and maximum financial reward are linked. The Department of Health and Ageing ( the Department ) has responded to these concerns by saying that providers do have an incentive to reduce dependence, as ongoing ACFI assessments are not required, and if an RACF is able to improve the condition of a resident who has been assessed as high care, they will still receive funding for that resident at a high care level. During the first year of the ACFI however, the APA has noted several problems with the operation of this incentive, primarily as the incentive is not made clear in any literature around the ACFI. Providers and staff may therefore not be aware of it at all. Even if this incentive was clear to providers, the APA believes that the initial outlay on professional staff may mean that busy providers and care staff do not see future potential cost savings as a high priority. Therefore potential improvements in residents quality of life can be lost to more immediate factors such as getting to the dining room quickly in a wheel chair rather than being provided with walking assistance, or the provision of continence pads, rather than be provided with physiotherapy to improve toileting control. Physiotherapists believe that low care residents have a great potential to benefit from physiotherapy to maximise mobility and independence. There is no funding for this in the ACFI even though physiotherapy could actively prevent these low care residents from prematurely drifting into high care. Funding for treatment for these residents should be incentivised through the ACFI. While the Federal Government contributes significant amounts to the residential aged care sector, the APA believes that physiotherapy is still under-utilised in facilities. The result is that many residents are not able to gain access to physiotherapy services that could improve such factors as: incidents of injury from falls pain management management of osteoarthritis management of osteoporosis management of type 2 diabetes improvement in mobility and dexterity management and improvement of incontinence 4 of 13

7 Factors such as perceived cost, supply and lack of awareness about physiotherapists skills have a role in this under-utilisation, and the APA urges the government to ensure that its funding instrument supports aged care residents to access care that facilitates restorative treatments. The 2009 Aged Care Survey In 2009 the APA undertook a survey to ascertain the changes to the provision of physiotherapy services within the residential aged care sector. The key findings were: Optimal pain management has been compromised since the introduction of the 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 must urgently address the problems identified in the survey, to ensure that Australia s aged care residents receive the most appropriate level of treatment from skilled practitioners. 2 A full copy of the report is appended to this submission. Matching funding to care needs The APA believes that RACF residents, like all Australians, are entitled to care that maximises wellbeing and quality of life. The APA believes that there are a number of specific care needs that are not well captured by the ACFI, resulting in poorer quality of life for older people in RACFs. In the APA s 2009 Aged Care Survey, an alarming 50 per cent of physiotherapists did not believe that residents therapy needs were adequately met in their RACF, indicating that the ACFI has done little to improve access to the therapy residents require. 3 The three primary areas in need of funding through the ACFI are restorative care, preventative care (particularly falls prevention), and pain management. The APA believes that funding must be matched more carefully to the needs of the whole person. Restorative care Aged Care Assessment Teams (ACAT) comprehensively assess people for the restorative, physical, medical, psychological, cultural and social dimensions of a person s care needs 4, yet the ACFI literature says that restorative care is explicitly excluded from the ACFI. This is despite restorative care and rehabilitation being greatly needed by many residents of RACFs. It also has the potential to reduce costs for providers in the mid and longer terms. 5 of 13}

8 The Quality of Care Principles specifically excludes providers from providing their residents with rehabilitation after serious illness, injury or trauma. These principles made under the Aged Care Act 1997 say that low care residents are not provided with this level of physiotherapy. While not within the scope of this review, the APA believes that these principles should urgently be amended to ensure that they do not preclude rehabilitation after an acute event. After hospitalisation Lack of any rehabilitation for residents after hip fracture is one example of the problem experienced when returning to a RACF after a period of hospitalisation. It is a fact of life that busy staff in our hospitals need to prioritise some patients over others, and identify those most at risk after discharge. Consequently elderly patients who will return to the community are often the first to receive rehabilitation, and there is an assumption that those returning or going to an RACF will be provided with both maintenance and rehabilitation by facility staff. Unfortunately this does not usually occur, and busy staff can often provide only basic maintenance care, which does not take into consideration the potential for considerable improvement during the sub-acute phase. Were adequate funding available, physiotherapists could provide rehabilitation services to people in RACFs after an acute episode requiring hospitalisation such as a hip fracture. Such services could prevent residents from becoming bed or chair bound and so reduce the burden and cost of care after a few shorts weeks of rehabilitation. A further disincentive to providing care that improves a resident s independence is the mandatory requirement that facilitates re-assess residents six months after an extended hospitals stay. Physiotherapists working in RACFs feel that this is a barrier to the improvement of residents condition after an acute episode. APA members have reported their frustrations when seeing resident s potential for improvement, but not having the opportunity to treat them. When asked about her experiences working in an RACF under the old funding model and then under the ACFI, one physiotherapist had the following to say about one of her private patients. 1. [I treated] a 58 year old man with a wife with Parkinson s disease. He was hospitalised with bowel cancer, had surgery and chemo. He then had Guillain Barré syndrome, probably from an infection while on chemo and then after some rehab ended up with a lot of muscle removed from his leg when a melanoma was eventually surgically excised. He was then told his paralysis was permanent, he wasn t for rehab and placed in a Nursing home After our rehab he walked out of the home on 2 walking sticks, started driving and looked after his wife at home. This level of physiotherapy intervention provided was not funded through the ACFI. The Quality of Care Principle that removes the obligation to provide rehabilitation after surgery also forms a barrier to RACFs providing this level of care. Another physiotherapist told a similar story about a client that she treated residing in an RACF. An elderly woman who had a severe stroke, was initially unable to sit, was full assist with hoist. [She] was not given rehab in hospital. She was very keen to walk again even though it seemed unlikely. She was given lengthy rehab in [the] nursing home by physios for many months and is now able to walk with a FASF [forearm support frame] with staff and uses a stand up hoist instead of the full hoist which is more dignified for her and easier for the staff. For each person who can afford to privately fund physiotherapy to improve their independence and mobility, there must be many more unable to access this kind of care. Statistics from the Private Health Insurance Administration Council (PHIAC) indicate that around 85,000 people aged over 85 years held general treatment coverage ( extras ) in December When compared to Australia s population of 515,000 males and females aged 85 or over 6, it becomes apparent that very few people in RACFs would have the assistance of private health insurance to assist them in accessing private physiotherapy rehabilitation. 6 of 13

9 National Physical Activity Guidelines for Older Australians The Australian Government published the National Physical Activity Guidelines for Adults, and has developed further recommendations for older Australians. These recommendations encompass all older Australians, including people living in residential care. The guidelines make five recommendations but the first two are most relevant to older people living in RACFs: 1. Older people should do some form of physical activity, no matter what their age, weight, health problems or abilities 2. Older people should be active every day in as many ways as possible, doing a range of physical activities that incorporate fitness, strength, balance and flexibility. By funding only dependency and failing to offer any funding for treatments that would improve older people s capacity to participate in physical activity (such as assistance to walk to meals) the ACFI is failing to follow the Guidelines. The ACFI provides more funds for pushing a person in a wheel-chair than it does to assist the same person to walk to meals, despite walking assistance taking more time but being more beneficial for the resident. The Guidelines also outline the following benefits of regular physical activity. These include helping to: maintain or improve physical function and independent living improve social interactions, quality of life, and reduce depression build and maintain healthy bones, muscles and joints, reducing the risk of injuries from falls reduce the risk of heart disease, stroke, high blood pressure, type 2 diabetes, and some cancers 7 A mechanism to assist RACFs to provide activities that work towards fulfilling the recommendations should be developed for all residents, including those with decreased mobility, at risk of falls, chronic disease and pain. Continence in older people Treatment delivered by a physiotherapist with expertise in continence issues to patients who have impaired bladder control can reduce dependence, thus helping to improve residents physical and mental wellbeing. Active management of incontinence rather than passive acceptance of the condition is in the best interests of residents and care facilities alike. Unfortunately this is not acknowledged by the ACFI. The ACFI funds dependency by providing money only for the supply of services and products such as incontinence pads and assisted toileting. It fails to support physiotherapy services which aim to increase residents ability to control and improve functional continence. Preventative care and falls prevention Falls have a huge economic and quality of life cost to the community. It is estimated that if nothing is done to prevent falls, by 2051 the total health cost attributable to falls-related injury will nearly triple from $498.2 million in 2001 to $1,375 million per year in In addition, an extra 3320 additional RACF beds will be needed. 8 Work has already been done by the Australian Commission on Safety and Quality in Healthcare (ACSQ) in producing guidelines around falls prevention in RACFs, however more must be done by the Australian Government to encourage providers to read and adopt the recommendations into their facilities no small task considering the full report runs for 189 pages. While expensive to implement in the short term, falls prevention programs that follow best practice guidelines are vital to the continued viability of both the aged care and health systems. To do this, falls and balance assessments and programs must be factored into the ACFI. 7 of 13}

10 Rather than doing this however, ACFI is diverting such needed physiotherapy time with its selective funding of only some modalities of physiotherapy treatment. Guidelines Multi-factorial multidisciplinary falls prevention programs are recommended by the ACSQ guidelines. Yet the APA s data actually shows that there has been a decline in falls prevention programs run by physiotherapists within RACFs. The APA s Aged Care survey shows that there has been an over-all decline in physiotherapy led falls and balance classes in RACFs of 20 per cent. 9 Physiotherapists who participated in the survey commonly attributed this to the perception that such classes are not funded. As part of the survey, physiotherapists were asked to make recommendations that would improve their RACF. The second most common response (below an increase in physiotherapy hours) was around the funding and provision of exercise programs for balance and mobility. It is important that appropriately trained health professionals run these programs, as to be effective at falls prevention, programs need to be designed at a level that will produce physiological change and challenge balance. This requires higher level skills and knowledge of pathology to be safely implemented. Physiotherapists are trained in these skills, and these programs should be delivered by physiotherapists in all residential aged care facilities. Other recommendations in the Guidelines include: As many falls occur during toileting, and physiotherapy intervention should be utilised to maximise continence (Section 8.2.2) For women in RACFs who have a history of fracture associated with osteoporosis, ongoing physiotherapy assessment and management is particularly important. (Section ) Pain management The APA applauds the Department s recognition that chronic pain is a poorly understood and undertreated condition in aged care facilities. However the APA is still concerned about the way in which pain management funding has been included in the ACFI. The ACFI supports only specific, passive modalities of pain management. This encourages providers to reduce or eliminate funding for other evidenced-based interventions, and undermines the independence of clinical decision making by physiotherapists. Funding for the management of pain which encourages the use of physiotherapy treatment modalities is dangerous. In 2009 a physiotherapist told the APA of her experiences in unqualified staff carrying using heat packs: Guidelines I have seen severe burns in my facility where [untrained] staff applied hot packs to residents with sensation loss [They] did not understand that this could happen. Pain management requirements under the ACFI should have reference to the Australian Pain Society s Pain in Residential Aged Care Facilities: Management Strategies The Pain Management Guide Kit for Aged Care. Guideline 19 of this document says that Physical therapies, such as superficial heat and Transcutaneous Electrical Nerve Stimulation (TENS) can be helpful in reducing pain intensity in the short term, for residents who are able to provide feedback on their experience. 10 The guideline goes on to say that such modalities are not indicated for the management of persistent pain, and most importantly for high care geriatric residents, that these modalities are contra-indicated for people with impaired cognition (ie dementia or Alzheimer s) or for those otherwise unable to communicate. Residents need to be able to relate any discomfort to staff, and treatments must be carefully monitored. This is also stated in the APA s Guidelines for the Clinical use of Electrophysical Agents 11 (which are appended to this document). 8 of 13

11 The ACFI ignores Guideline 18 from the Australian Pain Society, which says that Therapeutic exercise can decrease pain. Strengthening, stretching and aerobic exercises can be beneficial in increasing function and improving mood, as well as reducing pain intensity. Pain intensity can be reduced by up to 30 per cent, and has been shown to improve mood in older people with depression. Complex health care items There are some specific issues that physiotherapists have identified around the complex health care section of the funding. These are outlined below. Item 4a Complex pain management and practice undertaken by an allied health professional or registered nurse. This will involve therapeutic massage and/or pain management involving technical equipment specifically designed for pain management AND Frequency at least weekly, AND involving at least 20 minutes of staff time in total. This item precludes the use of prescribed supervised exercise for the management of pain, a modality that is well accepted, evidence based, and not contra-indicated for patients with a cognitive impairment such as dementia. Item 4b Complex pain management and practice undertaken by an allied health professional which involves therapeutic massage and/or pain management involving technical equipment specifically designed for pain management AND Frequency at least 4 times per week. In addition to the problem of exclusion of some modalities of pain management, physiotherapists are concerned that this level of intervention could be clinically justifiable in only extremely severe cases. Further more, in small facilities or outside major cities, adequate staffing to provide this care would be nearly impossible to find or fund. RECOMMENDATIONS That the requirement for residents to be reassessed under the ACFI six months after readmission from extended hospital leave be removed. That restorative assessment and treatment be included as a section in the ACFI. Treatment should be available for both low and high care residents. This care should encompass maximising physical functionality falls and balance continence especially functional incontinence pain management No funding levels should dictate the frequency of treatment, other than requiring that they be based on clinical best practice. Treatment options should support the clinical judgement of the most suitably qualified health professional, and should be based on the most up-to-date evidence and guidelines available. A mechanism should be implemented, that ensures funding for the incorporation of new, evidenced based guidelines as they are released. Funding incentives that are built into the current ACFI that encourage providers to improve and maintain the physical function of residents should be explicit in the ACFI documentation. 9 of 13}

12 Funding outcomes and impact on aged care providers The ACFI specifically funds some modalities. This has resulted in a perception by providers that certain modalities of treatment are not funded. This is particularly evident in the pain management section of Complex Health Care under which only massage, electrotherapy (eg. TENS, laser therapy, ultrasound therapy etc.) and heat packs can be funded, to the detriment of exercise programs for pain management. In 2009, the APA s Aged Care survey found that under the ACFI system, 32 per cent of physiotherapists have experienced a decrease in exercise programs delivered in RACFs with 2 per cent reporting that exercise programs have ceased completely. This is in comparison with 14 per cent of physiotherapists saying that exercise programs have increased under ACFI. 12 In contrast to this, 35 per cent say that the number of hours that are spent on delivering electrotherapy and massage for pain relief have increased, compared to 6 per cent reporting a decrease in these modalities. Some physiotherapists reported facing pressure from aged care providers to use techniques that attract funding, regardless of the suitability of the resident for that particular type of care. For instance TENS is contra-indicated for patients with cognitive impairment such as dementia, and heat-packs can be dangerous when applied to people with sensation loss and poor circulation (for example people with diabetes). RECOMMENDATIONS The APA recommends that the Complex Health Care section be amended to support the most appropriate clinician s clinical decision, rather than focusing on particular modalities and frequencies. Funded pain management modalities should include current modalities such as therapeutic exercise programs supervised by physiotherapists. Documentation and administrative arrangements Despite the ACFI not requiring regular re-assessment for funding reasons, annual review of a resident s condition is normal clinical practice. For this reason, physiotherapists do not feel that the administrative burden has improved in RACFs with the introduction of ACFI. Design issues including the roles of health professionals Physiotherapists are frustrated with the ACFI, as they feel that it limits their input into the care of residents of RACFs, despite the potential for improvement that some of these residents display. Some physiotherapists face a battle to convince RACF managers that they are able to do more than prescribe the pain management treatments outlined in the ACFI documentation. The ACFI needs to acknowledge that physiotherapists can run falls prevention programs, active pain management classes, can assist with improving continence and are imperative to assist residents achieve optimum levels of mobility and dexterity. Residents in RACFs often have multiple pathologies that impact on therapy options. Physiotherapists have the training and skills to treat these complex and co-dependent conditions. For instance there is a great deal of evidence for the efficacy of physiotherapy exercise programs for people with knee osteoarthritis, however residents may have co-morbities such as osteoporosis, which could limit mobility and increase the risk of fracture. Physiotherapists can tailor programs to the individual, so that programs are not only safe for people with these complex co-morbities and pathologies, but are effective in improving function, reducing pain and preventing injury. 10 of 13

13 RECOMMENDATIONS The ACFI should be changed to reflect the following: Section 2 Mobility should include a mandatory physiotherapy falls assessment (as per the ACSOHC Guidelines). Where clinically indicated, residents should be enrolled in a physiotherapist supervised falls and balance program that is based on current clinical practice guidelines Section 5 Continence should include a physiotherapy assessment to determine suitability for physiotherapy intervention to improve function. Section 12 Complex Health Care should: o define an allied health professional, and the list should be kept up to date o require all staff (other than physiotherapists and medical practitioners) administering heat packs, therapeutic massage or pain management involving technical equipment specifically designed for pain management to have undergone a minimum training requirement specific to the modality being applied. Training must include (but should not be limited to) such areas as: contra-indications; complications; tests required prior to treatment; required warnings; supervision of the resident during application; and familiarity with the APA s guidelines for the clinical use of electrophysical agents. o move the funding criteria away from the focus on duration of treatment. Funding should match the severity of the condition, rather than prescribing treatment categories o require that interventions used are based on the clinical requirements of the resident Interface with other elements of aged care Medicare Enhanced Primary Care program The APA believes that the ACFI is very poorly integrated with other elements of care for aged people, particularly those with complex and chronic conditions. APA research has found that despite its potential, the Enhanced Primary Care (EPC) program is under-utilised by residents of aged care facilities. Physiotherapists reported that 70 per cent of RACFs do not utilise Medicare EPC funding for allied health at all. Physiotherapists reported that the main reasons were that doctors are too busy to contribute to care plans (27 per cent of respondents), RACF staff were not aware of Medicare funding (25 per cent) and doctors were not prepared to contribute to care plans (20 per cent). The APA believes that this rate of utilisation is unacceptably low, given the benefits that residents could gain from restorative care by physiotherapists. Another barrier that clinicians see to accessing these rebates is the number of visits available each year. Five sessions with an allied health profession is sometimes seen by providers and medical practitioners as not worth the administrative requirements to access. Compounding the issues encountered by RACFs and health professionals is that these five sessions must be shared amongst the allied health professions. This funding applies to people with chronic and complex conditions (such as many older people residing in RACFs) and this population is often in need of a range of health professionals. 11 of 13}

14 47 per cent of respondents felt that the requirement for GPs to contribute to care plans was a barrier to their utilisation. The APA believes that the mix of healthcare professionals in aged care facilities is adequate to assess the need for physiotherapy treatment within RACFs, and health professionals such as physiotherapists and nurses are already well accustomed to involving a GP when they are presented with conditions that are outside of their own scope of practice. GP involvement should therefore not be mandated as a condition of Medicare funding. In addition, all RACF residents have already been assessed by an ACAT team to have been admitted to a RACF. RECOMMENDATIONS That the Department of Health and Ageing (DoHA) work with Medicare to ensure that the systems are integrated effectively, and that the mandatory requirement for GP contribution to care plans be removed. Residents of RACFs with a complex condition should be recognised as needing more than five sessions, and should be entitled to additional consultations with specified allied health professionals under the program. Acute and sub-acute care Residents of RACFs are likely to interact with acute and sub-acute services, yet ACFI does not recognise the need for rehabilitation after an episode of acute care. This results in problems where residents miss out on the rehabilitation that they need after an acute injury or condition. Rehabilitation workers within the hospital system often need to prioritise the rehabilitation of patients who will return to the community rather than RACFs, as patients who are in residential care have recourse to care within the facility. It has been physiotherapists experience that hospital staff may expect RACFs to provide some level of rehabilitation services. Unfortunately the reality is that the low level of functionality that is seen in the acute setting may never improve due of lack of physiotherapy time within many facilities. RECOMMENDATION That a pool of funding be allocated to people who move from an acute hospital bed to an aged care bed. This funding should be used for rehabilitation for a set period of time. Best practice guidelines The Australian Government has released several excellent evidence based guidelines for older people in both the community and residential care. However the ACFI system does support the implementation of guidelines such as Choose Health: Be Active, A physical activity guide for older Australians, or Preventing Falls and Harm From Falls in Older People: Best practice Guidelines for Australian Residential Aged Care Facilities RECOMMENDATION That the ACFI include a mechanism to ensure that incentives are offered to fund implementation of new evidence based guidelines into residential aged care facilities. 12 of 13

15 Conclusion It is extremely difficult for aged care providers to balance budgets based on medium to long term cost savings and intangible improvements in resident well-being. With slim day to day profit margins, providers find it difficult to invest in therapies which will provide long term cost savings. It is up to the Government of Australia to ensure that care to older people is not focused on maximising dependency in order to maximise funding, but instead focused on prevention of decline, maximisation of function and clinical best practice. The Government also needs to ensure that the treatment of pain in older Australians is based on the appropriate evidence base and clinical expertise of physiotherapists. If the focus on resident dependence is allowed to continue without an equal focus on the prevention and improvement of ill health, then the burden of Australia s ageing population will soon become unmanageable. This submission provides recommendations that aim to change the focus on dependency to ensure that people who have the potential to improve function are empowered to do so. References 1 Department of Health and Ageing, (2009). Review of the Aged Care Funding Instrument, Canberra DoHA 2 Australian Physiotherapy Association, (2009). APA Aged Care Survey 2009, Melbourne, APA 3 Ibid 4 Department of Health and Ageing, (2009). Review of the Aged Care Funding Instrument, Canberra DoHA 5 Private Health Insurance Administration Council, (2010), Membership and Coverage Data Tables December 2009, Canberra, PHIAC 6 Australian Bureau of Statistics, (2009). Population by Age and Sex, Australian States and Territories, Jun 2009, Cat No: , Canberra, ABS 7 Department of Health and Ageing, (2009). Recommendations on physical activity for health for older Australians, Canberra, DoHA 8 Australian Commission on Safety and Quality in Healthcare, (2009). Preventing Falls and Harm From Falls in Older People: Best practice Guidelines for Australian Residential Aged Care Facilities 2009, Sydney, ACSOHC 9 Australian Physiotherapy Association, (2009). APA Aged Care Survey 2009, Melbourne, APA 10 Australian Pain Society (2009). The Pain Management Guide Kit for Aged Care, Sydney, APS 11 Australian Physiotherapy Association (2001). Guidelines for the Clinical use of Electrophysical Agents, Melbourne, APA 12 Australian Physiotherapy Association, (2009). APA Aged Care Survey 2009, Melbourne, APA 13 of 13}

16 Apa Aged Care Survey 2009

17 AGEd CARE SURVEY 2009 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

18 AGEd CARE SURVEY 2009 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

19 AGEd CARE SURVEY 2009 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

20 AGEd CARE SURVEY 2009 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

21 AGEd CARE SURVEY 2009 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