7 May 2015
The importance of a robust framework for medical services in aged care is growing as the number of older Australians increases.
Between 2010 and 2050, the number of older people (65-84 years) will more than double, from 2.6 million to 6.3 million, and the number of very old (85 and over) will more than quadruple from 0.4 million to 1.8 million.
Urgent policy development and planning for aged care is needed now.
All Australians have a right of access to medical care when they need it. For older Australians, whether living in residential aged care facilities (RACFs) or in the community, access to ongoing medical care and supervision is fundamental to ensuring they receive the best quality of care as they grow older.
The aged care sector must be able to provide the level and quality of medical, nursing, and allied health services required to meet the needs of an ageing population.
Improving access to medical services for older people who live in the community and residential aged care will reduce unnecessary hospital admissions and emergency department attendances.
The AMA recommends that all patients have the opportunity to document their end of life health care planning.
1. MBS rebates for older Australians
1.1 A number of factors restrict access to medical care, such as inadequate infrastructure and workforce. However, the fundamental issue is the failure of the Medicare Benefits Scheme (MBS) to appropriately value the delivery of care to older Australians.
1.2 There is a disconnect between the MBS rebate and the true cost of providing the service at home or in residential aged care. While many medical practitioners are still bulk billing, this is unsustainable. Bulk billing of older Australians by medical practitioners is cross-subsidised by patient billing where the gap payments are significantly increasing.
1.3 MBS rebates for medical services provided in RACFs must be substantially increased to reflect the complexity of care and the significant amount of additional, but clinically relevant, non face-to-face time with the patient that goes into overseeing their care.
1.4 As with referred specialist consultations, MBS telehealth items for general practitioner consultations in RACFs have the potential to significantly enhance access to general practitioners and improve the efficiency in the delivery of medical care to residents of aged care facilities and patients who are immobile.
1.5 At present the telehealth initiative provides incentives for aged care providers to set up video consultation facilities. It is extremely inefficient for these facilities to be used only for referred specialist consultations. MBS rebates for general practitioner video consultations to residents of aged care facilities will improve the efficiency of providing follow up care by general practitioners, and ensure full use is made of the video consultation infrastructure in aged care funded by Government.
1.6 The delivery of palliative care in RACFs and in the community can be improved through the introduction of specific MBS rebates for the medical services provided to people, their carers and family members, at the end of their life. These rebates would recognise the holistic services provided by medical practitioners, not just the time spent providing clinical treatment.
2. Retainer arrangements between RACFs and medical practitioners
2.1 Specific financial support should be provided to encourage and subsidise retainer arrangements between aged care providers and medical practitioners to ensure residents can access ongoing face-to-face medical care.
2.2 Payments under these arrangements would offset the business costs that medical practitioners incur while they are not providing services in their surgeries, and will reflect incentives and remuneration over and above existing payments under the MBS for each medical service provided to a resident in an aged care facility.
3. Extending the role of nurse practitioners in aged care
3.1 Medical practitioners support appropriate expansion of the role of nurses within a team-based model of care. However, all health care provided to older Australians must be coordinated by a medical practitioner familiar with the patient, who provides continuity of, and takes ultimate responsibility for, that care.
3.2 There is currently no evidence that independent nurse practitioners improve the quality and efficiency of care.
3.3 The Federal Government has recognised this in the MBS and Pharmaceutical Benefits Scheme arrangements by requiring nurse practitioners to have collaborative care arrangements with medical practitioners before they are able to prescribe.
3.4 Proposals for nurse practitioners will not in themselves ensure residents in aged care have access to the comprehensive medical care they need.
3.5 Nurse practitioners can only provide care within their scope of practice. Residents will still require access to medical practitioners to provide comprehensive medical care.
3.6 Continuation of the current model in which the medical practitioner delegates tasks to other team members will ensure the ongoing quality of co-ordinated clinical care.
3.7 An accreditation standard for RACFs should ensure that nurse practitioners work collaboratively with medical practitioners.
4. Accreditation standard for ongoing access to medical care in RACFs
4.1 There are currently few obligations on providers of aged care to facilitate access to timely and high quality medical care and supervision for all residents on an ongoing basis. The provision of medical care must be an integral part of aged care.
4.2 The quality of care provided to residents would be improved through the introduction of a specific accreditation standard for RACFs to ensure their residents have ongoing access to medical care.
4.3 It is incumbent upon approved aged care providers to ensure that access to medical care for aged care residents is equal to the access to medical care enjoyed by the rest of the population. This includes:
- accreditation arrangements, monitoring processes, and collection of reliable data from aged care providers on access to medical care to monitor whether residents are receiving the care they need;
- access to adequately equipped clinical treatment areas that afford patient privacy, and information technology to enable remote access to medical records and to improve medication management; and
- access to sufficient number of registered nurses to monitor, assess and care for residents and liaise with doctors.
4.4 The AMA believes that accreditation standards for RACFs must be strengthened in this regard to provide greater certainty to residents that medical care and medical supervision is available to them on an ongoing basis.
5. Government support for RACF infrastructure
5.1 Federal Government investment in the residential aged care sector must ensure the sector can provide the level and quality of infrastructure and services to meet the needs of an ageing population.
5.2 This includes funding to expand the number of places to meet demand and to upgrade facilities to the standard the community expects and values for older Australians. They should also comply with the standards required for the provision of contemporary medical care.
6. Sufficient numbers of registered nurses
6.1 Sufficient numbers of registered nurses are required to monitor, assess and adequately care for residents of aged care facilities, and to liaise with medical practitioners.
6.2 Accreditation standards need to be improved in respect of ongoing nursing care of aged care residents by specifying a minimum acceptable staff ratio between registered nurses and patients in RACFs.
6.3 Having appropriate numbers of qualified nursing staff in RACFs will ensure that residents’ health is properly assessed and monitored. Those residents requiring attention from a medical practitioner must be identified quickly to provide the most efficient and effective medical management and care of the resident in the facility when the resident needs them, working alongside the nursing staff in the facility.
6.4 Good nursing care under this model can reduce the number of avoidable attendances by medical practitioners.
7. Entry points to care, aged care assessment and access to respite care
7.1 There is currently no clarity about where and how an older person living in the community who needs a range of medical, health and community care should enter the system to receive that care. Patients who enter at different points can have different outcomes which are sometimes suboptimal.
7.2 Entry points into community care must be clear. Coordinated service delivery models that streamline access to medical care and related services must be developed, taking into account the different resources available in each local community.
7.3 The effectiveness of the aged care assessment process can be improved by including the patient’s usual medical practitioner in the assessment arrangements.
7.4 Medical practitioners form long-term relationships with their patients. An older person’s usual doctor can bring his or her background knowledge of the whole person and their current circumstances to the assessment process. This information would ensure the person’s assessment results in them receiving the care that is most appropriate for them, be it community or residential aged care.
7.5 A streamlined process will improve access to timely respite care for people who have not yet been assessed by an Aged Care Assessment Team or who have not yet entered the aged care system.
7.6 Medical practitioners who work in aged care know their patient’s circumstances and requirements. As such, access to respite care will be streamlined by enabling medical practitioners to authorise access to subsidised respite care in emergency circumstances.
8. Teaching in RACFs
8.1 RACFs are a fertile ground for teaching. The provision of appropriate and accredited medical training places in RACFs would add to the overall breadth and depth of medical training and improve the quality of care of residents.
8.2 The relatively smaller and stable population of RACFs, compared to the patient population of large teaching hospitals, offers medical students and trainees a different experience. They would be exposed to patients over a much longer period of time.
8.2 Offering appropriate and accredited medical training places in RACFs would educate the next generation of doctors about caring for the aged as part of routine medical practice
Published: 7 May 2015