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Autumn 2003

Are our aged care structures and policies "ageing in place"?

Aged care is one of the most vexing problems facing Australia. In Tasmania, where we have Australia’s highest concentration of older people, the problem is doubly difficult.

Aged care is one of the most vexing problems facing Australia. In Tasmania, where we have Australia's highest concentration of older people, the problem is doubly difficult.

Because aged care has been consistently starved of funds by the Howard Government -except for a few sweeteners at election times - aged care dollars are stretched and squeezed to the last cent. The net effect of this is staff being pushed to breaking point, with workloads becoming unmanageable.

How do we best look after our ageing population and the dedicated staff who support them? In this article HACSU Industrial Organiser, Craig Stringer looks at the "Ageing in place" initiative and how it is affecting staff.

Ageing in Place is a Commonwealth Government initiative, introduced in 1997, bringing hostels and nursing homes together under a single funding model. In principle this initiative was a good one. However, there are many drawbacks.

Many things have not been thought through and the "coalface affects" are having a very harsh affect on cleaning, catering, laundry, nursing and personal care staff.

In fact, my view is that it is overall aged care structures, along with management practices, which are "ageing in place".

In this article I want to describe in a day-to-day, down to earth way, how policies and budget shortfalls are affecting aged care staff. I also want to talk about some of the structural problems and possible alternatives.

The first problem with the current "ageing in place" strategy is that the Commonwealth Government has not seen fit to change licensing arrangements of Aged Care Facilities.
We still have some licensed low care facilities involved with Ageing in Place.

Now here is an example of one of the difficulties.

A resident enters a low care facility needing help with minor tasks only. Then, once this resident has been in the low care facility for sometime, they develop other problems and symptoms requiring more care.

Lets just assume for this purpose the resident had agreed at the time of entry to the facility that, should they require more care than the facility could provide, then they would be willing to move to a high care facility. But time has moved on.

Enter the family who do not want their loved one to move away from staff who have provided care over a period of time and with whom they have formed important bonds. The family also do not want their loved one to move from their current facility because it is close to the family home and friends. It is also a more modern building than that of the high care facility, and has nicer surrounds.

The operator of the facility relents after a period - a period that is often quite stressful and upsetting for the resident and family (and sometimes leads to further health difficulties for the resident) - and the resident stays. We won't go into what happens if a resident is forced to move, that's another story and problem in itself.

Yes, when the resident moves to higher care, the employer does receive a higher amount of funding to provide the care required by the resident, and then the employer increases the hours of work for employees to provide that care.

Having now increased the hours of employees to provide the care required for an extended period of time, the resident then dies.

Now we've got a problem for the operator and the employee, or HACSU member.

The employer wants to reduce the hours worked by the employee. In the mean time the employee has come to rely on their income. It pays for their kids' netball and football fees, and pays off the home computer, which nowadays is often a requirement for the kids' homework.

The employee is desperate to keep up their kids' sports and recreation, and to make sure they get a good education. They need to continue to earn the money they received for working more hours than they were originally contracted for.

Enter the union representing the employee/s at the workplace because the employer wants to restructure and reduce hours of employees, as the extra hours are no longer required.

Union members start negotiating with the employer around how this reduction can take place, and if in fact it should take place.

The employer argues that they are no longer receiving the funding to provide care for the resident/s, and therefore needs to reduce operating costs, as s/he cannot continue to operate at this level. If they don't take some action, it may lead to the facility having to close.

In small facilities, this is often no exageration, although in the larger facilities there is a better chance employers can juggle or carry some extra costs for a short period.

The resolution to this problem is often not palatable to either side. The outcome, of course, varies between sites and employees.

Outcomes can include retraining, redeployment, and part redundancy. In the worst case, it could mean a full redundancy and loss of employment.

There are also lots of other impacts along the way as the residents' "age in place", and all of these either impact on the employer or the employee, and in some cases both.

Let's look at what happens in the catering area, which of course is considered by some to be the most important thing to the residents, as residents look forward to good wholesome food.

The impact of funding formulas often determines the types of food that can be prepared and served. Food in aged care facilities is often a complicated business. Food may range from a baked meal that requires cutting up for some residents, or blending for others. It could also mean a change to the menu to allow for the resident who has other special needs.

In some facilities, catering staff have stated that they are expected to even help feed, even though they have had no specific training to carry out this function. This obviously places an extra workload on the catering staff.

I have asked catering staff in many homes if they receive extra staff allocations when patients are moved across to high needs and meal menus get more complicated. The answer is always a funny looking stare and a comment along the lines "Are you cuckoo, no way". Catering staff are just expected to cope!

There's a little known fact that cleaning staff are also on the receiving end when it comes to "ageing in place". Often there are residents requiring complex care, resulting in more nursing or medical specialists having to be in their rooms, and for longer periods of time.

Efficient cleaning is very much about doing things in a smooth sweep, not having to spend valuable minutes backtracking and walking around checking when rooms are free.

This is especially the case in large nursing homes where there are miles of corridors.

Yet, the cleaner is still required to get all the rooms cleaned and on time, no matter what. There's no consideration for having to work around all sorts of variations in medical and nursing schedules. As well, higher levels of resident care mean there is extra cleaning required in other areas such as hallways, dining room, activity room and others due to little accidents that can and do happen.

Again, when asked, cleaning staff say they are just supposed to get on with it. They are offered no assistance, or pre-warning or plan about how they might get over these issues.

Some cleaners just stay back after their normal hours of work to get into rooms they could not get into during their normal work time. Unpaid overtime is the result.

Laundry staff are also impacted when residents "age in place".

Issues such as significant increases in incontinence with the elderly mean an increase in personal washing, towels, bed linen and kylies. And there are other factors, such as the inappropriate use of linen by other staff.

Again when asked if they receive any extra hours or assistance when this occurs, most say they are just left to get on with it and cope the best that they can.

When asked if the employer knows about the situation, most of the employees respond by saying they have asked for help in the past and have not been given it so now they don't even ask.

Boiled down, the funding formulas pay no heed to the needs of catering, cleaning or laundry staff, and there's often little respect shown by management by including these staff in their planning and consultation sessions.

Extended Care Assistants and nursing staff are the most impacted on by "ageing in place" process. These are the front line care providers and usually the first contact for residents' relatives.

And it's such a pity a lot of aged care operators don't give more consideration to providing these over worked care providers with more assistance. I am sure they would appreciate it, and would be in a better position to provide that happy welcome to resident's relatives and other visitors to the home if it happened. They may even be able to spend some quality time with the residents. That would be different wouldn't it!

How many times do you hear employees in aged care facilities say "I wish I had more time to spend with my resident".

I've heard it so many times, it's like a stuck record.

The list of duties ECAs and nursing staff are required to do on a daily basis is staggering, and it is no wonder nurses are looking to leave the industry and go back to acute care or other forms of nursing that don't require so much paperwork and a defined duty list.

Just some of the things carers and nurses do include; toilet residents, bath residents, feed residents, lift residents (with or without lifting machines or depending on the availability of machines and other staff to assist), give out medication, write reports /assessments/RCS's, answer telephones, answer residents' relatives requests, assist with transportation of residents from one place to another, find clothes that have not returned from laundry or because the resident does not have enough, attend the endless round of meetings, assist doctors and other health professionals, clean up after residents have had an accident, and numerous other things I could mention but would use up most of Tasmanian existing paper stocks and remaining forests.

Other issues carers and nurses have to deal with is the impact of high care residents on care provided to other residents.

Many low care residents have their care time reduced, or are simply left to cope as best they can because of the impact of high care residents.

Both nurses and ECA's will tell you that as a result of the above there is an impact on the residents social needs, as they have no time to spend with residents.

This manifests itself very clearly when a resident has died, and there is no time for the employees to grieve because the employer can't afford to have an empty bed.

The bums on beds syndrome can have a terrible impact on the emotional well being of staff.

It is true that some employees do attend the funerals of their much-loved residents, but that is the exception rather than the rule.

It is time we took some action to make sure this is not the way things continue to operate. Yes facilities do get some extra hours as a result of the "ageing in place" formula but most staff will tell you it is never enough.

The only staff that do seem to get any extra time with residents are those who start early, stay late and don't get paid for it. And this practise leads nowhere, or often leads backwards, with all staff soon expected to put in unpaid overtime. And then there are less jobs for people out in the community who need work, and less time with families for people in work.

And of course longer working hours inevitably means absenteeism, increase sick leave and higher than usual turnover in staff.

Of course we should also recognise that there are exactly the same overwork problems happening to staff working on administrative tasks.

These staff are being squeezed just like everyone else. All the above can be attributed to the "ageing in place" policy and the lack of foresight shown by our politicians when they play politics with providing care for those who are in need and sometimes can not speak for themselves.

In an important report into aged care into the future undertaken by the Myer Foundation, "2020 - A Vision For Aged Care In Australia", Professor John McCullum Dean of the College of Social and Health Science at University of Western Sydney, made a simple but important statement. "Get rid of hostels and just develop community care and residential high care," he said.

I believe this would be a move in the right direction and would help with the crisis that we are in at this time.

We also need to look at the type of low care facility that is providing high care due to "ageing in place". Do they have the appropriate staff mix with the requisite skills and knowledge to provide this type of care? Is the building design suitable?

In Tasmania there are some facilities providing high care, which are not designed to provide that care.

These facilities were often originally set up as hostels and have just continued to operate in that way, even though they now provide a percentage of high care.

These facilities often place a hell of a lot of stress on their staff, who are just expected to cope with the change without any change from the top.

There is little or no extra care staff, and in some cases lack of security for residents.

At one such facility recently members requested the employer erect a fence with an electronic gate for the security of both staff and residents.

The employees at that facility are still waiting and still having to chase residents who wander. This facility does meet with the accreditation process but you would have to wonder why there is no requirement to provide such security.

We can't afford to continue to allow the Federal Government to shirk its responsibility to provide adequate funding for the aged care sector into the future. We must act now to ensure all involved in the industry get a better deal; the residents, the staff and the community.

If we are to follow the idea put forward by Professor John McCullum, then we will also need to look at the resident classification system.

If Professor McCullum means that all facilities are high care facilities funded for the number of beds rather than the classification of resident, then this may go a long way to help with the current problems.

Such changes would also need to be underpinned with well run and supported community based programs such as HACC and CACP being provided in the community. The idea being that people would stay in their own homes for as long as possible, and only be admitted to a high care facility when this was required.

At this point in time the Federal Government provides the majority of funding for aged care $3.9 billion in 2000 to 2001, which is about 70% of the total cost of providing care.

In 2001 the number of high care residents in former hostels had risen to 13,015 of whom 8,874 had "aged in place".

From these figures we can only expect that "ageing in place" will continue to be an issue for both employers and employees into the future.

We need to take action now to start addressing the issues that arise from "ageing in place".

"Ageing in place" should be a right of the resident in accordance with the United Nations Principles for Older People in 1999, which includes independence, participation, care, self fulfillment, and dignity.