Tip:
Highlight text to annotate it
X
Dr Katrina Cubit: Thank you very much for including aged care
into the forum. We certainly appreciate it.
I'll take you on a little journey that some of you are probably quite familiar with, but
you may not have been familiar from the inside. Anglicare, like Calvary, is a mission based
organisation and I think I can speak quite freely in saying that most of us here belong
to organisations that have mission visions and values. That puts the patient at the centre
of that service. Anglicare is no different and we [called by cross] example to respond
to human needs. We're no different to anyone else. We happen to just be a nursing home.
For us, you're probably quite familiar with the story of Anglicare and Ginninderra Gardens
about 12 months ago and the facility was sanctioned. I just want to give you a little bit of an
insight as to what that actually might mean and it certain impacts transition of care.
I'm familiar with acute care and the EQuIP processes for accreditation. Aged care has
something very similar and I would quite happily wager a bottle of wine that it is a little
bit tougher than what the EQuIP process is in terms of meeting expectations and ensuring
ongoing accreditation, four standards and 44 expected outcomes.
Any error on a medication chart does bring problems for us and a missed signature is
certain one example of how quickly we can find ourselves in difficulty with our accreditation,
quite different from the acute care setting.
So what does it mean to be sanctioned? There are great implications for the community and
not just for us, as providers, in terms or reputation. Certainly the impact for Canberra
was quite astronomical. We had a facility of 136 beds that could no longer admit and
that went for about six months. So that had an impact on the discharges and we certainly
were aware of the pain suffered by Calvary and I'm expecting ACT Health were quite similar
with bed block during that time.
The impact was also felt by the other residential aged care providers as well, because they
were trying to pick up the slack, if you like, by taking the additional discharges. Implications
went through to the CAP services, to the EACH packages and the EACHD packages and also to
respite. Getting sanctioned has a very impact on the whole community. So what we needed
to do then was to put in place strategies and processes where we could prevent that
ever happening again. Part of that process is for us to commence renovations on site
and obviously at the moment our nursing home is offline and we've got 75 beds on hold at
that moment, as we go through renovations.
So for us, just as a little bit of a reality check, really many problems arise for us in
aged care purely because we are not a hospital and I don't think everybody truly grasps what
those implications might be. We don't have an imprest. We don't have drugs stored on
site. We don't have spare Panadol. We don't have - well, we do have Panadol, I beg your
pardon. We don't have Atropine. We don't have spare morphine. We don't have spare Midazolam.
We don't have doctors available 24/7 and our nursing ratio, instead of one to four or one
to six, is one to 61 and that's quite different in terms of managing care.
We have high and low care, obviously. But low care, as we once know it, is now managed
in the community. So those - for those residents that are coming to us now are much sicker
and are requiring high level of care. Systems and processes, yes we also battle with ACAT
assessments and we know the difficulties there and we also have ongoing regular visits from
agency and to ensure our accreditation is upheld.
Financial pressures on aged are quite extraordinary. We rely on new residents to come prepared
with their asset assessment. We need to know whether they're capable of paying additional
fees. We need to constantly reassess their care needs, to ensure our income. We battle
with Medicare. We have to discuss bonds, day care fees and income tested fees. So it's
baring everything to come into aged care.
Loss of stakeholders for us, as well as Clare Holland House, residents, families and nursing
staff, but our stakeholders also go further into the community with the pharmacies, Allied
Health, our GPs, older persons, DBMAS, the hospitals and we also have to work with the
tribunal as well, in terms of guardianship and financial management and again I've mentioned
agency already.
So what I thought I'd go through for you tonight is identify some of the barriers that we've
had and give you some solutions as to how we've got through it. I can proudly say that
Ginninderra is now fully accredited and we are very pleased with the journey that we've
come along to get there and we are going to maintain our accreditation as we move forward.
How are we doing this? We're identifying where things go wrong and then putting something
into place, to make sure that it doesn't go wrong again.
We are aware that the hospitals are under considerable pressure and the pressure is
to discharge quicker and sicker and we are all very familiar with that phrase. We know
that there is a lot of pressure on families for potential residents to remain in hospital
longer. We have issues certainly with managing families and managing their expectations of
what care might be when they're come into nursing homes and one of the most important
lessons I've learned is to manage families' expectations right from the admission process.
Bariatric care is a great concern and I would urge you to think about that very carefully
this evening. We've come across a number of barriers in terms of accessing ambulances,
accessing beds that can hold our larger community members, accessing lifters, accessing doctors
willing to take on the care of bariatric people.
Gastroenteritis is always a challenge for us, as well as for hospitals and we also have
the ongoing problems with discharge summaries, ensuring that we've got Webster-paks and ensuring
that we have GPs who are willing to continue the care of residents, once they're with us.
So what we've done, I like to talk to everyone a lot. So what I've done is I've called on
a few friends. I guess I've been very fortunate to have been working at Calvary and we've
been able to create some wonderful liaisons and some networks.
We've been lucky that they've invited me in. So I've had lots of meetings with the Calvary
social work team and we're working with them and we've spoken with the [Ratlan] to arrange
discharges and we've had visits from the Calvary social work team and their pharmacy team on
site, so that they can understand what the difficulties might be and how we can work
at ways of working around that.
I assess all our potential residents in person. We don't look at someone on paper and say
oh yes, that ACAT looks good and take them in. So it does slow the process down and that
can be frustrating for hospitals. I love to see people and I like to meet them and I like
to talk to them and I like to read their notes and until we're satisfied that we can deliver
care for that person and their family, we won't offer a bed.
We do like to know about infectious diseases and that has slowed things down in the past.
But we do need to absolutely have those discharge summaries, because that's the only documentation
that we've got, that we can start our assessments and start our [unclear] with and obviously,
inform our care.
A lot of collaboration and work has gone with our new pharmacy, so we're very proud to be
working with Kingston Capital Pharmacy and they are putting a lot of effort into supporting
us. They've provided training for our nursing staff. So we can now order our medications
online and that means that we can have our medications much more quickly, which improves
patient care.
The other fortunate way to move forward for us, is to welcome West Belconnen Health Co-op
on site and that's one of the ways we've got around not having that 24/7 cover of GPs available
to us. We've got a very good working relationship with them and sometimes when new residents,
a GP won't come with them, we're able to offer them, as an alternative, to ensure that they
have ongoing care.
For recollection, certainly when is I was working in Tasmania, one of the nursing homes
in Tasmania also had a primary GP servicing their residents and it does work exceptionally
well. Once we have someone moved into the facility, there is lots of issues for us in
ongoing care, so ensuring their transition of their ongoing care. Families and residents
still, even though we are managing their expectations, believe the GP will come immediately. They
believe that we store medications on site and that they expect a one to four, one to
six resident ratio with the nurse. We have to work with that.
GPs, bless them, still believe the fax is the best form of communication and if we could
work on that that would be great. There is a great residence to electronic documentation.
We use AutumnCare. A number of facilities use AutumnCare or iCare and I know there is
a little resistance out there to move into the 21st century. It does make it difficult
because we can't always read the GP's writing.
There is a little bit of reluctance out there for diagnosis of delirium, dementia and depression,
the three wonderful D's. That impacts on us quite significantly, firstly, in terms of
resident care, secondly, in terms of how we work with the family and thirdly, in terms
of funding and accreditation. We need these things documented and that's why we chase
GPs quite vigorously, to ensure that the assessments and diagnoses are made where appropriate.
We do have issues with deteriorating residents and they deteriorate rapidly and it would
be wonderful if at some point we can look at Compass for residential aged care and that
would be something we should possibly consider this evening. As I said, with bariatric care,
I think I rang every facility in Canberra to beg, steal, borrow equipment and it didn't
work. So we bought it. But we do need to work as a community, to work out how we are going
to manage people, as we know the obesity epidemic continues.
Guardianship processes and that's an ongoing issue for us. It's quite an ordeal to have
to go and sit through a guardianship hearing and put the information forward, where you
are taking someone's decision making away for them. We do need GP support to do that,
to ensure that people are safe.
Solutions, as I mentioned, managing expectations from day one, so we do actually meet with
families, as well as the resident, prior to admission. We have what we call special care
day, thanks to the wonderful administrators that were appointed to Ginninderra. They put
a lot of systems in place and we find special care day works very well. It ensures that
we have guaranteed monthly communication with families, where we give them an update on
their loved one's status and they have that opportunity guaranteed every month, to give
us feedback. There are other mechanisms as well. But that's one thing that's working
particularly well.
It sounds crazy. But I like to show everyone my laundry. It works. It puts things in context.
So it manages issues later on down the track and laundries may not be relevant in terms
of transfer of care, but it goes to managing expectations. We have regular case conferences
with the GPs and with families, again, the GP practice on site, the electronic ordering
of medications speeds up the process. We have commenced our medication advisory committee
meetings and I think that's going to be a great facilitator in improvement of medication
safety and certainly inappropriate prescribing of medications and ensuring that we're not
over-medicating.
Palliative care treating team meetings commenced today. Andrew will give you an update on that
at some point. We've taken quite a few new residents from Clare Holland House and people
from the hospitals who are in the terminal phase of their illness. We know that we need
to work much more closely with the GPs and the discharge GPs, to make sure that we do
have most importantly PRN medications written up in advance.
I think those who work in palliative care know that there are certain disease trajectory
where you can predict symptoms towards the end and it's quite often something that you
can prescribe for in advance. So at least aged care has a chance to order medications
in and have them. So you aren't stuck at the weekend without morphine, midazolam, whatever
else it is that you might be needing. We've had a great deal of support from the PalCare
[CNC].
Fostering ongoing links with the Older Person's Mental Health Unit and they have been fantastic
and it is that capacity to be able to ring them up and know that they will send someone
or they'll be able to give us support on the phone and we are working towards ongoing interdisciplinary
education and meetings within our facility and getting our staff out to additional trainings.
For example, the Pepper Program those sorts of opportunities, as I mentioned Compass.
Ongoing care, or us, getting discharges in and out of ED. So if we transfer someone to
hospital, please rest assured it's on the basis of a good clinical decision or our hands
are tied. We may not have medications. We may have someone under guardianship, who doesn't
have end of life wishes documented and we have to transfer. It's very difficult when
we receive patients back at 3:00 am in the morning in a taxi, wrapped in a blanket with
no discharge summary. We know that happens. We know EDs are under pressure. But it does
put us at a little bit of a loss as to where to from here.
We do need to encourage phone calls and communications overnight and we do ring the hospitals back
and we do get a discharge summary eventually and we get it emailed. So you need to know
the person to ring, to make sure that you get the discharge summary and you can work
around it to make sure you have the information.
The yellow envelopes don't work. Or I don't think they work and that's probably maybe
a dangerous statement to make. But I'm open to discussion. We find them very difficult.
It's good to put things in. It's very difficult to fill in. The lines are a little bit small.
The boxes are a little bit small and it asks a lot of questions that often in times aren't
relevant. That's a problem for us, so we'll get onto that - come back to that shortly.
Resident transfers to specialist appointments, once they've come to us, is an issue. How
do we get someone back to the hospital, if they need radiotherapy or chemotherapy or
outpatients appointments? Our goal is to facilitate access to treatment and to appointments. We
don't have a car. We don't have spare care staff and often times they're not eligible
for hospital transport. So we need to work out ways to get people back to hospitals and
back to specialist appointments.
We've got limited access to dentists, optometrists and hearing aids. For us to get Hearing Australia
in, we need a letter from the GP. It sounds tricky. But again, we have to hound people
for these documents, otherwise we can't do what we need to do. We have quite a burden
of documentation in aged care, to make sure we tick all of our boxes for accreditation
and funding requirements.
Solutions, culture change in ED. I think it's quite reasonable to make that statement. I've
taught nursing students, who are RNs, who have worked in ED, who have made some outrageous
claims about aged care nurses. Aged care nurses are qualified RNs. They know how to assess
someone. So if we send someone, it's for a legitimate reason. It would be great if we
could get some respect back.
Frequent meetings, phone calls and emails with hospital management. So ADONS and DONs.
They really help. Very helpful if we can have those ongoing relationships and certainly
within residential aged care, there is an opportunity for all the DONs to meet and that
is really helpful. We need to let each other know quickly what works and what doesn't work.
We need to notify our hospitals when is best to send new admissions to us and when it's
not a good time to send new people to us or to discharge to us.
For catering purposes, we need to know how many is there for lunch. In small facilities
something like that matters. Discharging several people or admitting several people on the
one day throws lunch meal service out. It's the little things that you may not grasp for
aged care. Encourage PRN medications to be prescribed at discharge and where possible,
if we know a disease trajectory, where we can predict what medications might be needed,
with clear parameters around when they can be used.
We are trialling an electronic transfer form, which can be generated through AutumnCare
and we'll see how that goes. But that may help with the yellow envelopes. We have an
ongoing resident consultative committee and ongoing forums with our residents to help
work through all of these issues, to ensure that they also have a voice in the transfer
of care.
For us getting through the sanction and getting back on track again, relied very heavily on
the collegiality and collaboration within Anglicare, so our sister facility Brindabella
Gardens, was very supportive of us. But we've also got a great relationship with all the
other aged care providers. A lot of goodwill out there. We've got great support going on
with the hospitals at the moment and that is imperative that we've got someone that
we can ring and they've got someone in return, that ring back to the aged care facility and
know the phone is going to be answered.
Liaison visits to hospitals are very important and we certainly welcome any visit in return,
if you need to come and see residents or if you want to have a look, like the social work
team and pharmacy from Calvary did. Importantly, to make things work are the partnerships and
working those partnerships, so it's a win/win for both sides. Negotiate unambiguous service
provision with your providers. So we are very clear on what we need from our pharmacy. We're
very clear on what we need from our GP practice. We are very clear on what we needed from our
RTO, key to learning. So they know what we need and we know what they can deliver and
it gets rid of any cause for complaint.
Looking at technology is absolutely imperative for improving communications. Let's move away
from the fax. Let's use email. Let's use all those other ways that we can communicate.
Hospital in the home can work well. It can work well in aged care. Universities, we're
very happy to have input from the university on our clinical governance committee. But
we are also very happy to have university involvement with a quality of life study,
around dementia. So those sort of networks help you think constantly and keeping you
updated, in terms of best practice.
One of the other great things is that we are being invited to the table to forums like
this and that is just fantastic for aged care. Thank you.
[Applause]