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Senate Select Committee on Health
16/04/2015
Health policy, administration and expenditure

AUCOTE, Mrs Karen, Financial Accountant, Colac Area Health

CREECE, Mrs Nola, Private capacity

FIFIS, Mrs Libby, Director of Nursing and Midwifery, Colac Area Health

HENRY, Mr David, Proprietor, RetireInvest

MATHESON, Ms Pamela (Pam), Manager, Corangamarah Residential Aged Care

[10:07]

CHAIR: Welcome. Before we start, do any of you have any comments to make about the capacity in which you appear today?

Mrs Creece : My mother is in Corangamarah. I am a representative for her.

Mr Henry : RetireInvest provides financial advice in the Colac and Geelong area.

Ms Matheson : I am also a registered nurse.

Mrs Fifis : Corangamarah is under my directorate at Colac Area Health.

CHAIR: Thank you very much. I invite you to make a brief opening statement. Who would like to do that on behalf of the group?

Ms Matheson : I am happy to speak on behalf of Corangamarah. We are a 75-bed residential aged care facility. We have an occupancy at the moment of 61 residents. The other beds are not open at the moment. Although I have only been with Corangamarah since November, I have been in aged care for five or six years. Nola, who I asked to join us today, admitted her mother recently into our facility and found it quite a daunting process. Nola might like to speak about that. Karen, although she said she was a financial accountant for the health service, has been co-located to our service two days a week to improve access for the public when they have inquiries about the financial side of the business—and there has been quite a lot of those since 1 July. We refer all of the residents to a range of financial advisers in Colac. However, David has worked on behalf of several of our last clients that were admitted into our service, so I think he speaks really well from a community perspective. You will have to ask us other questions. I am not sure what else you would like to know.

CHAIR: Mrs Fifis, you spoke earlier in your former role. Before we proceed, could you explain exactly how this aged care setting fits within the Colac Area Heath. It is quite different from other states.

Mrs Fifis : Probably seven years ago now, Colac Area Health had two aged-care facilities on their main site. They were merged into a new facility. Corangamarah is co-located on the same site as our acute services. Whilst the funding is through the Commonwealth separately to our acute services, we share a lot of the same infrastructure. Cleaning services, support services and catering are provided through the Colac Area Health service into both our acute service and our aged-care facility.

CHAIR: That is very interesting. I do not think I have come across that in any of the hearings that we have been a part of. One of the major concerns that we have had reported to us is the high personal cost to aged-care residents of inadequate access to monitoring and acute care, and the trauma of transferring them constantly from an aged-care setting in an ambulance to a hospital to have an X-ray perhaps because they might have had a fall. The problem is exacerbated by very limited access to GPs and also to specialists in aged-care settings. In fact, we had it put to us that it is the most underserviced, health-needy area of the population. Based on what we have seen and what your experience is, can you tell us how you make this work because it is very different?

Mrs Fifis : I guess there are pros and cons with it like anything. The benefits that we see are as those that you have suggested. In terms of access to acute medical services and acute health care, our residents benefit from being geographically co-located on-site with us. Our general practitioners are the medical providers to both our acute service generally speaking and to Corangamarah, which is literally just across the road from the hospital. So the residents enjoy a really good service from our general practitioners, which is generally unheard of in other aged-care facilities not just in Colac but wherever you seem to go. If they are acutely unwell, they have very quick internal access to our urgent care department, which is similar to an emergency department. We also have on-site radiology, so we can call in radiology out of hours if they should have a fall and we suspect they have a fractured neck of femur, for example, and that type of thing. That works really well.

CHAIR: Is that service mobile from the acute setting into the residential care?

Mrs Fifis : We generally put someone on a trolley and we wheel them around to radiology.

Senator JACINTA COLLINS: Why aren't you using all your beds?

Mrs Fifis : That is a really good question. The aged-care reforms that came into play in July really gave us a fantastic opportunity to review our service. We had struggled filling our beds. We struggled with occupancy of those 75 beds for quite a long time. The way the building had been designed meant there were a number of shared bed areas and they were not popular in the community. Anecdotally, we found that we were often losing residents to the other nursing homes in the area because of that. So we made a decision to bring our beds back to around 60. In doing that, we modified the staffing to work under that arrangement, and that has made an enormous difference to our bottom line.

Ms Matheson : If I could just say that I have come from a private local system—so, a private nursing home. For me, coming back into public health, all I can see are benefits. It is really responsive. The doctors are responsive. We have got really good access to a high level of education, because it is part of a health service.

CHAIR: Education for who?

Ms Matheson : Education for the staff. There is a very high level of intervention from a clinical skill set, because we have got coordinators who come from urgent care—which they do—if we need them to assess our residents. It is quite a responsive service. It is quite easy to look after the residents in public health. It was quite difficult in private health. As were summarising in private health, that has been my experience in private health; but I am not seeing that in my current setting in public health. It is quite a lovely model.

CHAIR: Could I ask you about your staff mix, because one of the comments we had a lot was about enrolled nurses.

Ms Matheson : I only have registered nursing staff—so, enrolled nurses and registered nurses. That is an expensive workforce. We have got really long retention, which you do not see in other nursing homes. Some of our staff have been with us for 30 or 40 years. They have got no intention of retiring. That does come with its own problems, because it is a very physical job and we have an ageing workforce.

CHAIR: Can I get you to compare that with the staff mix in other local settings that are not publicly funded? AINs, for example.

Ms Matheson : The other settings have a minimal amount of registered nurses. They have very few enrolled nurses and very few registered nurses. The majority of their workforce are personal carers. They have a very high level of multiculturalism in their workforce and a very transient workforce. We do not have that our public setting.

Senator DI NATALE: I am just interested in the medical coverage. If somebody needs to see a GP, is it done through the urgent care department? How do you get someone assessed by a GP?

Ms Matheson : We ring the general practices, which are co-located on either side of the setting. They are very responsive because it is very convenient. They can cross the road.

Senator DI NATALE: They can literally go out the front door and—

Ms Matheson : If for some reason they were caught up in theatre or they were extremely busy, we would just wheel the patient through to urgent care. But we rarely need to transfer out of our facility for that reason.

Senator DI NATALE: So a GP will be working in the hospital or in the urgent care department, might be doing an elective list of some sort and pop by.

Ms Matheson : Yes, they just pop over. They are very responsive in public health, but we may have waited eight to 10 hours in private health.

Senator DI NATALE: What about things like dental services? That is always a real problem in aged care facilities. Do you get good access?

Ms Matheson : We have actually got a dental health service on site as well. It is actually at Colac Area Health. Our residents can access that in the first instance, and they do.

Senator DI NATALE: I do not know if you expanded on what the downsides are. In terms of getting access to acute care, it sounds like it is way ahead of many other facilities. What are the downsides of being located in that sort of setting?

Mrs Fifis : For us it is really an internal cultural thing that we are trying to work through at the moment. Because we have to use registered nursing staff, we could not use personal care attendants even if we wanted to. Those staff have generally come from an acute care at some stage, so they are very acute health focused.

Senator DI NATALE: That is where I was going.

Mrs Fifis : They are not really resident lifestyle focused. That is something that we have acknowledged and a piece of work that we are progressing at the minute in trying to change that model. That is because it is their home; it is not a hospital setting.

Senator DI NATALE: One of the criticisms in many aged care facilities is that we have got people who are lots of medication, where often the drivers are to want to treat, investigate and so on. If you bring that culture with you across from an acute setting, then maybe we are not doing the best thing by the residents of the facility. Sometimes it is better that somebody be on fewer medications rather than more.

Ms Matheson : I honestly do not see it from that perspective. I do not think that we overtreat our residents. I think it is quite considered. I have not seen that. I think that the residents certainly do have a shorter length of stay with us. I know that Karen would like to comment on that, I am sure, because we have seen quite a change in the complexity of people coming into that setting. They are older and they have more complex needs. They are not with us as long as they would have been, traditionally. I know that Karen has done a lot of work on that, so I will let her speak to that if you are interested.

Mrs Aucote : Basically, you asked Lily about lowering the beds. The reform process, if I understand it correctly, was to bring state-run services to a commercially based service deliverer. We had, historically, for many years, around 60 to 65 residents; never 75. Basically, we never worried about taking bonds or refundable accommodation deposits or anything like that until the reform process was brought in.

So a lot of economic decisions had to be made to have the aged care service reasonably self supporting. We are not there yet, but to say that we need to be on the same footing as private, our staffing structure base, as Pam has said, is around 25 per cent higher in costs than private, due to non-qualified nursing and those kinds of things. That obviously does not give us a level playing field.

Senator JACINTA COLLINS: Let me understand where those restrictions on staffing come from?

Mrs Fifis : That is under our current enterprise bargaining arrangement.

CHAIR: Please continue.

Mrs Aucote : Basically, we made the decision to have three tiers of rooms based on anecdotal evidence coming from residents, and also from staff, that we needed to have some bigger suites that people might have been interested in. Then we have the single-bed and self-contained en suite, and then a shared en suite at our level 3. We then set prices based on the process that we were to follow, and put up our room prices and our DAP prices. It is fine to do that but with the constant changes in interest rates, we ended up having to change, every six months, our pricing structure of the rooms and the amount we would charge for a daily accommodation payment.

We have taken refundable accommodation deposits, but we cannot invest those. As a state facility we cannot invest those. The assumption behind this commercialisation was that we could invest them and expand the service and do those kinds of things. We cannot do that. So we are reliant on the interest as the accommodation income. I did a rough calculation on the RADs that we have taken in since July. The interest per day, based on the July rate—I had to try and looking at it in terms of a level playing field with this to try and work it out—gives us $226 a day. That is basically what we get. If someone is paying the RAD, all we get is the interest for the time. The maximum contribution if we were taking concessionals would be $310 a day for those same people. If we were able to collect the DAP that we want to collect on the advertised rooms as it is advertised, we would be getting $501 a day. We have to have at least 40 per cent of our residents at concessional, so, obviously, we cannot collect the amount of money that we thought we would be getting for the room pricing. What we found—and I am looking at discharged clients here, not residents at the end of each month—is the average age in 2004-05 of discharged clients over the years on admission was 78. Our average age now—again, it is rubbed out—is 88. People are much older when they are coming in and they are definitely staying a lot less. Someone who came in in 2004-05 had an average length of stay—again, I am talking about people who are deceased or have been discharged—of 2,585 days. When look at it now, we are looking at 49 days.

There has been a major shift and, obviously, we have community nursing. I used to work in Aboriginal health in Aboriginal affairs for a very long time, and a holistic approach was what we pushed for all the time. Colac Area Health has a model that has been talked about for many, many years in other areas. The very good work that they do, obviously, keeps people at home longer. We have people who are in their 80s and their partner will be in their 80s trying to look after one another. We need to be looking at a more coordinated approach for additional respite to come in to allow, if you want those people to stay at home—and most of them will tell you they do want to stay at home for longer and, obviously, they are. If you have got an 88-year-old man and an 87-year-old wife trying to look after him—or vice-versa—they need rest, because it can be 24 hours a day. Looking at additional models—and I do not have any expertise in this area where I am talking; I look at figures—if they are older and we want them to stay at home, then we need to be able to give the major carer at home additional support to allow that process to remain.

CHAIR: Could I just ask you for those numbers again: 2,400 roughly was the average stay in 2004; 10 years later we have changed and now it is roughly 50 days. That gives us some ballpark figures to work with. One of the questions that automatically springs to mind for me and echoes some of the concerns that we have had is about people's access to palliative care. For such a short stay for some people, I am wondering how much of this equates to palliation rather than aged care; and how important the acute setting of that palliative access might be for you.

Mrs Aucote : It is something that has been under discussion. We do have palliative care, but looking at how that may work across the areas is something that has been under discussion ever since the reform process started. There is a whole range of things that need to change. One thing that I think is important—and Nola might be able to tell you a little more about this—is when I talk to the people who want to come in they are worried about the costs. We are out there saying to people, 'Make sure you've got plenty of superannuation and put away for your retirement' and those kinds of things. In the years to come, if it continues the way that it is, we will not have nursing home beds available for people who are low means.

CHAIR: People who are low needs?

Mrs Aucote : No, low means. At the state facilities there is a difficulty in that whole process. When we talk to families, they are often very upset about making the decision to put mum or dad in a facility. They are worried about the cost. Also, the resident is very concerned about losing their individuality and—

CHAIR: Freedom.

Mrs Aucote : ability to look after themselves. So it is a very stressful process for everyone involved. We have been saying we are going to be older. We all know that. We need to be planning much further into the future so that people understand they need to put aside in their planning some funds that are earmarked for their care in later life.

CHAIR: Ms Matheson, you looked like you wanted to make a comment.

Ms Matheson : You were asking about the palliative care. Certainly that is something that we have been quite exposed to because people have come into hospital who have not been prepared for their aged care. When they are in hospital they have to have the aged care assessment team come in and assess whether or not they need the care. When they are in an acute hospital they cannot be assessed for respite care. They can only get an approval to come in as a permanent resident. That is one problem for us. They have to be at home to get respite approval, so some people are coming into care who perhaps could have just had respite. The other thing is that they are coming in quite unwell. We are finding those in palliative care coming across to aged care will not be with us very long, so it is quite a traumatic experience for the families that is probably unnecessary. It would be better if we had a holistic type of funding model where those people are cared for in a different setting for six to eight weeks rather than going through the trauma of coming into aged care. One of the other problems we are finding is that by the time we get their Centrelink assessment, which gives the family an indication of what they are going to have to pay, the relative has often passed away. They were waiting up to nine weeks; we are back to about five weeks now. If people are not with us that long, it is a very traumatic time.

CHAIR: They go through an awful lot.

Ms Matheson : They lose the resident anyway. It is very sad and very difficult for them. It is really not a good process.

CHAIR: Ms Matheson, we have not had any evidence of this nature at any point. Could you perhaps use the experience that you have to write up and put on the record your thoughts about the way in which some of the problems you have articulated could be responded to, where we could get better outcomes and where the key pressure points are. I know this new system since the first July has changed things quite significantly and people are paying more attention. We would be very keen to hear from you on that.

I want to ask a question about out-of-pocket costs. One of the things we know about regional areas and ageing and the chronic illness that comes with success in achieving greater age is that out-of-pocket costs are very, very significant—more significant in the regions than they are in the cities, certainly. How much are out-of-pocket costs and an inability to pay for prescriptions and managing prescriptions a part of what you see when people present to you or just from your own life and lived experience?

Ms Matheson : People worry about it. If they are fully supported and concessional residents, they are paying 85 per cent of their pension just for their care needs. So they have just that 15 per cent left to pay for everything else. It is a bit of a twofold problem at the moment because we receive funding according to the aged care funding instrument, which is a degree of money you get against the level of care. Obviously aged care settings look to push their aged care funding instrument to a high level. But when we push those people to a high level we have to provide a whole range of services that meet that. Pre July low-care residents paid for all their extra costs. They really struggled. Now it is organisations that are picking up the cost of most of the care. We find that there is a lot of polypharmacy. We have just done a study on ours, and ours have increased the use of medication. There are a number of residents who are on nine or more medication a day. We see that increasing because there is access to medication.

CHAIR: This is the point that Senator Di Natale was making a little while ago.

Ms Matheson : We do not want people on a lot of medications, and we certainly had that reviewed, but we have a community now who are expecting to be treated for a lot of things and to have a lot of medications, and there is usually a medication for something, but those medications can be expensive. If you are fully concessional and you are getting them subsidised, that is not too bad, but, if you are a self-funded retiree, it is quite significant because you have to pay for all of that. We provide the allied health services and, at Colac Area Health, because we are part of the health service, we have access to all the services we need, really, and it is very affordable because they are within the health service. So we can transfer funds, but we are not actually having to employ, for example, a private physiotherapist that might cost us a lot more. I do not think that there is a lot of other out-of-pocket expense for residents, but perhaps that is a good question for Nola, whose mum has come into care recently.

CHAIR: Mrs Creece, did you want to make any comments?

Mrs Creece : Mum is 93 and her medication level is quite low, actually, compared to a lot of the others, but if it kept going up we are finding at the moment that the money she had saved is starting to dwindle away because of the daily costs and the extra little bits and pieces all the time. It puts a lot of anxiety on the family to get the house sold and to get money to put into the nursing home. It is hard to get that balance. She is on not quite a full pension, and there are the nursing home fees and what she is paying now. If we do not get some more money to put into the nursing home, the pension will not cover it. That does not cover medications or anything, so, if she needed more medication or anything, we would need more money. I have noticed she has been very sick the last few weeks. Her pharmacy bill has gone up about $20 or $30 a month, which does not sound a lot, but, if you keep adding it up or things keep happening and you keep having to fork out more money, it becomes a lot. I handle her bank account. When she went in she had quite a bit of money in the bank, but, with bits for this and bits for that, it is slowly dwindling away. If they are in there long term, it could be quite a problem.

The other big problem is with Centrelink and DHS. You cannot get things done quickly. Often people cannot wait. You cannot wait for months or weeks for an answer or for some help or anything. It has to be done when somebody is really sick and things need to be organised, and we are sitting around waiting. You ring up the department and they say, 'We're reviewing it.' Before Easter I went to Centrelink to get Mum's thing reviewed because some of her money has gone into the nursing home and they are saying it is an asset. It still has not been done. I ring up and they say, 'Oh, yes, it's being reviewed; we'll let you know.' I imagine we will get the money back, but, in the meantime, we are paying what they set when she first went in.

CHAIR: That would be very difficult for people who might not have any family members around them to support them.

Mrs Creece : Yes. Mum is 93. She has a little bit of dementia and her memory is not fantastic, but, for even an 80-year-old, there is absolutely no way they could deal with the paperwork from the nursing home and the paperwork from Centrelink and DHS. You are just continually running from one to another. We went to a financial adviser and got financial advice, and Mum just cannot understand it all. She knows that we have to sell her house. She knows we had to sell her car. She knows we had to put her investment money into the nursing home. But it is really difficult and it makes their anxiety and their transition into the nursing home so much harder, and harder for the family.

CHAIR: One of the things we have had put to us is about the cuts that were announced in the budget—the $57 million that was withdrawn from hospital funding and also there was the co-payment, which was $7, and then there was a $20 change to the AB, and then there was the $5. There still remains a price signal—that is, the government saying they are going to put a price signal on people going to the doctor, saying people are overusing doctors. There is some mythology around that but it is often said to be older people who are looking for a companion, or whatever—not true, but nonetheless it is out there in the public conversation. In terms of Colac and this region, and people's access to their doctor, do you think a price signal will lead to better health outcomes for older people, or change people's behaviours about health seeking, or will it have an impact on your emergency department and its interaction with your aged-care setting? How does this affect older people?

Ms Matheson : I would have to think about that. Perhaps when I do a written response for you I might consider that question.

CHAIR: Thank you. It has been very helpful having you here this morning to give us the information about your local situation. You put on the record a pretty unique construction. Mr Henry, do you want to make one quick comment? We are going to move on to our next witnesses.

Mr Henry : I will be very brief. It is very challenging, the aged care sector, because it is an area in the community where there are more and more people taking advantage, obviously, with standards of living, modern medicines and everything. It is very challenging for a patient or client to walk into aged care—apart from the trauma involved with it—from a financial perspective and with the methodology of the pricing as well. We are seeing this more and more, where, once the calculations are done for the daily care fee and then a means-tested fee and then looking at a RAD or a DAP or a combination of both, and going into what the costings are, a majority of people find that their finances will slowly dwindle, depending on how long they will live and how long they are in the facility. In my industry, and in speaking to a lot of people at the higher end—the technical side and the so-called experts in my area in Sydney and Melbourne as well, they seem to have the same opinion: that since the change of 1 July it is very tough from a financial perspective, and it would be certainly advantageous if it were considered to be finetuned, some of the methodology around the pricing, just so it could be a little bit more favourable for a person going into this sort of care or facility.

CHAIR: In your role as a financial adviser, Mr Henry, do you have conversations with people where they worry about how much they have to pay to get their health care, or do you have conversations about how much money they need to put aside to access health care, let alone aged care?

Mr Henry : It is very difficult to answer that because a lot of the time you will find people now in their 50s may plan, and they will say, 'Down the track I will move into aged care.' They will be more interested in planning for their retirement first, and after that they will plan for something further. Most of the people we speak to are moving in there or have just moved in, and you are presented with a challenge right now. I would say that a high majority of people entering into aged care have not planned for it. It is a case where there are medical issues or some other reason that they need to go into aged care.

CHAIR: That is one thing about us humans: we always think we are going to well forever, don't we? Thank you for coming in and spending time with us this morning.