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Community Affairs References Committee
10/07/2013
Care and management of younger and older Australians living with dementia and behavioural and psychiatric symptoms of dementia

BUCHER, Ms Hazel Frances, Nurse Practitioner, Psychogeriatrics, Older Persons Mental Health Services, Department of Health and Human Services, Tasmania, and Nurse Practitioner, Dementia Behaviour Management Advisory Service

CLEARY, Dr Allison, Geriatrician, Dementia Behaviour Management Advisory Service

DAVIDSON, Mr Brendon Paul, Principal Policy Consultant, Complex, Chronic and Community Service, Tasmania Health Organisation South and Representative on the National Dementia Working Group, Department of Health and Human Services, Tasmania

MORRISSEY, Dr Martin, Senior Old Age Psychiatrist, Department of Health and Human Services, Tasmania

REED, Mr Stewart, Assistant Director of Nursing, Mental Health Services, Department of Health and Human Services, Tasmania, and Tasmanian Representative on the National Psychogeriatric Expert Reference Group

Evidence from Dr Morrissey was taken via teleconference—

CHAIR: Welcome. I understand that information on parliamentary privilege and protection of witnesses and evidence has been provided to everybody. I remind witnesses that the Senate has resolved that an officer of a department of the Commonwealth or a state shall not be asked to give opinions on matters of policy but shall be given reasonable opportunity to refer questions asked of them to superior officers or to a minister. This resolution prohibits only questions relating to opinions on matters of policy and does not preclude questions asking for explanations of policies or factual questions about how and when policies were adopted. We have your submission, thank you. I invite whoever has been allocated to make an opening statement to do so and then we will ask you some questions.

Mr Davidson : I will make the opening statement. I should point out—and you have already probably picked up—that I am the only nonclinical person here so others will be answering the questions better than me when we get into it. In terms of our opening statement, certainly the Tasmanian Department of Health and Human Services appreciates the opportunity provided here today to answer questions in response to its written submission and to expand on its views in relation to the committee's terms of reference. In introduction, it should be noted that the department through its regional service provision networks, known as the Tasmanian Health Organisations, has a direct interest in Commonwealth-funded aged care as both the provider of residential and community aged-care places in rural and remote areas across Tasmania.

In relation to the care and management of older people with BPSD, the department operates regional older person's mental health services across the state and is the statewide provider of the Dementia Behaviour Management Advisory Service, or DBMAS. Tasmania Health Organisation South also operates the Roy Fagan Centre at Lenah Valley in Hobart. The centre operates as a 40-bed statewide intake service for psychogeriatric patients and dementia patients.

The impact of dementia can be considerable on other parts of the health system outside of just general aged-care services. We would make the point in our introduction that many longstay older patients in hospital have dementia, including BPSD. The Tasmanian government's submission notes that older people with a diagnosis of dementia are likely to stay in hospital more than twice as long as those without dementia and, as the research shows, any stay in hospital, particularly a prolonged stay, poses a safety risk for older patients.

In 2012 the Tasmanian government strongly supported recognition and official designation of dementia as Australia's ninth national health priority area with the care and management of both younger and older people living with dementia and behavioural and psychiatric symptoms of dementia, or BPSD, as a major social and economic planning issue for Tasmania. For example, we know that the population ageing in Tasmania will increase hospitalisations. The likelihood of admission to acute care doubles between those aged 60 and those aged 80 years. With that potential to increase demand it is critical that avoidable hospitalisations and long stays by older people living with dementia and BPSD are able to be minimalised through better targeted care at home and in their local community.

As noted in the government submission, Tasmania's population is ageing more rapidly than any other Australian jurisdiction and the median age in Tasmania is the highest in the nation. Those numbers are compelling. In 2010 about 6,000 Tasmanians had dementia. By 2050 it is anticipated that this will increase up to over 27,000. In 2009 there were under 2,000 new cases of dementia in Tasmania. By 2050 this is projected to increase to nearly 9,000 new cases in that year alone. The government's submission highlighted the influence of Tasmania's dispersed population and reiterated the real challenge in providing safe and affordable services to its rural and remote communities.

Of the new cases of dementia in Tasmania in 2009, 43 per cent lived in the capital whilst 57 per cent lived outside of Hobart. Those relativities, for example, contrast with the state of Victoria, where just under 70 per cent of new cases lived in Melbourne while only 30 per cent lived outside the capital.

The Tasmanian government welcomes the measures introduced through the Australian government's Living Longer Living Better aged-care reform package. We would just like to mention a couple of challenges for Tasmania that it is hoped will be relieved by this important initiative. Firstly, Tasmania's aged-care workforce is itself ageing and struggling to be sustainable in an industry often characterised as unattractive, underfunded and overworked. In April 2007, 44 per cent of the department's own primary health nursing workforce, including community aged-care nurses, were aged 51 years or over. Of those, 77 per cent were between 40 and 60 years of age.

Secondly, the supply of new care capacity coming online has not been able to respond to changing demand. Past funding rounds for aged-care places in Tasmania have resulted in undersubscription for residential places and oversubscription for community places. We have had a long waiting times for residential care in some local areas and empty beds in others. So the Australian government is to be congratulated for introducing measures which directly address each of those two issues, together with others.

In conclusion, the Tasmanian government agrees with the experts and the families who stress that aged care and broader health reforms must continue to target the problem of dementia, as this is considered the major single driver of any impending aged-care crisis in Australia.

Senator THORP: We heard some evidence earlier today in relation to the closure of ADARDS. Was that back in 2008?

Mr Davidson : Yes—2007-2008.

Senator THORP: It was a change of management from the original management board to the Presbyterian Church, as I understand it.

Mr Davidson : Yes.

Senator THORP: Some of the evidence would suggest that had the state government been more forthcoming with funds then that would not have needed to have occurred. Would you like to fill us in on your position on that?

Mr Davidson : I certainly would. As you are probably aware, ADARDS was set up in the 1980s as part of a very good response by Dr John Tooth, Mr Allan Bester and their colleagues to alleviate the issues caused by the closure of Willow Court and the Royal Derwent. That was a terrific initiative at the time. It certainly over the years gained a very well-deserved international reputation for the innovative care and standard of care that it provided.

It had since 2005, as I was very well aware of, suffered from time to time problems of reliability in terms of financial management and being able to make ends meet. In 2007 the board approach to the Tasmanian government and the Commonwealth government and asked for assistance. The Tasmanian government's position at that time was quite clear: while it was quite happy to do whatever it could in terms of assistance and support for ADARDS, ADARDS was in fact a Commonwealth funded residential aged-care facility and, as such, the Tasmanian government did not see a role for itself in either deficit funding or topping up funding to facility like that. It was very much seen as the Commonwealth's responsibility.

The problem really was that with the size of ADARDS at the time, with 38 beds, it had become financially unsustainable. The benchmark around the country even at that time for a residential aged-care facility to be viable was around 60 but probably closer to 90 beds. At 38 beds, ADARDS was difficult to maintain in terms of financial management.

The board approached the Tasmanian government and the Australian government, but in the early discussions the director at that time was unwilling to consider an expansion of care, which was certainly put forward as an option by the Commonwealth government. The state government would not have any role in that at all because it was a Commonwealth funded facility.

Senator THORP: Even though the nature of the clientele was such that in other jurisdictions they are state-run facilities?

Mr Davidson : Yes, and Stewart could help me out here. We certainly have a state-run facility, called the Roy Fagan Centre, which is a psychogeriatric unit. ADARDS never had any official status as a psychogeriatric unit in the same way that the state-run facilities have. What it was funded as was a Commonwealth funded aged care facility under the Aged Care Act, not as a flexible or special service or anything like that. That was partly because of the service's own decisions over time. You may be aware from other submissions that ADARDS did receive special top-up funding from the state government in the 1990s. I think the minister of the day was then Minister Roger Groom. But there was no ongoing commitment made around that. In fact, ADARDS made the decision to withdraw from that arrangement themselves and to be more independent, and to be solely funded by the Commonwealth. So they actually withdrew from the top-up funding that had been arranged with a previous government in Tasmania.

In 2007, when they again got into financial difficulty, the proposal was made that the Tasmanian government should provide top-up funding and recognise their special status as a special facility under the Mental Health Act, I think it probably was—a psychogeriatric unit. There is no evidence to indicate, though, on advice that we received from everywhere, including the Australian government, that they operate that way. They have targeted people with dementia as preferred clients or residents, but there is nothing to indicate that they actually operate as a special facility different to what other dementia units around Tasmania funded by the government—

Senator THORP: Are you talking about now, or in the past?

Mr Davidson : In the past—at that time.

Senator THORP: Even though the information provided from the office of the minister for health says that 'the government is anxious that your facility should cater for all those demented elderly people with the most disturbed behaviour and difficult management prospects and require that the admission to the nursing home be subject to the approval of the mental health services commissioner's psychogeriatrician'? It seems that at least at that point in time there was recognition at the highest level that ADARDS was specifically established for that particular group of people, even though it may have been licensed under just the federal government, and the same communication makes it very clear that the state is very happy to top up their funding. So something clearly changed.

Mr Davidson : Perhaps what initiated the change was that ADARDS itself withdrew from that funding arrangement, because—and I cannot say this for certain, but it is what the board told me at the time—they did not want to be beholden to the state government. So they withdrew from state funding, for whatever reason—from that arrangement you have before you.

Senator THORP: Do you have any documentary evidence of that—say, a letter saying, 'We don't want your money anymore'?

Mr Davidson : I could endeavour to find that.

Senator THORP: It would be useful if you could.

Dr Morrissey : If I could just come in there. I am not catching everything that is being said, so my apologies if I state something that someone has already said. I have been going to ADARDS in my capacity as an Old Age Psychiatrist since 2002. At one stage, particularly in the first few years, I was going there on a weekly and then two-weekly basis. I continue to go there—I was there about a week or so, seeing a patient over there. So I have observed ADARDS during that time, and I also have a wider perspective on what is happening in terms of psychogeriatric services more generally.

ADARDS was certainly one of the leading lights of dementia care—not just in Tasmania but in Australia. But what has happened, particularly from 2000 to the present—and was even beginning to happen before then—is that many other dementia-care providers were taking on the very sorts of initiatives that ADARDS had led with. By the time the change in the financial arrangements and the management came, without any disrespect to anyone who was working at ADARDS at the time it was not doing things that much differently to what many other dementia units were doing across Tasmania and Australia. There were some changes that were related to some of the financial constraints; and some things related to health and safety—for example, cooking arrangements and things within the units. And some of those things, I think, are regrettable; particularly things like the change in cooking arrangements. But that is something that was related to things other than what was happening financially.

The other comment I would make is that I do not believe ADARDS has at any stage provided the really high-end care for folks with disturbed behaviour and dementia. As far back as 2002, and as continues to the present, the state funded facility, the Roy Fagan Centre, has always been and continues to be the port of call for people who cannot be managed in a standard nursing home or a dementia-care nursing home, and that includes ADARDS. So, certainly ADARDS has and continues to cope with some very disturbed people, but it does not cope with and is not geared for the really high-end level of disturbed behaviour that some folks with dementia will exhibit.

Senator MOORE: In your submission you talked about two of the services that you now have. I don't know the dates in relation to these, but the first instance you mention is that the Royal Hobart Hospital has established Tasmania's first designated medical ward specialising in acute geriatric care; and your next dot-point says a new sub-acute care psychogeriatric unit has also been developed. I would like to know more about those two particular services—how many people are in them; how long they have operated; who funds them; and, when you have a specialist ward, what is the intended length of stay? We have heard a lot of evidence over the years that people with dementia do not have options, and some of them are placed in hospitals—and the comparative cost of that to other aged-care services. And on the 'sub-acute care psychogeriatric unit', which reads very well: how many people are there, what are the costs and who pays for that?

Dr Cleary : I am a clinician and I work across a lot of those sectors, so I might be the best person to answer. I am a Tasmanian graduate. I was here as an advanced trainee from 2008 and have worked as a consultant since 2010 and trained alongside the Older Persons Mental Health Team. So I am a specialist physician/geriatrician but I have also been trained by psychiatrists.

The acute geriatric unit at the Royal Hobart Hospital is a very new initiative. It opened only approximately 18 months ago, and it is a very new concept even worldwide. There are various models of care that have been introduced worldwide. One is a directed mission model, so they are seen in the emergency department. The emergency department has had issues with bed block over many years, and one model was to go to an acute assessment unit for all general medical admissions and from there to have a geriatric model of care—multidisciplinary, shortening length of stay and getting better outcomes for people. The Royal Hobart Hospital unit opened with, I gather, is it 22 beds?

Mr Davidson : Maximum capacity of 22 beds.

Senator MOORE: Neither of the paragraphs mentioned capacity.

Dr Cleary : I think only about 20 or 22 beds. It was not actually staffed or funded up to that full capacity, unfortunately, because of state budgetary constraints. I think most of it is operating like it has been running at 16 beds. There has been an issue with staffing within the geriatric department in the last six to eight months with illness and leave of our director, and the capacity has unfortunately had to reduce. There are only four geriatricians. We are all stretched very thin at the moment. We are running between 12 and 16 beds at the moment.

Because of that constraint, what has happened is that the model of care is slightly changed within the acute sector, in that what we are looking to do is work collaboratively with the rest of the hospital and with their pressures as well. So the geriatric team at the moment has decided to prioritise surgical patients and also to prioritise patients that are at high risk coming through the ED department. One initial focus was targeting medical patients, but they have already got a very good model of care with collaborative input from social workers and physiotherapists. That already sits very well within the division of medicine. Whereas surgery, particularly with their bed pressures and their waiting lists, do not actually have a true multidisciplinary older age focus, and people will often have escalating morbidity on those wards. So they will sit around in a bed for a week or two with nothing happening, because no-one is quite sure. They are losing strength, they are having complications happen.

Similarly, out at the ED, if there is bed block down there, older people can wait there for up to two or three days and have further complications and poor communication and not get input early. So at the moment the acute older persons unit is working at 12 to 16 beds with a focus on working collaboratively within the hospital with their bed pressure. So surgery and emergency are the primary focus.

Senator MOORE: Can you give us the average length of stay?

Dr Cleary : Yes, it does vary. Recently we have had one issue with staffing both our social work and physio up there, which is being addressed. But, through illness and rostering, those two multidisciplinary team members are absolutely critical to length of stay. If we do not get people up and going and if we do not have the social workers linking, we cannot get them out. I gather at the moment length of stay—

Mr Davidson : I was looking at this yesterday, and across that ward—the psychogeriatric one that you also mentioned—we had some sort of spike for whatever reason, in that the average length of stay was blowing out quite a bit, but it has actually come back down to what it was in November last year.

Dr Cleary : That was about a month ago. We had no social worker and it was a real problem. I think it is sitting at, still, eight to 10 days or so.

Mr Davidson : Yes. That is quite low—

Dr Cleary : That is very low on a national and international level. The other facility which I will comment on, which I am more closely involved with, is the Roy Fagan Centre.

Senator MOORE: Is that the psychogeriatric unit?

Dr Cleary : Yes, the psychogeriatric—

Senator MOORE: So that is Roy Fagan, the second one.

Dr Cleary : Yes. It is located at Roy Fagan. Roy Fagan is 40-bed, purpose-built unit for older persons mental health and dementia care. The hospital funds 10 of the beds there now, and that arrangement happened two or three years.

Mr Davidson : It was enabled through Australian government funding through the National Partnership Agreement on Hospital and Health Workforce Reform. We funded that over three years—

Senator MOORE: Of existing beds. So they are not new beds; they are existing beds.

Dr Cleary : At that time, I think the funding model for mental health had come under incredible pressure and they had actually been forced to shut beds there. It is an exquisite facility, it is purpose built, and it was a gross underuse of a brilliant resource out there. So efforts were made to put that funding together to enable those beds to be—

Mr Reed : Can I just clarify that the notion of shutting or closing beds was not any decision that may have been financial at the time. It was around presentations requiring that specialist service.

Senator MOORE: Geriatric psycho—

Mr Reed : Psychogeriatric service and high-end dementia. What was seen across the board was that nursing homes, aged-care facilities, were starting or continuing to manage a higher level of complexity, and the amount of referrals that used to be a persistent number daily almost started to drop off. Because of the way the facility is—it is like a star with four units coming out—

Senator MOORE: How many beds is it—100?

Mr Reed : Forty. What was happening was that, for specific needs in specific units—for example, pure psychiatry or pure dementia—it was getting very problematical to staff and run it effectively. So the numbers continued to dwindle, to a point where a decision had to be made around the viability to sustain it as it was and keep vacancies dotted all over or to try and put the most appropriate clients together for a period of time and then assess whether the decreased need was on an ongoing basis or whether the other unit would need to be reopened. It must be said that, all the time it was empty, the ability to reopen it was always there, but the need never arose within our own mental health and psychogeriatric sector. The need was then identified through the geriatric sector. There were some dual diagnoses, comorbid conditions, that might be of benefit for all aged persons and that centre would be an ideal place to place some of those individuals—with a psychiatry resource, a geriatrician resource, high medical input and high nursing input. The ratio at the Roy Fagan Centre currently is three to 10, which compared to aged care is extremely high.

Dr Cleary : On the Jasmine Unit there is a full-time medical registrar as well as me, so there is also a very high level of medical input.

Senator MOORE: The Jasmine Unit is?

Dr Cleary : The Jasmine Unit is the state funded—

Senator MOORE: Thirty beds?

Dr Cleary : Ten beds.

Senator MOORE: I need a graph! The whole Roy Fagan Centre has 40 beds, and that is the one that we were told was the option to the ADARDS discussion. The whole of that centre is 40. I do not want to verbal you, but you were saying that the usage was dropping off and that this is an expensive centre to run because of the specialised nature of staff and conditions. So the state decided 18 months ago?

Mr Reed : Probably it was before that when discussions were mooted about what could be used and what would be needed with the Royal Hobart Hospital. Then funding was sought to open the Jasmine Unit.

Senator MOORE: Which is 10 beds.

Mr Reed : Which is 10 beds. That funding application was successful and so that was reopened and it went back up to fill the numbers. That then is fed from the Royal Hobart Hospital. So that core group of psychogeriatrics is still maintained at sort of the 30 level. That is the way to look at that.

Dr Cleary : There was a big level of need within the public sector which was very much unmet and a high priority for the hospital.

Senator THORP: How do you see the Commonwealth-state split when it comes to care for people who have dementia? Is it an aged based thing or diagnosis based? How does the effort get divided?

Mr Davidson : With dementia, it is probably delivered by our Commonwealth state funding system through two areas—through aged-care funding under the Aged Care Act and through mental health, through mental health services.

Senator THORP: So, if someone is over 65 and they develop dementia, it is purely a Commonwealth responsibility, is it?

Mr Davidson : It is now, under the aged-care reforms, yes.

Senator THORP: So it is picked up under aged care?

Mr Davidson : The split that we have had recently through the aged care reform was that the state government takes responsibility for people under 65 and the Commonwealth for people over 65. Where there is going to be, say, ageing in place, then that might be an exchange of Commonwealth-state transfers or something, through a billing system. But, as it stands now, if you have a diagnosis of dementia after 65 the Commonwealth will be responsible for general aged-care services, but of course the state will still be responsible for anything delivered in a primary care setting or in a hospital.

Senator MOORE: As to the ownership of over-65s and dementia and hospitalisation, that has not changed at all. The new aged-care changes have not touched that. Other things have changed but if you are over 65 and have had a diagnosis, that has been a federal responsibility. The difference was: if you had special mental health behaviours; that was the difference. But if you have dementia and are over 65, that has been—since, I think, Hogan at least—a Commonwealth thing.

Mr Davidson : Pretty well, yes. The age changed a bit. It used to be, notionally, 70 years old and then for some reason—

Senator MOORE: Yes, they dropped that to 65. It was linked with the pension age.

Mr Davidson : But you are quite right. Could I just clarify something? You asked about the financing side of things for both those units.

Senator MOORE: I think Senator Thorp was on the financing trail as well—following the money.

Senator THORP: That is right. So how does it come to be the states' responsibility to provide a facility like Roy Fagan? I would imagine that a lot of the people out there would be older. Are they?

Dr Cleary : That is the older facility.

Mr Reed : It is predominantly for those 65 years and older, high-end complex dementia care, psychogeriatric care, and the Jasmine Unit. There are younger people that have been admitted but they are behaviourally similar to people over 65 with ageing problems. So you may well get someone in their 40s but the behaviour itself is the criterion for admission to that unit; it is not specifically on age.

Senator THORP: It was built by the state, wasn't it, some time ago?

Mr Reed : Yes.

Senator THORP: And it was funded by the state?

Mr Reed : Yes.

Mr Davidson : With assistance. That gets recurrent assistance from the Commonwealth—doesn't it? Or does it not anymore?

Mr Reed : I am no longer in policy or that division, but my understanding is that it is state funded.

Mr Davidson : I think it is state funded. I think that what they used to give in that area was actually what became DBMAS—the funding that we get through there these days. We used to get some psychogeriatric—

Senator THORP: Could we get some clarification on the funding arrangements?

Mr Davidson : Yes, but I will have to look back to the history of that.

Senator THORP: I am just trying to get my head around the separation of responsibilities around this particular area and why it is that the state would fund one set of services but not another.

Mr Davidson : Yes, and I think there is something to clarify there, which is: when we did see the opportunity to open up that 10-bed Jasmine Unit, that was, as I said, with assistance from the Commonwealth government under national partnership agreement funding. So that was a terrific opportunity and it responded to a need that had been identified. We went into that and said, 'Yes, let's open up those 10 beds again,' and one was as a psychogeriatric unit. What I probably need to point out is that the funding for that is under the national partnership agreement and, as with all of those national partnership agreements, that expires in June next year. So then the Tasmanian government is going to have to find $3½ million a year from its own resources to continue to keep those beds open.

Senator THORP: I suppose that that is where my question comes in. If, as we are led to believe, aged-care facilities now all have patients who are living with dementia and have specialist staff and specialist areas for them, why would you even need the Roy Fagan Centre anymore?

Dr Morrissey : Can I come in there?

CHAIR: You certainly can.

Dr Morrissey : If I heard the question correctly, it is: why do we need a Roy Fagan Centre if Commonwealth-funded aged-care facilities deal with people with dementia? Is that what you are asking?

Senator THORP: That is it.

Dr Morrissey : It is about degrees of disturbed behaviour. So, for example, an elderly man with dementia who might be mistaking a female patient within a nursing home for his wife and trying to hop into bed with her is something that nursing homes do not cope with. Someone in a nursing home throwing chairs through windows will not be coped with in a nursing home facility. It is about the degree of care and intervention and expertise that is needed. That is where the Roy Fagan Centre has its place for caring for folks with dementia. That is one of its roles.

Senator THORP: Who refers them?

Dr Morrissey : The standard Commonwealth funded nursing homes do not deal with folks with very disturbed behaviour as part of their dementia.

Senator THORP: Okay, and—

Dr Cleary : Referrals can come through many sectors, so through DB MAS—that is a general point of referral—carers, nursing home staff, community members, acute care—

Senator THORP: And then their assessment is made.

Dr Cleary : Yes. A lot of our patients come from the hospital sector, both from the geriatric division department and a lot through emergency, and also in my role I liaise throughout the hospital for disturbed behaviour. As Martin said, there is a proportion that just cannot be managed and dealt with within those sectors. Within a Commonwealth aged-care facility, the staffing ratios are very low. Although the training has been provided and the skills are changing, the level of expertise in how to manage very high end behaviours is still limited, and a lot of that comes down to needing more attention. So one thing that DB MAS often do is provide additional top-up funding to just do some one-on-one care, to do some diversions and distraction, and that will allow the facility to manage a difficult behaviour but to continue to keep them in that place, to stop a lot of hospitalisations and also provide education and tailored behavioural management around that person.

But, as Martin mentioned, there is always a population with severely disturbed behaviours that, no matter what you put in to support them—and that is always our first strategy—cannot be contained or managed safely. There is a very serious level of risk to carers and to other staff members within aged-care facilities. Everyone from the cleaner down to the kitchen staff who are popping in to give the cup of tea can be put at a significant level of risk, and they do not have the skills and the abilities always. So those are people that we often are referred, people that we need to manage in that more highly staffed, highly specialised area to address that level of risk.

Senator THORP: And they move then from being Commonwealth aged-care facility residents to state health patients?

Dr Cleary : Yes, we see ourselves as an acute facility, so they are having a hospital admission. They are having an acute admission to medically assess them, stabilise them and look at behavioural strategies or medication. I think that was a bit of a shift within the Roy Fagan Centre through the nineties. Rather than more of an accommodation centre for people that we felt could not be accommodated elsewhere—as everyone has said, facilities were accommodating all sorts of people, and a lot of somewhat more long-term residents were actually able to be moved out. We found that our turnover was increasing, our length of stay was coming down, and we were very much managing people as an acute assessment admission and management process. I do not know about the data, but I think the length of stay has reduced a lot. We see that we have close working relationships with all the aged-care facilities. That is a beautiful thing in Tasmania: there are actually small-town kinds of relationships. We support them, particularly when people return to a facility, through DB MAS and through additional support and education so that we can manage people across the sectors.

Senator SMITH: And it is the definition of those services as acute services that means it falls back into the state jurisdictions?

Dr Cleary : That is how I would see it, but—

Mr Davidson : To clarify, in the Roy Fagan facility itself, the other 30 beds are operated under the Tasmanian Mental Health Act. The 10 beds, the Jasmine unit, are described as a Royal Hobart Hospital subacute ward located at that centre, so it is off—it is not simply on a different campus but actually formally a hospital, not an acute but a subacute, ward.

Senator THORP: So there are no state provided specific facilities for people with behavioural and psychological symptoms of dementia—BPSD?

Mr Davidson : Yes, the 30 beds actually do cater for those, but the 10 beds were additional capacity for the Royal Hobart Hospital as a way of meeting the needs once their acute episode had been completed. The problem was: do they then stay in the acute ward, or, with the opportunity of funding, do we open up another 10 subacute beds somewhere so that we can get them safely out of the acute part of the hospital and into more appropriate and safer care?

Senator THORP: Given the kinds of statistics that you mentioned earlier in your presentation, are you confident that Tasmania has all the facilities and resources it needs to cope with our ageing population and, therefore, the proportion thereof that will have either one dementia or BPSD?

Mr Davidson : Dr Morrissey has a state-wide role in this area.

Dr Morrissey : I think the question was: do we currently have the facilities looking ahead to deal with those with dementias? That is the question?

CHAIR: Essentially, yes.

Dr Morrissey : The short answer to that question is no. It is quite scary when you look at some of the statistics that will be before you in terms of demographic changes. If you look in terms of what people with dementia and their families and their carers want, it is greater access to community based facilities and resources. People with dementia want to be in their homes for as long as possible, and that is reflected in any sort of forum, such as this one, across Australia. It is the message that will be heard again and again. As to the resources available to meet those needs, if we look at, for example, things like each of the dementia packages, such as the Commonwealth funded packages, there are huge waiting lists for those both here and interstate. They are not cheap but they are the very sorts of services that people want and expect and will certainly need more of in the future.

In terms of the DBMAS resource, it has come up a few times here. I am not sure of the extent to which you fully appreciate DBMAS. It is a tiny resource. It equates to about 3½ clinicians or so—give or take half a clinician—across Tasmania. When you are asking a service to deal with disturbed behaviour not just in nursing home settings but in acute care settings and community settings, I think you will get some idea of how thinly that resource is spread. I could go on about various other state services that deal with folks with dementia.

Senator THORP: I think it was you who also said that the skill level of staff in our existing aged care facilities is mosaic at best. Would you like to clarify that a little in terms of the best practice care and management you would like to see people with dementia receive compared to what we have got.

Dr Cleary : I go into various facilities in my role as a DBMAS, but I do not have a great depth of understanding across many facilities. These are just my own observations. It is just a basic understanding of dementia. Within facilities, yes, they have specific dementia care units, but I think the statistics are that roughly 80 per cent of all people within a residential facility will have some level of cognitive impairment. There are people within secure—the ones who need a locked door, otherwise they may wander off or come to harm. However, across a facility, the vast majority of people have cognitive impairment largely related to ageing.

There is a limited understanding about that and about how people see their world and what they understand; therefore, a behavioural management strategy comes from the ground up. The ratios are low. The nursing level of education and understanding is very good, but those nurses are very thin on the ground. So it is about getting education into the care assistants and into the people providing the hands-on physical care—so those doing the showers and the meals and that sort of thing—because that is where behaviours are often precipitated. People with different educational or cultural backgrounds is a big issue nationwide—coming at it with their understanding and beliefs and how they expect people to behave, and how they interact with Australian aged people, again from various religious and immigration backgrounds. That is where we see a lot of behaviours precipitating. When you go in and educate those people or behaviour map or talk about what would be relevant for a person regarding their culture and their level of cognition, often a lot of behaviours are resolved.

Senator THORP: That is a strong theme that we have been hearing through the evidence—when someone has the right kind of person in the first place. When they have been educated/trained to deal with people who are living with dementia, they know not to provoke situations.

Dr Cleary : A very big service provider of that is DBMAS, here and also nationwide. Tasmania runs a slightly different service to that nationwide. Nationwide, DBMAS runs as a phone assistance service with input largely just over the telephone and without a lot of clinician input. In Tasmania we run as a clinical on-the-ground service, so our nurses will go out, if it is a priority, within 24 hours, assess the situation, and get some information and feedback. We also do a lot of on-the-ground education. That is subcontracted out with some Commonwealth funding. We then put education officers in to run in-house support programs. A lot of facilities run their own and are very good at that. DBMAS, as Martin mentioned, is a very thin resource. There are two RNs. I am a part-time clinician there and they are struggling to fund me. Hazel works alongside with the memory clinic. Again, she will be doing some urgent callouts. We find we are a good rapid response. We can often address situations where they are, tailor things around it and limit escalations. That would be a very high priority for further funding and for a future approach. As Martin said, it is keeping people where they are, it is giving education and it is giving support—a lot of support to carers and families too, who are the ones who suffer the most.

Senator THORP: In the absence of the resource of the size you would like, do you believe that there are patients or residents in aged-care facilities who are medicated more than they need to be?

Dr Cleary : Absolutely. It has been going on for a very long time. There is also a level of chemical restraint. Clinically, people have moved away from physical restraint in the last 10 to 15 years because of increased harm. We know there is a significant amount of harm that comes with chemical restraint, but, again, if you look at the data, it is very highly persistent. There is always a balance between risk and safety. On a lot of levels, some degree of chemical restraint is required for staff and the person's own safety, but the concern that is ongoing from doctors and other clinicians is: who is watching that? Chemical restraint should only ever be a short-term measure. It should be continually assessed and it should be titrated. The Australian Geriatric Society say that there should be a revision within three to six months. There should be a weaning off of particularly antipsychotics to see if behaviours persist. A lot of times the natural history of it is that they settle in anyway. There is a lot of harm and morbidity that comes with most medications—cardiac deaths, strokes, falls and injuries.

As specialist clinicians, Martin and I are not resourced. We cannot follow up on those people once things settle at three and six months. A lot of that is thrown back to GPs. A lot of them are managing large numbers of people within facilities. They are not monitoring those behaviours and they are not sure where those time frames are to have the confidence to pull those drugs back. We have some good GPs out there—do not get me wrong. We have some we work very closely with who are skilled up and are onto it, but the majority are not. So, chemical restraint is used. I think it is very necessary at times, but it should only ever be a short-term measure and it should be reviewed.

Senator THORP: From your experience of going into facilities, as you do, what do you think of the range of services available to make sure that people are stimulated? I am thinking of music therapy or the possibility of going out into gardens and experiencing the pleasure of eating nice food—that kind of issue.

Dr Cleary : I think most of the facilities these days, particularly the larger ones, are doing an excellent job of that. In almost all facilities there are therapy programs addressing everything, including, as you said, music and a lot of exercise programs—which are vitally important—a lot of outings and a lot of community access.

The other thing that often needs to be done for people with dementia though is not so much about facility-wide opportunities but tailored opportunities for the particular person. Several facilities in Tasmania that I deal with and that are larger are very good at doing that and are putting extra programming in, including individualised care programming. I think, however, some facilities that are smaller or do not have the resources do struggle with that. Again, that is where DBMAS can often step in and provide some additional education support and funding for those facilities that are just not resourced for it.

Mr Reed : If I can add to that, and it has come up a couple of times under the education and training of individuals across the aged-care sector, one of the problems that I have seen in the past—and to me it is still there—is this. It is all very well to say you provide this—which you do—but there seems to be a quite fluid workforce in the aged-care sector in that you can train all of your people today but in six months time you would have to go back and do it. So if the component is not there on an ongoing basis, it actually gets lost because it is almost a stereotypical patient that people look after and those people that fall outside of those cases is where the special learning needs to take place. Because the people you might have trained in that or educated in that have moved on or gone elsewhere to other facilities, you have to go back and quite often there is a lull before you claw back because people do not realise what is not going right. So there are issues around that and there are ongoing issues too.

CHAIR: Senator Smith? Go ahead, Dean.

Senator SMITH: I was just going to make one observation. As I think it is fair to say that dementia type services have been an add-on, although that is not quite the right word, and have not been a core competency in residential aged-care homes, as people go into residential aged care at a much older age with higher levels of need, we might start to see the dementia care component being a more core element in the provision of residential aged care in the future. Would that be fair to say?

Dr Cleary : I am hoping it needs to be already. As I said, with over 80 per cent of people there—

Dr Morrissey : Sorry, but it is hard to hear. Yes, but the nature of folks going into aged-care facilities now, compared with 20 years ago, is vastly different. The proportion of folks with dementia in your average nursing home now would be 60 per cent or more whereas it was a much tinier proportion. So I think that time has already happened where aged-care facilities need to address meeting dementia care needs. The topic of education has come up a couple of times in the last few questions. On a quite positive note and on the role of the Wicking centre, they are doing some really amazing stuff with not huge amounts of dosh to assess the needs of people providing care in aged-care settings, recognising things like transient working population—so all those sorts of things—and they are starting to actually deliver some really cost-efficient education packages specifically around dementia care, end-of-life care and appropriate dementia care. So there are some really cutting-edge things happening in Tasmania on an education front. Obviously, lots more needs to be done but there are some pretty good things happening.

Mr Davidson : I feel really remiss that we should have mentioned that in our introduction, that we do have a terrific partnership with the Wicking Dementia Research and Education Centre and that we are very lucky in Tasmania to have that centre available to us. The state government has very strong links, research and working links, with that centre. So that is terrific and I think everyone would agree.

Senator MOORE: I have a question on an issue that is to do with evidence which we have received in camera, so I have got to be very careful but I am trying to ask a general question about an issue that was raised about HACC services. I know the federal government has taken over HACC since 1 July, but up until then the state was actually deeply involved in HACC services—was it not? I know Queensland was the one that was the most but I thought Tasmania was pretty significant as well.

Mr Davidson : I am not quite sure how you would describe it but probably 30 to 40 per cent of HACC funding in Tasmania was delivered through state government directly supplied services. That is pretty understandable because, with the economies of scale and the number of alternative providers available in a small state like Tasmania, it often falls to the state government, because they have got the services up and running to do that, whereas other states have a lot more NGOs and private providers.

Senator MOORE: The particular concerns are about treatment and access of dementia patients into HACC respite services and day-care centres—the number of centres that operate and what services they can provide and, particularly for dementia patients, their access to those things which, without breaching confidence, is quite a general question in an inquiry like this. There were concerns about serious limitations to HACC services.

Mr Davidson : I am aware that some submissions have raised the issue of access to respite and day-care centres in Tasmania, HACC ones. I do not know of the validity of that or if it is true or not; what I do know is that people who are not ineligible, or have not been eligible, because they have dementia—and I think something about wheelchairs was raised as well—

Senator MOORE: I cannot understand how any day-care centre or respite service can say no wheelchairs are allowed.

Mr Davidson : No. And it certainly should not make people ineligible to receive HACC services. Although HACC is described as a basic services program, people are not ineligible for it because they have dementia or because they have a wheelchair. On a practical basis, I suppose some people might not be safe or appropriate in some types of services being developed to a particular target group. But I have not heard of any example where somebody has been excluded from a service that would not have been seen as being unreasonable. I have never—

Dr Cleary : The two HACC respite services that are most highly skilled with dementia patients in southern Tasmania are Vesty House and the John Tooth Day Respite Centre. Prior to that, it was the Shore Street Centre. We have linked in and used those centres for very challenging people. They have always taken it on and there has never been a problem. Again, we provide a bit of a report or some lead-in information so that settling goes well. But those centres really are centres for excellence and manage some very complicated people. Tasmania is very geographically dispersed. Those centres are excellent but there is just one in Glenorchy and one on the eastern shore. Down in the channel and other isolated areas, travelling times and distances are tricky. But I am sure that is the case throughout Australia for people in semirural areas.

Senator MOORE: What I might do is talk with the person who provided the evidence and see whether they are prepared to have the specific questions asked back to you—because there does seem to be a complete disjoint between the evidence we received and the comment you have just made. I will see whether they are prepared to have that question asked.

Mr Davidson : There were concerns raised about access to the Roy Fagan Centre and the John Tooth Day Respite Centre, which we cannot comment on. We would be quite happy to talk to whoever that was.

Dr Cleary : We will clear that up for you.

Senator THORP: We have talked about the need for much more in the way of education and training of staff to enable them to better look after people with dementia, and also the need for more resourcing into the future. The third string to that bow is facilities. Given that so many more people in existing aged care facilities are going to be living with dementia, are the facilities up to it, are they appropriate, or do they need significant remodelling, reshaping and redesigning to better meet the needs of people into the future?

Mr Reed : My view of that would be that the open environment is the thing that reduces the difficult behaviours. Where people have space to wander around and they are not forced into other people's faces, if you will, the more space you seem to have, the easier it is to deal with difficult people or the fewer the problems that you get from difficult people. I think that one of the issues is space—that is appropriate space, whether it is an external yard or an internal space. The nooks and crannies need to go; it is the flowing, internal and external paths that they can follow to give purpose, not just a block of ground that people are herded into.

Senator THORP: It sounds very much like the old Adards.

Dr Cleary : The short answer to that is that what is available at the moment is limited. Things do need to be redesigned and made more purpose-built. Wicking centre in Hobart has a design project. They have launched a website to enable people to do an audit of their facility, to look at problem areas and to have some input from specialist architects with expertise in aged care. That is a brilliant initiative and is available nationwide through the website. Definitely, environment has become a critical area of dementia care and behaviour management. It would be ideal to see all facilities redesign their specific dementia area for those with more challenging behaviours who do need secure location. A lot of facilities are naturally doing that to maintain best practice, to provide best care and also to continue to be viable and be attractive to people who want to live there. I know there are two or three in the southern region that have done that recently and it is very rewarding for everyone involved.

CHAIR: Thank you. We have given a little bit of homework but we need to supply some further questions for that to happen. We undertake to do that. Thank you for your submission, for your time today and for participating in the inquiry. It is really appreciated.