Is Australia over-reliant on residential aged care to support our older population?

Comprehensive analysis of Australia's aged care system to inform policies for a sustainable future

Background

Australia's aging population presents significant socioeconomic challenges, necessitating the aged care sector reforms. Projections indicate continued growth in this demographic, prompting the implementation of various funding mechanisms to support healthy aging. However, notable disparities persist, including care quality concerns, workforce shortages, and safety issues, hindering the sector's ability to meet consumer expectations. Despite recognition of these challenges, no comprehensive overview exists addressing these shortcomings. This study aims to provide a comprehensive analysis of the literature to identify these challenges and inform policy development.

Methods

In this study, a scoping review was conducted, examining primary and secondary sources, including peer-reviewed articles, government reports, and aged care policies. The Scopus database was searched using relevant keywords, and a snowball search technique was employed to identify additional literature. The inclusion criteria were applied, and journal articles were screened for titles and abstracts before full-text analysis. Thematic analysis was conducted on selected literature, and secondary data were from administrative and organizational websites and agencies.

Results

Findings indicate a preference for home-based care among older Australians due to concerns about quality and safety in aged care facilities. While the Australian government has developed reforms and policies to govern the sector, funding remains insufficient to meet the escalating demand for high-quality care. Challenges include workforce shortages, the growing burden of aging, and difficulties in adopting emerging technologies, which impact the quality of care delivered to older Australians.

Conclusion

This paper serves as a resource for policymakers and aged care professionals, informing the development of reforms to address pressing issues in the sector. A comprehensive evaluation of existing knowledge provides a clearer understanding of current and future obstacles ensuring a holistic view and fostering the development of sustainable aged care reforms.

Gerontological educational interventions for student nurses: a systematic review of qualitative findings

OBJECTIVES

This systematic review of qualitative studies explored interventions to improve student nurses' knowledge, attitudes or willingness to work with older people. Student nurses are likely to encounter older people in all health and aged care settings, however, research demonstrates that few have career aspirations in gerontological nursing.

METHODS

Qualitative systematic review method based on the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Search of Medline, Embase, PsycINFO, EBSCOhost and Scopus yielded 1841 articles which were screened to include primary research about educational interventions to improve student nurses' knowledge, attitudes and/or willingness to work with older people. Data extraction was performed on the 14 included studies, and data were analysed using directed content analysis. The Mixed Methods Appraisal Tool (MMAT) was used the assess the quality of the studies.

CONCLUSIONS

Educational interventions included theory or practice courses, or a combination of theory and practice. While most interventions changed nursing students' negative attitudes towards older people, few increased their willingness to work with them. Practice courses had the most significant impact on willingness to work with older people. Quality assessment revealed methodical limitations. More research is needed to better understand the elements of practice interventions that enhance student nurses' knowledge, attitudes, and willingness to work with older people, so that they can be replicated.

'Going Above and beyond': Residential Aged Care Staff Experiences of Providing Care During the Changing Context of COVID-19

The COVID-19 pandemic required residential aged care facilities (RACFs) to meet the high care needs of residents in the context of stringent public health measures and staffing pressures. Given the likelihood of ongoing COVID-19 waves and seasonal surges in acute respiratory infection outbreaks, this study explored RACF staff experiences in providing care while limiting COVID-19 risk. Ten focus groups were conducted across six RACFs in metropolitan and regional New South Wales, Australia. Findings highlighted the impact of negative media representation on staff and the need for risk-based clear public health messages to reduce complacency. Findings also highlighted challenges in meeting clinical needs while keeping residents safe, and the benefit of new initiatives and opportunities for future training. Clear, targeted communication is essential to ensure ongoing understanding and adoption of public health measures when required. Awareness of the challenges provides RACFs and policymakers valuable insights for future planning including staff support and training needs. Key areas that require attention include promoting work in RACFs as a valued profession, clear public health risk messaging, strategies to facilitate prioritizing care, and broadened scope of skills.

Further Evidence of Feasibility, Validity, and Reliability of Quality of Life-Aged Care Consumers: Evidence From Home-Based Care Settings

OBJECTIVES

The Quality of Life-Aged Care Consumers (QOL-ACC) is an aged-care-specific preference-based instrument currently being rolled out in residential care across Australia as part of the aged care Quality Indicator program. This study aimed to provide a comprehensive assessment of the feasibility, reliability, and construct validity of the QOL-ACC in a large national sample of older adults receiving aged care services at home.

METHODS

Older adults receiving in-home aged care services completed a survey including the QOL-ACC, Quality of Care Experience-ACC, adult social care outcome tool, EQ-5D-5L, and 2 global single item measures of health and quality of life. Feasibility was assessed by missing responses (≤5%) and ceiling/floor effects (≤15%). Construct validity was assessed by exploring the relationship between the QOL-ACC and other instruments (convergent validity) and its ability to discriminate varying levels of self-rated health and quality of life (known-group validity).

RESULTS

A total of 802 respondents (mean age, 74.5 ± 6.3 years; 56.0% females) completed the survey. The QOL-ACC had no missing responses, no floor effects, and very low ceiling effect (3.5%) and demonstrated moderate correlation with adult social care outcome tool (r = 0.59, P < .001), EQ-5D-5L (r = 0.65, P < .001), EQ-VAS (r = 0.53, P < .001), and a lower correlation with the QCE-ACC (r = 0.41, P < .001). Respondents with poor self-rated health and quality of life had significantly lower preference-weighted scores on the QOL-ACC.

CONCLUSIONS

The QOL-ACC demonstrated adequate feasibility, reliability, and construct validity in a large population of older people accessing government-subsidized aged care services at home. Further studies will explore the responsiveness of the QOL-ACC to aged-care-specific interventions both in home and residential aged care settings.

A systematic review of typologies on aged care system components to facilitate complex comparisons

Objectives: Typologies are frequently utilised in analyses of the quality, funding, and efficiency of aged care systems. This review aims to provide a comprehensive resource identifying and critiquing existing aged care typologies. Methods: Systematic search of MEDLINE, Econlit, Google Scholar, greylit.org and Open Grey databases from inception to July 2020, including typologies of national, regional or provider aged care systems. Article screening, data extraction, and quality appraisal were conducted in duplicate. Results: 14 aged care typologies were identified; five applied to residential care, two to home care and seven to mixed settings; eight examined national systems and seven regional or provider systems. Five typologies classifying national financing or home care services, provider financing of staff and services and quality of residential care were considered high quality. The schematic provided summarises the focus area and aids in typology selection. Discussion: The aged care typologies identified cover a wide range of areas and contexts of aged care provision. This schematic, summary and critique will aid researchers, providers, and aged care policy makers to examine their own setting, compare it to other approaches to aged care provision and assist in identifying alternatives and important considerations, when undertaking aged care reform.

A Quantitative Meta-Analysis and Qualitative Meta-Synthesis of Aged Care Residents' Experiences of Autonomy, Being Controlled, and Optimal Functioning

BACKGROUND AND OBJECTIVES

The poor mental health of adults living in aged care needs addressing. Improvements to nutrition and exercise are important, but mental health requires a psychological approach. Self-determination theory finds that autonomy is essential to wellbeing while experiences of being controlled undermine it. A review of existing quantitative data could underscore the importance of autonomy in aged care, and a review of the qualitative literature could inform ways to promote autonomy and avoid control. Testing these possibilities was the objective of this research.

RESEARCH DESIGN AND METHODS

We conducted a mixed-methods systematic review of studies investigating autonomy, control, and indices of optimal functioning in aged care settings. The search identified 30 eligible reports (19 quantitative, 11 qualitative), including 141 quantitative effect sizes, 84 qualitative data items, and N = 2,668. Quantitative effects were pooled using three-level meta-analytic structural equation models, and the qualitative data were meta-synthesized using a grounded theory approach.

RESULTS

As predicted, the meta-analysis showed a positive effect of aged care residents' autonomy and their wellness, r = 0.33 [95% CI: 0.27, 0.39], and a negative effect of control, r = -0.16 [95% CI: -0.27, -0.06]. The meta-synthesis revealed seven primary and three sub-themes describing the nuanced ways autonomy, control, and help seeking are manifest in residential aged care settings.

DISCUSSION AND IMPLICATIONS

The results suggest that autonomy should be supported, and unnecessary external control should be minimized in residential aged care, and we discuss ways the sector could strive for both aims.

The risk of fractures after entering long-term care facilities

BACKGROUND

Stratifying residents at increased risk for fractures in long-term care facilities (LTCFs) can potentially improve awareness and facilitate the delivery of targeted interventions to reduce risk. Although several fracture risk assessment tools exist, most are not suitable for individuals entering LTCF. Moreover, existing tools do not examine risk profiles of individuals at key periods in their aged care journey, specifically at entry into LTCFs.

PURPOSE

Our objectives were to identify fracture predictors, develop a fracture risk prognostic model for new LTCF residents and compare its performance to the Fracture Risk Assessment in Long term care (FRAiL) model using the Registry of Senior Australians (ROSA) Historical National Cohort, which contains integrated health and aged care information for individuals receiving long term care services.

METHODS

Individuals aged ≥65 years old who entered 2079 facilities in three Australian states between 01/01/2009 and 31/12/2016 were examined. Fractures (any) within 365 days of LTCF entry were the outcome of interest. Individual, medication, health care, facility and system-related factors were examined as predictors. A fracture prognostic model was developed using elastic nets penalised regression and Fine-Gray models. Model discrimination was examined using area under the receiver operating characteristics curve (AUC) from the 20 % testing dataset. Model performance was compared to an existing risk model (i.e., FRAiL model).

RESULTS

Of the 238,782 individuals studied, 62.3 % (N = 148,838) were women, 49.7 % (N = 118,598) had dementia and the median age was 84 (interquartile range 79-89). Within 365 days of LTCF entry, 7.2 % (N = 17,110) of individuals experienced a fracture. The strongest fracture predictors included: complex health care rating (no vs high care needs, sub-distribution hazard ratio (sHR) = 1.52, 95 % confidence interval (CI) 1.39-1.67), nutrition rating (moderate vs worst, sHR = 1.48, 95%CI 1.38-1.59), prior fractures (sHR ranging from 1.24 to 1.41 depending on fracture site/type), one year history of general practitioner attendances (≥16 attendances vs none, sHR = 1.35, 95%CI 1.18-1.54), use of dopa and dopa derivative antiparkinsonian medications (sHR = 1.28, 95%CI 1.19-1.38), history of osteoporosis (sHR = 1.22, 95%CI 1.16-1.27), dementia (sHR = 1.22, 95%CI 1.17-1.28) and falls (sHR = 1.21, 95%CI 1.17-1.25). The model AUC in the testing cohort was 0.62 (95%CI 0.61-0.63) and performed similar to the FRAiL model (AUC = 0.61, 95%CI 0.60-0.62).

CONCLUSIONS

Critical information captured during transition into LTCF can be effectively leveraged to inform fracture risk profiling. New fracture predictors including complex health care needs, recent emergency department encounters, general practitioner and consultant physician attendances, were identified.

Impact of lifestyle risk factors on admission to nursing home care: a cohort study of 127 108 people aged 60 years and over

BACKGROUND

Little is known on how lifestyle factors, individually or in combination, may relate to nursing home admission, an outcome of great societal and economic importance with increased population ageing. The aim of this study was to determine the association of lifestyle risk factors with nursing home admission.

METHODS

This prospective cohort study linked data from the 45 and Up Study, Australia, to health records. 127 108 men and women, aged ≥60 years, were recruited between 2006 and 2009. A healthy lifestyle score categorised participants into three risk groups based on five equally contributing risk factors: smoking status, physical activity, sedentary behaviour, sleep duration and diet quality. HRs for incident nursing home admission were estimated using multivariable Cox proportional hazards model.

RESULTS

One-quarter of participants were in the low-risk lifestyle group, 62% were in the medium-risk group and 14% in the high-risk (least healthy) group. During a median (IQR) follow-up of 11.3 years, 23 094 (18%) participants were admitted to a nursing home. Compared with those in the low-risk group, risk of nursing home admission was 43% higher among participants in the high-risk group (multivariable adjusted HR (aHR) 1.43; 95% CI 1.36 to 1.50); and participants in the medium-risk group had an intermediate 12% greater risk (aHR 1.12; 95% CI 1.08 to 1.16). Participants aged 60-64 years in the high-risk (aHR 2.15; 95% CI 1.82 to 2.54) lifestyle group had the greatest risk of nursing home admission.

CONCLUSION

An unhealthy lifestyle was associated with a marked increased risk of admission to a nursing home in adults aged 60+ years. Interventions focused on lifestyle modifications may prevent or delay nursing home admission.

A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest

BACKGROUND

The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort.

RESULTS

77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years = 18,956; 90-100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the '15/5/0' score - highly comparable to a previously-published American cohort.

CONCLUSIONS

Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point '15/5/0' prognostic score defining which patients will gain most from advanced resuscitative measures.

From the ground up: assessing the face validity of the Quality of Life – Aged Care Consumers (QOL-ACC) measure with older Australians

Purpose

This paper aims to assess the face validity to inform content validity of the Quality of Life – Aged Care Consumers (QOL-ACC), a new measure for quality assessment and economic evaluation in aged care.

Design/methodology/approach

Semi-structured interviews were conducted with older adults (66–100 years) receiving aged care services at home (n = 31) and in residential care (n = 28). Participants provided feedback on draft items to take forward to the next stage of psychometric assessment. Items were removed according to several decision criteria: ambiguity, sensitive wording, not easy to answer and/or least preferred by participants.

Findings

The initial candidate set was reduced from 34 items to 15 items to include in the next stage of the QOL-ACC development alongside the preferred response category. The reduced set reflected the views of older adults, increasing the measure’s acceptability, reliability and relevance.

Originality/value

Quality of life is a key person-centred quality indicator recommended by the recent Royal Commission into Aged Care Quality and Safety. Responding to this policy reform objective, this study documents a key stage in the development of the QOL-ACC measure, a new measure designed to assess aged care specific quality of life.

The integration of mixed methods data to develop the quality of life - aged care consumers (QOL-ACC) instrument

Background

This paper describes the collection and integration of mixed methods data to facilitate the final selection of items for the Quality of Life – Aged Care Consumers (QOL-ACC) instrument. The aim of the wider project is to develop a preference-based quality of life instrument that can be used for quality assessment and economic evaluation. Older people have been involved at every stage of the development of the QOL-ACC to ensure that the final instrument captures their perspectives and preferences.

Methods

Mixed methods data was collected on draft items for the QOL-ACC instrument across six key quality of life dimensions (mobility, pain management, emotional well-being, independence, social connections, and activities). Qualitative face validity data was collected from older people (aged 66 to 100 years) living in the community and in residential aged care via semi-structured interviews (n = 59). Quantitative data was collected from older people (aged 65 to 91 years) receiving aged care services in the community via an online survey (n = 313). A traffic light pictorial approach was adopted as a practical and systematic way to categorise and present data in a meaningful way that was easy for non-academic workshop members to understand and to be able to discuss the relative merits of each draft item.

Results

The traffic light approach supported the involvement of consumer and aged care provider representatives in the selection of the final items. Six items were selected for the QOL-ACC instrument with one item representing each of the six dimensions.

Conclusions

This methodological approach has ensured that the final instrument is psychometrically robust as well as meaningful, relevant and acceptable to aged care consumers and providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02614-y.

‘Knowledge is everything?’ How well do the general public understand aged care and how does this affect their attitudes towards quality of care and future funding?

The recent Royal Commission into Aged Care Quality and Safety in Australia has documented systemic failures and shocking incidences of abuse and neglect, a not uncommon story internationally. As aged care in many countries is predominantly publicly funded, it is important to understand the general public's attitudes towards aged care quality, what aspects of care quality they think are most important and their willingness to contribute to increased funding to the sector. This paper asks specifically whether self-reported aged care literacy impacts expectations and willingness to pay. More than 10,000 members of the general population were surveyed stratified by age, gender and state. Regardless of the level of aged care literacy, there was consensus about what constitutes quality care, and care priorities for the sector. However, aged care literacy affected willingness to pay to fund a better-quality aged care system. The current crisis facing Australia's aged care system and that of many other countries internationally demonstrates the central importance of general public support to drive quality improvements, recognising that increasing public expenditure on aged care is a necessary part of the solution. This study provides important baseline data from which to commence national and international conversations to consider all options for ensuring the quality, safety and sustainability of aged care now and into the future.

A critical decision point: Short- and long-term outcomes of older surgical patients admitted to a Queensland intensive care unit

OBJECTIVES

Critical care admission is a pivotal juncture for older patients undergoing surgery. We aimed to identify the in-hospital and postdischarge outcomes of older postsurgical patients (≥65 years) admitted to the intensive care unit (ICU).

METHODS

We collected clinical, morbidity and survival data on all patients aged ≥65 years postsurgically admitted to a tertiary metropolitan ICU between 2014 and 2019.

RESULTS

Within this older cohort (n = 370), the oldest patients (≥85 years) had the highest 1-year mortality (RR: 4.00; P < 0.001). Major surgery (RR: 5.67; P < 0.001), emergency surgery (RR: 2.89; P < 0.001) and APACHE III score ≥50 (RR: 2.63; P < 0.001) were associated with reduced 1-year survival.

CONCLUSION

APACHE III score and surgery subtype are strong predictors of post-ICU mortality and may be useful to preoperatively stratify whether surgery and subsequent ICU admission are in patients' best interests. These data may also inform prospective discussions regarding end-of-life care and advanced care planning.

Individual and organizational factors of nurses' job satisfaction in long-term care: A systematic review

BACKGROUND

In long-term care facilities, nurses' job satisfaction predicts staff turnover, which adversely affects resident outcomes. Thus, it is important to develop a comprehensive understanding of factors affecting nurses' job satisfaction in long-term care facilities.

OBJECTIVES

To analyze factors associated with job satisfaction among nurses in nursing homes from individual and organizational perspectives utilizing a deductive approach.

DESIGN

Systematic literature review SETTING: Nursing homes.

PARTICIPANTS

Registered nurses and licensed practical nurses in nursing homes.

METHODS

A systematic literature review of seven online databases (EMBASE, CINAHL, PsychINFO, MEDLINE, PubMed, Scopus, and Web of Science) to July 23, 2020 was conducted. Studies were included if they examined factors associated job satisfaction in the target population and setting. Decision rules on how to determine factors important to nurse job satisfaction were developed a priori. Two team members independently screened the publications for inclusion, extracted data, and assessed included publications for methodological quality; conflicts were resolved through a consensus process and consultation of the third senior team member when needed.

RESULTS

Twenty-eight studies were included. Of these, 20 studies were quantitative, 6 were qualitative, and 2 were mixed methods. Factors associated with job satisfaction were grouped into two categories: individual and organizational. Individual factors significantly associated with job satisfaction were age, health status, self-determination/autonomy, psychological empowerment, job involvement, work exhaustion, and work stress. Individual factors identified as not important or equivocal were gender and experience as a nurse/in aged care. No organizational factors were identified as important for nurses' job satisfaction. Facility ownership, supervisor/manager support, resources, staffing level, and social relationships were identified as equivocal or not important. Findings from qualitative studies identified relationship with residents as an important factor for job satisfaction.

CONCLUSIONS/IMPLICATIONS

Factors identified as important to nurses' job satisfaction differ from those reported among care aides in nursing homes and nurses employed in acute care settings, suggesting that there is a need for unique approaches to enhance nurses' job satisfaction in nursing homes.

Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity

The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.