Bold insights into quality home care in Australia.

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1 Faculty of Health Bold insights into quality home care in Australia. Ms Jenny Mee Lecturer in Nursing, RN, BN, Master of Applied Science (Research), PhD Candidate Acknowledgements: Principal Supervisor: Dr Linda Jones Associate Supervisors: Dr Daniel Terry and Associate Professor Penny Cash. Federation University Australian Post Graduate Research Scholarship National Education Excellence Leadership Incentive Women in Leadership Scholarship (ASAM) To my participants- thank you

Background to the research Faculty of Health Defining Home Care: Home care encompasses an array of medical, nursing and social care, which are essential to assisting people to maintain their

2 Background to the research Faculty of Health Defining Home Care: Home care encompasses an array of medical, nursing and social care, which are essential to assisting people to maintain their independence at home or in their space within their communities. AIHW (Australian Government, 2014) in report that 1,192,800 people accessed care from Disability Services or Home and Community Care (HACC) services across Australia. Aging population- by million or 20% of population will be over 65 (Commonwealth of Australia, 2015). Australian Government, Department of Social Services, 2014; Toofany, 2007; Blackman, 2009; Byrd, 2012; Goodridge et al., 2012; Hendig, Mealing, Carr, Lugic, Byles and Jorm 2012; Brennan et al., 2012; AIHW, 2012) Impacts on social & political planners for health, social & human services. Major political reforms occurring in aging & disability sectors (Andersonwurf 2017).

Social & Historical Home Care Contexts Modern Day Past History Public health during industrialization Traditions of district nursing in UK Not-for-profit traditions, church and charity Poor public

3 Social & Historical Home Care Contexts Modern Day Past History Public health during industrialization Traditions of district nursing in UK Not-for-profit traditions, church and charity Poor public funding RN lead care Queens Nurses Volunteers & family as care givers 1985 HACC funding- fragmentation of care Governing of the private spaces Common Community Care standards Aged Care Reforms- Consumer Directed Funding/ new CHSP Disability Reforms NDIS Privately funded/ private businesses emerging Limited research published in home care governance

4 Integrated Review of Literature Search terms: Literature Review Approach (Commenced 2013) community care in home, home care, home care service, in-home care, home care service Databases included: Cinahl, Cochrane, Medline, PsychINFO, SocINDEX, Health Business Elite Excluded: home care for children and foster care Further consideration and exclusions applied: palliative care, end stage renal failure treatment, technology monitoring, institutional respite care, and informal care Initial yield = 86 articles Secondary and tertiary sources then examined to develop a genealogy of home care in Australia

5 Trends in the literature Mostly interventionist & evaluation of health outcomes of programs and care plan delivery Experiences of consumers & program evaluation Home care governance costs, policy & quality local & international Recent paper on Consumer Directed Care early perceptions & experiences of staff, clients and carers (Gill et al., 2017)- conducted in NSW and SA. Highlighted difficulties of the culture of industry, industry controls and client expectations, staff and client/carer role change. To note was the recommendation for effective education, information and redistribution of power relationship through change management and resourcing systems and education. Gaps in research limited research on home care business managers/owners and especially inclusive of the for-profit sector 5

PhD Title: Australian Home Care Quality: a Political Tango The PhD Research Question: What are the challenges for business managers of home care services in meeting regulatory quality requirements of

6 PhD Title: Australian Home Care Quality: a Political Tango The PhD Research Question: What are the challenges for business managers of home care services in meeting regulatory quality requirements of state and national standards in Australia? The PhD Research Purpose 1. To gather information about home care business in Australia and how business owners/managers meet quality processes. 2. To provide new insights and additional information about home care quality & governing for policy makers, researchers and practitioners. 6

7 Faculty of Health Power of the political tango: Quality in the home care arena 7

8 Faculty of Health Qualitative Research Approaches & Methods Post structural critical discourse analysis and creation of a genealogy (informed by theorists eg. Foucault, 1978; Dean, 2010; Powers, 2001 & Cheek, 2000) Qualitative researcher informed by critical social research with post modern/ post structural sympathies. Face to face semi-structured interviewing & self reflectivity through journaling (Denzin and Lincoln, 2018 & 2011; Fook, 2011; Cheek, 2000; King & Horrocks, 2010).

9 Governmentality in the Home Care Arena Power Economics Knowledge Discipline Reasons of state Surveillance Dean, 2010; Burchell, Gordon & Miller, 1991; Foucault 1978

10 Faculty of Health Ethical considerations Power/knowledge Power over data- consent Collecting data Company secrets Storing data Analysing data Rigor- concept of confirmability 1. Federation University Ethics approval granted October Adaptive snowballing recruitment of 10 business owners and managers of home care services (Qld & Vic) 3. Face to face semi-structured interviews X 3 for each participant from April 2016 to February gift certificates given for participation 4. Journaling 5. Dissemination

11 Profile of the Participants 10 participants from Qld and Victoria All had tertiary qualifications: nursing, medicine, psychology, occupational therapy, social work, gerontology, disability and management (some with multiple degrees) Some professionally registered, some were not Represented metropolitan, city, urban, regional/ rural and remote areas of Australia. Business models ranged from LHAs, LGAs, NGOs (not for profit), private (for profits) and brokered including franchised business models 11

finance/account keeping & changing systems over Navigating My Aged Care- Finding the rules &

12 Cheering in the arena Business growth- both private & public Meeting & adhering formal quality standards Staff adjusting to changes Models of business changing Meeting goals of finance/account keeping & changing systems over Navigating My Aged Care- Finding the rules & score cards & the requirements of the arena Bigger players doing better & some competitive moves over smaller business

Watching for Risk Moves in the Field Communication in the arena Accessing & deciphering information Misinformation in the sector Connectivity issues- networking with people and with IT Concerns of

13 Watching for Risk Moves in the Field Communication in the arena Accessing & deciphering information Misinformation in the sector Connectivity issues- networking with people and with IT Concerns of unethical marketing to consumers Advocacy- hearing silenced voices Geographically location- regional & remote areas Poor assessment of needs and communication of same Competition in the market place & smaller competitors Potential for risky situations Dirty plays in the field Brokerage rules and tensions Power over clients Control over communication with clients & quality control issues Moves with difficult clients Marginalised clients-poor mental health, hoarders, dementia & other mental health concerns- knowing how to care Field staff knowledge & qualification low

14 Tensions and Challenges in the Arena: Cross cultural communication Managing cultural expectation of clients and staff: Sharon: I ve had two occasions I think where I ve gone back and said to the brokerage, I won t provide staff for this client, because you know, they re not just there to be treated like that, you know. It was more around that, you know, I want someone of a specific race because you know, they ll work harder than anyone else, or something like that. And I won t - I won t do that. Yeah. It s not nice. It s not, you know. I have to - you know, my staff need to be treated with respect you know, as well as we, you know, treat the clients with respect. 14

15 Challenges in client care: Communication & sharing of information Sharon: Well, you cannot provide a quality service if you don t know what the service is you re providing. I m sending staff into homes that you know, I haven t got a clue. I - we end up googling half the time. Doing the view of the home to make sure the external environment - you know, sometimes you can make an assessment on the external environment and go, there s a house that s falling down so we know that the inside s going to be probably pretty much looking like the outside, you know. So there s a risk, you know. We always get for new clients - our staff to do a home safety assessment on their first visit. But you know, I ve got staff going out, so there s a risk if I don t know what the environment is.. you know, if you haven t got a comprehensive picture of the client, you know. Are there behavioural issues? Are they at risk? Is their family hanging around? Is there - you know, you don t know, you know. So there s risks to the clients and there s risks to the staff going in, you know.risks of injury. Risks of harm. 15

16 Challenges with complex behaviours Jasmine It's a - it's a challenge because if someone's living at home and they've got cognitive impairment and they don't have family, that can be real challenging getting someone on the program so that we can start helping them But even them understanding, understanding their illness, yeah. Like I went out with one of my care managers last week and the um, we spoke to the husband and the son for quite a long time. And the wife who will come onto the package, she had a stroke about five months ago in February, and she had some cognitive impairment before the stroke but had some more after the stroke. And she (is).. legally blind, and you know, the son and husband were talking about different things that she was doing, you know, some of it's because of the blindness and some of it's because she - she wants control over whatever, you know, the little she's got left behaviour associated with their illness, you know. 16

Challenges in the Arena Marketing Performance Local is Best: David: Regardless of what's happening in the marketplace, I think the culture has certainly been local is best, and establishing that

17 Challenges in the Arena Marketing Performance Local is Best: David: Regardless of what's happening in the marketplace, I think the culture has certainly been local is best, and establishing that loyalty and that brand awareness and relationship-building at a local level. This office doesn't try and deliver a service all over the state. It's really just focused on one portion of the metropolitan area. So my interest isn't across the other side of town at all. It is just here, and I think that that sort of goes well in building up that local reputation. New small business versus traditional large service provision: Daphne: And you have to start thinking okay well if, if potentially because of these huge monoliths that are already out there and established over 50 years, that little pie, has to sustain us, so how is that going to sustain us? You know are we just going to accept that we re a boutique business and that we focus on some special aspect of the aged cared sector.... So those are, those are part of the challenges you know over this 12 months. And so we ll have our own little niche that we do very well [um] and not even try and compete with them. 17

Disrupting, Innovating and Thriving for the Future of Quality Home Care Policy Support More research and inclusion of people from the margins (especially regional, remote and socially isolated) More

18 Disrupting, Innovating and Thriving for the Future of Quality Home Care Policy Support More research and inclusion of people from the margins (especially regional, remote and socially isolated) More seeking and hearing the voice of all industry performers and competitors More instruction on the rules in the arena (for-profits and regional areas) Codes of practice for equal and fairer competition and to protect clients Infrastructure Support Research & Development funding for regional collaborative networks Research funding for online/ virtual training for workers caring for complex clients Online home care simulation research & development (Partnering with academic experts) Development needed of webinars & online networking forums to collaborate with others & improve accessibility to information Money, time & support for IT, software transition, NBN needed for reliable & faster connectivity (regional & remote)

Regional Innovation Potential Faculty of Health Multi Campus University: Victoria: Ballarat, Gippsland & Berwick Queensland: Brisbane Fed Uni School of Nursing, Midwifery and Healthcare is uniquely

19 Regional Innovation Potential Faculty of Health Multi Campus University: Victoria: Ballarat, Gippsland & Berwick Queensland: Brisbane Fed Uni School of Nursing, Midwifery and Healthcare is uniquely and strategically positioned to: Develop online & face to face educational programs and forums which are inclusive of regional and remote areas To provide expertise in online education, forums and simulation and high fidelity learning. Home care simulation curriculum content and utilise SHELLs (Simulated Home Environment Learning Laboratory) Draw on existing networks & collaborations in the regional areas with LHAs, LGAs, NGO services and private providers.

20 Innovations in Simulated Home Care Learning Photos by J.Mee

21 Home care simulation in action 21

Conclusions for bold insights for quality in home care: Inclusive practice & developing new knowledge for home care quality through research and education An inclusive analysis of the disruptive

22 Conclusions for bold insights for quality in home care: Inclusive practice & developing new knowledge for home care quality through research and education An inclusive analysis of the disruptive events to inform policy & consumer directed change is vital for ensuring quality provision of home care services for the consumers. Based on some of the new knowledge emerging from this study, new alternative and innovative ways of communicating in the business of home care Is needed so as to be inclusive of all groups and communities of practice. This can be realised in Australia through research development and educational strategies to address the changing needs of home care communication across the sector.

23 Any Comments or Questions? Faculty of Health Images: Retrieved 29/1/2015 from google images unitedwayballarat.org.au and theposh.com Contact Jenny Mee

24 References Australian Bureau of Statistics. (2011). Population by Age and Sex, Australian States and Territories. Retrieved April 20, 2014 from Australian Government, Department of Social Services. (2014) My Aged Care. Retrieved December 23, 2014 from Australian Bureau of Statistics (2016). Population Clock retrieved 13/9/2016 from Australian Institute of Health and Welfare. (2014). People Using Both Disability Services and Home and Community Care Retrieved September 27, 2014 from Australian Institute of Health and Welfare. (2012). Use of health and aged care services. Retrieved September 27, 2012 from Blackman, A. (2009). District nursing past and present. Primary Health Care, 19(2), 16. Retrieved from EBSCOhost November 2, 2012 from d4b8113%40sessionmgr110&vid=1&hid=113&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=mnh&AN= Burau, V., Theobald, H. and Blank, R.H. (2007). Governing Home Care A Cross National Comparison. Cheltenham, UK: Edward Elgar Publishing. Burchell, G., Gordon., C. & Miller, P. (Eds) (1991). The Foucault Effect Studies in Governmentality with two lectures by and an interview with Michel Foucault. The University of Chicago Press, Chicago. Burchell, G. (1991). Peculiar interests: civil society and governing the system of natural liberty in The Foucault Effect Studies in Governmentality with two lectures by and an interview with Michel Foucault (eds Burchell, G., Gordon, C & Miller, P.). The University of Chicago Press, Chicago. Byrd, M. (2008). Back to the future for home care: Roots of social work and nursing in America. Home Health Care Management & Practice, 20(6), 487. doi: / Cheek, J. (2000). Postmodern and Poststructural Approaches to Nursing Research. Thousand Oaks, California: Sage Publications. COTA, (2012). COTA Media Release. Living Better For Longer. Retrieved April 25, Dean, M. (2010). Governmentality: Power and rule in modern society. Thousand Oaks, California: Sage Publications. Denzin, N.K. & Lincoln Y.S. (2011). The Sage Handbook of Qualitative Research (4 th ed). Thousand Oaks, California: Sage Publications. Department of Health and Ageing (2012) Community Care Common Standards Guide. Retrieved April 25, 2012 from Fook, J. (2011). Developing Critical Reflection as a Research Method. In J. Higgs, A., Titchen, D. Horshfall & D. Bridges (Eds) Creative Spaces for Qualitative Researching pp Rotterdam, Netherlands: Sense Publishers. Foucault, M. (1972). The Archaeology of Knowledge And The Discourse on Language. (A.M. Sheridan Smith (Trans)). New York: Random House Inc. (Original work published in French in 1971 by Editions Gallimard). Foucault, M. (1977). Discipline and Punish: The Birth of the Prison. (A. Sheridan (Trans)). New York: Random House Inc. (Original work published in French in 1975 by Editions Gallimard). Foucault, M. (1980). Power/Knowledge Selected Interviews and Other Writings (C.Gordon, Marshall, L., Mepham, J., & Soper, K. (Trans)). (Ed C.Gordon). New York: Random House Inc. (Original work published in French in 1972 by The Harvester Press Ltd). Foucault, M. (1991). Governmentality. In G. Burchell. C. Gordon and P. Miller (Eds), The Foucault Effect Studies in Governmentality with Two Lectures by and an Interview with Michel Foucault (pp87-104).chicago: The University of Chicago Press. Gill, L., McCaffrey, N., Caameron, I.D., Ratcliffe, Gresham, M., (2017). Comsumer Directed Care in Australia: early perceptions and experiences of staff, client and carers. Health &Social Care in the Community, pp , 25:2. Doi: /hsc Kendig, H., Mealing, N., Carr, R., Lugic, S., Byles, J., & Jorm, L. (2012). Assessing patterns of home and community care service use and client profiles in Australia: A cluster analysis approach using linked data. Health & Social Care in the Community, 20(4), doi: /j x King, N. & Horrocks, C. (2010). Interviews in Qualitative Research. Thousand Oaks, California: Sage Publications. Reisigi, M. & Wodak, R. (2014). The Discourse-Historical Approach (DHA). In R. Wodak & M. Meyer (Eds.), Methods of Critical Discourse Analysis (pp ). Thousand Oaks, California: Sage Publications.

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