20 April 2017 Single Aged Care Quality Framework About the Victorian Healthcare Association The Victorian Healthcare Association (VHA) welcomes the opportunity to contribute to the Single Quality Framework Draft Aged Care Quality Standards Consultation (the standards) and the Single Quality Framework Options for Assessing Performance against Quality Standards. The VHA agrees to this submission being treated as a public document and being cited in any reports that may result from this consultation process. The VHA is a not-for-profit peak body supporting Victoria s public health services to deliver quality care. We represent public sector providers of residential aged care, Home Care Packages, the Commonwealth Home Support Programme (CHSP), Multi-Purpose Services, and Bush Nursing Services. Public sector aged care in Victoria In Victoria, unlike in other states and territories, a significant proportion of aged care is delivered by public sector health providers, comprising: 24 per cent of residential aged care organisations and 11 per cent of places; 1 17 per cent of service outlets and provides 20 per cent of operational Home Care Packages 2 with the proportion of places delivered by public sector providers increasing as remoteness increases; and 45 per cent of Home and Community Care (HACC) now CHSP - funded services and representing 28 per cent of funded HACC/CHSP organisations, 75 per cent of which are located in rural and regional areas. 3 Introduction The public sector holds a strong ethos of ensuring high quality care for consumers. Our services offer holistic care and support to often complex consumers with high care needs. As such we act as a safety net for Victorians who may otherwise struggle to access aged care services that meet their needs. As public sector aged care is typically co-located with other health services, public sector providers of aged care in Victoria also operate under requirements that go above and beyond existing minimum aged care accreditation requirements. For example, public sector providers have legislated nurse to patient ratios and are assessed for clinical 1 AIHW 2016, Residential Aged Care and Home Care 2014-15, Australian Institute of Health and Welfare 2016, Canberra, http://www.aihw.gov.au/aged-care/residential-and-home-care-2014-15/ 2 AIHW 2016 3 State Government of Victoria 2014, Who gets HACC 2010-2011, A Statistical Overview of the Home and Community Care Program in Victoria in 2010-2011, Department of Health, Victoria. VHA Submission - Page 1
quality under a range of advanced standards including but not limited to the National Safety and Quality Health Service (NSQHS) Standards. Given this unique positioning, the main concerns for public sector providers as they relate aged care accreditation reform are: ensuring the delivery of high quality care across the whole aged care sector inclusive of public, private and not for profit providers; and minimising unnecessary process burden for public sector providers of aged care who are already operating under a higher standard of regulation and accreditation. Minimising process burden public sector The VHA supports the intent of the Single Aged Care Quality Framework (the Framework) to simplify regulation and reduce red tape for aged care providers. The VHA also considers that accreditation against quality standards is a crucial element of ensuring the high quality of government funded services. However, all accreditation should result in clear quality and safety benefits to service users and must not be designed and implemented in a way that imposes unnecessary administrative burden or waste of public funds. As many of Victoria s health services and community health organisations provide multiple services across the health, aged, disability and community care spectrum, they are currently required to achieve accreditation against multiple, often overlapping, standards. In particular, assessment of areas such as corporate policy, governance and management processes are often repeated in each accreditation. This situation represents a significant resource and cost impost on health services which the VHA considers is likely to be compounded as a result of the subjective and vague nature of the draft standards. Assessing the level of compliance with the standards is inextricably linked to the clarity around key terms such as quality and safety. In addition the organisation requirements under the draft standards contain language that the VHA considers is ambiguous. By way of example, terms such as maximise and optimise need to be well-defined so that each requirement can be reliably assessed. In the absence of clear definitions, the draft standards are inherently unmeasurable. The VHA is concerned that the increase of subjectivity required to perform accreditation with a tool that does not include key definitions and explicit language is likely to increase process burden, and inconsistency between assessment outcomes resulting in an increase in burdensome red tape. Furthermore, the VHA considers that the options outlined in the Single Quality Framework Options for Assessing Performance against Quality Standards consultation paper do not go far enough in reducing process burden for health services and influencing the nature of assessment needed in relation to aged care. The VHA considers that for health services delivering aged care the Commonwealth should implement mutual recognition of accreditation standards. As highlighted above, VHA Submission - Page 2
health services are currently being assessed multiple times against similar core standards under the various accreditation schemes. The introduction of mutual recognition in the Commonwealth aged care accreditation process would recognise the currently accredited status of health services for similar core standards such as corporate policy or management processes. This would significantly reduce the current regulatory impost, overlap and duplication in the accreditation system for those organisations that provide a range services and are already accredited against similar standards under a range of other accreditation schemes such as the NSQHS Standards. Ensuring quality whole sector Victoria s public sector residential aged care services are required to staff at designated nurse to resident ratios. 4 Public sector providers of aged care deliver nurse-led, integrated, high quality care and support with a focus on consumer experience, health and wellbeing. These arrangements in effect see the public sector operating under increased levels of clinical oversight than those expected under the current and future aged care standards. However, public sector providers of aged care have an ethos of delivering quality care and believe the standards for older people should be strengthened over time and don t want to see a lowering in quality and safety levels. In this context, the VHA considers that the draft standards do not strengthen the current clinical quality framework across the sector. The VHA is particularly concerned that the standards are silent on key clinical and quality risk areas including: Restraint A restraint-free environment is the recommended standard of residential aged care. While aged care providers monitor the proportion of use of physical restraints through the voluntary/optional National Quality Indicator Programme, the draft standards do not address restraint. Providers should have regular processes in place for checking and reviewing the ongoing need for restraint which should be monitored through the compliance process and included in the national standards. Elder abuse Commonwealth changes are under way which intend to improve safeguards against abuse for older people in receipt of aged care. The VHA believes that providers of aged care have a responsibility to safeguard the rights, dignity and independence of older people. Providers are required to report to the Commonwealth Department of Health and the police. However, a gap exists in the draft standards as they relate to compliance monitoring of instances of elder abuse. The standards are silent on the processes required to ensure such monitoring is taking place, for example the presence of an assault register. Polypharmacy 4 In 2015, the Victorian Government passed the Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Bill 2015 which enshrined nurse to patient ratios in law. VHA Submission - Page 3
Research has found that residents with polypharmacy taking nine or more regular medications have an 89 per cent higher risk of hospitalisation and utilise a higher number of hospital days. 5 The findings highlight the importance of regular medication review and if necessary, strategies to discontinue or de-prescribe medicines that are unnecessary or no longer consistent with a resident s goals of care. The standards should play a role in embedding practices that minimise risks associated with polypharmacy. Advance care planning and end of life planning The elevated role of individuals in managing their care is positive. The management of care at the end of an individual s life and recognition of their preferences, values and rights is a crucial expression of consumer centred care. The VHA welcomes the addition of advance care planning and end of life planning in the draft standards ensuring older Australians receive the appropriate pain relief and have genuine choice. However, the standards need to articulate an expectation around the clinical review processes in place that is subject to assessment. Additionally, while still in early stages, it is important to be cognisant of the development in Victoria of the voluntary assisted dying legislation. If this is passed, there may be additional considerations for Victorian aged care providers. Avoidable hospital admissions As well as leading to poorer outcome for older people we see a risk that a lowering in quality of clinical care can lead to an increase in unnecessary hospitalisations of older people. Significantly for the public health sector, the prevalence of avoidable hospital transfers from non-public sector residential aged care facilities continues to increase. The negative impacts of transferring older people living in residential aged care to hospital emergency departments are well known and include increased risk of delirium and other iatrogenic events such as falls, medication errors, pressure injuries, deconditioning and death. 6 The benefits of avoiding unnecessary transfers to emergency departments, for both the resident and the healthcare system include: reduced morbidity and mortality of older people; reduction in costs associated with emergency transport; and increased ability of emergency department staff to more effectively and efficiently manage emergency patients. 7 The VHA considers that the Government should take the lead and work with state and territory governments to develop and implement a strategy to reduce avoidable hospital admissions of consumers of both residential and home based aged care. 5 Use of multiple medication strongly associated with hospitalization from aged care facilities, Monash University, available at: http://www.monash.edu/pharm/about/news/2017-news-archive/use-of-multiplemedications-strongly-associated-with-hospitalisations-from-aged-care-facilities 6 Hulick et al. 2016, Emergency Department Transfers and Hospital Admissions from Residential Aged Care Facilities: A Controlled Pre-Post Design Study, Bio Med Central Geriatrics, vol. 16, no. 102, http://web.a.ebscohost.com.ezproxy-b.deakin.edu.au/ehost/pdfviewer/pdfviewer?sid=ae14f8b4-9d34-4dc3-8252-62731e7fc4b5%40sessionmgr4008&vid=0&hid=4112 7 Ibid VHA Submission - Page 4
This strategy should aim to improve the health and wellbeing outcomes of older Australians and ensure they are receiving the care they need in their preferred setting. It should also consider requirements for a level of clinical expertise and quality of care in residential aged care facilities to reduce the avoidable transfers of residents to emergency departments (particularly in the private and not for profit sector) in order to reduce the burden on the public health sector and improve health outcomes for older people. The VHA considers that the standards play an important role in this overall strategy in ensuring high quality clinical care across the sector and for assessing provider capacity to meet the clinical needs of consumers and/or residents. Transition arrangements Irrespective of the outcomes of this consultation, the implementation of the new quality framework represents a change for aged care providers. Particularly for home and community care organisations, the new quality framework will likely entail an increase in the depth of the assessment process. Providers will require support and time to understand and fully implement the new framework. The VHA therefore considers that the expected implementation date of 1 July 2018 is unrealistic and should be extended in order to ensure aged care providers can successfully implement the standards. The VHA recommends that all policy changes - including the recommendations within this document be coupled with comprehensive transition support, thorough communication plans and adequate timeframes. Conclusion While public sector aged care providers deliver quality care above and beyond the existing minimum accreditation requirements, our members feel strongly that the new framework must ensure quality and safety across the broader sector, while also minimising process burden and red tape for the public sector. These outcomes can be achieved: through the implementation of mutual recognition of accreditation standards to remove unnecessary duplication and reduce regulatory burden for health services that provide a range of funded services; and through a strengthening of the quality framework. VHA Submission - Page 5
Further information For further information, contact: Tom Symondson Chief Executive Officer Ali Georgalas Aged Care Project Officer ali.georgalas@ 03 9094 7724 VHA Submission - Page 6