Southern Fleurieu Positive Ageing Taskforce Strategic … Fleurieu... · Lisa Sparrow November 2009 Southern Fleurieu Positive Ageing Taskforce Strategic Plan 2009 - 2018 Background

Lisa Sparrow

November 2009

Southern Fleurieu Positive Ageing Taskforce

Strategic Plan 2009 - 2018

Background Paper 1: Environmental Scan

Southern Fleurieu Positive Ageing Taskforce 2 Strategic Plan Background Paper 1: Environmental Scan

Contents Influences on Service Demand ........................................................................................... 3 Workforce ........................................................................................................................... 4 Community Care Reform.................................................................................................... 7 Service Delivery.................................................................................................................. 8 Approaches to Care........................................................................................................... 13 Technology ....................................................................................................................... 14 Health and Aged Care Integration .................................................................................... 15 Healthy Ageing ................................................................................................................. 16 Health Reform................................................................................................................... 17 Housing ............................................................................................................................. 17 Social Planning ................................................................................................................. 20 Rural and Remoteness....................................................................................................... 20 Local economic impact and opportunities ........................................................................ 22


Influences on Service Demand Population ageing, increasing consumer expectations, lower levels of informal care and the increasing complexity and expectations of care will have significant impact on the level and nature of service demand. In the next four decades, the older Australian population will grow twice as fast as the total population and the number of older people will almost triple. The rate of growth of the older population across the Fleurieu will be even higher in the next ten years than it has been in the past 10 years. Between 2001 and 2011 the population aged 70+ is expected to increase by around 47%. Between 2011 and 2021 it is expected to increase by 65% (Table 1).

Table 1: 70 years and older population by year

4,898

6,358

7,184

9,161

11,830

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

2001 2006 2011 2016 2021

Year

Popu

latio

n

Ageing of particular sections of the population also has the potential to place additional pressure on the aged care system. People from culturally and linguistically diverse (CALD) backgrounds will form a large proportion of older Australians We will also see the affects of significant social changes on the lifestyles and care of older people. Trends toward delayed marriage and childbirth; divorce, second and subsequent marriages are resulting in a vast array of family structures and financial circumstances that will impact on retirement incomes, housing, other lifestyle issues and the balance of formal and informal care. Over the years, the shift from institutional care to care in the community has greatly increased reliance on informal care provided by family and friends. At present, unpaid family and informal care accounts for 74 per cent


of the support provided to older people and persons with a disability1. With more women working and people working longer it is expected there will be smaller numbers of people able and willing to provide informal care. The National Centre for Social and Economic Modelling estimated that the ratio of the number of people likely to provide care to the number of people anticipated to require care was 2.5 in 2000. Over the next 50 years it is expected the ratio will fall below one.2 These key drivers might result in a three to five times increase in demand for aged care services over the next 40 years.3

Not only will there be an increase in number of people seeking services, but it is likely that people will have more complex needs and demand a higher level and quality of service. A report by Allen Consulting Group (2007)4 indicates that the prevalence of dementia among older people will increase by 22 per cent between 2002-03 and 2042-43.56 This means a greater proportion of community care clients will have very complex needs, raising the average cost per client of delivering community care. The desire of older people for independence, quality of life, control over personal matters, and the opportunity to continue to contribute and participate in society, accompanied by increasing client contributions to care will continue to drive consumer expectations. Consumers will increasingly demand services that meet their individual needs. Provision of more flexible responsive services is then likely to reinforce increasing consumer expectations. Furthermore, as client outcomes improve, non–clients in the target population may become more likely to seek care services, and to be more demanding about their quality.5

Workforce . The Australian workforce pool is shrinking with the ageing of the population. Concurrently, the health and aged care workforce is ageing and is suffering significant losses to other employment types and overseas as a result of global shortages and the high standard of Australian qualifications. The intentions of the workforce are also affecting supply with many employees seeking fewer hours of work. A poor distribution of some skills is the result of inconsistent access to university courses across states and the practice of recruiting health professionals from overseas is unsustainable in an

1 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne. 2 The Parliament of the Commonwealth of Australia Who Cares ...? Report on the inquiry into better support for carers. House of Representatives, Standing Committee on Family, Community, Housing and Youth April 2009 Canberra 3 Hogan, W P. 2004, Review of Pricing Arrangements in Residential Aged Care Commonwealth of Australia 4 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne. 5 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne.


environment of international shortages.6 Future workers will also need to be more highly skilled, to meet the more complex needs of clients, such as those with dementia.7

Current estimates indicate significant shortages either currently exist or will develop in the next 10 years in most fields. Population projections and current staffing ratio’s indicate that within the next 13 to 14 years the Fleurieu region will require around 20 GP’s, 400 personal care workers, 60 enrolled nurses and 60 registered nurses to cater to population growth and ageing, over and above workforce requirements resulting from natural attrition8. There are a number of factors that are expected to escalate demand for health workforce: The ageing population, environmental and lifestyle factors are expected to increase the burden of disease in our population. New technologies, pharmaceuticals and treatments continue to increase potential within the health and care system and therefore expectations within the community. Policy directions that aim to manage demand for health and aged care services will, in themselves, increase and change demands on the workforce. For example deinstitutionalisation, out of hospital and ageing in place strategies will increase demand for community care staff and specialties and decrease in reliance on Registered Nurses will potentially increase demand for Enrolled Nurses. In the context of population growth and ageing in the Fleurieu, it is necessary to understand that the potential to grow aged care services and to meet the needs of this population is dependent on an available and skilled workforce. Regions will be competing for limited human resources and employers will need to be savvy about their recruitment and retention strategies. There still exist a wide range of opportunities for regional collaboration on workforce initiatives. The development of new healthcare roles, a regional response to attracting workers, improving the image of aged care, provision of more training, development and peer support and attracting tertiary training opportunities to the local area could help ease the strain. Sharper targeting of supply to demand, strategic collaboration to share staff-related resources and better linkages and coordination between the industry, training providers and potential workforce supply will better direct the limited resources we have9. Improving access to management training within the local industry could address retention as poor management is often cited as a major reason for staff leaving10. Creativity on behalf of the industry locally might see the development of loyalty projects such as discounts at local businesses. The semi-retired and retired workforce along with volunteers offer an unrealized workforce opportunity that requires further investigation.

6 National Health Workforce Taskforce, Health Workforce in Australia and Factors for April 2009 7 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne. 8 Fleurieu Regional Development, Recruitment and retention in the Fleurieu health and aged care sector- Issues and Opportunities – December 2008 9 Home and Community Care South Australia, 2006 Workforce Planning Project: ‘HACC is a sector investing in its workforce’, Office for the Ageing Department for Families and Communities, Government of South Australia Julie Sloan Management Pty. Ltd. with assistance from Dr. Kate Barnett June 2006. 10 ACSAWorkforce Framework for Action. Vision – Quality care for older people from a well led, committed and supported workforce (2007-2008 strategic priority)


Workforce redesign Realignment or extension of existing workforce roles or scope of practice, the creation of new or assistant roles and reorganising work to minimise duplication of effort and make best use of available staff may be necessary to make optimal use of workforce skills and ensure the best outcomes for clients11. Greater use of the vocational education and training qualified health workers would enable tertiary trained health professionals to work at their optimal level. This is particularly evident for the nursing profession where better use could be made of all the existing nursing roles (nursing assistants, enrolled nurses, registered nurses, midwives and nurse practitioners). Allocation of tasks that could be more sensibly and cost effectively provided by nurse practitioners, and physician assistants may increase accessibility of General Practitioners to older people and aged care facilities. The National Health and Hospitals Reform Commission12 recommend that funding be provided for use by residential aged care providers to make arrangements with primary health care providers and geriatricians to provide visiting sessional and on-call medical care to residents of aged care homes. If this recommendation comes to fruition, it may provide the sector with greater flexibility to show innovation in this area.

Education and Training The National Health and Hospitals Reform Commission recommended that a higher proportion of new health professional educational undergraduate and postgraduate places across all disciplines be allocated to remote and rural regional centres, where possible in a multidisciplinary facility built on models such as clinical schools or university departments of Rural Health13. The new Rural Clinical School in Victor Harbor provides untold opportunities to work with Flinders University to improve the delivery of health training in the Fleurieu.

Research A further recommendation of the Health and Hospitals Reform Commission was to build health service, clinical and workforce capability through a remote and rural health research program. The Health Services Framework for Older People14 provides a commitment from SA Health to increase the focus on ageing research by involving each Regional Older People’s Health Service in research to improve health outcomes for older people in conjunction with Universities and research foundations.

11 National Health Workforce Taskforce, Workforce Innovation and Reform: Caring for older Australians, December 2008 12 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission 13 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission 14 Health Service Framework for Older People 2009–2016: Improving Health & Wellbeing Together / South Australia, May 2009, Dept. of Health, Statewide Service Strategy Division.


An increased local presence from universities including local conduct of research activities in health and aged care fields will provide a greater diversity of professional development and growth opportunities that will significantly compliment the regions capacity to attract and retain quality health professionals. The ageing population, proximity to Adelaide and the beginnings we have with the development of the Rural Clinical School provide a platform for such development15.

Community Care Reform For some time stakeholders, including consumers, carers, services providers and Government, have agreed on the need for reform of Australia’s community care service system. The Government then undertook a range of reviews including The Way Forward and the Subsidies and Services Review. These attempts have been commendable but they have moved slowly and seen little result in their 5 years. Some activity at the local level has been “put on the back burner” awaiting direction through Government Reform Agenda that has not come to fruition.

The Way Forward In 2002 a review of community care programs was initiated by the Commonwealth Government to identify strategies that would simplify and streamline the administration and delivery of community care services. The aim was to make it easier for people to access the care they need and to align community care programs to ensure an appropriate continuum of care in the community, that is of high quality, affordable and accessible. The resulting recommendations outlined in “A New Strategy for Community Care - The Way Forward” involve agreed and consistent access, assessment processes, eligibility criteria, consistent accountability and quality arrangements, fees, planning and information management and targeting strategies. Access points o Access point demonstration projects are currently being undertaken in the Western

Metropolitan and Wakefield areas. Evaluation was completed by KPMG in August 2009. The industry is awaiting government deliberations to give the project direction for the future particularly, how the roll-out of Access Points will proceed. The SA Access Points "Access2HomeCare" are currently putting considerable effort into getting the supporting infrastructure, particularly IT, strengthened & modernised to be able to support the Access Point functions and be ready for the roll-out.

Eligibility and Assessment: o Two tools have been developed to assist with eligibility and assessment. These are

the ACCNA-R (frail aged and disabled) and CENA-R (Carers). These tools were trialled in 2007 and continue to be refined.

Financial and quality reporting and accountability, planning and information management o A common set of standards have been endorsed.

15 Fleurieu Regional Development, Recruitment and retention in the Fleurieu health and aged care sector - Issues and Opportunities, December 2008


o The implementation of a standard quality reporting process for all of community care (HACC, NRCP, CACP, EACH & EACH-D etc) using a set of common standards is progressing. The draft report into the pilot was to be finalized in October 2009.

o A National Planning Framework for Community Care is currently being developed with the aim of improving the coordination and allocation of funding and services across programs and regions.

o A feasibility study has been conducted into an electronic Continuous Client Record and is currently being considered.

Health and Hospitals Reform Commission16

Depending on the momentum it gains, the Health and Hospitals Reform Commission report could have significant impact on aged care. Some recommendations overlap with initiatives of The Way Forward including recommendations for streamlined, consistent assessment for eligibility (Access Points?) and developing new assessment tools for assessing peoples care needs (ACCNA-R and CENA-R?). The interesting addition involves consideration of ACAT at a level not previously considered in The Way Forward. The Commission recommendations involve transferring the Aged Care Assessment Teams to Commonwealth Government responsibility and integrating assessment for Home and Community Care Services with more rigorous assessment for higher levels of community and residential care (ACCR). Recommendations also include a more flexible range of care subsidies for people receiving community care packages, determined in a way that is compatible with care subsidies for residential care – an outcome which appears to be likely.

Service Delivery Targeting With increasing demand for aged care and increasingly limited resources, the allocation of resources will continue to be a challenge for service providers. Community Aged Care Packages (CACPs) and Extended Aged Care at Home Packages (EACH) have developed in a way that provides clear parameters around program eligibility and capabilities and the number of clients that can be supported. Responsibility for determining eligibility for CACP and EACH is removed from service providers (requirement for ACAT). Program guidelines clearly set out the range of services that can be provided, services are funded on a per client basis (although the allocation of hours to individuals has some flexibility) and there is a tentative agreement by the industry with respect to how this funding interprets to the number of hours of support per week. Clients entering CACP and EACH packages are clear about the limitations of the service and at what point alternative support will need to be sought.

16 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission


HACC services on the other hand are not so clearly defined. As a result decisions about allocation of resources to individuals continue to plague service providers. Should finite resources be allocated to the individual with complex needs already receiving significant support or to the individual requiring initial and limited support and reassurance in order to maintain their independence and confidence? This ambiguity is resulting in a lack of community confidence in the service system. According to Anna Howe17, the answer to the targeting debate is in striking a balance in the number of clients to be served at different levels of service use and the share of resources to be allocated to those levels of use supported by systems and processes to achieve them. Limits, as a ceiling to service should be set with availability, appropriateness and cost of alternative models of care in mind. Acceptance of such limits would be enhanced by having limits clearly set out, and should facilitate appropriate allocation of clients between types of care. Information about discharge criteria should be provided at admission and reinforced throughout service delivery, along with timely and realistic information about other care and the circumstances in which this may be appropriate. This will assist in ensuring that clients have realistic expectations about the capacity of the service and experiences a more timely, appropriate and comfortable transition to alternative care. While this makes perfect sense in theory, there are a number of limitations to this approach. With increasing cost of care (wages, reporting and accountability, travel etc) and very limited increases in government funding, the number of hours of care provided by CACP and EACH have decreased significantly over time. Over the past 20 years the number of hours for an average CACP has reduced from 8 per week to just 5. Furthermore, waiting lists for CACP and then for EACH have blown out creating a bottleneck at each level of care. More recent work by Anna Howe suggests that service providers need to define the critical difference between levels of service in order to control and facilitate transition between services. In the situation where far greater numbers of clients are being referred for CACPs than are likely to receive them, it is perhaps increasingly inevitable that HACC services and CACP’s will overlap with respect to the number of hours of service they offer. If this is so, there is a need for greater clarity about the type of clients who will benefit from CACP’s and the nature of these benefits as distinct from the benefits they would otherwise receive from alternative services.

17 National Ageing Research Institute & Bundoora Extended Care Centre. 1999. Targeting in the Home and Community Care Program. Aged and Community Care Services Development and Evaluation Reports. No. 37. Department of Health and Aged Care, Canberra


Funding for aged care The proportion of people receiving a full age pension will fall from around two thirds of all Age Pensioners to one third by 205018. Baby boomers will have increased access to personal finances in the form of superannuation and commitment to retirement saving and greater openness to concepts such as reverse mortgages. However the gap between those with money and those without will continue to increase. In 2004 the net worth of 45-64 year olds was $68300 for the poorest 25% and $910400 for the wealthiest 25% of the population. The combination of population ageing, reduced access to informal care, increasing expectations of older people is likely result in a need for substantial increases in expenditure on the range of health and aged care services. As a result, Australian Government spending in the areas of health and aged care could double as a proportion of GDP if current policies are retained19. Over coming years, perceptions of what governments should fund and what is an accepted expectation for private financing (such as home cleaning) may change. Baby Boomers are more likely to pay for the quality and level of care they want through the private system and the amount of total aged care being privately financed could increase significantly.

Increasing Care in the Community The proportion of funds allocated to community care has increased over past years, however the majority of government funding, about 75 per cent, is still allocated to residential aged care. In February 2007, the Australian Government announced additional funding for CACPs and EACH packages, which it said would meet an increased target of 25 community care places for every 1000 people aged 70 years and over. In an environment where the costs of providing care are increasing, policy responses that divert patients from primary or acute care to other, less expensive forms of care — such as community care — will be important. The Australian Government has recognised both the financial and social benefits of moving away from institution-based primary and aged care systems, encouraging people to remain at home and utilise community care services rather than entering residential aged care. Based on current trends and policy it is likely that there will be a shift in demand away from low-level residential care and towards community care over the next 10 to 15 years — in addition to the projected growth coming from population ageing20.

18 National Strategy for an Ageing Australia An Older Australia, Challenges and Opportunities for all, Commonwealth of Australia 2001 19 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne 20 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne


This trend is already being noticed in the new aged care funding instrument (ACFI). The implementation of this funding tool in residential aged care has seen a reduction in government funding for lower levels of care to the point where individuals previously assessed as level 7 (and some level 6) under the Resident Classification Scale, no longer attract a government subsidy for care. This generally means it is unviable for aged care providers to admit individuals requiring this level of care. While reduction in access to residential care has been accompanied by an increase in community care, it remains to be seen what other gaps arise in the aged care system as a result of this transition.

Consumer Directed Care While Consumer Directed Care (CDC) has been in place overseas and in the disability sector in Australia since 1990 and has been favourably considered by the industry for several years, it is now gaining support through a number of government enquiries and reports. The ‘Who Cares’21 report released early in 2009 recommends ‘that the Minister for Families, Housing, Community Services and Indigenous Affairs and the Minister for Health and Ageing undertake pilot studies to test the potential for the Australian Government’s funding for carer respite and in-home assistance to be re-allocated directly to carers through ‘individualised funding programs’ (also known as ‘consumer directed care’ and ‘self managed funding’). The Health and Hospitals Reform Commission22 recommend that once assessment processes, care subsidies and user payments are aligned across community care packages and residential care, older people should be given greater scope to choose for themselves between using their care subsidy for community or for residential care. They also recommend that government subsidies for aged care should be more directly linked to people rather than places and that people supported to receive care in the community should be given the option to determine how the resources allocated for their care and support are used. Consumer Directed Care is about consumer choice and control, but it has also been proposed as a cost-effective option for expanding home-based care provision. CDC models range from direct payment or ‘cashed out’ programs that give actual dollars or vouchers directly to the ‘consumer’ and their family (or other nominee), enabling the direct purchase in the public market of care services (which may include purchases from existing aged care providers), to models that direct funds through existing community packaged care providers, offering consumers both a choice of provider and a choice of services from the chosen community care provider. A ‘more radical’ experiment in CDC could see eligible recipients and their carers aggregating their community care and

21 The Parliament of the Commonwealth of Australia Who Cares ...? Report on the inquiry into better support for Carers. House of Representatives, Standing Committee on Family, Community, Housing and Youth April 2009 Canberra 22 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission


residential care subsidies to pay for congregate ‘in home’ care. CDC might also see clients being invited to choose between residential and home-based care. If subsidies were allocated to the recipient rather than to the service, this would allow more choice as to whether care should be received in a residential facility or at home. ACATs would assess for the level of care rather than for location of care23. Viewed as a set of options along a continuum rather than as a prescribed framework or model for care delivery, CDC may provide positive benefits and opportunities for both providers and consumers of community aged care. Experience to date, internationally and in the disability sector, indicates that many consumers, when offered the choice, exercise that option by choosing an established provider to manage their care. Benefits include: o Individualised services that enhance choice (how, when, where, and notably by

whom, they will receive care). o Aged care cost control / minimization o Incentive to encourage informal carers o the belief that allowing clients to enlist the support of relatives or other informal

caregivers will help overcome the problems in the community care sector to attract and retain community care workers

Issues and concerns include: o Ability or willingness of older people & their families to take on the administrative

burden & responsibility for managing their own care o The issue of trust when consumers have public cash in hand o Control over quality of care o Accuracy of the assumption for government that if a client plays a greater role in their

own care provision, this will reduce the cost of delivering some service types’ o The need for public provision, at substantial cost, of brokerage services, financial and

employment advisers or negotiators, counselling services to assist individual consumers and their families identify required services, quality assurance monitors, auditors etc., most of which are more easily provided through existing packaged aged care providers.

o potential impact it would have on the care delivery system o consumer choice is already integrated to a considerable extent into community care

delivery in Australia without the specific labeling of CDC o Capacity of the community care market to offer the services individuals wish to

purchase (with any greater flexibility than current options). o Increased and different demands CDC places on families and carers o unknown potential for new demand from eligible (but previously self-sufficient) users o concern that CDC will be rolled out as a cost cutting exercise on the part of

governments rather than as a consumer empowerment exercise

23 Consumer Directed Care in Community Care, Discussion paper for ACSA policy development. November 2008


o possible shift in responsibility for outcomes of community care programs from government and providers to clients and carers, and an undermining of service infrastructure that may not be replaced with a care market in which consumers with small amounts of cash can find high quality bargains

o Increased competition and potential that competition may undermine collaboration and coordination between services.

Approaches to Care Concepts around individualised services, holistic assessment, supporting not supplanting informal care and encouraging consumer participation, choice and decision making have been central to aged care now for many years. However the practice of these concepts has been refined and improved.

Better Practice Project The Better Practice Project promotes a comprehensive philosophical approach endorsed by Office for the Ageing in South Australia and funded through the Home and Community Care Program. The approach supports the key concepts of empowerment, choice, participation, access and equity; a focus on the individual, valued social roles, relationships and informal supports; maintaining and developing skills and independence and acknowledging personal strengths.

Independence model of care A recent trend in community care provision is to focus on promoting and enhancing the independence of clients, rather than the traditional paradigm of responding to their dependence needs. This ‘independence model of care’ has been adopted by some jurisdictions and individual providers, but overall is not widespread24.

Early intervention, prevention and re-ablement At the core of the independence model is a commitment to early intervention and prevention. The idea of the independence model is not to replace services that are directed at ‘support and maintenance’, but to provide other services earlier to promote clients’ independence, so as to reduce the need for ongoing support in the future. This would be highly valued by clients who want to receive assistance before they reach a crisis point. It may also help to contain the future cost of community care, by reducing the number of clients with ongoing care needs, and possibly decreasing the average intensity of service provision per client25. Re-ablement was a key feature of the 2008 HACC forum in Melbourne. It is defined as services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living. Common principles and features of re-ablement services include helping people ‘to do’ rather than ‘doing to

24 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne. 25 The Allen Consulting Group 2007, The Future of Community Care, Report to the Community Care Coalition, Melbourne.


or for’ people and outcome focus with defined maximum duration. A UK trial26 showed that 88% of individuals in a re-ablement service had decreased or discontinued formal care compared with 18% in a matched service users control group.

Technology Technology has the potential to play a significant part in responding to the growing number of older people, increasing care costs, the desire for independence, the need to support those living in rural and remote areas and the challenges of managing increasingly complex needs at home. Telehealth technologies can provide the tools to help older people and their health providers monitor and manage health and to help care coordinators to organise, dispatch and track the delivery of needed care and services. A study of 281 congestive heart failure patients who received telehomecare found that they experienced a 60 percent reduction in hospital admissions, a 66 percent decline in emergency room visits and a 59 percent reduction in pharmacy utilization. In contrast, the control group experienced increases in all of these areas. Electronic health records serve as a repository of information which an older consumer could choose to share with all caregivers and health care providers, thus ensuring that each member of the care team has access to accurate, up-to-date and comprehensive information about the consumer’s medical history and current health status. Safety technologies can help prevent falls by notifying caregivers or providing high-tech assistance with walking and balance. Others might detect when a person has fallen and send alerts to caregivers who could provide quick assistance. Still others might turn off stove burners left idle, monitor water temperature to prevent scalding or detect smoke or other home hazards. Technologies that provide social connectedness might include computer-based products designed to assess cognitive decline or help older users enhance memory, entertainment systems that offer both physical and mental stimulation and highly complex systems that provide important reminders to older people with memory loss. In addition, cell phones, video telephones and communications software could be adapted for older people so they are easier to use and, therefore, more useful in reducing isolation among this population27.

26 Care Services Efficiency Delivery, Gerald Pilkington HomeCare Re-ablement – The UK Experience, HACC National Forum promoting independence, Melbourne 21st Feburary 2008 27 State of Technology in Aging Services: Summary, Majd Alwan, Ph.D., Center for Aging Services Technologies (CAST) American Association of Homes and Services for the Aging (AAHSA) and Jeremy Nobel, M.D., M.P.H, Harvard School of Public Health Summary Report Submitted to: Blue Shield of California Foundation March 2008


The Health and Hospitals Reform Commission28 acknowledge that safety, efficiency and effectiveness of care for older people in residential and community settings can be assisted by better and more innovative use of technology and communication. Their report recommends: o supporting older people, and their carers, with the person’s consent, to activate and

access their own person-controlled electronic health record; o improved access to e-health, online and telephonic health advice for older people and

their carers and home and personal security technology; and o increased use of electronic clinical records and e-health enablers in aged care homes,

including capacity for electronic prescribing by attending medical and other credentialed practitioners, and providing a financial incentive for electronic transfer of clinical data between services and settings (general practitioners, hospital and aged care), subject to patient consent.

Health and Aged Care Integration The Aged Care System is increasingly being viewed as the panacea for reducing hospitalisation and length of hospital stays. The Health and Hospital Reform Commission listed greater choice in aged care services and advice and outreach to residential care facilities ask key components in reducing avoidable hospitalisations and enabling more effective discharge to the best care environment for patients29. The SA Palliative Care Services Plan30 projects a significant increase in demand for end of life care and outlines an expectation that a significant portion of this demand will be managed by GP’s, community health, community and residential aged care providers. The concept of rehabilitation in aged care is (re)gaining favour. As people live longer and with advances in medicine it is expected that individuals will live longer with disability and will be more likely to benefit from rehabilitation. Evidence indicates that perhaps as much as half of the functional decline associated with ageing is the result of disuse and can be reversed by exercise aimed at increasing the fitness of older people. Individuals will come out of hospital with the capacity to get better and it will be important that the health system has a strong focus on restorative and preventative measures. The demand for rehabilitation and other services following an acute episode will certainly increase.31

28 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission 29 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission 30 Palliative Care Services Plan 2009-2016, SA Health May 2009 31 National Strategy for an Ageing Australia An Older Australia, Challenges and Opportunities for all, Commonwealth of Australia 2001


A range of interventions have emerged over the past several years, which bridge the gap between acute and aged care32. Transition care programs target older people at the conclusion of a hospital episode who require more time and support in a non hospital environment to complete their restorative process and optimise their functional capacity while assisting them and their family or carer to make long-term care arrangements. The aim is to refrain from placing individuals in inappropriately high levels of care due to rehabilitation not being optimized. Aged Care Services in Emergency provide expert aged care multidisciplinary assessment and management within the emergency department (ED). Their focus is on facilitating appropriate admission to hospital from ED or safe discharge home with appropriate care plans in place. Acute to aged-related care services work in close conjunction with inpatient health care teams to facilitate timely referral, assessment and ACAT approval and the provision of information to assist older patients and their carers/families to negotiate the entry process to appropriate residential or community-based care. ‘Hospital in the Nursing home’ involves specialist advanced practice nurses coordinating advanced nursing care for clients in the nursing home which is linked to the emergency departments of acute hospitals. Metro Home Link provides hospital avoidance and early discharge packages. To date these have been a range of trials or projects. More recently we have seen a start to more standardisation and moves towards some programs being more uniformly available.

Healthy Ageing While people are expected to experience more years of good health, a significant proportion of older people will be managing chronic conditions such as diabetes and heart disease. Co-morbidity (the existence of more than one health condition) is expected to increase with increasing life expectancy. As health care and technology improve, there is greater capacity for these conditions to be managed well and for individuals to maintain good health and independence despite them. However physical impairment, reduction in quality of life, increasing social isolation, mental disorders and depression will still be experienced with the increasing disability associated with ageing and chronic disease. One of the four main directions of the National Strategy for an Ageing Australia33 is Healthy Ageing. Improving nutrition, maintaining (or regaining) continence and managing incontinence, early detection and management of sensory loss, and reducing risk of medication misadventure are just some of the other things that can enhance healthy ageing. The Australian Longitudinal Study on Ageing34 confirmed that that

32 National Health Workforce Taskforce Workforce Innovation and Reform: Caring for older Australians, December 2008 33 National Strategy for an Ageing Australia An Older Australia, Challenges and Opportunities for all, Commonwealth of Australia 2001 34 Centre for Ageing Studies at Flinders University and the Govt of SA, 2008 The Australian Longitudinal Study of Ageing:15 years of Ageing in SA


many of the factors identified that promote longevity and quality of life are lifestyle factors such as poor nutrition, lack or regular exercise and poor social networks and are therefore amenable to change. Many older people are healthy and completely independent. The healthy aged are an essential part of our society, providing vital and invaluable services such as volunteer work, fundraising, childcare, care for family and friends, and mentorship to our young. There are many examples of rural older people working incredibly hard and providing innovative solutions to provide for themselves and their peers. Healthy ageing requires effective assistance for people of all ages to maintain and enhance their health, to avoid preventable health problems and to cope effectively with unavoidable diseases and disabilities. Key considerations for the healthy ageing of older include: o avoiding loneliness and social isolation; o having access to various types of accommodation in their home town o opportunities to continue to use skills in the workforce and as volunteers; o access to a range of health providers, services and support, leisure recreational and

lifelong learning opportunities; o transport

Health Reform Recommendations of the Health and Hospitals Reform Commission35 follow the movement towards development of comprehensive primary health care centres, incorporating coordinated multi-disciplinary health care services co-located and based around the general practice. This is likely to occur through the evolution of Divisions of General Practice and follows recent trends where Divisions have been targeted for the lions share of primary health funding over the past few years. General Practice will increasingly be the source of primary health care including early diagnosis, management and treatment of ill-health, health promotion and access to healthy ageing programs.

Housing The health and well being of older people is intrinsically linked to housing and can be influenced by many factors including, the type and security of housing tenure, the location of the home in relation to neighbours and access to services, the design of the home, the ability to maintain it and affordability. This is supported by extensive qualitative research that has identified direct links between unmet housing needs and poor health. The 2006 Census showed large increases in the number of older people who were homeless of nearly 30% between 2001 and 2006, significantly more than any other age cohort. There has also been a 30 per cent increase in the numbers of older Australians in housing stress between 2003 and 2007.

35 A Healthier Future for all Australians Final Report June 2009, Final Report of the National Health and Hospitals Reform Commission


The scarcity of affordable housing is becoming a serious contributor to poverty and disadvantage among older Australians. NATSEM estimate that the number of people 70 years and over in housing stress increased 100% in 4 years from 56,000 in 2004 to 112,000 in 2008. AHURI estimate that the number of people aged 65 and over in low income rental households will increase by 115% from 195,000 in 2001 to 419,000 in 202636. There are only 163 housing trust or housing cooperative households in the Fleurieu, making up 1.13% of all households and 9% of all rental arrangements. This is compared with 4.94% households and 25% rental arrangements state-wide. There are more than 120 people aged 60 years and over on the waiting list for local cooperative housing representing a demand for 96 homes. As a result there is a high level of private rental by low income individuals. 18% of private rental tenants in the Fleurieu have an average weekly income of less than $500 per week compared with 13% of the South Australian private rental market. According to Housing SA “affordable” is defined as paying no more than 30% of household income in rent or maintenance fees. analysis of rental bond data for the period (1/7/2006 to 30/6/2007) showed there were no private properties rented for less than 30% of the single pension and rent assistance during the period37. Property managers estimates of the time it may take to find a smaller, easy to manage property, closer to facilities, with cheaper rent, varied from 3 months to 3 years. Alternately, if these criteria were not applied, a property could be found for a tenant with good references straight away. Detached dwellings are the most common dwelling type in Victor Harbor, comprising 86% of the total housing stock compared with the state average of 78%38. Collectively this information indicates a shortage of higher density housing stock. The white paper ‘The Road Home’39 provides a commitment to amend the Aged Care Act 1997 to recognise older people who are homeless as a ‘special needs’ group. This will better allow the needs of older people who are homeless to be specifically addressed during the annual allocation of new residential places and community care packages. It will also allow aged care providers who care for older people who are homeless easier access to targeted capital assistance grants. The Australian Government also provided a commitment to continue to fund the successful Assistance for Care and Housing for the Aged (ACHA) and expand it into new regions. ACHA helps to link older people who are homeless and those in insecure housing to care and accommodation.

36 A fair share for Older People – The Need for a National Older Persons Housing Strategy COTA & Aged and Community Services Australia, Older Persons Affordable Housing Alliance March 2009 37 Housing Issues and Older People, Southern Fleurieu Positive Ageing Taskforce March 2009 38 Victor Harbor Urban Growth Management Strategy 2008-2030 39 White Paper: The Road Home, A National Approach to Reducing Homelessness 2008


A significant number of aged care providers are reporting that the new aged care funding instrument (ACFI) is making low care facilities less viable40. This observation has also been made by stakeholders in the Fleurieu, noting that the ACFI has reduced access to individuals requiring lower levels of care. The reasons many individuals provide for choosing to enter residential care include inextricably linked housing and care needs. As such it is expected that reduced access to residential low care will in turn result in an increased demand for affordable and appropriate housing for older people in the community. Home maintenance and modification services can enhance safety, support a slower rate of decline, reduce care costs and enhance lifestyle and capacity for social participation. AHURI’s analysis of these services in Australia identified a complex patchwork of services that is inadequate to meet the needs of the population. The Older Peoples Affordable Housing Alliance41 has identified that home maintenance and modification programs require urgent attention. It also recommends that sector capacity building activities be undertaken including ILU research and assistance to providers to develop strategic plans and alliances that will lead to improved management, governance and housing stock with better links to community care providers. A strategic approach to enhance the supply of affordable housing that is appropriate for older peoples needs is encouraged including increasing the supply of rental housing, public/social housing and the adoption of universal design principles in built environments and urban design. Interestingly, the alliance makes further recommendations for an incentive scheme to assist in the redeveloping low care facilities into assisted living units. They also recommend developing models that demonstrate how mixed developments (including sale, rental and retirement village models can operate) either within or outside a retirement village. There are more opportunities for interested parties to gain government support to develop affordable housing now than there have been for around 20 years. Most initiatives are managed through the Affordable Housing Unit of Housing SA (Department of Families and Communities). The Affordable Housing Innovations (AHI) Program focuses on housing responses that require direct Government funding and on affordable housing projects (including high need) with partners (private sector, government agencies and community partners) contributing equity or investment capital. The National Rental Affordability Scheme aims to help address the shortage of rental housing and rising rents by facilitating the supply of new lower-rent homes through the allocation of a National Rental Incentive to participating organisations. Other short term opportunities have arisen through the Governments Economic Stimulus Package.

40 A fair share for Older People – The Need for a National Older Persons Housing Strategy COTA & Aged and Community Services Australia, Older Persons Affordable Housing Alliance March 2009 41 A fair share for Older People – The Need for a National Older Persons Housing Strategy COTA & Aged and Community Services Australia, Older Persons Affordable Housing Alliance March 2009


Government directions aim to include at least 15% affordable housing requirements in all new significant developments. This requirement will apply to two major housing developments within Victor Harbor at Hindmarsh Valley and Encounter Bay over the next few years.

Social Planning Many countries throughout the world are currently using the WHO Aged Friendly Cities framework to address issues for older people such as housing, transport, community services, urban design and infrastructure. Some local governments in Australia are adopting the framework. The UK government is funding the development of Lifetime Neighbourhoods. Community infrastructure such as transport services, civic space and amenitites are designed to make it possible for older people to have a full life and participate in the life of their local community42. With support from the Positive Ageing Taskforce councils across the Fleurieu, particularly the City of Victor Harbor have begun to adopt similar enhancements to community infrastructure through urban design that acknowledges the wide range of needs of the growing number of older community members. However there remains significant further potential in this concept and it’s expansion across the region.

Rural and Remoteness Australians living outside major cities have shorter life expectancy, higher death rates, and are more likely to have a disability compared to city dwellers, even when taking into account the effects of the known poorer health of Indigenous Australians, who make up a greater proportion of the population in more remote areas. Aged and Community Services and the National Rural Health Alliance43 recognized a range of specific difficulties experienced by older people and service providers in rural and remote areas. Issues they identified that particularly relate to the Fleurieu experience include: o particular difficulties in attracting and retaining staff and upgrading their skills; o the regions used in planning and service provision do not always reflect local

communities of interest; o a lack of alternative providers to care for people with specialist needs so small rural

providers are forced to support people to a higher level without additional funding; o the need to provide outreach services and the additional cost of travel; o health and community care workers in rural and remote areas often need special or

advanced skills for effective practice, including in aged care; o lifelong learning opportunities including formal and informal education and training

are not readily available to all staff in rural and remote areas; o minimal public transport infrastructure in most rural areas of Australia.

42 A fair share for Older People – The Need for a National Older Persons Housing Strategy COTA & Aged and Community Services Australia, Older Persons Affordable Housing Alliance March 2009 43 Older People and Aged Care in Rural, Regional and Remote Australia, National Policy Position, September 2005, Aged & Community Services Australia and the National Rural Health Alliance.


Government has attempted to respond to some of the issues faced by rural and remote communities by providing, and recently increasing, the viability supplement for residential services, and by introducing some service models with greater flexibility such as Multipurpose Services, Regional Health Services and the Innovative Pool. However many of these initiatives are not available to the Fleurieu region. Recommended actions, identified by Aged & Community Services Australia and the National Rural Health Alliance44 included: o Develop alternative models of aged care delivery that are tailored to the specific

needs of people in rural and remote areas, including those from indigenous and culturally diverse backgrounds, by:

- providing targeted research and development grants; - trialing and evaluating local models; and - tailoring funding and quality regimes to individual circumstances.

o Introduce a viability supplement for community care services, similar to that received by residential services, in recognition of the additional costs faced by country providers.

o Provide short term and tied funding to enable local communities and providers to: - explore long term organisational arrangements such as mergers, alliances

and partnerships that would enhance viability and/or the responsiveness of service delivery;

- develop concrete business strategies and plans to guide implementation of locally developed solutions;

- better utilise information technology initiatives and appropriate telecommunications; and

- develop and/or support networks of rural and remote providers to meet and share information.

o Governments, health and aged care employers and professional bodies should work together to ensure that all health professionals in rural and remote areas have competencies in geriatrics and the care of older people, including dementia and palliative care.

o State and Territory Health Departments should identify older people’s transport needs and integrate transport issues into the planning of health services in rural and remote communities. This should consider such issues as location of services, admission and discharge practices, and arrangements for appointments.

44 Older People and Aged Care in Rural, Regional and Remote Australia, National Policy Position, September 2005, Aged & Community Services Australia and the National Rural Health Alliance.


Local economic impact and opportunities Consumers The ratio of over-65s to working-aged Australians will almost double over 30 years. When this is applied to regions with already significant retired populations, the need to cater to an ageing population of consumers becomes particularly apparent. Over the next decade nearly half of the growth in retail sales will be to individuals over the age of 60 years45. This can present both considerable opportunities and challenges to the Australian business community. While annual spending may fall once a worker retires, certain types of retailing benefit, such as health insurance, gambling, books, home improvement and electronics as well as communications and travel.

Employees The working age population currently grows by 170,000 people a year. However trends already in place will see the working age population grow by just 125,000 for the entire decade of the 2020s. Unless organisations adjust their thinking on mature workers,market forces may do it for them. The ‘supply’ of mature workers will grow much more rapidly than the ‘supply’ of younger workers. There are a number of benefits for the community of having employees work longer: o In an environment of shrinking workforce and skills shortages, businesses will not

be able to afford to lose valuable skills of their older employees. o Mature aged consumers are likely to prefer mature aged sales people and business

will seek to capture this growth by accommodating this preference. o People will be living longer, be healthier at the current retirement age and be

seeking the participation and challenge offered by employment. o We have already seen one increase in retirement age in order for governments to

reduce the number of people eligible for aged pensions. This trend may well continue.

45 The Impact of Ageing: Business risks and opportunities in an ageing Australia, PKF Business and Population Monitor, 2008

Southern Fleurieu Positive Ageing Taskforce Strategic … Fleurieu... · Lisa Sparrow November 2009 Southern Fleurieu Positive Ageing Taskforce Strategic Plan 2009 - 2018 Background

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