Ownership, quality and prices of nursing homes in Australia: Why greater private sector participation did not improve performance

The quality of residential aged care in the context of the Australian aged care reforms: A scoping review

OBJECTIVE

Australia has been undergoing a major aged care reform process since 2012 focused on consumer-oriented home and community-supported care, but little is known about the impact of these reforms on residential aged care delivery. This study aimed to review research about the quality of residential aged care service delivery during the implementation period of these reforms.

METHODS

The review followed a five-stage scoping review framework and searched five databases for articles published between 2012 and February 2022 (the 10-year implementation period of the reforms). Initial searches identified 495 articles. Articles were imported to Covidence™ for title, abstract and full-text screening.

RESULTS

Twenty-two articles were included in the review. Articles were framed using the micro (residents and families)/meso (staff)/macro (governance, government) continuum in the operation of residential aged care facilities. Most articles focused on workforce perspectives.

DISCUSSION

Attention was paid to workforce issues and a limited focus was on consumer experience and expectations. There is a need for an evaluation of the reforms as a vehicle for promoting consumer empowerment. Many contributing factors to quality of care were identified, and there were some quality issues that were contrary to the intended objectives of the reforms. These warrant closer attention.

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Quality effects of home acquisitions in residential aged care

OBJECTIVE

The recent consolidation of the Australian residential aged care market has raised concerns about the potential adverse effects of acquisition activity on quality of care (QoC). We examined changes in QoC outcomes within acquired homes and the influence of the acquiring providers' characteristics on these post-acquisition outcomes.

METHODS

A retrospective observational study was conducted using de-identified data sets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was used to investigate post-acquisition changes in QoC outcomes for 225 Australian home acquisitions between 2015 and 2019. The outcomes were analysed for the first two full financial years before and after the acquisition.

RESULTS

After controlling for other factors, we find acquired homes were associated with significantly worse QoC outcomes in the 2 years after acquisition, with higher rates of hospitalisations and reported complaints to the regulator. However, these results were driven by homes acquired by providers that were smaller in scale, for-profit or had comparatively poorer average quality across the other homes they operated.

CONCLUSIONS

Our finding that homes' QoC on average declines in the first 2 years following acquisition, are consistent with studies in other countries and points to the potential risks that consolidation poses to the care delivered to older people in Australia during that period.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study)

BACKGROUND

This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations.

METHODS

Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators.

RESULTS

Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators.

CONCLUSIONS

This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Relationship between residential aged care facility characteristics and breaches of the Australian aged care regulatory standards: non-compliance notices and sanctions

OBJECTIVES

To examine the relationship between structural characteristics of Australian residential aged care facilities (RACFs) and breaches of the aged care quality standards.

METHODS

Facility-level analysis of audits, sanctions and non-compliance notices of all accredited Australian RACFs between 2015/16 and 2018/19. Structural factors of interest included RACF size, remoteness, ownership type and jurisdiction. Two government data sources were joined. Each outcome was analysed to calculate time trends, unadjusted rates and relative risks.

RESULTS

Non-compliance notices were imposed on 369 RACFs (13%) and 83 sanctions on 75 RACFs (3%). Compared with New South Wales (NSW), non-compliance notices were less likely in Victoria, Queensland and the Northern Territory (NT), more likely in South Australia (SA), and comparable in Western Australia (WA), Tasmania and the Australian Capital Territory (ACT). RACFs with more than 100 beds and RACFs located in remote and outer regional areas (vs. major cities) also increased the likelihood of non-compliance notices. Compared with NSW, sanctions were less likely in Victoria, Queensland, NT and WA and comparable in SA, Tasmania and ACT. Additionally, the likelihood of sanctions was higher for RACFs with more than 40 beds. For both non-compliance notices and sanctions, no significant relationship was found with RACF ownership type.

CONCLUSIONS

We partially confirmed other Australian findings about the relationship between RACF structural characteristics and regulatory sanctions and reported new findings about non-compliance notices. Routine and standardised public reporting of RACF performance is needed to build trust that Australia's latest aged care reforms have led to sustained quality improvements.

The 2021 proposal to increase market forces in the Australian residential aged-care sector

In Australia, the US and Europe, policy makers use markets to incentivise aged care providers to produce greater quality care. The Australian Government announced in 2021 that it would further increase market forces in residential aged care to improve quality. The proposals respond to poor quality found within residential aged care, with overuse of psychotropic medications and physical constraints, social isolation and neglect. This paper outlines the market-orientated reforms the Government seeks to implement, including the policy development pathway over the last two decades. It refers to a theoretical model of provider behaviour under administered prices, and empirical research on the impact of similar market-orientated reforms delivered elsewhere, to highlight the reforms' strengths, weaknesses, and potential market outcomes. This paper concludes by identifying additional reforms that could better incentivise care quality and offers lessons to countries that have sought to marketise their nursing home care sectors.