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AGED care & retirement

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The big Ageing Well Science Challenge clinical

InterRAI MADE MANDATORY

Community Care

On the soapbox:

Graeme Titcombe – what’s standing in the way of home-based care?

FOCUS

Focus on nutrition: texture-modified diets, the power of protein, dementia diets, the new Food Act and more

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Ed’s LETTER I always leave my editorial to the last minute. It’s a bad habit in some ways, but a necessary one in others, as it gives me a chance to reflect on what’s happening in the aged care and retirement arena before putting pen to paper, metaphorically speaking. As I look through the proof of this particular issue before it heads to the printers and into cyberspace it strikes me just how many people play a part in this vast and dynamic sector. From its pages we hear from the new NZACA boss, the long-time head of home-based care organisation Access, the Retirement Villages Association, government officials, researchers, clinical nursing staff, kitchen staff, caregivers and, importantly, residents and clients. In terms of penetrating the multi-faceted issues that define aged care and retirement in New Zealand, it is a drop in the ocean. But the diversity of voices does illustrate the complexity involved with meeting the needs of our current and future older populations. There is not one particular focus point in this sector, no singular goal or strategy. Certain topics will occupy media interest from time to time – some more than others – but in the background there are many, many aspects of care and service provision that go largely unrecognised and unapplauded. This is our annual ‘nutrition’ edition and in sourcing its content and tapping into this one aspect of care, I realised the depth of expertise and knowledge that must lie at every point of providing a top-notch service to our older people. As an onlooker and commentator I have the luxury of critique. But ultimately I have nothing but praise for those who, with their piece of the jigsaw, help support and constantly improve this diverse and important part of New Zealand life.

Editor, Jude Barback editor@insitemagazine.co.nz www.insitemagazine.co.nz

For aged care news, views, trends and analysis visit: www.insitemagazine.co.nz Connect with INsite magazine on Twitter Follow INsite for breaking news, the latest innovations, and conversations with editor Jude Barback on the professional issues close to your heart. Find us on Twitter@INsite_NZ

INsite is distributed to key decision makers in the aged care sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).

In this issue... FOCUS: Nutrition and diet in aged care

2 4 8

The new Food Act and how it will affect providers

The three ‘S’s and the three ‘A’s – ensuring optimum nutrition for residents with dementia

10 12

InterRAI: the tight and tiring race to meet mandatory deadline Texture-modified diets – part of the care

The older athlete The power of protein

Opening our doors for healthcare work experience

Getting to the HART of ageing

Ageing Well: the big challenge ahead

Is it time for a large dose of technology disruption?

The dangers of polypharmacy

Bill’s story: dialysis at home

On the soap box... Graeme Titcombe

Spotlight on... chronic kidney disease

Conference report: Retirement Villages Association (RVA), 15-17 June, ‘Opportunities and High Demand’

28 29

Conference preview: New Zealand Aged Care Association 2015 Conference: 8-10 September, Auckland A typical day in the life of... Avril Grant

Let’s snoop around... Aspen Care

On the bookshelf... Active Ageing

Last Word... Simon Wallace

Editor: Jude Barback P: 07 575 8493 E: editor@insitemagazine.co.nz Advertising: Belle Hanrahan P: 04 915 9783 E: belle.hanrahan@nzme-ed.co.nz General Manager & Publisher: Bronwen Wilkins Production: Aaron Morey David Malone Subscriptions: Gunvor Carlson P: 04 471 1600 E: gunvor.carlson@nzme-ed.co.nz

July/August 2015 Volume 9/Issue 3 NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6141, New Zealand PO Box 200, Wellington 6140 Tel: 04 471 1600

© 2015. All rights reserved. No part of this publication may be copied or reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy, recording or otherwise without the prior written permission of the publisher. ISSN: 2324-4755

Errors and omissions: Whilst the publisher has attempted to ensure the accuracy and completeness of the information, no responsibility can be accepted by the publisher for any errors or omissions. www.insitemagazine.co.nz

July/August 2015

Policy

The new Food Act

and how it will affect providers The residential aged care sector has long maintained that providers should be exempt from the obligations set out in the new Food Act; however the Ministry for Primary Industries says the sector must comply with the new legislation.

iscussions around the new Food Act have been taking place for over a decade, but finally the new legislation is set to come into force. The Food Act 2014 will become operational by 1 March 2016, replacing the Food Act 1981. It will apply to new food businesses and suppliers who begin trading from that date. Existing businesses will come under the new law over a threeyear period from this date; the Food Hygiene Regulations 1974 will then be revoked. But what about aged care providers, who occupy a grey area (no pun intended) in the field of food regulations?

Aged care sector’s request for exemption

From the outset, aged care providers have been against any change to the current regime. The New Zealand Aged Care Association (NZACA) has long argued that the aged residential care sector should be exempted from any additional regulations around food as the sector is currently regulated through the Health and Disability Act. It also argued that over the last 10 years of operating under that Act there has been no evidence of a problem with foodborne illnesses in aged residential care. It requested that there should be a clause in the new Food Act which excludes the aged care sector from the new regime. The Ministry for Primary Industries (MPI) investigated the sector to gain a better understanding of how it operates and if such an exemption might be plausible. The NZACA’s submission to Parliament’s Primary Production Select Committee on the Food Bill in 2013 requested that “given the existing regulatory structure for our sector, it would be preferable to be able to achieve any improvements to food safety management within the existing structure and systems”. The submission stated that while NZACA supports the objectives of the Food Bill it believes it is appropriate for the aged care sector to be exempt from any obligations under the Food Bill.

Ministry’s response

However, in 2013 Parliament made the decision that businesses in the aged care sector 2

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“

… one of the main selling points of the new Food Act is that it recognises that each business is different; it is said to mark a departure from the old Act’s one-size-fits-all approach to food safety.”

will not be exempt and will need to meet certain requirements under the Act. A spokesperson for MPI told INsite that while the sector is currently regulated by the Health and Disability Services (Safety) Act 2001, this legislation “is not primarily focused on food safety and does not set out detailed expectations to ensure the safety of consumers, for example, keeping records of where food is being sourced from to be able to recall the food if there is a food safety incident”. Under the new Food Act, aged care providers will be required to register with MPI and be checked (verified) on a regular basis. Earlier this year, MPI consulted with all affected stakeholders, including the aged care sector, on the regulations under the Food Act.

“MPI recognises that the new Act will have an impact on some aged care providers and we will work with the sector and other government regulators on how impacts and costs can be minimised, such as removing unnecessary regulatory duplication and reducing compliance costs. “At the same time, we cannot take short cuts on our food safety system because it provides for the safety of the elderly population, who are vulnerable to food safety risks, and supports New Zealand’s worldleading reputation as a producer of safe food.” The NZACA says it is happy to work with MPI to minimise the impact on the sector. However, chief executive Simon Wallace says that the association maintains its position, as stated in its 2013 submission, that the

STOCK

Policy sector is already meeting stringent food safety requirements, as set by various health regulations. “While we accept the overall objectives of the Food Act and agree it is important that food is safe for consumers, we think the new rules contained in the Food Act are potentially onerous and will place an extra burden on providers who are already doing a good job to ensure the safe preparation of food,” he says.

How is the new Food Act different?

Despite the NZACA’s concerns, one of the main selling points of the new Food Act is that it recognises that each business is different; it is said to mark a departure from the old Act’s one-size-fits-all approach to food safety. The central feature of the new Act is a sliding scale where businesses that are a higher risk from a food safety point of view will operate under more stringent food safety requirements and checks than lowerrisk food businesses. Higher-risk food businesses – for example, those that prepare and sell meals or sell raw meat or seafood – will operate under a written food control plan (FCP). In the plan, businesses identify food safety risks and steps they need to take to manage these risks. The FCP can be based on a template or business owners can develop their own plan to suit their individual business. Businesses that produce or sell low to medium-risk foods – like non-alcoholic beverages, for example – will come under national programmes. There are three levels of national programmes, based on the level of food safety risk. National Programme Level 3 applies to food sectors with the highest level of food safety risks and National Programme Level 1 the lowest. National programme requirements will be set out in regulations, with requirements increasing between levels. Regulations are being developed and proposals will be publically consulted on before being finalised. Businesses under national programmes won’t have to register a written plan, but will have to make sure they are following the requirements for producing safe food that will be set out in regulations. This includes having to register their business details, keep minimal records and have periodic checks. The new Act provides a clear exemption to allow Kiwi traditions like fundraising sausage sizzles or home baking at school fairs to take place. The only rule will be that food that is sold must be safe. Growing food for personal use, sharing it with others or ‘bring a plate’ to a club committee meeting, or providing lunch for a visiting sports team or social group, is outside the scope of the Food Act. The Act only covers food that is sold or traded.

There will be extensive consultation during the development time, giving people the opportunity to have their say on the detail of the new food safety system. When the new Act comes fully into force, food businesses will transition in groups into the new rules over a staggered three-year period. Generally, businesses in higher-risk food sectors will transition first. At the end of the three-year period, all food businesses will be operating under the new Act. Although aged care providers must comply with the new Food Act, MPI has promised to work with the sector to help minimise compliance costs by taking steps to remove unnecessary regulatory duplication.

What happens now?

MPI is developing a package of materials to implement the Food Act and to support the regulations, including food control plan development manuals and templates, guidance for businesses operating under national programmes and guidance for food sectors that are exempt from having to operate under a national programme or food control plan. www.insitemagazine.co.nz

July/August 2015

POLICY

InterRAI: the tight and tiring race to meet mandatory deadline On 1 July, after a somewhat hurried and harried introduction, interRAI became the mandatory clinical assessment tool for nurses to use in residential aged care facilities nationwide. FIONA CASSIE caught up with some nursing leaders as facilities headed down the home straight in a race to meet the deadline to train nurses in an already time and resource-stretched sector.

Getting enough nurses to be proficient with the new electronic interRAI tool by the Government’s 1 July deadline was a tight race. Some facilities crossed the finish line early; others made it after hard slog; some got there only after considerable panic, with nurse turnover undermining their best efforts to be prepared. Training courses were run right up to 1 July and will continue for some time to ensure nurses are competent in the clinical assessment tool – a 53-hour process that is costly both in time and resources. Concerns about lack of government support for its own project prompted a backlash from the aged care sector during contract talks last year, leading to a post-budget, pre-election funding boost for ongoing interRAI support, which started from 1 July this year (see timeline sidebar for details of interRAI funding). The Ministry of Health reported that 2,302 registered nurses had reached interRAI competency as at 21 May and it expected to exceed the project target of 2,370 and have 2,500 RNs trained by July.

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It appears the problem a number of facilities face is not getting nurses interRAI trained, but retaining them, said aged care nurse practitioner Dr Michal Boyd. Boyd was the lead researcher for an initial demonstration trial of interRAI in residential aged care in Waitemata and Bay of Plenty DHBs back in 2008. She has always believed the standardised interRAI assessment tool could bring rewards, as long as effort was put in to making the electronic tool user-friendly for time-pressured nurses. “They have succeeded in training staff in residential aged care for interRAI, that is true,” said Boyd. “And they have succeeded in people doing interRAI in residential aged care, but at different levels depending on the facility and how up to speed they are.” She said a major dilemma for facilities with interRAI is the huge turnover of nursing staff. “I was talking to one facility manager who said she has trained five nurses in interRAI and only one of them still remains at the facility.” Boyd said high turnover is now an ongoing issue as residential aged care is a relatively low-paid sector and if nurses get an opportunity for higher pay or better shifts they will take it. Staff turnover of interRAI-trained nurses has hit Metlifecare’s eight facilities hard, said Amanda Iavarone, an experienced aged care nurse who is Metlifecare’s clinical quality and risk manager. She said all of its facilities have lost interRAI-trained staff and had to start over and train more, with the result being in early June they had 14 of the 35 interRAIcompetent RNs that they required. Iavarone said Metlifecare was one of the first providers to get on board with interRAI and the initial response had been positive. “This has changed now…” Hilda Johnson-Bogaerts, an experienced aged care sector who is general manager of

“

In theory, InterRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly.”

July/August 2015

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POLICY residential and community care for the Selwyn Foundation’s 10 facilities, said it also had had to train”a few more nurses than initially envisaged” because of staff turnover. However, it had also been able to recruit some trained interRAI nurses and had been able to meet the ratio of interRAI-competent RNs set by the DHB, “which I’m confident will be sufficient”. She said it had initially thought that all its primary nurses with a care-planning caseload needed to be interRAI proficient, but after gaining more experience with interRAI, that was no longer the goal. “We may have interRAI-trained nurses preparing the assessments for the primary nurses, who can then use the information to further work on their residents’ care plans.” Sylvia Meijer, an older adult nurse practitioner, said most of the facilities she worked with in Horowhenua had the majority of RNs trained and appeared to have systems in place to ensure they met the deadline.

Audit and hardware

Early in the interRAI journey much of the frustrations were IT-based in a largely lowtech health sector – and the length of time interRAI assessments take. Boyd said an ongoing struggle has been integrating the electronic interRAI tool with facilities’ existing IT systems or, in some cases, facilities that still largely operate a paperbased system. She said another conundrum for facilities has been that, prior to interRAI becoming mandatory, auditors have not recognised interRAI data for certification and spot audit purposes, so facilities already using interRAI have had to double-up and continue with traditional assessment reporting, as well as interRAI. Johnson-Bogaerts said all Selwyn facilities now have Wi-Fi internet access and at

least one COW (computer on wheels) but government funding had not been enough to cover the hardware or the backfill cost to cover training and ongoing increased demand on staff time. Iavarone said Metlifecare facilities are using desktop PCs to carry out interRAI and thinks

the government investment in hardware was “enough”. But she said a lot of the RNs “aren’t very computer savvy”, seeing hands-on care as their priority, and find interRAI assessments take a very long time. Meijer said there was initial reluctance by some nurses because of the IT requirements Continued on next page >>

TIMELINE FOR interRAI

»» 2008: Pilots using interRAI assessment tool in residential aged care facilities are held in Canterbury, Waitemata and Bay of Plenty DHBs. »» 2011: The Government allocates more than $10 million over four years towards nurse training, a software licence and funding for at least one laptop or computer to implement interRAI in facilities. Forty facilities are selected as ‘early adopters’ in the planned four-year national rollout across the about 700 facilities nationwide. »» 2012: From June all DHBs are using a community version of interRAI for assessing older people living in their homes who may need home-based support services or a place in residential aged care. »» In October the Government announces that from July 2015 using the interRAI Long Term Care Facilities (LTCF) assessment to inform care planning will be mandatory in all aged residential care facilities in New Zealand. »» The NZ Aged Care Association criticises the Government for implementing interRAI too quickly, investing too little money in training and making it mandatory. »» In late 2012 the Ministry of Health sets up a project training team to fast-track the training of one RN per 15 facility beds (training process takes 53 hours per nurse). »» 2013: In April the Government announces an extra $1.5 million towards the cost of interRAI implementation. DHBs report facilities making slow progress hampered by IT infrastructure issues and the cost and time required for nurse training. »» 2014: In June the Government announces a post-budget grant of $4.5 million a year for four years from 1 July 2015 to provide “ongoing support and training for nurses and rest homes”. The announcement follows concerns about interRAI raised by the aged care sector during a pre-election contract dispute. »» The Ministry reports by November 2014 that 1,706 nurses in 580 facilities have been trained to competency level in interRAI; this had risen to 2,302 RNs by 21 May 2015 and it was predicted that by July this year 2,500 nurses would be competent with interRAI (the initial target was 2,370).

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July/August 2015

POLICY of interRAI and she still hears occasional comments by nurses about the time interRAI assessments take. Nurses also talk about finding it hard to concentrate on completing assessments, she said, because facility computers are often in a busy office, leading to many interruptions. Boyd said another conundrum for facilities has been that auditors have not recognised interRAI data for certification and spot audit purposes; so facilities already using interRAI have had to double-up and continue with traditional assessment reporting as well as interRAI. Auditors are now officially considering how facilities are using interRAI assessments to inform care planning. Meijer agreed, saying most facilities she deals with still have separate care plans and IT compatibility with organisational policy sees some facilities continue to simultaneously operate an electronic and paper system.

Next step: using interRAI for care planning

Boyd said the next step, now that interRAI training has been established, is to really focus on using interRAI assessment findings to inform care planning. Currently, nursing staff often view interRAI as too time-consuming and tedious, said Iavarone, and don’t always see the big picture of what interRAI can offer. “In theory, interRAI is excellent, and of course in time when everyone is trained and faster at doing the assessments then things will run more smoothly,” she said. “In reality, there are many RNs who are struggling with this, those older RNs who aren’t tech savvy, or those with English as a second language – often both. So far there isn’t a great benefit for our residents that we have found.” Meijer said interRAI is helpful in her NP role as it provides more detailed information on residents that is used as a basis to discuss care with the client and/or staff. She has noticed some variability in interRAI skills

What is interRAI?

among nursing staff, with some RNs more “confident and competent” to do assessments and others needing additional teaching. “Assessments in general should be personfocused, but as a starting point, interRAI is helpful to have a level of consistency and rigour throughout the country,” she said, about the now-mandatory tool. Johnson-Bogaerts said Selwyn nurses also initially felt that the increased time spent on interRAI assessment was taking them away from actual ‘hands-on’ caring for residents. “Now that they have more experience in using the tool, there is greater understanding of how the evidence-based interRAI assessments contribute to improved care

The original version of this article can be found in Nursing Review at www.nursingreview.co.nz.

InterRAI stands for international Resident Assessment Instrument. The interRAI assessment tools were developed by a network of researchers from over 30 countries making up the interRAI collaborative. The aim of the tools’ standardised questionnaires and algorithms are to promote evidence-based clinical practice and policy to improve health care for the elderly, frail or disabled. The tools use a common language to assess the health and needs of people

July/August 2015

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planning and, ultimately, to improved care,” said Johnson-Bogaerts. “InterRAI enables nurses to quickly focus on health issues and plan care interventions to improve or prevent the issue from getting worse.” Nonetheless, she expected there to be increased pressure on nurses’ time for a period post-1 July as they work to ensure all existing long-term residents have an interRAI assessment. With the finishing line having finally being crossed, it may still be some time before the country’s residential aged care facilities can catch their collective breath and decide whether they’ve won the race.

in community care or residential care including their medical, rehabilitation and support needs. The electronic tool, which can be used on a tablet or laptop, uses standardised data collection so statistical trends can be gathered on a facility-by-facility, regional or national level. New Zealand is the first country in the world to have a national implementation of the tool. To find out more about interRAI contact 0800 10 80 44, visit www.interRAI.co.nz or email interrai@dhbss.health.nz

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FOCUS

Texture-modified diets – part of the care Registered dietitian LIZ BEAGLEHOLE of Canterbury Dietitians says facilities need to plan ahead to ensure they get the texture of the food right for each resident, while also meeting their nutritional needs.

exture-modified diets are required at almost every site I visit. Residents are given a texture-modified diet due to problems with chewing and/or swallowing, known clinically as dysphagia. Modifying the texture of the food is a practical way to make chewing easier and to allow a safer swallow. In some cases, liquids are thickened too. The aim is to allow residents to continue to meet their nutritional needs with an oral diet, while managing the risk of choking and developing aspiration pneumonia. A speech language therapist will determine the texture modification required. A dietitian can then assist in developing a menu of suitable foods to provide.

Terminology

The New Zealand Speech-Language Therapists’ Association and Dietitians New Zealand have adopted and follow the Standards for Texture-modified Foods and Fluids developed by the Dietitians Australia Association and Speech Pathology Australia. The three modified textures are soft, minced/ moist, and smooth puree and the thickened fluids range from mildly, moderately or extremely thick. Foods that can be mashed gently with a fork are as regarded as soft. Many of the foods on the regular menu of an aged care facility would be regarded as ‘soft’. The food is well cooked; the meats should be tender and the vegetables soft. Usually meats are served with a gravy or sauce. Sometimes the soft terminology gets confused and a person who requires a soft diet is given a puree. It is important that all staff understand the correct terms to use, and what they mean in texture. Being consistent with textures served to a resident is important too. If a resident requires a puree diet, this means suitable in-between options should be provided too. Scones, muffins and soft sandwiches are not suitable for residents requiring a minced/ moist or puree diet.

Menu options

To create a minced/moist or a smooth puree meal, a blender or food processor is needed. Often the regular option is able to be modified. However, there are foods on the menu that are not suitable for pureeing. 8

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In these circumstances a different option is needed. I recommend that sites plan these options on the menu. The risk of poor nutrition and unwanted weight loss is higher for residents who require a texture-modified diet. The secondary meal i.e. lunch or tea, is often more difficult to cater for texturemodified diets. When all residents are having toasted sandwiches, or eggs on toast with bacon, what can we provide for puree diets? In many cases, the option provided for puree diets is scrambled eggs. Technically, scrambled eggs are not a puree texture as they are not smooth and lump-free. My other concern is that while most residents are provided with eggs, toast and bacon, the residents on puree are only provided with eggs. Nutritionally, their meal is not the same as everyone else. Using leftovers and pureeing these is also not providing a nutritionally equivalent option. The best way to cater for puree diets is to plan these on the menu in advance. To assist with swallowing, texture-modified diets must also be served with sauce or gravy as this helps to moisten the meal; for example, pureeing savoury mince and serving with brown gravy, or pureeing macaroni cheese and serving with extra cheese sauce. To boost the nutritional intake, a puree pudding served with the lighter meal is also a good idea. A simple mousse, instant pudding or custard, perhaps with puree fruit, is sufficient.

Thickened fluids

Sometimes hot and cold drinks will need to be thickened using a food thickener. It is important to note that not all residents on a texture-modified diet require thickened fluids. Staff should be trained in the preparation of thickened fluids to ensure the right consistency is made. Often I observe fluids that are too thick being served. These are unpalatable and do not offer hydration. Mildly thick fluids will still drip off the spoon and can be sucked up a thick straw. Moderately thick fluids will ‘blob’ off a spoon, but will still be pourable. Thicker textures than this are usually not used by speech language therapists. Check the thickness of the fluids at your site and compare these with the recommended standards.

“

The aim is to allow residents to continue to meet their nutritional needs with an oral diet, while managing the risk of choking and developing aspiration pneumonia.” In-between meal snacks

The in-between snacks need to be planned too. When the residents are served a scone for morning tea, what are the residents on a soft, minced or puree diet offered? When sandwiches and slices are served for supper, do the residents on puree get an alternative? Try serving milkshakes, smoothies, puree fruit and cream, dairy foods or smooth yoghurts between meals. Jelly and ice cream may not be appropriate if the resident requires thickened fluids, as these foods melt in the mouth.

Presentation

One of the biggest challenges with providing texture-modified meals is how to present them well. Thankfully, gone are the days where all the food was blended together! Using different colours on the plate is important. Sometimes serving the puree meal in a small dish may improve the look. Layering colours in a clear dish looks good too. Some sites are working with food moulds that shape the puree into the whole food. For example, pureed carrots can be shaped to look like a serving of baby carrots. These look good, but require some changes in the kitchen production process. Providing quality texture-modified diets requires time, planning, equipment and money. But without this, residents requiring a texture-modified diet are at a real risk of malnutrition caused by inadequate food intake.

Talk to your local dietitian to help you plan texture-modified diets on your menu. Resources are available on the New Zealand Speech-Language Therapists’ Association website. Choice Catering Equipment also have coloured posters on texture-modified diets available. Contact Steve Preston at steve@choice.co.nz to order a poster.

FOCUS

The three ‘S’s and the three ‘A’s – ensuring optimum nutrition for residents with dementia Recently qualified dietitian Debra Nell completed her master’s thesis on meeting the nutrition and hydration needs of residents in dementia care units. As part of her research, she developed a series of recommendations for facilities catering for these special residents.

esidents with dementia can often be underweight and prone to dehydration, unless they are carefully monitored. Because of their dementia, they may also need special consideration at mealtimes. Debra Nell’s research aimed to gain a better understanding of the issues affecting the nutrition of residents with dementia and to provide some useful guidelines for the facilities tasked with ensuring their health and wellbeing. The study involved asking caregivers from two Specialised Dementia Care Units in Auckland about their perception of issues that might affect residents’ ability to have an optimum diet and adequate hydration. The results of the interviews with the caregivers were sorted into similar themes, and two main themes, each with three subthemes, were evident. The main themes were environmental factors and individual factors. Environmental factors fell into three sub-groups – surroundings (the dining environment), social factors, and support (the need for and provision of support with mealtime activities) – the three ‘S’s! Individual factors affecting food and fluid intake related to appetite, food appeal and functional ability – the three ‘A’s! All of these factors need to be considered when providing food and nutrition care for these residents. Nell formulated 21 recommendations that should assist dementia care units and their food service providers to address the two main themes, as well as the menu.

These include: Environmental factors »» Minimise distractions in the dining room during mealtimes, such as turning off the TV, and setting tables with essential items only. »» Relaxing background music may be beneficial during lunch and dinner, depending on the wishes and behavioural responses of residents. »» Shared dining rooms should be available and residents encouraged to use them. Observational cues from others allow the individual with dementia to mimic appropriate eating behaviours. Seating arrangements should be such that more independent individuals are not distracted by more dependent residents. »» A suitable dining space and staff support should be available for residents requiring time away from the group. »» Visits from family and friends at mealtimes should be encouraged as appropriate. The dining room environment should be managed to ensure that visitors do not distract other residents from eating. Individual factors »» Allow the individual with dementia to set his/her own pace for eating and drinking. »» Food should be attractively arranged on the plate, and a plated meal should include a variety of colours. »» A special effort should be made with texture-modified foods to ensure the best possible presentation, with foods visually identifiable, and varied from day to day. »» Some foods or menu items create problems:

»» Foods that are difficult to pick up with a fork, e.g. peas, rice, salad, may need to be combined with other foods or presented differently when possible to make them easier to manage. »» Meals served on or with toast, e.g. baked beans or savoury mince, may be better served with an alternative carbohydrate food, such as mashed potato. »» Sandwiches may fall apart when made with dry fillings such as lettuce or tomato. Soft, mixed sandwich fillings hold together better. »» Consider presenting suitable foods as either a ‘bite size’ or a ‘finger food’ for individuals preferring this option. »» Mealtime support from caregivers should recognise an individual’s needs and desires, assessing the level of ability or dependence at the time. Interventions involving appropriate encouragement of physical assistance should be provided. The menu »» Meal and snack times should be optimally spaced during the day to ensure individuals have an appetite for each meal. »» Sufficient nutritionally adequate foods should be available at supper, particularly for individuals with a low intake at dinner. Food and drink should be available to residents outside set mealtimes. »» Menu cycles should be of adequate length with sufficient variety for main meals, snacks and drinks (Dietitians NZ recommends cycle menus of at least four weeks in extended care facilities). »» Taste and smell of food should be optimised for older people with reduced taste sensation. Creating flavourful food and opportunities to allow pleasant cooking aromas to enter the lounge or dining room should be utilised. »» Increase the variety of foods by celebrating special occasions with a special meal, introducing occasional events such as barbecues or a weekly ‘happy hour’ or special afternoon tea.

This article was adapted from Dietitians NZ’s “Talk with” series, No 17, February 2015 with permission from Dietitians NZ, Debra Nell and the author, Julian Jensen. www.insitemagazine.co.nz

July/August 2015

FOCUS

The older athlete JUDE BARBACK looks to the New Zealand Nutrition Foundation for advice on nutrition considerations for the older athlete.

felt pretty good as I completed my first half marathon in seven years, clocking a time of one hour and 42 minutes and finishing ninth female over the line. However, it was somewhat humbling to note that one of the ladies who had beaten me was over 55,and another over 50. Impressed – and somewhat heartened that I might have plenty of running miles in me yet – I looked up the results only to find there had been 18 competitors over 60, and four of these were over 70. It turns out athletes are getting older. In fact, just recently, a 92-year-old cancer survivor became the oldest woman to finish a marathon in America. And an Asian man retired from marathon running at the grand age of 101. While these extraordinary people are not your typical older adults, they do represent a growing breed of older athletes. Here in New Zealand, there is an increasing number of baby boomers lining up for major endurance events, like open sea swims, the Lake Taupo cycle challenge, the Coast to Coast endurance event, ironman and half ironman events, marathons and half marathons.

Benefits of keeping active

The Ministry of Health’s Guidelines on Physical Activity for Older People (aged 65 years and older) emphasises that physical activity has many benefits for health. It can help increase muscle strength, flexibility, balance and coordination; enhance sleep, wellbeing and quality of life; and increase social interaction. Physical activity can also prevent falls, stroke, heart disease, obesity, type 2 diabetes, osteoarthritis, certain cancers, obesity and depression. The guidelines recommend older people should: »» be as physically active as possible and limit sedentary behaviour »» consult an appropriate health practitioner before starting or increasing physical activity »» start off slowly and build up to the recommended daily physical activity levels »» aim to do aerobic activity on five days per week for at least 30 minutes if the activity is of moderate intensity; for 15 minutes if it is of vigorous intensity; or a mixture of moderate- and vigorous-intensity aerobic activity 10

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»» aim to do three sessions of flexibility and balance activities, and two sessions of muscle-strengthening activities per week.

The older athlete

However, when an older person chooses to undertake or compete in major events that demand extra training, special care must be taken to ensure the body replenishes its fluid and nutrient stores. An increasing number of older adults are choosing to achieve physical fitness for health and wellbeing by using recreational or competitive athletics, and to include performance as a goal. The recommended dietary intakes (RDIs) of nutrients are the foundation for various age groups to maintain health and reduce the risk of chronic disease. When considering the needs of older athletes, the life stages of 51–70 years and 71+ years form the basis for increased needs, but it is difficult to assign a chronological age, because nutritional goals need to be adapted to meet the sports-related needs of the individual athletes. Consistent physical activity can offset some of the detrimental effects of ageing, increase psychological wellbeing, decrease the risk of chronic disease and reduce overall mortality rates, relative to age.

Nutritional issues for older athletes

Energy requirements are usually lower than in younger people. Energy need is the amount of energy required to maintain a desirable body weight, to perform the activities of daily

living, and to balance energy expenditure to maximise the training effects of their sport. Compared with younger counterparts, older athletes typically require less energy for weight maintenance, and an athlete’s overall energy needs decline with age (probably because of a reduced lean body mass and a drop in resting metabolic rate). However, older athletes are likely to have higher energy needs than their peers who remain sedentary or minimally active, and should monitor their energy intake to ensure sufficient energy is consumed to balance energy expenditure and maintain appropriate body weight and composition. Failure to do this may result in loss of muscle and bone mass, fatigue, injury and illness. Macronutrients Carbohydrates should provide around 45–65 per cent of energy intakes, depending on the type and duration of the activity. This may amount to five to 15 per cent more than the recommendation for a healthy lifestyle. Some older athletes may be at risk of not consuming sufficient carbohydrate to meet the minimum recommendations. Ideally, they should be eating six to eight servings of colourful fruits and vegetables per day and choosing at least six to eight servings of breads and cereals, including at least five wholegrain, high-fibre options. These will provide: »» fuel for exercising muscles. Older athletes retain the capacity to store ingested carbohydrates as glycogen in liver and

FOCUS muscle tissues, to use glycogen as a source of energy during submaximal exercise and to restore muscle glycogen levels postexercise »» vitamin C and B group vitamins that are essential for nerve health, stopping connective tissue breakdown during training and competition and enhancing tissue repair during recovery »» fibre that may help to reduce the incidence of bowel upsets, particularly constipation and diverticular disease, which are common in old age. However, excessive fibre is not recommended, especially prior to competition, as it may cause discomfort, bloating and wind while exercising.

Protein RDIs are higher for older adults than for younger people. Most experts agree that older people in training require a higher protein intake than their sedentary counterparts to build lean body tissue, and to provide adequate amino acids to repair exercise-induced muscle damage and to replace the protein used for energy during exercise. Given that with ageing there is a decline in lean body tissue and a likely decline in volume and intensity of training, it is difficult to establish exact protein needs for the older athlete. The level of protein required will depend on the intensity and duration of their exercise bouts. Specifically, endurance athletes may require 50–80 per cent more protein and strength-trained athletes 100–110 per cent more protein than the RDI.

In practical terms, this means increasing the daily intake of foods from the ‘meat group’ – lean meats, chicken, seafood, eggs and legumes, and the ‘milk group’ – low fat milk, yoghurt and cheese, by serving larger portions and including these foods as snacks between meals and after exercise. It is important to note that these recommendations are for healthy people, not those with acute or chronic diseases that may require therapeutic diets, such as lower protein intake for those with impaired kidney function. Depending on individual factors, levels around 1.2–1.7g/kg of body weight (normal RDI for people 51+ years is 0.8–1 g/kg body weight) per day may be required (10–35 per cent energy intake) for older athletes. Studies have shown that while not increasing protein intake in older athletes did not impact on muscle size, it did not prevent the apparent loss of whole body fat-free mass. Fat is essential as a source of essential fatty acids, fat-soluble vitamins (A, D, E and K) and as an energy source (providing nine calories or 37 kilojoules/gram). Fat should provide 25–30 per cent of energy needs for all older people. The recommendation to decrease saturated fats and increase mono- and polyunsaturated fats may enhance health and slow the progression of disease, but does not necessarily improve athletic performance. Including good sources of Omega-3 and Omega-6 polyunsaturated fatty acids is as important for athletes as for non-athletes. In terms of meeting these goals, all older people should aim to consume oily fish at least twice

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a week, and opt for polyunsaturated table spreads rather than butter, use plant oils such as olive, rice bran and avocado oils, and minimise trans fats. While not a big issue in New Zealand, trans fats act like saturated fats, and are found most commonly in foods containing partially hydrogenated oils. Check the food label ingredient list for ‘hydrogenated vegetable oils’.

Micronutrients

An intense training schedule can increase an athlete’s need for micronutrients and older athletes are no exception. Training depletes stores of vital vitamins and minerals which are lost via sweat, urine and faeces. Senior athletes may be less able than younger competitors to synthesise and absorb vitamins D and B12. Generally speaking, micronutrient adequacy is assured when people have a varied and good-quality diet with sufficient energy. But with older athletes, changes associated with the ageing process, such as lower energy intakes, impaired nutrient absorption, chronic medical conditions, medications and specific age-related risk factors may affect nutrient intake and requirements, and the older athletes are advised to consult with a sports dietitian or nutritionist to evaluate the adequacy of their nutrient intakes in light of their specific training or performance requirements.

Content sourced from New Zealand Nutrition Foundation’s Healthy Ageing Bulletin, August 2014, with permission.

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FOCUS

The power of protein Is the aged population getting enough protein? KAREN KINGHAM discusses the need for protein in an older person’s diet.

“

…recommendations for protein intake by adults aged 70 years and over are around 25 per cent greater than that for younger adults.”

rotein is a nutrient essential for growth, muscle function and immunity and plays an important role in health at the extremes of life stages. In the early years, protein is essential for the normal growth and development of children. However, in later years adequate protein intake is vital for the preservation of muscle mass and the benefits to strength, mobility and general health that this brings. Current New Zealand and Australian recommendations for protein intake by adults aged 70 years and over are around 25 per cent greater than that for younger adults. However, research has highlighted the importance of even greater protein intake by healthy older adults for the continued support of good health, promotion of recovery from illness and maintenance of normal levels of physical function. Sarcopenia is the progressive loss of skeletal muscle mass and strength that occurs with ageing and is accelerated with immobility, disease and under-nutrition. This process

was long believed to be inevitable; however, in light of evolving research, evidence-based guidelines (Bauer et al, 2013) now support a higher range of protein intake for older adults (1–1.2g/kg) than that currently recommended in New Zealand and Australia (0.94–1.07g/ kg). In October 2014, the Nestlé Nutrition Institute, Commonwealth Scientific and Industrial Research Organisation (CSIRO) and Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) collaborated to convene a symposium on the role of protein in a range of clinical conditions and life stages. The theme of the symposium, ‘The Role of Protein: Over-rated or Under-stated’ was explored by eminent researchers in the area of ageing and nutrition, including Professor Douglas Paddon-Jones from the University of Texas. At the symposium, Professor Padden-Jones outlined that along with a greater daily intake of protein for older adults, we also need to consider how protein is distributed over the

How much protein and where to find it? Recommended dietary intakes (RDIs) for protein for older people aged 51 years and over

Women

Men

Age (years)

RDI (g)

RDI (g/kg)*

51–70

0.75

>70

0.94

51–70

0.84

>70

1.07

RDI expressed as grams of protein per kilogram of body weight.

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Karen Kingham

day. Age-related muscle loss occurs for many reasons; however, age-related resistance to the protein building effects of dietary protein from a meal (known as anabolic resistance) is a significant contributor. Professor PaddenJones outlined research that reveals people’s ability to utilise protein for muscle building at any given meal occasion is optimal at around 30g of protein, or the equivalent of 100g of cooked lean meat. This research highlights the need to review current menu-planning guides for the elderly and to consider balancing out their protein intake evenly across the day.

Karen Kingham is the brand nutritionist at Nestlé Professional. She completed her Master of Nutrition and Dietetics at the University of Sydney, and has experience working as a clinical dietitian both in public and private hospital systems. References available from editor@insitemagazine.co.nz.

Sources of protein in the diet

The principal sources of protein in the diet of older men and women are bread, milk, beef and veal, fish/seafood and poultry. Other good sources of protein include eggs, milk products, legumes, cereals and cereal-based foods, nuts, and meat alternatives, such as soy protein in tofu. Source: Ministry of Health. 2013. Food and Nutrition Guidelines for Healthy Older People: A background paper

Great tasting protein enriched desserts your residents will love.

Education & training

Opening our doors for

healthcare work experience Director of nursing at Bethesda Care Dr NOELINE WHITEHEAD supports healthcare student placements and says the work of trained HCAs is skilled and needs to be recognised.

t is possible that in the coming years older people’s needs for health services, and especially residential care, will outstrip the available workforce. According to the Ministry of Health’s Workforce for the care of older people: Phase 1 Report (2011), some predict that a 100 per cent increase in the workforce will be needed by 2026. A quality workforce is essential for the wellbeing of older people. April 2013 was a changing point in my life, leaving a senior nursing role at the DHB and taking up the role of director of nursing in a residential care facility (Bethesda Care) for older people. I was quickly reminded of the value of skilled, caring staff who work together as an efficient and effective team.

requires skills over and above those that can be provided by a person with no formal training. In recognition of this, a decision was made for Bethesda to be a dedicated training unit for agencies that provide the disability support training. We believe that we are well positioned to provide an exceptional clinical experience to the students undertaking training programmes from Levels 2 to 6. We provide student placements for up to five training agencies and accommodate students on both morning and afternoon shifts. The students undertake a day’s orientation learning about key policies and procedures and our culture before commencing floor work with the buddy.

Varied and complex demands

Hands-on experience for secondary students

Bethesda Care is the home of a dynamic and diverse group of adults who require medium to very high levels of care. Medium care (rest home) caters for frail older people and younger disabled persons who need the assistance of one person and are frail or need constant monitoring for safety. Very high level care is hospital level care where a registered nurse is on duty at all times. In addition, we provide slow stream rehabilitation, palliative care and some acute care when our residents need it. Our residents have multiple comorbidities and multiple disabilities from hearing and vision loss, speech difficulties, mobility issues, continence issues to serious cognitive disability. The average number of disabilities for our residents is five. In addition to these disabilities they have many health issues and are high users of medicines; on average in excess of six per resident. A number of the residents have behaviours that cause concern to others. These range from wandering/ absconding, theft of others’ belongings, shouting, falls, physical/verbal aggression, to resistance to care. Furthermore, our residents have age-muted responses to illness, especially infections, making early identification of acute illness problematic. We have residents who are receiving palliative care and are on pain pumps, have complex wound care, are on enteral feeding, have serious swallowing difficulties and need close monitoring for choking, and from time to time a resident may require intravenous therapy. Clearly, caring for our residents requires a great deal of skill. The role of our healthcare assistants is complex and 14

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In the past 12 months we have had requests to support students from secondary colleges undertaking the Gateway and Pathway programmes. Bethesda Care has opened its doors to students from South Auckland secondary schools so that they can experience what a career in the healthcare sector might be like. The secondary students learn about interventions and therapies required when maintaining the wellbeing of the Bethesda residents. Through this interaction students can assess whether healthcare for older people, nursing, physiotherapy or occupational therapy is a career pathway for them. On their first day, we explain to the students how to treat the residents; we talk about the importance of valuing and venerating older people. We emphasise that when they enter Bethesda they are entering the residents’ home and must show the same respect as when they visit their grandparents. Students learn that physical, social, sensory and intellectual requirements can be provided in creative ways that help the residents to continue to learn and provide opportunities for the students to learn from the residents as well. The students learn how rewarding the work is and what a difference it can make to a person’s life. It’s also valuable for the residents to relate to young people and many have given the teenagers guidance and have played a part in developing the students’ confidence. By the end of the placement the camaraderie between the students and residents is very special. The students from Manuwera High School, Mangere College, Aorere College,

Southern Cross Campus and the Auckland Seventh Day Adventist High School in the Mangere-Otahuhu Youth Guarantee Network participate in the placements at Bethesda as part of a Level 2 health programme supported by either their school or private training organisations. We provide the hands-on component for the course and students earn sector-related credits while they work. The credits go towards a Vocational Pathways Award in Social and Community Services, which positions them for a career in health. They can continue to study for a Healthcare Level 3 National Certificate or progress to a Bachelor of Nursing. Bethesda supports its own employees to increase their qualifications utilising Careerforce training. The success of student placements has resulted in a steady stream of applications for HCA positions, including a pool of casual staff and volunteers. We are able to assess the students’ compatibility with the principles of the Eden Alternative, our resident-directed model of care. Our residents have a shrewd knowledge of student capabilities and help to select staff when there are vacancies for HCAs and volunteers. We like all HCAs to have a minimum of a Level 4 advanced disability support certificate. Where our long-term staff do not have this, we are supporting them to achieve this level of training.

Immigration rules a problem A number of the non-secondary school healthcare students are in New Zealand on work visas and pay large sums of money to undertake healthcare training. Many of these students complete a Diploma in Health Care Management (Level 6) and make exceptional employees. They work up to 20 hours a week as students but on graduation are unable to find work that qualifies as ‘skilled’ under the immigration classification and a work permit. This is very unfortunate as these students have knowledge and skills that are so essential to the quality care and wellbeing of the residential care residents. Immigration classifications include residential care officers as a skilled worker. Unfortunately, the approved position description does not match the role of a senior skilled HCA in residential care so it is difficult to support these students to gain a work visa. This is such a loss to our industry where we struggle to find well-educated, skilled HCAs. By supporting student placements at all levels we hope that Bethesda is contributing to a skilled and viable workforce for the future.

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Why is protein important? Protein is a nutrient essential for the preservation of muscle mass and for benefits to strength, and general health this brings

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RESEARCH

Getting to the HART of ageing Last year INsite reported on the findings of the Inclusion, Contribution and Connections (ICC) study led by Massey University’s Health and Ageing Research Team (HART). Here, we look at HART’s next steps.

he first report from the 2013 ICC study provides some key messages about healthy ageing in older New Zealanders. It showed that over half of participants reported daily internet use, while nearly 16 per cent said that they never used the internet. Those with the lowest socioeconomic status were least likely to use the internet and most likely to report feelings of loneliness and isolation. The survey also showed a demand for small local housing. Nearly half of participants saw themselves moving house in the near future, with the majority of these looking to move to a smaller home in the same area to release finances and reduce work and maintenance. It also revealed the importance of cultural engagement, showing that Māori participants who remained engaged with marae throughout the transition from work to retirement were likely to report greater life satisfaction.

HARTS professors Fiona Alpass and Christine Stephens

Looking ahead to 2016

In 2016 HART will celebrate a decade of research into healthy ageing and retirement in the New Zealand population and planning is now well underway for the 2016 wave of the survey. The Ministry of Business, Innovation and Employment will provide $1.867 million in support of the Health, Work and Retirement study over the next four years to answer two important questions about the wellbeing of the growing population of older people in New Zealand: 1) What kinds of retired lives do New Zealanders want and how can this be supported? And 2) How do early life events and wider societal changes impact on quality of life in later years, and how can these be addressed? Findings will be shared with government ministries, housing organisations, healthcare providers, city and district councils, community and social services, and advocacy bodies. These findings will be used to develop information services, housing provision, and policies that support the health of all older people. HART will be in contact with current participants again and will also be selecting a new random sample from the electoral role to invite additional New Zealand residents aged 55–75 to participate.

Linking to health records

In 2013 HART first asked permission from participants to link their survey data to health records kept by the New Zealand Health Information Service, such as lifetime health diagnoses and levels of health service utilisation. This information will provide accurate healthrelated information and meet international best practice standards for national health and ageing surveys. Such linkages allow researchers to answer questions that neither survey nor health information service records could address alone. This allows the team to provide accurate data for use by national policy makers and for use in cross-national comparisons with sister studies. As for all data collected by HART, all personally identifying information is removed from health records, with names and contact data kept in a separate database stored on a secure server. This important data-linkage initiative will also be offered in the 2016 wave of the survey.

More information about HART’s research can be found at hart.massey.ac.nz

Aged care news, views, trends and analysis If you want to know what your colleagues are thinking or doing in the aged care and retirement sector, subscribe to INsite. Multimedia format includes: » Four print editions per year » In-depth website, newsfeed, opinion pieces and sector updates. 16

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RESEARCH

Ageing Well:

the big challenge ahead INsite looks at the ambitious task ahead of the Ageing Well National Science Challenge, now underway. What is the Ageing Well National Science Challenge?

The Ageing Well National Science Challenge is the fifth of 11 science challenges planned by the Government to tackle the country’s biggest science-based issues. The challenge will bring together researchers from seven New Zealand universities and is aimed at improving the health and wellbeing of older people. The long-term goal is to enhance New Zealand’s ability to deal with the rapid demographic change underway which Science and Innovation Minister Steven Joyce described as one of the country’s biggest long-term societal and economic challenges. Deputy Pro-Vice-Chancellor for Health Sciences at the University of Otago, Professor David Baxter says people are living longer now, with life expectancy in New Zealand having gone up by around 20 years since 1901, pushing life expectancy for men into the late 70s and women to the low 80s. Baxter, who led the challenge through its establishment phase, says in about 10 years people aged 65 and over will exceed the number of children under 15 years of age for the first time in New Zealand’s history. “Over coming decades, the number of people with degenerative conditions such as dementia, arthritis, cerebrovascular disease and frailty will increase significantly. 18

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Furthermore, growing numbers of older people experiencing social isolation, reduced economic participation, and increasing vulnerability to poverty and sub-optimal living conditions will pose additional challenges.” The Ageing Well Challenge will look to address these trends, identifying ways to delay the onset and reduce the impact of these conditions. Researchers will focus on reducing and moderating the impact of dementia, strokes, depression, impaired vision and hearing, and physical disability. The challenge will also develop new techniques and technologies that improve the ability of older people to live independent lives by researching innovations in housing, transport and care services. Five interlinking strands of research are presented to address the mission: 1. Enabling independence and autonomy/tino rangatiratanga of older individuals and their whānau and families 2. Ensuring a meaningful life through social integration and engagement 3. Recognising at a societal level the value of ongoing contributions of knowledge and experience of older people 4. Reducing disability 5. Developing age-friendly environments. The Ageing Well challenge will receive initial funding of $14.6 million. Up to a further $34

million of additional Health Research Council funding for existing projects on ageing tie into the challenge, which complements the new Brain Health Centre of Research Excellence (CoRE) announced last year, aimed at unlocking the secrets of the ageing brain.

A collaborative approach

The challenge will be administered out of the University of Otago School of Physiotherapy’s Centre for Health, Activity and Rehabilitation Research, but will partner with other New Zealand universities and research institutions, including Auckland, Massey, AUT, Waikato, Canterbury, and Victoria, as well as AgResearch and the Centre for Research, Evaluation and Social Assessment (CRESA) in Wellington. Professor Richard Blaikie, Otago’s Deputy Vice-Chancellor (Research and Enterprise) and co-chair of the oversight group for the challenge, emphasises the need for strong inter-institutional collaboration to achieve the challenge’s 10-year mission. “If we are going to realise the longevity dividend from having a healthy, independent and socially connected aged population in Aotearoa, then we must have the best minds from the research community and aged care sector working together on the most pressing research questions, finding practical solutions that can be applied in clinical or community settings,” he says.

RESEARCH “No single institution has all the expertise or end-user connections that are needed, and Otago is very proud to be taking the lead in coordinating the national effort in this particular challenge.” The challenge will be overseen by a Governance Group, of which former Summerset chief executive Norah Barlow has been appointed the independent chair. A Science Management Group will make decisions on which research projects will go ahead. The group comprises high profile researchers and academic leaders from around New Zealand, such as Professors Fiona Alpass (Massey), David Baxter (Otago), Richard Bedford (AUT), Martin Connolly and Ngaire Kerse (University of Auckland). There is also an International Science Advisory Panel to provide an independent perspective on research plans and strategies, review the quality and potential impact of research, as well as translational activities. It will ensure that the science is innovative, meets international best practice, and may provide advice on new or evolving research opportunities. The panel also brings connections with international research programmes and networks.

In 10 years, it is hoped the health and disability support needs of older Māori and Pacific peoples will be met by appropriate, integrated health care and disability support services, and that transformative approaches will be developed to help reduce the stark inequities in health and wellness outcomes that still exist. It is also anticipated that the work of the Ageing Well challenge will deliver a relative reduction of people in residential care facilities and will also introduce affordable housing strategies that facilitate ageing in place, access to home equity and market diversity in housing options. Certainly, no small task confronts the team driving the Ageing Well Challenge. With much of the administrative detail now complete, including key appointments and approval for research projects, it is time to get down to business.

What will the challenge achieve?

The challenge’s mission is to “push back disability thresholds to enable all New Zealanders to reach their full potential through the life course with particular reference to the latter years of life”. Ultimately, it hopes to harness science to sustain the health and wellbeing of older people. The challenge has established a number of ‘high-level impacts’ which they expect to follow from the various research initiatives undertaken. By 2025, it is hoped that national debate stimulated by Ageing Well research and associated stakeholder and public engagement has led to the development of a new government strategy to support the maintenance of health and wellbeing of older New Zealanders. It is also anticipated that local bodies across New Zealand recognise, and have incorporated into planning documents, the importance of age-friendly environments that facilitate engagement and participation by older New Zealanders and value their contributions to society and the economy.

The Ageing Well National Colloquium is scheduled to be held in Wellington on 14 August.

Subscribe to INsite is a magazine at the heart and soul of New Zealand’s aged care, retirement, and community care sectors. Through its close ties with industry associations and attendance at conferences, INsite provides extensive coverage of the issues that are important to the sector. INsite’s four themed editions include retirement villages as a business, long term care needs, nutrition, diet and clinical focus. Each issue is packed with in-depth feature articles and opinion from your colleagues. INsite reaches the decision makers. It is targeted at owners and managers of New Zealand aged care facilities, chief executives, financial officers, directors of nursing, government departments and decision makers directly involved in the aged care and retirement sectors. Subscribe to INsite today so you can be in the know about what really drives the sector.

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Technology

Is it time for a large dose of technology disruption? RON EMERSON discusses ways that technology could improve healthcare for our growing ageing population.

hen it comes to mapping a vision for New Zealand’s healthcare industry, it’s clear that major changes are needed to improve fiscal management and clinical outcomes in order to create a sustainable future; particularly, when you consider that by 2041almost a quarter (24 per cent) of New Zealanders will be aged 65 or older. John Ayling, PHO (Primary Health Organisation) Alliance chair, summed it up when he said, “Our health service is one of the greatest in the world. But we have an ageing population living with more long-term conditions, increasing incidence of obesity, the challenge of technological advancement and rising public expectations, all of which are combining to place unsustainable pressures on hospitals, general practices and aged care providers.”

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Healthcare providers are starting to realise that prevention is better than cure, and that patient care should shift from treating ill health and chronic conditions to prevention and wellness – keeping people healthier for longer.” It’s clear that this continued growth in an older population and subsequent demand on health services infrastructure, including access to specialists and practitioners, poses a significant challenge. Healthcare providers are starting to realise that prevention is better than cure, and that patient care should shift from treating ill health and chronic conditions to prevention and wellness – keeping people healthier for longer.

When wellness and improved care coordination makes fiscal sense

Putting in place a strategy that focuses on wellness and prevention is not only good medicine, but it’s also good business. According to a number of studies, it costs 3.5 times more to treat patients with chronic illness than it does to treat patients without it.

Technology

A study published in The New Zealand Medical Journal reported that 13.8 per cent of all acute medical admissions in over-65year-olds were 30-day readmissions and 25.5 per cent were 90-day readmissions. This is not good for the patient, the hospital, or for the financing agencies. On the other hand, research has shown that excellent planning and good follow-up care coordination can improve patients’ health, reduce readmissions and decrease healthcare costs. With more New Zealanders choosing to live at home as they age, what additional facilities and provisions are they going to need? It is expected that the delivery of collaborative and home-based care will become increasingly important. Home-based care involves a broad spectrum of professionals, from nurses to medical specialists. Together, these advisors and specialists can work to address physical, emotional, spiritual and social concerns that reach beyond a single patient to involve family members and close friends. There is a requirement for collaboration and communication across all types of government agencies and citizens (both healthcare providers and patients with their support networks), regardless of location or situation.

Will disruptive technologies be the much needed catalyst for change?

Technology has long been used within the healthcare industry to deliver patient services and demand has continued to grow. With rapid advances in technology, is it time to question if existing technology is still relevant to the future needs of the healthcare sector? Disruptive technology – essentially any innovation that helps create a new market and value network, and eventually disrupts an existing market and value network, displacing an earlier technology – is predicted to play a greater role in the delivery of healthcare services over the next decade. This includes things like mobile devices, the Internet of Things (IOT), wearable devices, cloud and big data, which healthcare has started to adopt, but which will evolve to become even more critical. In fact, I believe that by 2025, we will see disruptive technology becoming one of the

most efficient ways to overcome healthcare bottlenecks. Increased accessibility to broadband, mobility devices and applications has already enabled healthcare practitioners to deliver primary care. However, by 2025 it is expected that this will be accessible to the majority of all citizens. This will be driven by technology such as tablet devices and video collaboration solutions, which enable healthcare professionals to consult with patients anywhere. Personal connectivity is also expected to change the way health services are delivered. Devices such as personal heart rate monitors, smart textile apparel that monitors the body’s vital signs, and sleep trackers will not only change the way healthcare professionals monitor and treat patients, but will also give patients greater power over their own healthcare outcomes. These disruptive technologies are also expected to enable greater adoption of in-home virtual consultations, support the reduction of in-patient readmissions and increase the number of virtual appointments for remotely located patients.

Healthcare’s tech future

The healthcare industry is indeed transforming – ageing populations, healthcare reform and

rapidly increasing costs are forcing us to do things differently. With these changes comes the need for effectively connecting care providers, team members, patients, and families so they can collaborate naturally and with impact, regardless of location or device. Healthcare professionals need to understand how to take full advantage of disruptive technologies in the delivery of daily services. It will be vital to have leaders with technological experience to properly embed technology into workflows and ensure adoption throughout organisations. Given New Zealand’s geographically dispersed population, we have the opportunity to lead the way in showing how innovative healthcare services and disruptive technology can help alleviate the challenges facing the sector. There is no doubt that incorporating technology like video collaboration into the delivery of healthcare services, will be critical to creating a positive healthcare future in New Zealand and around the world – but healthcare professionals need to start now. Are you ready?

Ron Emerson RN BSN is Global Director of Healthcare for Polycom Inc. For references for this article, please contact editor@insitemagazine.co.nz.

edward@activerehabequipment.co.nz

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July/August 2015

DEMENTIA

The dangers of polypharmacy CAROLINE BARTLE and HELEN BEHRENS discuss the risks associated with inappropriate polypharmacy, particularly for older people with dementia.

s health and social care trainers, we straddle the medical and social model and believe wholeheartedly that holistic and integrated practice is required to enable positive outcomes and wellbeing within our communities. It is our responsibility to encourage staff to reflect upon their clients and the complex nature of the conditions to equip them with skills to observe, report and signpost. One subject often raised is polypharmacy. Many of the services we work with are commonly working with comorbidity and complexities around fluctuating states, often resulting in competing care and treatment strategies. Inappropriate polypharmacy is a very real and present threat, as many prescribing practitioners face tensions between treating common conditions and the risks associated with polypharmacy. Many people with dementia, together with the older population, are affected by polypharmacy. Older people generally will have multiple health conditions that require medication. However, given the potential communication difficulties presented with dementia, particularly around problematic pain management, it is possible that there is a higher prevalence of polypharmacy in this group.

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Polypharmacy carries substantial risks: for example, there may be severe side effects, some of which further compound cognitive challenges.”

What is polypharmacy?

There is no clear definition for polypharmacy. It is sometimes numerical; for example, greater than six medications being taken at once. Accepting a numerical definition of polypharmacy has the disadvantage that it does not recognise that in some cases the

Supporting evidence There is much research to highlight the problems with polypharmacy. In a prospective cohort study of 294 older people, 22 per cent of patients taking five or fewer medications were found to have impaired cognition, as opposed to 33 per cent of patients taking six to nine medications, and 54 per cent in patients taking 10 or more medications. Other research found that polypharmacy affected patients’ nutritional status. A prospective cohort study found that 50 per cent of those taking 10 or more medications were found to be malnourished or at risk of malnourishment. A study in elderly patients with dementia reported that those patients who reported a fall had an increased prevalence of polypharmacy. An American study revealed that two-thirds of hospitalisations for adverse events involved four medicines or classes — warfarin, insulins, oral antiplatelet agents or oral hypoglycaemic agents — taken alone or in combination. For a full reference list, please contact editor@insitemagazine.co.nz

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combination use of certain medications is beneficial to the older person. Inappropriate polypharmacy is when the person takes more drugs than are clinically indicated. Polypharmacy is a concern in this group because there are age-related physiological changes that alter the ways in which drugs are handled by the body. These may include: »» reduced renal function »» reduced liver function »» reduced ratio of body fat to water »» delayed stomach emptying. Polypharmacy carries substantial risks: for example, there may be severe side effects, some of which further compound cognitive challenges. There may also be drug-drug interactions and drug-disease interactions. The impact can be far-reaching; side effects may cause drowsiness leading to an increased risk of falls. There may be adverse effects on appetite and poor nutrition leading to multiple problems, not least a compromised immune system. In addition to the physiological effects, certain medications may change sexual drive, affecting identity and ultimately self-esteem. Changes in mood caused by the medication, coupled with cognitive difficulties,

DEMENTIA

Too Many Medicines? Whanganui DHB tackles polypharmacy may lead to emotional distress and challenging communication. In some instances, the inappropriate use of medication can create the very problem that it is trying to solve. There are many possible causes of inappropriate polypharmacy: »» Multiple physicians »» Self-medicating »» Over-the-counter medicines, including herbal preparations »» Medicine-dependent culture »» Medication administration errors »» Treating medication side effects with other medications e.g. a medication may cause constipation, which may then result in a laxative being prescribed. Alternatively, it may be appropriate to consider a ‘nondrug’ approach: diet. When the side effects of medication are misdiagnosed as symptoms of another condition, further medication is prescribed (cascade prescribing), and further side effects

and unanticipated drug interactions may present. Older people with dementia who take a cholinesterase inhibitor and who experience urinary incontinence are more likely to receive an anticholinergic medicine to manage their symptoms. Drugs including some antidepressants, muscle relaxants, antispasmodics and antihistamines may have anticholinergic effects and, therefore, may cause confusion, blurred vision, dry mouth, light-headedness, constipation, and difficulty with urination and/or loss of bladder control, causing additional difficulties. Within each realm of medical and social perspective, many factors that may be viewed in isolation may be interdependently linked; manipulating one factor may impact upon others. We need to take a balanced approach, informed by consent; at times, pharmacological strategies are warranted, and at others times we should consider nonpharmacological approaches.

A polypharmacy pilot rolled out in Whanganui found that most patients can safely reduce the number or dosage of the medications they take, saving money and decreasing health risks. The pilot, called ‘Too Many Medicines?’, was launched in 2013 to help draw attention to the potential risks of polypharmacy. Whanganui District Health Board allied health manager Louise Allsopp said that taking a number of different medicines puts people, particularly older people, at a higher risk of serious medicine-related side effects. “As we get older, we tend to be given more medicines for different conditions. Sometimes we’re given them by different doctors, so we need to stop and check that what we’re taking, including medications purchased at the supermarket, are working well for us,” Allsopp told the Wanganui Chronicle. The polypharmacy service has reportedly been well received, with many prescribers referring patients, in addition to a number of patient self-referrals.

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July/August 2015

CLINICAL

Bill’s story: dialysis at home Bill Veth tells JOHN ALLIN that living with kidney disease needn’t restrict his life, thanks to his dialysis home support team.

ill Veth was 32 when he wondered whether he was like the proverbial cat with nine lives. In 1979 he was on standby for a sightseeing trip to Antarctica on Air New Zealand Flight 901. But the DC-10 was full and he couldn’t get on. Just hours later, he heard the news that the aircraft had flown into Mount Erebus on Ross Island, killing all 257 on board. “You know what,” says the Invercargill house painter, shaking his head with an expression that betrays both relief and sadness. “There were four of us who couldn’t get on that plane. We were the luckiest people in the world that day.” Bill nods at the dialysis machine set up in the corner of his lounge room where his office desk and fax machine used to be. “That was 36 years ago and here I am with my dialysis machine being given yet another life!” Bill’s kidneys began to fail nearly 10 years ago and since then he has tried different types of dialysis. The most inconvenient one had him hooked up to bags every night for 10 hours, leaving him exhausted as he worked long days and also cared for his wife who was terminally ill with cancer. He even moved out of home for a year and lived in Dunedin where he had five hours of

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dialysis daily, three times a week. Today, Bill is a widower. He is tough, resilient and totally likeable. With the unmistakeable Dutch accent salt-andpeppering his conversation, he describes himself as an “easy come, easy go guy who loves the Rolling Stones, Pink Floyd and Cream”. His craggy, weather-beaten face is a legacy of his life at sea. As an able seaman in the Dutch merchant navy he had seen every continent but Antarctica, which was why he wanted to be on Flight 901. One room of his house is given over to shelves of medical supplies for his dialysis. It is a small sacrifice for the freedom he now enjoys. Like most New Zealanders, he follows the rugby closely. He barracks for the Highlanders or the Crusaders – or indeed any team that gives him a good game. “My mates knocked on the door the other Saturday and within a few minutes we were off to Dunedin to watch a match,” he said. “I drive because I don’t drink so my mates love that. This machine has totally freed me up – it’s brilliant.”

Coffee, telly and a few laughs

Bill has the support of Royal District Nursing Service (RDNS) New Zealand for his dialysis. Support worker Leanne Nieborg-Reid visits Mondays, Wednesdays and Fridays. She helps him connect to the machine and for the next five hours or so he watches TV with a thermos of coffee and the remote just within reach as his blood is filtered. Leanne visits other clients while the process is happening and returns to help ’unhook’ him.

I may have kidney disease but I am so grateful for the freedom that this machine, the Southern District Health Board and RDNS have given me.”

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“I may have kidney disease but I am so grateful for the freedom that this machine, the Southern District Health Board and RDNS have given me,” says Bill. “They have been fantastic and as a result my mind and body are in perfect balance.” RDNS has a contract with the SDHB to provide services to people in their homes and communities. The aim is for people to stay in their homes with whatever support is necessary for them to be safe. In recent times RDNS New Zealand has worked with the specialised staff at the renal unit to help people to be at home with support for their haemodialysis. In charge of the RDNS team is Adele Knowles RN – the company’s service delivery manager South Island. She is delighted with the support being given to people needing dialysis. “The training is tailored for support workers and is provided by the renal team at the Dunedin Unit. Support workers express an interest in doing the training and the successful candidate is selected by RDNS in consultation with the unit after an interview process. Training takes four weeks and is a combination of training in the unit in Dunedin and with clients in the community,” says Adele. “Each year, about 1,000 New Zealand adults are diagnosed with end stage kidney disease, and about half of those will start dialysis treatment. For Otago and Southland the specialised unit is at Dunedin Hospital and people who need haemodialysis will start their treatment there. “Home dialysis is the preferred option for many of these people as they would like to be at home. Most people need some help to get themselves set up on a haemodialysis machine and that help will come from family or friends but in some cases there is not anyone who is able to support them. RDNS can provide that support.” Leanne was the first RDNS support worker to be trained in dialysis at Dunedin Hospital. A second RDNS support worker has just completed her training and has recently embarked on similar work with dialysis clients in the Invercargill area. “I love my job because I feel I am making a difference,” says Leanne. “Bill and I share a laugh and we have enormous respect for each other. Just to see him happy is a reward in itself.” Bill has the final word: “I didn’t get on that aircraft and I have my machine – in fact I have my life. I’m a bit like that cat.”

Community Care

On the soap box... Graeme Titcombe

Access chief executive GRAEME TITCOMBE was recently presented with a lifetime achievement award at the 2015 Home and Community Health Association Conference Awards. Here, he discusses the limitations to providing a nationally consistent and effective home support service.

health and a social impact on wellbeing? How can chronic conditions management and dementia services be safely integrated into home-based services? What is the required relationship between primary, secondary and community care to give a health sectorwide effective, clinically safe and cost effective approach to these issues within the community? The District Nursing Service is a New Zealand institution and is well respected. However, is this really a single service, or would the client be ultimately better served by nursing services at secondary, primary and community care level that integrate to other services more effectively? A person-centred, coordinated service is both advocated and supported. However, what is the trade-off between this ideal and cost effectiveness, the restorative approach and client safety?

The obstacles to an effective home support model – a personal perspective

The New Zealand Positive Ageing Strategy was established in 2001, now 15 years ago. The themes of this strategy have been continued in the Ministry of Health’s Health of Older People Strategy and numerous other government strategy and planning documents. What, therefore, has inhibited progress on such a key objective? There was an initial accountability for the implementation of this programme by District Health Boards in their planning processes and this was reinforced by the Minister of Health’s Letter of Expectation. Whether or not this expectation of direct accountability continues today is uncertain, but there is little evidence of the measuring of this across all DHBs. Undoubtedly, a number of DHBs have made progress in the development of homebased services with their rehabilitation and enablement programmes; others have made very little progress and rely on services that are task-based and build dependency. We have a wide variation of services throughout the country and still have not materially progressed the development of an effective and sustainable home support model. While the implementation of the national interRAI Assessment model is bringing a national consistency to assessment of client need, we have yet to build a consistent national response to that identified need, nor have we embraced the philosophy of an integrated home-based service. That clients favour the philosophy of ‘ageing at home’, and that the changing demographics of the nation require this to occur effectively for economic reasons, are undeniable. However, this is not merely about providing basic home support services in place of residential care services; it has to be about fundamental change. It is more cost effective to keep a client in the home, and to delay entry into residential care by using current home-based services if their requirement for service is less than 20 hours per week. This, however, does not take into account the

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An effective, sustainable service is not about simple replacement of labour, but about fundamental change with measured outcomes.”

potential for increased hospital admissions, which could impose greater costs on the health sector. Nor should the limitations of the current non-integrated home support service be the benchmark for what could be more cost effective under a truly integrated model. An effective, sustainable service is not about simple replacement of labour, but about fundamental change with measured outcomes.

Integration debate needed

We are yet to have an effective debate about the integration of other community services into a home-based model. What should be the approach in the breaking down of funding silos to enable the integration of such services as physiotherapy, occupational therapy and social work into a service that has both a

Debilitating process continues

The greatest limitation to developing the nationally consistent and effective service that was envisaged in the Positive Ageing Strategy has been the contracting, pricing and planning model of this occurring through 20 DHBs and not as a single national process. The recent Deloitte report on home-based service provision that paints a picture of a home support sector in financial crisis is a direct result of this process. Government states that both contracting and service development for home-based services are negotiated between provider organisations and the individual DHBs. A number of DHBs neither negotiate nor develop such services as they have not been directed to do so, or feel that they cannot afford to do so. This debilitating process has gone on like a pantomime video, on a continuous loop, since 2003, and is continuing even after DHBs became aware of the critical financial state of the home support service. An effective, integrated and cost effective home-based service to meet the ever-growing needs of New Zealanders both in volume and in acuity levels will not be developed until we institute a national planning, contracting and pricing model. www.insitemagazine.co.nz

July/August 2015

Clinical

Spotlight on...

chronic kidney disease CARMEL GREGAN-FORD sheds some light on the causes, treatments and management of chronic kidney disease.

ost people have two kidneys. They are located near the middle of the back, just under the ribcage. Each kidney is about the size of an adult fist. They are bean-shaped and reddish brown in colour. The kidneys act as filters to clean the blood. They get rid of waste and extra fluid. They make and regulate important hormones in the body. These hormones control red blood cell production, blood pressure regulation and calcium absorption. When the kidneys do not work properly it is called kidney disease. Kidney disease can happen very slowly without anyone noticing (called chronic kidney disease or CKD). Kidney disease usually affects both kidneys and can also cause damage to other parts of the body, especially your heart. It is estimated that by the age of 70 years approximately 30 per cent of the population will have some degree of CKD. Patients with untreated progressive CKD are at extremely high risk of experiencing a cardiovascular event, and if they live long enough they are likely to require dialysis and/or kidney transplantation. In New Zealand the rate of people requiring dialysis is continuing to increase at a significant rate, almost doubling since 2000. Currently there are 2,600 people receiving dialysis treatment for kidney failure and 1,600 people with a kidney transplant. The main cause of kidney failure is diabetes, with almost 50 per cent of those receiving dialysis as a result of diabetes. Other more common causes include glomerulonephritis (inflammation of the glomeruli, the filters in the kidney), hypertensive nephropathy (damage from chronic high blood pressure), and polycystic kidney disease (multiple cysts on the kidneys). Thousands of New Zealanders are at high risk of developing kidney disease and don’t know it. If you have a family history of kidney disease, are over 60 years old, have a Māori, Pacific or South Asian heritage, are diabetic, smoke or have high blood pressure, you are at high risk of developing kidney disease. Kidney disease can be treated. The sooner you know you have it, the sooner you can get help to keep your kidneys working for longer. 26

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Thousands of New Zealanders are at high risk of developing kidney disease and don’t know it.”

How do you know if you have kidney disease?

Unfortunately, as most people don’t know they have anything wrong with their kidneys until the damage is done, it is recommended those with the above risk factors ask for a kidney health check by their doctor. As many of the signs and symptoms are non-specific and may be attributed to other causes, kidney disease is often discovered by chance. Some of the symptoms can include discomfort or burning when passing urine, passing blood in urine, change in the frequency and quantity of urine, needing to pass urine frequently at night, frothing or foaming urine, and shortness of breath. The main tests are: »» Blood pressure – high blood pressure can be caused by kidney disease or can cause kidney disease »» Urine test for protein – leaking of protein from the kidneys is an early sign of kidney damage in diabetes. The more damage to the kidneys, the more protein they leak »» A simple test of the blood creatinine level enables overall kidney function or the estimated GFR (glomerular filtration rate) to be checked; this will tell you how much damage your kidneys have.

Chronic kidney disease is not usually curable. The good news is that if you find out early that you have a kidney problem, there are a number of ways to help slow down the disease. Lifestyle changes such as losing weight, exercising, eating less salt, stopping smoking and drinking less can all help. For those with end-stage kidney failure there are four treatment options available. These include the two types of dialysis (haemodialysis and peritoneal dialysis), transplantation and supportive care. Currently approximately 600 people are on the waiting list for a kidney transplant. With only around 120 transplants being performed annually, however, many are waiting for a number of years and may die before they receive a kidney. The aim of supportive care is to manage the symptoms of kidney failure without using dialysis or transplantation. Conservative treatment includes medical, emotional, social, spiritual and practical care for both the person with kidney failure and their family/ whānau. Although many people who choose conservative treatment are elderly, old age is not the only reason to choose this option.

Carmel Gregan-Ford is national education manager for Kidney Health New Zealand. If you would like any further information visit www.kidneys.co.nz

Conferences

Conference report:

Retirement Villages Association (RVA), 15-17 June, ‘Opportunities and High Demand’ JANET BROWN reports on the recent RVA conference in Melbourne. RVA president Margaret Owens opened the conference, highlighting achievements over the past year and key issues facing the organisation. Keynote speaker Dr Alexander Kalache, co-president of the International Longevity Centre in Brazil, then introduced delegates to his Ageing Framework, supported by the four pillars of participation, health, security and lifelong learning. Richard Hinchliffe, ANZ, highlighted ways in which operators make things difficult for themselves, and conversely some key indicators for success. Next, James Schofield from First NZ Capital gave delegates a sharebroker’s view of the RV sector. MC Sean Plunket, donning his political commentator’s hat, introduced us to the New Zealand political landscape from a Game of Thrones perspective. Sean identified three key, big picture policy areas that are currently hot topics: entitlement to or rationing of national superannuation, inter-generational discord over property ownership, and assisted dying and euthanasia. Then the focus shifted to research. First, Mark McCrindle took delegates through the results of McCrindle Research’s recent survey of resident wellbeing, using the net promoter score methodology. The RVA sector’s score was the highest yet, 20 points ahead of the next, the online shopping industry, and significantly ahead of the Australian RV industry’s score. Mark characterised residents as usually being “pre-choice resisters and post-choice embracers” and urged operators to keep their offering and service real, relevant, responsive and relational. Mary Wood, from the Retirement Living Council of Australia, gave an update on preliminary results from their recent census and research, which will be used to inform and lobby policy decision makers. After lunch, Cameron Bagrie, ANZ Bank principal economist, gave his customary annual economic update. Michael Voges, executive director of the UK’s Associated Retirement Community Operators, shared with delegates the challenges of establishing retirement villages in the UK, noting that 75 per cent of his sector was currently social housing. Academic staff from Melbourne University briefed delegates on their newly developed multi-disciplinary Master of Ageing degree, and the Healthy Ageing quiz, accessible online at www.nari.net.au

Wednesday’s proceedings started with a high-energy, inspirational keynote address from Rod McGeoch, chair of MediaWorks. Then retirement commissioner Diane Maxwell, who leads the Commission for Financial Capability, updated delegates on the Commission’s work with future retirees and their recent highly successful series of seminars for intending RV residents. Richard Grayson and Richard Gates from the ANZ gave delegates a comparison of the New Zealand and Australian RV and aged care markets from a financier’s perspective. A key difference currently is that New Zealand is dramatically outbuilding Australia in the RV sector, and the reverse applies to building of care facilities. In the intriguingly named “What happens in Vegas doesn’t stay in Vegas” session, Martin Oettli and Andrew Joyce took us with them on their recent group tour of California RV facilities, highlighting key differences. They noted the focus on personalised and anticipatory customer service, the wide variation of pricing models in response to customer preference and need, the availability of care for every need but at a price, and the lack of a safety net for those who can’t afford care. Michael Ambrose then took delegates on a different journey: the process of preparing 17 retirement villages and over 200 shareholders for an IPO process, creating the Arvida Group. Arvida chief executive Bill McDonald completed the story, highlighting the challenges facing him on appointment and describing their determination to create “a corporate that isn’t a corporate”. Next the focus shifted to innovative RV design, with professor Alan Pert and associate professor Clare Newton of Melbourne University highlighting options and key criteria such as social inclusion, community focus, modular and prefabricated building design. We also had a whistle stop tour of some of the highly individualistic designs for the network of Maggie Jencks Cancer Centres in the UK. Delegates were relieved that the Covenant Trustees’ free health checks indicated they were mostly in good shape, although the results for male delegates were not as good as for females. Since 2011, the ANZ has

Norah Barlow accepting her RVA Life Member Award

surveyed delegates annually to discover their current concerns and expectations. Richard Hinchliffe noted the three top issues in 2015 were finding good employees, likely higher wage demands, and increasing levels of compliance; the three top priorities were further building development, improving the quality and skills of employees, and acquiring land for development. Corporate anthropologist Michael Henderson’s conference wrap-up session shared what he described as his obsession with culture – “why we do it this way round here?” After the conference closed, many delegates took the opportunity on Thursday and Friday to experience the unique Virtual Dementia Lab and also explored several local retirement villages. Between sessions, delegates explored the trade show, the $5,000 travel voucher draw, won by Stephen Hanson from Geraldine Retirement Village. The Monday night opening cocktail party gave delegates an opportunity to catch up and share stories from the Grant Adamson Memorial Golf Tournament or the laneways and arcades tour earlier that day. They wined, dined and danced at the conference dinner on Tuesday night, where Norah Barlow was presented with life membership of the Association, and on Wednesday evening had the option of joining 91,500 other footy fans at the State of Origin game at the MCG or enjoying a stunning production of the classic 1930s musical, Anything Goes, at the Princess Theatre. Conference presentations are available online on the RVA website. www.insitemagazine.co.nz

July/August 2015

Conferences

Conference preview New Zealand Aged Care Association 2015 Conference: 8–10 September, Auckland

he theme for this year’s NZACA conference is ‘Aged Care Technologies: From the Page to the Cloud’. For the health sector to be efficient and effective for all New Zealanders, it must be integrated at all levels from primary care through to tertiary care. If this outcome can be achieved for the elderly then everyone will be better off as they are the biggest users of the health system. The goal must be to provide a seamless service for the elderly as they move from community care through to full-time and acute care. For this to happen, the public sector needs to integrate with the private sector, not just in terms of records, but in terms of specialist care and treatment. An elderly person should not have to answer the same question more than once or produce documents unnecessarily, or be moved because the care cannot come to them. To create this outcome, we must continue to adopt IT solutions that allow information to

be shared, meaning seamless care and treatment can be provided. The aged residential care sector has made a good start with interRAI. This needs to be supported by telehealth, e-pharmacy, electronic patient management systems and modern government payment systems. Achieving this outcome will require support and acknowledgement by the Government that developing efficiencies needs resource and regulatory support. There also needs to be an acceptance that IT solutions need to be developed in conjunction with the private sector. There will be 88 companies from New Zealand and Australia exhibiting their goods, from bedding and furniture to continence products, medical supplies, flooring and carpet, nursing and homecare, insurance, laundry and laundry supplies, software and IT companies and many more products used in the age care sector. We are expecting around 300 delegates to attend from all over New Zealand and some from Australia.

Greg Garrett Greg is a registered pharmacist with 25 years’ pharmacy practice experience. He is a shareholder in a retail pharmacy that works with a number of aged and community care facilities and has vast experience with robotics in pharmacy. Greg’s team has developed Medi-Map – a New Zealand- based solution for aged care with electronic charting of medication, administration, audit and reporting and later this year the e-prescription interface for the aged care environment, moving the sector from a heavy reliance on paper-based systems to a fully integrated e-health solution. Greg will speak about medication management and integration in aged care.

Heather McLeod In South Africa Heather worked on health and social security policy issues for government and served on a number of statutory and regulatory bodies. As a consultant professor, she has worked with healthcare funders, trade unions, NGOs, primary healthcare practices, and hospital and pharmaceutical industry groups. Heather became resident in New Zealand in 2010 and since 2012 has been with the Ministry of Health as senior analyst palliative care, advising the Palliative Care Council. She teaches on the postgraduate programme at the University of Canterbury and collaborates with researchers at The University of Auckland and the University of Otago, Wellington. Heather’s presentation will address Palliative Care in Aged Residential Care: Estimates of Need and Strategic Challenges. 28

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Save the date: Careerforce Conference, 2–3 November, Wellington The 2015 Careerforce Workforce Transformation Conference will be held in Wellington on November 2–3. Careerforce has already confirmed four international speakers from the United Kingdom and Australia; people with significant central government and industry experience in the social services and health and wellbeing sector. National speakers are still being confirmed, but will include top officials from the tertiary education, health and wellbeing, and social services sector, to discuss workforce transformations already underway and the planning and actions that are needed to cope with future demands. Early registrations of interest can be made at the Careerforce website.

Dianne Adamson With a background in hospital management and 15 years’ experience consulting to prestigious clients in the healthcare and aged care industries in Australia and New Zealand, Di is known for her ability to connect with people in a way that allows her to uncover the core issues and influence people to achieve outstanding results. Her company, Adamson and Associates, specialises in optimising personal and organisational performance. Her leadership development programme, Solutions from Within, has shaped many upcoming leaders.

Dan Levitt Dan Levitt is the executive director of Tabor Village, Canada, with 300 seniors and a team of 400 employees and volunteers. He is an adjunct professor teaching Long Term Care Administration in the Gerontology Diploma Program at Simon Fraser University. He will be delivering keynote presentations on integrating care pathways and transforming senior care through sensor technology.

Michelle Dickinson Invisibility and invincibility are two superpowers that Dr Michelle Dickinson always dreamed of as a child, and is still trying to achieve them as a full-time nanotechnologist and engineer. With a background in fracture mechanics, Michelle is formally trained in breaking engineering components, but is passionate about devoting her life to breaking stereotypes through her science media work on national TV and radio.

Education & training

A typical day in the life of...

Avril Grant

INsite asks AVRIL GRANT about her job as head chef at Ryman Healthcare’s Charles Fleming Retirement Village in Waikanae. INsite: How did you become involved in this line of work? Grant: I started out working in delicatessens and then got a lucky break when I landed a job with Ruth Pretty Catering. Over the next 13 and a half years Ruth taught me everything I needed to know to be a chef. INsite: Describe a typical day as head chef of a retirement village. Grant: I start at 8am by preparing morning tea, then lunch, then dinner and finally ordering and prep for the next day. I finish about 5pm. While there are the set-piece meals to prepare each day, there are a lot of other challenges. I have to prepare meals for residents with special clinical dietary requirements including diabetes, gluten free and those who require fortified foods. The challenge is to make meals to fit the dietary requirements, but also to provide residents with good variety. There are always extra events such as happy hours, cocktail parties and fine dining events

to prepare for. Fine dining happens once a month and I prepare a special three-course meal for residents who dine in style. Each day there is a base menu to work to, but we have scope to put a twist on it. I like having the opportunity to do that. INsite: What training did you do for this job? What training would you like to do? Grant: I trained with Ruth Pretty before I joined, and the job ticked all the boxes in terms of predictable hours and challenges that I needed. It also meant I didn’t need to travel to Wellington for work – I live on the Kapiti Coast. I started when the village was just being opened, so I began by setting up the kitchen and providing one meal a day, and now we provide more than 160 meals each day.

“

I am a foodie; I love food shows (Rick Stein is my idol!) and events such as Wellington On A Plate are research for me. I love travelling and trying out new food. I’ve been on holiday and already I’ve got a couple of great new things I’d like to try out at fine dining. INsite: What do you enjoy most about your job? Grant: The best thing is the interaction with the residents. I love going out and talking to the residents, and they always let me know what they think. INsite: What are the challenging aspects of your job? Grant: I love the satisfaction of coming to work each day and having such a significant impact because food is a really important part of the day here. Residents really look forward to their meals so you can never have an off day. You have to be great every day.

I love the satisfaction of coming to work each day and having such a significant impact because food is a really important part of the day here.” www.insitemagazine.co.nz

July/August 2015

AGED CARE

Let’s snoop around... Aspen Care JUDE BARBACK finds Tauranga’s Aspen Care Rest Home in the middle of exciting changes.

s far as Tauranga real estate goes, it doesn’t get much better than the spot occupied by Aspen Care Rest Home. The residents’ lounge and dining room overlooks the harbour, which today glistens beautifully in the winter sunshine. Manager Mary McDonald says when she first took over the management at Aspen, in November last year, the chairs were all facing the television so she went about facing some of them towards the view. “But they still turn them back to face the telly,” she says with a laugh. There is a small cluster of residents there now, doing just that – facing the telly. They quiz Logan, Aspen’s flamboyant administrator, about when his morning exercise class is taking place. The majority of the residents are being whisked off in a van to the 65+ club, basically a local set-up for older people to catch up over a cuppa. I get the sense the residents move at their own pace, getting involved with as much or as little as they please.

One resident, McDonald tells me, is hardly ever there as she juggles 65+ club with bingo, coffee mornings and other social engagements. “We’re happy to take any of our residents in the van to wherever they need to go, and pick them up when they’re ready.” Being a small rest home, they can accommodate residents’ requests and engagements. It has just 54 rest home-level beds in total – and like other small facilities I have visited in the past,- it possesses a real sense of community. Aspen was previously owned by Oceania, but sold in September 2014 to three Tauranga businessmen. Being locally owned, McDonald says there is a real effort made to support local businesses and those of the residents’ families. One resident’s daughter is a florist, so she supplies the home’s flowers. Another’s son is a coffee importer so he supplies their coffee; he also runs the men’s group.

Changes bring challenges

The home, originally a Salvation Army rest home built in the 1970s, has undergone massive changes since the new owners took over. Half of the home is a building site. There are builders and tools and half-finished rooms. It is noisy. It will be good when the work is done, however. I see some of the completed rooms, which look fresh and spacious. There are some interesting features to note, including a converted larger room, which 30

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“

Aged care is a great place to be; it grounds you, hones your skills and you learn so much about history.”

McDonald hopes might eventually become a palliative care suite. The home’s famed sensory lounge and garden will be restored as well. McDonald says the renovation, while exciting, has been challenging for the residents and staff, particularly due to the amount of noise. However, one resident, who has taken an avid interest in the builders’ progress, frequently critiquing their work, says he will miss them when they’re gone. The work is expected to be finished in the near future, closely followed by a Ministry of Health audit. Following the audit, Aspen expects to achieve hospital certification and looks forward to extending the services provided to their residents. McDonald says it will be good to be able to offer hospital-level care. “We have one resident who has recently been reassessed and needs hospital-level care. He has been here for 10 years, so he is sad that he has to leave his mates and the staff.” In addition to the changes to the building, there has also been a lot of flux with staffing, which I sense has brought its own challenges. Many of the senior staff have retired and

AGED CARE

in their place there is a newer, more diverse team. Diversity brings its own challenges and McDonald says there are some female residents who prefer not to be cared for by the two male caregivers, and some residents who have objected to being cared for by caregivers of certain ethnicities. I find this confronting and saddening; McDonald agrees, but says she respects the residents’ rights. “Nothing is ever an issue. All requests are respectfully dealt with. Our carers know it’s not personal. It’s about protecting our resident’s rights.” While Aspen isn’t required to have a registered nurse on site at all times, McDonald says they have recently recruited a new grad nurse. Aspen has two fulltime registered nurses, and both think it is important to support and encourage new people coming into aged care. “It’s about giving back,” says McDonald. When I ask why aged care generally isn’t perceived as an attractive option for nurses, McDonald reflects that perhaps they are not convinced that aged care nursing is ‘real’

nursing, as it lacks the emergency content found in hospital settings. “Aged care is a great place to be; it grounds you, hones your skills and you learn so much about history.” McDonald is a nurse herself. A latecomer to nursing, she worked as a carer while studying. She says she has done every shift possible at Aspen, from cleaning and laundry to the night shifts.

Collaboration and independence

Aspen has a good relationship with the other aged care facilities in Tauranga and they collaborate on a variety of activities and professional development. “We pride ourselves on the care we provide, and our friendliness. We encourage family involvement and the independence of our residents.” The camaraderie between residents and staff is clearly evident. I am shown a lovely garden that is apparently the pride, joy and responsibility of Bill, a resident. McDonald jokes with Bill about an escapade where they went on a gardening-related mission to

Bunnings but couldn’t find it and ended up driving all around the Bay. I am looking forward to returning to Aspen to see the home when the work is complete; however, it is nice to catch it in the throes of change. While the commotion and dust must no doubt be frustrating and inconvenient for all, the home is in good heart.

www.insitemagazine.co.nz

July/August 2015

RESEARCH

On the bookshelf... Active Ageing BEATRICE HALE reviews Active Ageing, edited by Andrea Principi, Per H. Jensen, Giovanni Lamura (Pub.Policy Press 2014) and finds it has much to offer policy makers and social gerontologists on the under-researched area of voluntary organisations.

ctive Ageing has much to offer academic readers and those working in voluntary organisations, and of course, volunteers themselves. The book is divided into four parts: the first is a scene-setting and theoretical discussion, and the second provides eight chapters on the experiences of volunteering in different European countries. Part three discusses opportunities and restrictions for older volunteers through case studies in different European voluntary organisations, and part four concludes the book with discussions on the data offered. The value of the book is expressed in the first two chapters; it lies not only in the range of the contributions, but in its conceptual framework, focusing as it does through active ageing, and considering volunteering in all its aspects, including organisational, recruitment and management of volunteers and its relationship with the employment sector, with policy, legal and structural contexts being discussed. The second part of the book discusses volunteering in each of eight countries. One of the important areas for discussion is the relationship of volunteering to employment, and to caring activities. Gender involvement is also explored. Each chapter explores the nature of the non-profit sector in terms of individual volunteering, the meso or organisational level and the policy levels. Very sensibly, the editors start right at the beginning, quoting Haski-Leventhal et al (2009) by defining volunteering as “a relationship between two actors: a volunteer who as a provider gives his/her time freely to help or support others, and a client or recipient who accepts the services provided by the volunteer”. But as this book shows, there are gains, both conscious and subconscious, for the volunteer in the activity of volunteering.

Active ageing – individuals

In the early chapters, volunteering at the individual or micro level is discussed. Older people are often theorised in terms of disengagement theories, which allows, postretirement, for much self-reflection and slow or limited activity. This theory suggests there is a decrease in the interaction between the older person and society. 32

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On the other hand, activity and continuity theories argue that a satisfactory old age is created by remaining active and continuing earlier lifestyles, contributing to different societies and different social institutions, and thereby gaining considerable satisfaction, increase in social interaction and friendships and decrease in loneliness and isolation. It can be self-centred or self-expressive but older volunteers are also motivated by altruism and philanthropic ideals such as the desire to help others. The editors observe that volunteering and active ageing is connected with older people’s role changes, with increasing social commitment, and a willingness to contribute. The value of this is inestimable: social activity can help alleviate isolation and loneliness for many older people,producing gains in social health.

Organisations

Chapter Two sets the scene for focusing on the meso or organisational section of volunteering. This is an innovative and muchneeded approach. The editors focus on the development of organisations and their views and usage of volunteering, and interestingly, the existence of paid work alongside volunteering. It seems that more people involved in paid work are willing to volunteer than those outside paid work. At the meso level, voluntary organisations have to consider the value of older people, and whether they can contribute well, learn the ‘job’ and help in the organisation. They also have to consider the ratio of volunteers to employees. Chapter 11 has several pages of figures showing the wide range of volunteering activities across different countries. The book raises several questions around recruiting and managing volunteers and the place of employees. For example, by recruiting volunteers, are agencies avoiding paying people to work? It counters that volunteers carry out shorter and smaller tasks with less responsibility, and with a different commitment.

Place of family carers

Of considerable interest is (p.292) the comment on the increase in informal care – and its impact on the supply of volunteer carers: “at its simplest, more informal caring may mean less work and funding to bid for

by voluntary service providers than would otherwise have been the case” (as noted, for example, by the Salvation Army in Sweden). Rather than seeing the increase in informal family care as, in some way, potentially reducing the funded demand for the services of voluntary care organisations, some organisations assessed the position from a different perspective. They thought their services would not decrease but would rather increase by the need for more support and assistance to family carers.

Analytical deficit

However, say the editors, there is some need for different volunteer organisations to assess possible future demand, and what that demand might be. They term this an ‘analytical deficit’ on the part of organisations. It seems to me that the editors are requiring a far more formalised approach to volunteering than currently exists. It has been the nature of volunteering to accept volunteers when they appear, consider their recruitment or refer them to other more suitable agencies. But the editors are considering a more structured approach, and that does seem a good idea. The current lack of structured information is based on the contrast between the lack of regular information available on developments in the ‘market for unpaid volunteers’ and the considerable volume of labour market information and analysis available to conventional employers. Most voluntary organisations are not used to thinking in these terms.

Conclusion

This book is an excellent addition to the existing literature on volunteering, active ageing and quality of life. The book demonstrates what many of us know to be the case: that retiring is not to lose out on interesting work, but it is to use our knowledge to the full, to have our wealth of experience used in a productive effective manner, and in so doing, to maintain our own self-esteem and assist in our life-long learning. This book underscores this. It would be good to see an analysis of New Zealand volunteering in terms of active ageing and thus, social health.

Aged care

Last Word... Simon Wallace Simon Wallace

New Zealand Aged Care Association’s new chief executive SIMON WALLACE questions the concept of a ‘TripAdvisor for rest homes’, as discussed in the last issue of INsite.

resh from a long stint working in the tourism sector, TripAdvisor is an issue I’ve been close to. That’s why it’s been fascinating to hear of the developments of a so-called TripAdvisor for rest homes. I’m all for improving the ‘visitor experience’, or in our case the ‘resident experience’, as that’s what people expect these days and rightly so – developing a quality rating system for rest homes is certainly one way of doing that. For those who have the choice of rest home – and let’s remember not all of our residents or their families do – being armed with the best information they can to select the right provider for their situation is certainly important. But I can’t help thinking that choosing a rest home where someone is possibly going to spend the last, and we hope some of the best, years of their life is not like booking a hotel or motel for a night – far from it. So, as a sector we need to be cautious about a rating system of this type. It helps to look to the tourism industry to understand the pros and cons of TripAdvisor. In that industry, staying at the property is not a requirement of making a rating or comment. Booking.com and Expedia are far more reliable because the comments on those websites can only be made by those who have actually stayed at the property. A bad, unverified review on TripAdvisor can potentially jeopardise the viability of a small business.

“

Choosing a rest home … is not like booking a motel or hotel for a night.”

It might be worth looking at the Qualmark rating system used in the tourism industry as a comparison. Qualmark is New Zealand tourism’s official quality assurance organisation. It stands independently of any commercial interests and assesses properties on a wide range of criteria including amenities, conformity to regulatory requirements such as health and safety, and commitment to environmental practices among others. Each property then receives a star rating. Like any quality system, Qualmark is not without its pitfalls and one of those is that it can’t rate service. However, what it does do is give any prospective customer and wholesale booking agent the confidence that the property has met stringent quality standards in order to earn its Qualmark star. I understand that the Ministry of Health (MOH) now publishes its audits of rest homes online which I believe has met with mixed views from the sector. Like Qualmark, the MOH audits cannot accurately reflect the service experience offered by rest homes. But at least it’s a start.

I maintain that individual providers should on a regular basis be measuring satisfaction, but really focusing on dissatisfaction, and where issues are highlighted, act on those. I guess in the end it comes back to ‘buyer beware’ and that means the resident and/or their family assessing the options and making the choice that suits them. So I’m not suggesting that we abandon rating for rest homes. What I’m saying is let’s be careful, look at what happens in other industries for examples so that we’re confident that whatever we adopt is the right system for us.

Nursing news, views, trends and analysis If you want to know what your colleagues are thinking or doing, subscribe to Nursing Review. Multimedia format includes: » Five print editions per year » In-depth website, newsfeed and professional development tools

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July/August 2015

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