INsite May 2015

May/June 2015 | $10.95

AGED care & retirement

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Aged care

Spiritual care

- its place in our

Research

rest homes

Under threat: home and community support services

Management

Meeting the new NZACA boss Design and innovation

New Zealand's first dementia village

Technology

Rating rest homes - the arrival of Aged Advisor

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Ed’s LETTER I attended the Home and Community Health Association’s 2015 conference in Auckland last month. Among the excellent speakers was Professor Nicholas Mays from the United Kingdom, who spoke about the difficulties in achieving a truly integrated health system, one where all parts of health and social care work together to provide a seamless and coordinated service for the customer.

He talked about the Integrated Care and Support Pioneer Programme, which involved 14 groups or ‘pioneers for integration’ across the UK. Each group was tasked with taking a proactive approach to integration and some great examples emerged. One group leveraged self-care through the use of technology; another undertook a redesign of care pathways. But despite the apparent capacity for creativity and productivity at the local level, it was difficult to leap the hurdles presented by central government.

Alliances and initiatives that had the potential to roll out on a larger scale were stifled by central regulatory government bodies and financial barriers.

Here in New Zealand, there is an emphasis on innovative and resourceful service delivery, and the Government is quick to applaud initiatives that are working well. The trouble in New Zealand seems to be that integrated and innovative care provision is only as effective as the district health board (DHB) driving it. Some are better at it than others. We hear of examples like Canterbury DHB’s CREST programme, Waikato DHB’s START initiative, and the Taumarunui integrated health care model. The tricky part is rolling out best practice to other parts of the country.

DHBs can be so effective, but the inconsistencies between them can be problematic. All New Zealanders should be entitled to the same access to health care and the same level of service, regardless of where they live.

Home and Community Health Association chief executive Julie Haggie says the lack of a consistent national approach to planning and funding is placing home and community support services under threat.

Achieving both consistency and innovation is a challenge to health systems the world over as each country strives for better integration within its system. But the sharing of ideas, experience and research is bound to help, as Professor Mays demonstrated at the HCHA meeting. These conferences are invaluable for this very reason.

In this issue...

FOCUS: long-term care needs

2

Rating rest homes: is it about time?

4

Our aged care workforce – when will it become a priority?

6

Spiritual care – is this needed in a rest home?

8

Dementia design – the Kiwi way

10

Canine comfort – pet therapy at play

12

Don’t give up on octogenarians

13

Redefining retirement

14

Dancing with dementia

15

RRR professional development activity

19

Here come the baby boomers

20

Nurturing the social health of older people

22

’You only get to die once’ – palliative care gets an overhaul

23

Spotlight on... oral health in older people

25

Up close and personal with... Simon Wallace

26

Conference preview: HCHA 2015 Conference

29

Let’s snoop around... Pohlen Hospital

30

Key reports released

31

Typical day in the life of... Claire Roskruge, RN

32

Last Word... Brien Cree

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

Attention aged care nurses: RRR professional development activity

In this issue, we’re delighted to give INsite readers access to Nursing Review’s highly regarded RRR professional development article and activity. The RRR article feature in this article is particularly relevant to nurses with an interest in aged care and/or pain management.

Go to the special four-page pullout RRR to find out more.

Reading the article and completing the related professional development activity is equivalent to 60 minutes’ professional development. And if you like what you see, become a subscriber to Nursing Review’s print edition to get regular access to future RRR articles and also online access to its back catalogue of nearly 20 RRR professional development activities on a range of topics.

To subscribe go to www.nursingreview.co.nz/subscribe 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).

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

May/June 2015 Volume 9/Issue 2 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 | May/June 2015

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Technology

Rating rest homes: is it about time?

The arrival of a new website that allows anyone to rate and review aged care facilities and retirement villages has left some providers feeling anxious. JUDE BARBACK looks at the issues that providers face in the push for more transparency and accountability.

“O

ften the residents are left in the living room to sleep/wait for death to happen, in their chairs, with very few activities being instigated or seemingly encouraged.”

So reads a scathing review of an Auckland rest home on Aged Advisor (agedadvisor.nz), a new website that rates aged care facilities and retirement villages. The reviewer (name withheld) has awarded the rest home two stars. They are “not sure” whether they would recommend it to others.

Others are more positive.

“Great food and lovely homely atmosphere! Staff are very attentive and caring,” states the review of a Tauranga rest home – the reviewer (again, name withheld) awarding it the maximum five stars.

It is not hard to understand why some aged care providers are sceptical of a service that allows Joe Public to openly comment on their facility and its operation, but it’s also easy to see why such a site would appeal to the general public. The real question is: will such a site help to bring transparency to the sector and, in doing so, help keep operators accountable to high standards?

Aged Advisor founder and general manager Nigel Matthews believes it will.

“We know that places make changes when the people speak. We wanted to give everyone a voice. One of our goals is to highlight the best, and give those not so good an opportunity to deliver what they promised.”

What is Aged Advisor?

Aged Advisor is a bit like the travel site TripAdvisor, but for rest homes and retirement villages. It encourages residents and visitors to rate aspects of care and operation out of five, and to comment on the pros, cons and whether they would recommend the facility to others.

Nigel Matthews says it was only a matter of time before a comparison site emerged to help people select an aged care or retirement facility, which he describes as “a far more important decision than where one should go to for dinner”.

Matthews, who is also the founder of LifeFriends, a volunteer-based visitation programme, says the idea for Aged Advisor came from a frustration with how

something was not working as well as it should be.

“After assisting parents move for a third time in two years due to changes in health, it became clear that retirement homes and aged care facilities varied greatly in environment, activities, workplace culture and management approaches. Although there was audit information available on each of the facilities, this primarily covered health systems and processes – there was nowhere that you could go to compare facilities or read reviews from people who were either residents or friends and family that visited.”

And so Aged Advisor was born. The intention was to create a site for people to share their experiences – good or bad – so that others can make informed decisions on where they or their loved ones can plan to spend the next stage of their lives. There are plans to extend it to a range of other age-related services, including home and community support services.

Independence the key

In some ways, it is surprising there hasn’t been such a site until now in New Zealand.

Aged care facilities in New Zealand are operating at high occupancy levels.

Extensions and new facilities are being built in order to keep up with demand as the number of older adults rapidly increases.

Yet, until now no site has existed to review and compare these facilities. ElderNet is developing its own feedback and review section on its site; it is currently in test phase.

Both the United Kingdom and United States have comparison sites. The UK site has several thousand comments; however, the review component appears very limited and the sites do not seem to be fully independent of government or health care funding. Matthews believes maintaining independence is important, and as such this is a key feature of Aged Advisor.

Public keen, providers not so sure

The general public appears keen for more information on aged care facilities. People outside of the aged care sector told INsite they would be interested in reading people’s 2

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Technology reviews and ratings of rest homes and retirement villages.

“I’d keep in mind that it is just their opinion, but I’d still be interested to read what people have written about a home, particularly if I was looking into a rest home for my dad,” said Waikato dairy farmer, Alan Charles.

“It would be good to see what people have to say about rest homes, although there would need to be at least several reviews for it to have any credence,” said Neil Morris of Te Puke.

While Aged Advisor is essentially meeting a public need, Matthews is also keen to get buy-in from aged care providers and retirement village operators. They have contacted each facility or facilities’ head offices, advising them of the new website and the need for them to ‘opt in’ if they would like to receive immediate emailed notification of the reviews about their facility when posted.

Facilities also have the opportunity to ‘upgrade at their discretion’, which allows them to add photos, video, contact details, a website link, and also the ability to reply to any comments or reviews from users.

Matthews says aged care facilities can currently upgrade their listing from $29–$49 per month and retirement villages from $59–$99 per month, depending on size. The costs for upgrading are based on the number of beds.

Some providers have expressed concerns over the site.

Fran Pucilowski, manager of WesleyCare in Papanui, Christchurch, says perhaps consumers will find the site useful, although she is not convinced it is something the sector particularly needs. She says she had never used TripAdvisor or other such sites to publicly review services.

“If I didn’t like the hotel I stayed at, I simply wouldn’t go there again. And if I wasn’t happy with the care provided at my mother’s rest home, I’d remove her. You let the cares speak for themselves, really.”

Pucilowski said a bad review could be really damaging, especially when they’re all trying so hard to do a good job.

Robyn Molony, manager of Holly Lea retirement village in Christchurch, agreed it would have a “hugely damaging effect” if a negative review appeared.

Matthews says that in the event a comment is posted that the facility disagrees with, or it falls outside of Aged Advisor’s review policy, the facility owner, or anyone else logged in, may report the comment for moderation. That comment is then immediately removed from view until it has been moderated.

“We know that places make changes when the people speak. We wanted to give everyone a voice. One of our goals is to highlight the best, and give those not so good an opportunity to deliver what they promised.”

“If the facility has upgraded, then they can also reply to the comment, which we see as an excellent opportunity of showing how responsive and open a facility is in dealing with people’s comments and suggestions.”

Matthews says the organisations that do a fantastic job shouldn’t be nervous about the introduction of Aged Advisor.

“Just like the restaurant review sites, people become familiar with comments given and can see through certain one-off comments where the majority share a different perspective.

“No one wants a bad review – and just like TradeMe has shown with their feedback, people go out of their way to be nice and helpful to ensure great feedback. We do hope that Aged Advisor helps raise the quality of care given to such an important generation.”

Even so, some providers have voiced concerns over whether the site was the best way to communicate a resident’s or family member’s dissatisfaction with a service.

“There are formal, approved processes people can take if they aren’t happy with something,” says Molony.

Matthews says they certainly encourage users to follow the approved complaint process outlined by the facility.

“However, we also understand how intimidating a formal complaints process can be, and for many the idea of having to lay a formal complaint carries with it the fear of retribution or being branded the ‘difficult’ one. If a situation has to get to the formalised stage just to be heard, then there is clearly room for improvement on the facility’s behalf,” says Matthews.

Molony is also sceptical about the validity of the reviews, saying it would be easy for people to skew the ratings.

“What’s to stop a facility getting all of its staff to give it excellent reviews?” she questioned.

The New Zealand Aged Care Association even encouraged providers to take this approach. In its In Touch newsletter, the association urged providers to encourage residents, staff and family members to write positive reviews about their facility.

“You should consider this an essential part of your marketing plan. This site is effectively just a physical manifestation of word-ofmouth promotion that takes place within any community.”

The push for transparency

In spite of some reluctance from aged care providers, there is no denying the public has been hankering after more transparency from the sector for some time.

It was this push for more public accountability that prompted the Ministry of Health’s decision to post full rest home audits online.

Following a positive six-month trial of publishing the full audit reports online, the Ministry decided to continue with the practice. During the trial period, over 200 people per week visited the full audit reports site, with around 80 of those downloading a copy of a full audit report. In the two years prior to the trial, the Ministry confirmed they received just 12 requests under the Official Information Act for full audit reports.

The Ministry has worked with key stakeholder groups, including Age Concern, Grey Power, the New Zealand Aged Care Association, and Consumer NZ, to further improve the audit reports, making them more streamlined and reader-friendly, while still retaining the full content.

Many rest home operators were initially a little fearful of the decision to publish full audit reports online.

Routine audit inspections look at approximately 247 criteria within the 57 health and disability standards, with which facilities are expected to comply. The average number of failings across the industry apparently sits at around 15 (out of 247) and there is a tendency for the public and the media to focus on the 15 things they are doing wrong rather than the 232 things they are doing right.

Even when these routine audits are complemented with an internal auditing process, it is still not feasible for most rest homes to address the individual care for each resident in these audits.

Unannounced inspections are more useful, but these generally occur only when a complaint has been raised.

Making full audit reports publicly available could be considered a lightweight approach in comparison to that taken by other countries.

The United States, for example, applies a five-star rating system to its rest home audits.

The audits operate on an unannounced, spot-check basis with full transparency and heavy financial penalties for facilities that www.insitemagazine.co.nz | May/June 2015

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Aged Care

Technology

Our aged care workforce don’t meet the standards. Rest homes are given a rating of one to five stars based on state-conducted health inspections, nursing and physical therapy staffing, and quality of medical care. The ratings are then posted on Nursing Home Compare, a website run by the federal Centers for Medicare & Medicaid Services.

Compliance and customer satisfaction not the same thing

Audit reports tell only half the story though. Audits are a measure of a facility’s compliance, and are not necessarily a reflection of customer satisfaction levels.

Most rest homes and villages will routinely conduct some sort of customer feedback survey and report the results back to residents and families. However, there has never been any move to make this sort of information public.

In an opinion piece for INsite, Consumer editor David Naulls said the individual experiences of residents and their families need to be heeded by the sector.

“We continue to hear from people who tell us their relative – often their mother or father – has been in a home where there have been failings in care. We also hear from people who have experienced good care and are full of praise for the home.

Unfortunately, there are more of the former than the latter. More than the bare statistics, it’s these experiences – good and bad – that the aged care industry needs to listen to and learn from.”

Perhaps this is where a site like Aged Advisor might add value – as a forum for examples of good and bad care to be heard.

A review might tally with what an audit report says, or it might give a different picture. It is up to users to weigh up the reliability of the information at their disposal, make their own impressions of a facility or village, and draw their own conclusions.

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– when will it become a priority?

A new survey shows that while aged care workers love their job and value the training they receive, low pay levels, high workloads, an ageing workforce and an increasing demand for aged care add up to a concerning picture for the sector.

How many more research reports and legal battles will it take for funding and workforce pay levels to be properly addressed? By JUDE BARBACK.

J

enny Goodman’s pay sits just above the minimum wage. For a long time the community support worker earned $8.50, before the DHB rate increased her wage to $14.10 in 2007, where it sat for seven years until increases in the minimum wage brought about small increases. Jenny’s role includes household management and personal care for a range of clients, most of whom are over 75 years old. She ended up in community support work “not for the pay but for the love of the job”.

Goodman is typical of the 900 caregivers surveyed in the inaugural New Zealand Aged Care Workforce Survey, carried out

by Dr Katherine Ravenswood from AUT University’s New Zealand Work Research Institute.

According to the survey, which gathered responses from approximately 600 home and community support sector workers and 300 aged residential care facility workers, the average aged care worker is female, aged over 45, the primary breadwinner in her family, but earns $15 or less per hour.

She sees herself as skilled but low paid and while she generally loves the work she does, her morale at work is slipping.

Ravenswood says low pay, high workloads, an ageing workforce and an increasing demand for aged care add up to a concerning picture for the sector.

“Overall, our impression is that although many caregivers love the job and have good management support, the negative aspects of their work outweigh the positives.

This should be a major concern for those planning for the future of New Zealand’s aged care workforce.”

New Zealand’s ageing population is growing and if the workforce tasked with ensuring its care and wellbeing is becoming demoralised and looking elsewhere for better pay and employment conditions, then surely this is of concern to everyone.

A tick for training

With all the emphasis on low pay levels, it is easy to forget the good things that are happening in aged care workplaces, such as the positive developments around education and training. The AUT survey confirmed the anecdotal evidence that caregivers are receiving welcome opportunities for training to support them in their role.

Employers are finding creative ways of training their workforce that don’t impinge on scant resources.

Eldred Gilbert, from the HHL Group (the parent company of Healthcare New Zealand), shared with attendees at the Home and Community Health Association’s recent conference her experience of rolling out a free e-learning dementia course to a group of 14 learners, all of whom passed.

“We had no budget, no time, a willing branch manager – we made it happen,” she said.

At the close of the presentation, an attendee asked if the learners’ efforts were recognised in their pay, to which Gilbert responded, “Two words: I wish”.

“The training carries an intrinsic value,” she said, “but it does nothing to put bread and butter on the table.”

The intrinsic value of acquiring knowledge and upskilling should not be dismissed out of hand. In a subsequent session at the HCHA conference, Cherie Saunders from PSN Enliven shared from her experience that one of the main barriers to learning was the attitude of the learners; many saying they were “too old”, “too dumb”, “no good at school”, or English was their second language.

However, once these barriers were overcome and the learners successfully completed their training, Enliven’s evaluation revealed that their training not only helped the learners with their job and their clients, but also improved their

Aged Care personal lives, in areas of communication and stress reduction.

Goodman shares a similar experience, where a fear of learning was turned into personal and professional gain.

“It can be difficult for some women who have never received any qualification, are illiterate, and have not been exposed to a classroom environment in a long, long time. A colleague admitted she couldn’t read or write, and the employer set her up with a friend and they underwent literacy training and then went on to get Level 2.”

Industry training organisation Careerforce has introduced a Peer Mentor Programme to help address such issues. Peer mentors are carefully selected people within facilities who can help co-workers identify and overcome their barriers to learning, and support them to complete qualifications. Their mentoring role extends to raising workplace awareness of literacy and numeracy issues, as well as becoming champions for new ways of working or new technology.

Careerforce and Health Workforce New Zealand are also driving one of the more exciting initiatives on the table at present: the Kaiawhina Workforce Action Plan, a plan focused on developing the health and disability non-regulated workforce. It includes closer inspection of future training needs and career pathways.

As part of this, and tying in nicely with a review of all qualifications, Careerforce have started to launch their new qualifications, with more to follow this year. The first batch included the New Zealand Certificate in Health and Wellbeing (Levels 2 and 3) and the New Zealand Certificate in Cleaning Level 2.

Careerforce transition manager Penny Rogers says they wanted to look beyond a ‘tick-box’ approach to gaining the qualifications.

“When we developed our new learning and assessment material, our focus wasn’t just on helping trainees to understand the requirements of their role; we also wanted them to gain the skills they’ll need to improve the health and wellbeing outcomes for those they support,” says Rogers.

This is exemplified by the Health Assistance and the Support Work strands of the qualifications, which focus on developing carers who can work with others to support people using a person-centred approach.

“The qualification suite as a whole will allow employers to develop experienced staff and provide them with further opportunities for skill development and recognition,” says Rogers.

Most find it rewarding being able to help older people and are able to draw satisfaction from the fact that they are making a difference.

The intrinsic benefits of job satisfaction, training opportunities and feeling valued are significant. But, as the AUT Survey also concludes, the negatives – namely low pay and high workloads – are starting to outweigh the positives for aged care workers.

The Caring Counts initiative, Kristine Bartlett’s ongoing pay equity case, and pressure from aged care providers all help shape the growing argument for the Government to increase funding to these sectors.

The recently launched Deloitte report on the sustainability of the home and community support services sector shows that many providers have responded to insufficient funding by increasing employees’ workloads yet not their pay, leading to high turnover rates.

The sleepover case and in-between travel time negotiations are steps towards a fairer deal for community support workers, but Home and Community Health Association chief executive Julie Haggie says the lack of a consistent national approach to planning and funding is placing home and community

support services under threat as providers struggle to stay afloat. She says that although DHBs have agreed a national funding model based on client need, until this is implemented the situation will only get worse.

How many more reports, research, surveys and legal battles will it take for funding and workforce pay levels to be properly addressed?

While there are obvious cost pressures on the Health budget, the value derived from social capital shouldn’t be ignored.

Economist Dr Ganesh Nana stresses the importance of social capital and the increasing irrelevance of GDP, which he describes as a flawed economic measure as it doesn’t take into account the future or social aspects. He says the New Zealand Treasury’s Higher Living Standards are an attempt to look beyond GDP, factoring in ‘sustainability for the future’, ‘increasing equity’, and ‘social infrastructure’ alongside more traditional, monetary economic measures.

Under this framework – one that places value on the social inputs and outputs – investment into the aged care sector, and consequently into its workforce and the people they care for, is likely to produce benefits that extend well beyond the balance sheets.

“Overall, our impression is that although many caregivers love the job and have good management support, the negative aspects of their work outweigh the positives. This should be a major concern for those planning for the future of New Zealand’s aged care workforce.”

Love of the job is not enough

The AUT survey found that caregivers generally love their jobs. Indeed, it is hard to find a caregiver or community support worker who, in spite of the poor pay, dislikes her or his job. www.insitemagazine.co.nz | May/June 2015

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Aged care

Spiritual care – is this needed in a rest home?

Do caregivers understand what spiritual care is and how to meet residents’ spiritual needs as they approach end of life? JUDITH HARDIE discusses her research into spiritual care in New Zealand rest homes.

S

ome years ago a friend’s mother asked that I visit her. A resident in care, her life was nearing its end and now the estrangement from her childhood faith caused by a marriage that had not been accepted by her denomination caused her to be fearful of death. She was distressed by her memories of childhood teachings of what her fate might be. She wanted help. I listened. We talked.

She gave permission for me to contact a leader of her former denomination to visit her. This was done, her fears dispelled in the light of her denomination’s current teachings and a few weeks later she died in peace. For me this was a profound experience.

It raised the question, what exactly is meant by ‘spiritual care’ ? Furthermore, if the provision of spiritual care to rest home residents is mooted then a further series of questions arise – who is likely to need spiritual care? Who is to provide it? Finally, and of real importance to the frail elderly, when does such care need to be offered?

It was with questions such as these in mind that I began two years of research to discover answers. I had some knowledge of the spiritual needs of the frail elderly in rest homes, gained from many years of pastoral work amongst them. However, I came to understand there were greater, often unspoken, spiritual needs amongst the residents with whom I had no contact. As a consequence, I began to explore a way to discern the spiritual needs of the frail elderly and whether or not these were being met.

To accomplish this I employed a qualitative research methodology. I gained the support of the managers at two rest homes who gave permission to work and talk with residents and caregivers. Residents, staff and management were then interviewed to address the question: to what extent and in what ways is spiritual care a part of the caregiver role in New Zealand rest homes?

Holistic care in rest homes has long been regarded as providing the physical, mental and social care so essential for residents’ quality of life. Only since the latter part of last century has the importance of spiritual care of the elderly become more widely recognised.

Caregivers providing spiritual support

Within the rest homes of my study, religious care was officially provided by chaplains, local 6

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church workers or leaders of other faiths, all of whom ministered to those for whom both the teachings and participation in the rituals of their faiths was important. But there was another group of workers to whom some residents turned – the caregivers.

The rest home caregivers were aware it was possible to call on the help of religious professionals if a resident asked for this.

However, when talking with caregivers I found the need for spiritual care was less well understood. Spirituality was regarded as an element of the residents’ culture – I was given as examples the food constraints of Jewish residents and the dying rituals of Māori as being their ‘spiritual’ needs. Otherwise spirituality was felt by caregivers to be a deeply personal and private element of life beyond a boundary that must not be crossed. Yet I found that it was often the trusted caregiver, the woman or man who offered intimate, personal care each day, to whom a resident would turn for help in sorting through the spiritual dilemmas that troubled them.

for meaning of life, for answers to definitive questions about life. At no time does this quest become more important than when life appears to be drawing to an end.

Within the rest home community the residents’ frailty and inability to participate in life as it was formerly lived now gives long hours for private contemplation. Pain and helplessness, fears of death and what, if anything, might be faced after death, become accentuated, particularly in the long hours of night. Caregivers on night shifts spoke of distressed residents – when loneliness, deterioration in health, hopelessness or seeming alienation from loved ones became too much to bear. When asked if residents ever spoke to them about their fears, most answered that spiritual questions revolved around how the residents expressed a wish to die but feared the outcome of death. The caregivers listened but were only able to respond to residents from their own religious or spiritual backgrounds, constantly aware that there were boundaries they must not overstep.

Religion or spirituality?

More training needed

It is not easy to make a clear distinction between religion and spirituality, as each, to a greater or lesser extent, may embody elements of the other. Their significance in the life of the ageing will depend on the individual life experiences of those to whom care is offered.

In assessing the role of caregivers in attending to spiritual needs, dimensions of religion and spirituality are both therefore relevant.

Understanding the ways in which thoughts of religion and spirituality converge or diverge as ageing brings changes in the lives of those cared for was particularly relevant to my study.

I found that caregivers, exposed to the spiritual needs of rest home residents, needed to be helped through training to recognise that it is not always a religious response that is required – sometimes attention to the spiritual response is more appropriate.

Through religious practices some people are able to find shared answers to questions evolving from transcendental experiences.

People in such a community find comfort and strength in facing the unknown in daily life. For many people, however, the practices of religions have no significance, yet they do not deny the need to understand the meaning of life. At the heart of this study, therefore, was spirituality defined as a personal quest

From my research, I consider that caregivers are very likely to be the staff members in rest homes to hear residents’ stories, through which their spiritual needs might be identified. Caregivers’ personal involvement in the life and concerns of those for whom they care appears to be a positive factor in promoting the residents’ wellbeing. However, it must be acknowledged that while they are intelligent women and men, many caregivers have limited educational backgrounds or skills. This, accompanied by ethnic and language difficulties, places them in a complicated position with regard to finding the resources or opportunities to develop skills in understanding or responding to residents’ spiritual needs. The training curricula for caregivers could include a greater emphasis on this aspect of caregiving.

Spiritual care is an important aspect of holistic care. The context of the work of caregivers places them in positions to hear residents express their spiritual needs. Their caring brings them into the wider network of physical and social care offered by rest homes.

A greater understanding of the spiritual needs of residents will enhance the care they offer and contribute to the holistic care so important to the frail elderly.

Design and innovation

Dementia design – the Kiwi way Rotorua will be home to New Zealand’s first dementia village, based on the acclaimed Dutch village De Hogeweyk.

JUDE BARBACK talks to Thérèse Jeffs about her vision for the village and the journey so far.

A

t the country’s first dementia village, residents will be able to wander down to the sports bar for a drink, buy their groceries from the supermarket, and meet family and friends in the cafe. They will live in households with like-minded people and participate in running their household.

It all sounds a far cry from the secure dementia units with which we’ve become so accustomed.

The village, which is expected to open in Rotorua in May 2017, is the vision of manager Thérèse Jeffs and her team at Whare Aroha CARE, an aged care facility in Rotorua wholly owned by the Rotorua Continuing Care Trust, a not-for-profit charitable trust. Thérèse’s quest for better care delivery at Whare Aroha took her on a journey that led her to the renowned dementia village De Hogeweyk in The Netherlands, from where she took her inspiration.

In search of better care delivery

Thérèse says the concept started with a general dissatisfaction with the way care was delivered. She felt there was a lack of emphasis on the person receiving the care. A resident’s background, preferences, needs and wants were often forgotten in the process, and with everything done for them, a resident could become institutionalised very quickly.

“Everything gets taken from you – you can’t make a cup of tea because of the Health and Safety police; you can’t cook a meal – your food just appears; you can’t do your own washing. People are plonked together and treated as ‘a people’, not individuals.”

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Thérèse makes the point that we’re all very different and that huge assumptions are often made about what is best or appropriate care for individual residents. She gives the example of giving residents fish and chips to eat out of the newspaper, when many were probably brought up to eat fish and chips off a plate with cutlery.

This desire to do things differently prompted Whare Aroha to pursue elements of the Eden Alternative philosophy.

Yet they were still limited by their old building, located adjacent to the lakefront near the Rotorua CBD. With the lease expiry looming, they needed to think about finding a new site and building a new facility. Approximately 80–90 per cent of residents across all levels of care at Whare Aroha have fairly advancing dementia, so dementia-friendly designs were top of mind.

A visit to the Hammond Dementia Design School in Australia was a source of inspiration. They looked at a range of different designs and ideas, but the De Hogeweyk concept “just felt right”.

Following a trip to London to see family, Thérèse added an excursion to De Hogeweyk to her itinerary. The visit proved to be invaluable.

“Essentially it will reflect a typical small Kiwi town made up of streets and houses, with shops and facilities including a supermarket, a cafe, a sports bar, a hairdresser and a library.”

The De Hogeweyk concept

De Hogeweyk is part of the Hogewey care centre in The Netherlands. Its 23 houses accommodate 152 older people living with dementia.

Perhaps the most interesting aspect about the structure of De Hogeweyk is the way the houses are differentiated by seven different lifestyles, allowing residents to live in a manner to which they are accustomed.

Groups of six to eight residents with shared values, interests and backgrounds live together in a lifestyle-group.

The ‘homey’ lifestyle allows residents to participate in housekeeping tasks, like folding the laundry, for example. The residents of these households might enjoy old-fashioned games and traditional Dutch cuisine, whereas residents in the ‘gooise’ (upper class) lifestyle will tend to eat fine French food and attend classical concerts.

The design and decoration of the homes reflect the various lifestyles. So while the ‘gooise’ homes are elaborate and classical, the ‘homey’ homes are more solid and traditional in design.

In addition to the ‘homey’ and ‘gooise’ lifestyles, there is also an ‘artisan’ lifestyle, for residents whose lives revolved around their trades; a ‘Christian’ lifestyle which is based on the Dutch Reform Church; an Indonesian lifestyle initially created for those who had returned from the Dutch colony in Indonesia which is slowly being phased out as fewer residents now fit this profile; an ‘urban’ lifestyle; and a ‘cultural’ lifestyle.

While some argument could be made as to whether it is appropriate to segregate people in this way, the lifestyle approach means residents find comfort and familiarity in their surroundings, allowing them to remain active in daily life. With the help of staff members, the residents manage their own households together, taking care of washing, cooking and cleaning themselves.

Design and innovation The Hogeweyk approach draws inspiration from everyday life. Residents have already shaped their own lives, making decisions along the way about their own household and standards. While dementia may prevent them living as they once did, it does not follow that they no longer have a valid opinion on their day-to-day life and surroundings.

The public spaces of Hogeweyk village offer the residents privacy and autonomy.

The village has streets, squares, gardens, water and a park, with much emphasis on green spaces to enhance the wellbeing of residents and provide them with a recognisable setting. There is a supermarket, a restaurant, a bar, a theatre, shops, healthcare facilities and others. Residents can roam freely around the village, but they remain inside the protected environment.

Building a New Zealand version Following her visit to De Hogeweyk, Thérèse and her team attended a Dementia Care Innovations Conference in Sydney, where they met with the managing director of De Hogeweyk, Janette Spiering and cofounder, Yvonne van Amerongen. Thérèse expressed their interest in creating such a village in New Zealand.

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“They gave me the plans for De Hogeweyk but said ‘don’t build this, you need to build a New Zealand version’,” says Thérèse.

And so began the process of working out what a New Zealand dementia village should look and feel like. They secured 1.4 hectares by Lake Rotorua in Ngongotaha, approximately 10km from their current location. They gained resource consent for a one-level village to house 80 residents.

With Ignite Architects on board, the plans for the village are coming together, although they are subject to constant tweaking.

Essentially it will reflect a typical small Kiwi town made up of streets and houses, with shops and facilities including a supermarket, a cafe, a sports bar, a hairdresser and a library. It will have gardens, squares, and promenades, and features commonly found in a New Zealand town, such as street furniture, seating, post boxes, and street signs. There will be a strong emphasis on the village’s proximity to the lake. The village will have secure, light fencing with one access in, one access out.

The accommodation will be divided up into households. Each household will have six or seven people in it, as well as one key person (a member of staff) who will help with cares, household management,

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budgeting, and so on. Thérèse acknowledges it will be quite a different sort of role for many staff and says staff are very excited about the prospect.

Perhaps the most difficult aspect of replicating the concept in New Zealand is how to group people according to lifestyle and shared interests.

Upon entering the ‘gooise’ house during her visit of De Hogeweyk, Thérèse commented that she could imagine her mother being happy here, but was appalled to be told it was the ‘upper class’ household.

Indeed, it is hard to envisage such class segregation working in New Zealand.

The University of Auckland is helping Thérèse and her team with this complex task.

There are crude assessment tools available to help group people, but it will need to be more finely tuned for a society like New Zealand.

Thérèse says households won’t be formed on the basis of ethnicity. Nor will they be defined by the level of care. Therefore each household will be equipped to accommodate people at rest-home level, dementia level, and hospital level, including end-of-life care.

Funding for the various levels of care will not change, although Thérèse suspects the contracts held with the Ministry of Health and the District Health Board may need altering. She says they will probably have to look at certification a little differently as well, and auditors will have to think differently about the model of care they are offering.

Thérèse says that while the ‘front of house’ may look different, the ‘back of house’ will still look the same in terms of financials, quality, staffing, care hours, and so on.

It is a huge project and there is a long way to go, but the prospect of taking dementia care to a new level is exciting.

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Register your interest at www.careerforce.org.nz www.insitemagazine.co.nz | May/June 2015

9

Aged care

Canine comfort

– pet therapy at play ANNETTE DOUGHERTY says pet therapy is highly valued at many aged care facilities in New Zealand.

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wenty-five years ago, Eileen Curry took her golden retriever Kris to visit a friend who had recently moved into a retirement home where she couldn’t take her beloved dog. It was this visit that inspired Eileen to establish Canine Friends Pet Therapy Inc, in the Lower Hutt suburb of Wainuiomata. She founded the organisation with Cay Bridge, Joan Mackie and Elaine Varcoe, who all shared a desire to help and an understanding of dogs and people.

Canine Friends was initially trialled in four residential care homes in the Hutt Valley, with positive results.

Big growth from small beginnings

Eileen’s first visit to a rest home in Lower Hutt was memorable.

She was greeted with rows of elderly smiling faces waiting for her to speak. She was handed a microphone and asked to describe her dogs, including what they ate, where they slept, and so on. Obligingly, Eileen talked a little about her dogs. She spoke about how they were part of the family, and how the greatest joy was having a dog you could trust, talk to, love and receive unconditional love from in return. Then she stopped.

“Talking about my dogs isn’t pet therapy,” Eileen said. The residents and staff looked puzzled. “Wouldn’t you rather meet my dog, Kris?”

The residents nodded eagerly, so Eileen walked amongst them as they smiled, chatted and stroked Kris, though of course she avoided those who were unsure of dogs. As she walked and talked,the residents recounted stories of their own dogs and how much they were missed. Before they knew it, the bell went for lunch and the staff asked everyone who had touched the dog to wash their hands.

Despite striking some initial resistance over health concerns with patients and residents, support began to grow as word got around about the difference Canine Friends was making. What started with four founding members is now a national organisation of over 400 volunteers who share the company of their well-behaved dogs with hospital patients and residents of hospitals, hospices and rest homes.

The organisation has a governing body in Wellington that meets monthly. It is a fun organisation that brings much satisfaction and pleasure to both members and to the people they visit, both young and old.

Who can join?

To be considered to become a Canine Friends Pet Therapy member, applicants need to go online and complete the application form, which can be emailed or posted to the new members coordinator.

Once the application has been processed, it will be sent on to the appropriate liaison officer in that area, who will then arrange a suitable time to meet and assess both dog and owner for suitability.

All sorts of dogs make good pet therapy dogs. Size, shape and breed are not important – it’s all about temperament. It is a job for dogs who like people, who love being patted and fussed over, and dogs who can concentrate for around about an hour and stay reasonably calm. All breeds of dogs are considered, except those listed as banned under the New Zealand Dog Control Act 1996, such as the American Pit Bull, Dogo Argentino, Fila Brasileiro and Japanese Tosa breeds. Dogs crossbred with these breeds are also not selected.

“Retriever Rusty” sparks a smile Rusty the Golden Retriever is a regular visitor to a North Island hospital’s children’s ward, and on a recent visit the parents of one of the sick children told Lisa, Rusty’s owner, how much they appreciated their visits.

Their daughter really looked forward to seeing “Retriever Rusty” and the visits were not only helping her cope with her ongoing and often harrowing treatment, but were also a link to her home life – she had been in hospital for many months and just loved seeing the dog.

“She’d had a particularly bad week treatmentwise and had been quite uncommunicative with her parents – she’d barely talked for two days,” said Lisa. “But upon Rusty’s appearance her entire

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demeanour changed. She really loved reading to Rusty and cuddling into his soft fur.”

Lisa said she knew how much the little girl enjoyed seeing Rusty and found it very difficult to leave each time, knowing how much she wanted them to stay.

Rusty and Lisa also visit the hospital’s Rehabilitation Unit. When visiting a woman recently, Rusty pulled away to go to another bed where an elderly man was lying. Rusty stayed with this man for quite some time being cuddled and patted; when he and Lisa left, the other patients said it was the first time they had seen the man smile since he had been admitted, as he was generally very sad and often grumpy.

Aged care

”What started with four founding members is now a national organisation of over 400 volunteers who share the company of their well-behaved dogs with hospital patients and residents of hospitals, hospices and rest homes.”

The dogs do not need to be specially trained, they just need to be well-behaved, happy, loving and under the control of their owner at all times. Their owners need to be warm, caring people, who are good listeners and enjoy talking to people of all ages.

After a successful trial period, new canine friends are registered, become members and are then issued with their scarves and badges.

This is an important step as owners and dogs are committing to visiting “their place” regularly and to building relationships with both staff and residents.

Major health benefits

A lot of research has been carried out in New Zealand and internationally into the benefits of pet therapy dogs. All research shows conclusively that pet therapy improves overall health, including lowering blood pressure, treating depression due to loneliness, improving physical and mental stimulation and brightening emotional outlook.

There comes a time in many people’s lives when they are unable to care for themselves at home and need to move into some form of residential care. Members of organisations such as Canine Friends

Pet Therapy feel privileged to be able to share in some small way the love they have for their animals with the residents and patients of their rest homes and hospitals, and perhaps help them to remember animals they have owned and loved over the years, and have a cuddle with one of ours.

Annette Dougherty is president of Canine Friends Pet Therapy Inc. To celebrate the organisation’s journey from small beginnings 25 years ago (one visit by a dog) to the hugely successful voluntary organisation it has become today, an Anniversary Book has been published. It can be purchased from the secretary at secretary@caninefriends.org.nz for the modest cost of $20 plus postage and is a beautiful collection of stories, quotes and photos of the Canine Friends Pet Therapy dogs in action over the years.

Nursing news, views, trends and analysis If you want to know what your colleagues are thinking or doing, subscribe to Nursing Review.

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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.

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11

Research

Don’t give up on octogenarians NGAIRE KERSE gives an update on the fascinating LiLACS NZ study in which the quality of life for a large group of Māori and non-Māori in their eighties has been monitored and analysed over five years.

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urrently Māori people make up approximately 15 per cent of the total New Zealand population of 4.4 million and the Māori population is ageing faster than the non-Māori population. Of those aged 65 years and older, 87 per cent are nonMāori and five per cent are Māori; 15 per cent of non-Maori and four per cent of Māori are aged 65 and over. Over the next two decades the population of Māori older than 65 years will more than treble, whereas nonMāori will less than double. The proportion of the population in advanced age (aged 80+) will go up by more than eight-fold in the next half century.

As there is not very much known about this very old group, a cohort study in

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New Zealand, Te Puawaitanga O Nga Tapuwae Kia Ora Tonu: Life and Living in Advanced Age (LiLACS NZ), has gathered together over 400 Māori aged 80–90 years and 500 non-Māori aged 85 years in the Bay of Plenty region and followed them with yearly interviews and health assessments for five years. Over half those we identified and contacted (56 per cent overall) agreed to participate and community interviewers have been working with them ever since.

Measuring quality of life

From the two-year follow-up visits onwards, we interviewed caregivers of participants as well and from three-year follow-up visits onwards, have commenced qualitative interviews with the relatives of participants who have died. The range of questions for the participants includes activities and pastimes, mental and physical health, social support, cultural perspectives and housing. Physical assessments covered heart tracings, blood pressure, grip strength and lung function. We thought that quality of life was probably the most important aspect of life and so we used a validated scale to measure quality of life related to both mental and physical health, which gives a score out of 100.

This has created a rich database about this precious group of older New Zealanders.

Of the group recruited, eight per cent were living in residential care and 46 per cent were living alone. Women were much more likely to live alone than men, with 65

per cent of non-Māori women living alone and 51 per cent of Māori women living alone. Men were much more likely to live with a spouse and about 30 per cent of Māori participants were living with family members.

On average, participants had five chronic medical conditions and took about five medications. Despite this high number of comorbidities the average quality of life score was high, with a score of 55 out of 100 for mental health-related quality of life, which is good considering the age of 85 years. For physical health-related quality of life, average scores were in the 40s, reflecting a greater impact on quality of life from physical health problems.

We asked the participants whether they had someone to provide support with daily tasks and 80 per cent said that they did.

This varied by living arrangement with those who lived with family members saying they could have used more support than they got. This may have been because this group (who lived with family members) had higher levels of disability. More men said that they could have used more help than they got and this ‘unmet need’ for practical support was associated with having lower scores on the mental health-related quality of life scale and the physical health-related quality of life scale.

We also asked participants if they had someone to provide emotional support when they needed it and over 80 per cent said that they did. Not having enough emotional support was also associated with having lower mental health related quality of life.

Support services were not used as frequently as we thought they would be with 49 per cent of participants having some sort of support, including personal care, home help, meal support or gardening help. Less than 20 per cent had personal care support.

Encouraging results

This report shows, on the one hand, that overall this age group is doing well, with nearly half living alone and high quality of life scores overall. The report also shows how important ongoing help and support is for people in their 80s, as those who reported needing more support than they got had a lower quality of life.

Over the first year of the study we showed that

Retirement

”The recovery potential for octogenarians is intact, something that we all should remember and allow to happen, rather than expecting the worst all the time.” the average level of function and quality of life went down. But it was interesting to see that there was a lot of variation in how function and quality of life changed. When we looked at what proportion of participants got better we saw that 38 per cent of Māori women and 22 per cent of Māori men had higher quality of life after one year than they had at the beginning of the study – not bad for people in their 80s! Level of function (that is the ability to do things for themselves, like shopping, cooking and housework) also got better for a quarter and stayed the same for 20 per cent.

Similar patterns for non-Māori showed that there were almost as many whose quality of life improved over the year as declined and level of function also improved for over 20 per cent of non-Māori.

This shows that while on average there was decline over time, actually there is a lot of variation in that, with some people getting better and some people getting worse. The recovery potential for octogenarians is intact, something that we all should remember and allow to happen, rather than expecting the worst all the time.

Overall the LiLACS NZ study has been enjoyed by the participants and the researchers. We are looking forward to being able to share more information with anyone who is interested.

For more information on the LiLACS NZ study, visit www.fmhs.auckland.ac.nz/en/ faculty/lilacs.html Ngaire Kerse is a GP, professor and head of the School of Population Health at The University of Auckland.

For a full reference list, please contact editor@insitemagazine.co.nz.

Redefining retirement The Retirement Commission recently ran a competition to get people thinking about the changes to life, needs and lifestyle that occur over the 20–30 years that many spend in retirement.

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competition to find a better way of describing the different stages of retirement has drawn a multitude of entries, from the poignant to the playful.

Retirement Commissioner Diane Maxwell asked for ideas to capture the changes to life, needs and lifestyle that occur throughout the retirement years, which can amount to decades.

The winner was Erica Whyte from Lower Hutt with: »» Discovery: the time to have a go at all the things you’ve said you’d get around to ‘some day’. »» Endeavour: time to choose the fun things, develop old skills, explore fresh talents and grow new friendships. »» Reflection: a time when health and finances limit choice, to accept help graciously, to make the most of all those memories, and to keep up with old friends because we hold each other’s history.

Erica is at the ‘discovery’ stage, looking forward to an overseas holiday to celebrate her birthday aand enjoying more time to play the piano at singalongs and in a classical music group.

“It’s lovely now to have the time to do it and the time to enjoy the arts generally.

Living in Wellington, there’s so much to experience.”

There were two runners-up: Nicola Deacon from Auckland, and Liz Hunt from Waikanae.

Liz came up with ‘Can do; Might do; Used to’.

“I thought of my own experience and know that ‘can do’ is how I feel now. I hope that when I am in my 80s I still might be able to do some things,” she said.

Nicola suggested: »» Investers (65–74): because they invest in themselves and others. »» Divesters (75–84): because they simplify their lives and concentrate on what matters. »» Resters (85+): because they have earned it.

Nicola’s parents enjoyed the ‘investers’ stage, but the ‘divesters’ stage was much shorter than the family had expected, with her father passing away and her mother suffering ill health – a reminder that the stages are different for everyone.

“It’s brought into clarity for me how important it is to keep your physical health as long as you can,” said Nicola.

The Retirement Commissioner was thrilled with the quality and quantity of entries.

“The team at the Commission were impressed, heartened and sometimes brought to tears by the humour and wisdom that came through.

“It’s a great reminder that our retirees are a major asset to New Zealand, with a lot to contribute to discussions about the future.”

The winners will enjoy high tea at The Langham with the Commissioner and the Minister for Senior Citizens Maggie Barry.

More information is available at www.cffc.org.nz/retirement/the-threestages-of-retirement www.insitemagazine.co.nz | May/June 2015

13

Dementia

Dancing with dementia JUDE BARBACK looks at a recent dance and dementia project that has had a lasting impact.

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collaborative and innovative new project in Auckland is exploring ways that dance might help people with dementia, adding to a growing body of research on the topic.

As part of the project – a collaborative effort between Alzheimers Auckland, The University of Auckland Dance Studies Programme, and Wellesley Studios, with support from the Gavin and Susan Walker Postgraduate Scholarship in Dance Studies – 12 Alzheimers Auckland clients completed a six-week dance project.

The 12 participants were people living with dementia aged between 51 and 75.

Over the course of six weeks, the sessions at Wellesley Studios explored ways to create and perform movement in a variety of fun and interactive ways.

The project was driven by Carlene Newall, who is embarking on a PhD at The University of Auckland and whose research interests lie in the field of dance and dementia.

With the help of a group of postgraduate dance studies students from The University of Auckland, Newall led the project. The dance students partnered up with those with dementia, engaging with them to work through the choreographic exercises set by Newall for stimulating creative movement, and sharing their experience and training.

Musical memories

The sessions allowed for the class to dance together to familiar music hits from the past, allowing the people living with dementia an opportunity to bring their life experience to 14

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the students. Dance sessions were filled with laughter and fun, and were followed by time for cold drinks, biscuits, and socialisation.

People living with dementia can be hesitant to try new things and have sometimes let go of hobbies and social connections that enhanced their lives for many years. The people involved in this project were able to engage in a socially interactive activity that was intellectually and physically challenging.

“I’m sure many of the participants were nervous about what to expect going into the project but it was brilliant to see people being so brave and open-minded,” says Newall.

Participation in dance provides a unique combination of activities and experiences for those involved, something that Alzheimers Auckland looks for across their range of socialisation services.

Physical exercise, socialisation and working with others, as well as problem solving, creative thinking, memorising and recalling movement, and interacting with music are all incorporated into dance activities.

It isn’t currently known why dance is having an impact on people with dementia, but it is thought the physical, social, cognitive and creative components may all play a part. Researchers want to find out which activities in a dance class are having the greatest impact, and why.

Boosting wellbeing

British researcher Trish Vella-Burrows from Sidney De Haan Research Centre for Arts

“We have anecdotal evidence for these classes being phenomenal ... but it is very important that we get a systematic way of monitoring what is happening for research purposes.” and Health UK has found that dementia sufferers’ wellbeing increases from class to class regardless of the advancement of their condition.

“We have anecdotal evidence for these classes being phenomenal... but it is very important that we get a systematic way of monitoring what is happening for research purposes.”

Newall’s research will also contribute to this growing body of research, and she has learned much from the Auckland project.

However, while this project was about dance and dementia, the most lasting impact was the mutual exchange of respect and friendship between participants.

“It was a great group of people and such a positive experience; it was wonderful to see the new personal connections that developed between participants and the friendships that formed,” says Newall.

A pRoFessIoNAl developmeNT AcTIvITy pRoUdly bRoUghT To yoU by:

ANd

NursingReview

REAdING, REfLECTION, ANd AppLICATION IN REALITy Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development

By LesLey Batten and Marian BLand

Enhancing pain management in aged residential care

Aged residential care facilities are currently home to approximately 30,000 older New Zealanders with complex health needs. Research reveals the need for enhanced pain management for residents, which has implications for nurses working in those facilities, acute care hospitals, and general practice.

This article argues that effective, individualised pain management for older people requires the expertise of registered nurses together with well-developed institutional systems and processes.

Introduction

Pain is an unfortunate fact of life for a significant number of older adults. This is an international challenge, with resident pain prevalence rates in aged residential care (ARC) ranging between 83 per cent in Canada1, 62–80 per cent in the USA1 and 68 per cent in the Netherlands2. In New Zealand results from the 2013/14 Health Survey3 showed almost half of all adults in the general population aged 75 and older suffered from arthritis, a condition commonly associated with chronic pain, and rates may be much higher in those receiving residential care.

In this country more than 30,000 residents in aged care facilities are receiving rest home, geriatric hospital or dementia care4.

Residents must have a significant degree of either physical and/or cognitive disability to be eligible for admission to these facilities.

The acuity level of residents is such that it is not uncommon for hospital-level residents to die within a few months of admission.

Although there has been an increasing and appropriate focus on residents’ palliative care needs at the end of life, the same attention has not been directed towards other forms of pain that residents experience. This article argues there is a need to prioritise pain

LEARNING OBJECTIVES

Reading and reflecting on this article will enable you to:

» Further your understanding of pain in older adults, especially those in aged residential care settings » Reflect on how staffing and other institutional factors impact on older adults’ pain » Reflect on your personal and professional response to older adults experiencing pain » Utilise a variety of strategies when assessing and managing pain for older adults.

management in residential care facilities.

This requires the commitment of all nurses who come into contact with residents, whether they are residential care nurses, practice nurses working with GPs delivering care to facilities, or acute hospital nurses.

Residents and experiences of pain

Knowing most residents experience pain on a daily basis, if not continuously, tells little about how this pain affects their wellbeing.

It also tells little about how their pain may differ or be more complex to manage than, for example, pain experienced by a younger person with an acute pain episode. Some of the complexities related to pain and the elderly are identified in Fig. 1. This article discusses just three examples of the complex relationship between pain and ageing.

The first of these complexities was identified by nurse researchers interviewing Norwegian rest home residents5 about their pain. These researchers talk about there being two interwoven dimensions of pain: physical pain, and pain as suffering.

They identified important consequences of physical pain, including inactivity, social isolation, needing more time and energy to undertake daily activities, medication side effects, and reduced quality of life through reduced appetite and poorer quality sleep. The suffering component of pain was described in terms such as loneliness, hopelessness, fear, and helplessness:

… participants described [pain as] suffering as a personal threat to the core of being a whole person. They expressed a loss of meaning of life, and a loss in life with others and in one’s environment 5 .

These authors5 highlighted some important points for nurses to consider. Firstly, older people rarely used the word pain, instead reporting aching or hurting; secondly, residents were often reluctant to report pain and to request analgesia. Residents expressed concerns about losing control of their bodies, fear of addiction, and scepticism about analgesics, possibly because their pain had previously been poorly managed.

The second example relates to the complex relationship between ageing, concurrent conditions and pain. There is a pervasive, but incorrect, belief that pain is a normal part of ageing6. This belief, combined with the multiple, pain-inducing conditions that are more prevalent in the elderly, makes pain management a challenge for everyone. For example, older women with a history of breast cancer struggled to identify if their pain related to their previous breast cancer treatment, cancer recurrence, other conditions such as arthritis, or ageing7. Untangling this web of pain, and the perceptions and associated fears, would take more than an analgesic prescription.

The third example relates to pain assessment when a resident may have reduced cognitive ability, which changes their expression and response to pain.

American researchers8 compared the pain relief offered to residents with similar diagnoses of conditions likely to induce pain, and found that residents with cognitive impairments had fewer analgesic prescriptions and received less analgesia than residents without cognitive impairment.

Therefore those with conditions such as dementia are even more vulnerable for under-recognition and under-management of their pain.

Enhancing pain management in aged residential care figure 1:

examples of complexities in pain management in ARc pain in the elderly » » » » »

Age-related conditions more comorbidities Frailty possible decline in cognitive abilities social isolation

Factors within ARc that can positively impact on pain management

There are factors within the aged residential care environment that can provide the basis for effective pain management for all residents, including continuity of care, organisational policies, and nursing workforce development.

Some residents spend lengthy periods, even years, in residential care. This enables nurses to get to know residents and family members, enabling a partnership approach towards pain management and opportunities for continuity of care. It also means that nurses, over time, may be able to develop a much better understanding of how a resident’s pain is experienced, expressed, and responds to different types of management.

More work is being done so that the organisational environment prioritises residents’ pain management. All facilities must have a pain management policy to guide clinical practice, and that policy must be regularly reviewed. Specialised pain assessment tools for the elderly are available, including tools for use with residents with cognitive impairment.

There is increased recognition of the need to upskill ARC nurses, with new NETP (Nursing Entry to Practice) programmes for new graduates entering ARC and access to funding for postgraduate qualifications. A growing awareness of palliative care needs within residential care is now reflected in partnerships with hospice services. The associated emphasis on symptom management as part of end-of-life care has a spin-off effect on pain management for other residents.

The introduction of the nurse practitioner role in ARC in some areas has resulted in positive benefits, such as the reduction in acute presentations to emergency departments and hospital admissions in the Horowhenua9. Frequently one of the key drivers for these types of transfer is pain.

Factors within ARc that can negatively impact on pain management

There are also factors within the residential care environment that might negatively impact on pain management for residents, including

ARC residents » significant level of physiological and or cognitive impairment

staffing mix, access to GPs and educational opportunities for nurses.

Although ARC residents have complex care needs, there can be limited access to qualified nursing staff. Unregulated caregivers, who have an annual turnover rate of 25 per cent, deliver most services.

Hospital-level residents usually receive between 6.6 and 7.3 nurse hours per week4.

The aged care nursing role often includes responsibility for lengthy medication rounds, leaving little time for other nursing duties, such as resident assessment, care planning and evaluation. ARC nurses overall have lower levels of post-registration qualifications than nurses working in other practice areas. Only 26 per cent have a post-registration qualification, compared with, for instance, 45 per cent of those working in palliative care10.

Support for staff to undertake nonmandatory training, such as pain management, is at the employer’s discretion. The growing cultural diversity of ARC nurses (25 per cent of RNs are from India or the Philippines10) also increases the potential for cross-cultural misunderstandings related to pain, when 86 per cent of residents are New Zealand European4.

Residents must be reviewed by their general practitioner at least three-monthly, and more frequently if clinically indicated.

Getting a GP to visit can be problematic, as the following extract taken from research11 into the experiences of ARC nurses in New Zealand demonstrates:

I called the gp early in the morning to say that she had been in severe pain all night and we had nothing prescribed. he came at 7pm that night, by which time the pharmacy was closed. An RN who works here (but was off duty) drove her own car on a two-hour return journey to an urgent pharmacy so that she [the resident] would not have to go through another night in such pain11.

GP workload demands are such that their facility visits often occur at times when nurses may be in the middle of a medication round, and residents partway through their meal.

Obtaining GP services outside normal office hours or over weekends for urgent medical situations can be next to impossible. In those

Complexities in pain management » » » » » » » » » » »

Acute on chronic pain polypharmacy Reduced ability to report pain difficulties communicating pain difficulties comprehending pain assessment tools used in other settings different pain expression Using other words to describe pain, such as ‘ache’, ‘hurt’ Access to non-pharmaceutical pain-relieving measures Reluctance to report pain Relationships between pain, distress & suffering Relationships between depression, anxiety & pain

circumstances, the only option may be to transfer the resident to the nearest hospital, even though residents and families may be extremely reluctant to agree to such transfers.

Access to extra medications outside normal pharmacy hours can also be problematic.

Only facilities with hospital-level residents are permitted to carry bulk supplies of medication for emergency situations12. Residents who had managed their own analgesia when at home must also now meet robust safety criteria to continue with self-medication within the ARC facility12.

making a difference

As identified, many factors must be considered if pain management is to be improved for all ARC residents. Action is needed on two levels: the institutional level, and from all nurses. International researchers13 argue that a systematic, whole-of-organisation approach to pain management is needed. This type of approach: 9 Is interdisciplinary – all ARC staff involved, including diversional therapists, kaumātua and chaplains 9 Includes enhanced relationships with specialist pain and palliative care services 9 Is based on enhanced relationships with general practice teams 9 Provides staff with a range of assessment tools, including for cognitively impaired residents 9 Facilitates partial self-medication where appropriate 9 Actively supports ongoing education for all staff on pain management, including caregivers, and postgraduate education for registered nurses 9 Explores options for nurse practitioners and specialist nursing roles

A pRoFessIoNAl developmeNT AcTIvITy pRoUdly bRoUghT To yoU by:

9 Considers how the care offered addresses the social, cultural, spiritual, religious and psychological needs of residents with complex pain 9 Is family-centred 9 Audits pain management, including use of assessment tools, and regular and as-required analgesia.

Registered nurses also have a key role and responsibility for pain management for ARC residents (see sidebar 1). Considerations include: 9 Working from the expectation that every resident has pain, and nurses will need to use a range of strategies, both pharmaceutical and non-pharmaceutical, to address that pain 9 Accepting the validity of residents’ selfreports of pain and discomfort – what does self-report mean for each resident?

9 Consider cultural differences in pain expression 9 Finding out what residents believe helps their pain, such as movement or rest 9 Using formal, ongoing, pain assessments as part of the regular evaluation of individual residents (with evaluation of the outcomes of pain management interventions)

About the authors:

Lesley Batten RN PhD Researcher at the Research Centre for Māori Health and Development, Massey University, Palmerston North.

Marian Bland RN PhD Researcher, quality coordinator at the Ranfurly Residential Care Centre, Feilding, and health care auditor.

This article was peer reviewed by:

Judy Leader RN MN Pain management nurse practitioner working for MidCentral District Health Board.

Janet parker RN MN Gerontology nurse practitioner working in community and residential aged care for Waitemata District Health Board.

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Sidebar 1:

Nursing council of New Zealand code of conduct14 principle Four: maintain health consumer trust by providing safe and competent care 4.1. Use appropriate care and skill when assessing the health needs of health consumers, planning, implementing and evaluating their care.

4.3 Keep your professional knowledge and skills up to date.

4.5 Ask for advice and assistance from colleagues, especially when care may be compromised by your lack of knowledge or skill.

4.6 Reflect on your own practice and evaluate care with colleagues.

4.7 deliver care based on best available evidence and best practice.

9 Seeking active feedback from caregivers about patients’ pain 9 Being attuned to the multiple dimensions of a resident’s pain and distress and also the potential for them to have more than one type of pain?

9 Care with language – what terms does each resident use to describe their pain?

9 Recognising that a resident’s pain is complex and multidimensional and that pain levels often fluctuate on an hourly basis 9 As-required analgesia is charted for all residents on admission 9 Care is individualised, with analgesia not restricted to medication rounds 9 Judicious use of transfer to hospital if pain is unmanageable

9 All residents receiving analgesia must have a care plan for pain management, including non-pharmacological measures.

conclusion

Pain is a fact of life for many frail older adults living in aged residential care facilities. The multifaceted nature of their pain is compounded by the presence of chronic conditions, the ageing process and communication challenges. Factors within the aged care environment, such as limited access to medical practitioners, further contribute to less than optimal pain management practices.

Improving residents’ pain management requires commitment from both the institution and individual staff to address the barriers that currently result in less than optimal care.

Recommended resources 1) These websites provide a range of useful resources related to pain and the older adult, including standards of care and links to assessment tools: • HORGAS A, YOON S & GRALL M (2012) Nursing standard of practice protocol: pain management in older adults. consultgerirn. org/topics/pain/want_to_know_more.

• INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (2015). www.iasp-pain.org 2) This article would be useful for refreshing understanding of the different types of analgesia and their use with older adults: • BRYD L (2013) Managing chronic pain in older adults: a long-term care perspective.Annals of Long-term care: Clinical Care and Ageing 21(12).www.iasp-pain.org 3) This video, available on YouTube, also provides a comprehensive approach to pain management:

• HARTFORD INSTITUTE FOR GERIATRIC NURSING (2014) Pain assessment in older adults. www.youtube.com/watch?v=WGCglW4sYP8 4) The Pain Assessment Care Guide, produced by the Waitemata District Health Board in 2012 as part of the Registered Nurse Care Guides for Residential Aged Care (3rd ed) is a great resource, covering assessment and pain management. Available from www.waitematadhb.govt.nz/ HealthProfessionals/RACIPcareguides.aspx 5) Two useful articles that focus on spiritual needs and their expression through pain are: • SARTORI P (2010). Spirituality 1: Should spiritual and religious beliefs be part of patient care? Nursing Times 106: 28 14-17 • SARTORI P (2010). Spirituality 2: Exploring how to address patients’ spiritual needs in practice. Nursing Times 106: 29 23-25

ReFeReNces 1. FOX P, RAINA P& JADAD A (1999) Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review. Canadian Medical Association Journal 160, 329-333.

8. REYNOLDS K, HANSON L, DEVELLIS R et al (2008) Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. Journal of Pain and Symptom Management 35 (4), 388-396.

2. SMALBRUGGE M, JONGENELIS L, POT A et al (2007) Pain among nursing home patients in the Netherlands: prevalence, course, clinical correlates, recognitions and analgesic treatment – an observational cohort study. BMC Geriatrics 7, 3 doi: 10.1186/1471-2318-7-3

9. PERI K et al (2013) Evaluation of the Nurse Practitioner in aged care: a report prepared for Central PHO and MidCentral DHB. www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/NP_aged%20Care_15NM.pdf

3. MINISTRY OF HEALTH (2014) Annual Update of Key Results 2013/14 New Zealand Health Survey www.health.govt.nz/ system/files/documents/publications/annual-update-key-results-nzhs-2013-14-dec14.pdf 4. GRANT THORNTON NEW ZEALAND LTD (2010) Aged Residential Care Service Review. www.grantthornton.co.nz/Assets/ documents/home/Aged-Residential-Care-Service-Review.pdf 5. GRAN S, FESTVÅG L & LANDMARK B (2010) ‘Alone with my pain – it can’t be explained, it has to be experienced’. A Norwegian indepth interview study of pain in nursing home residents. International Journal of Older People Nursing 5 25-33.

6. THIELKE S & UNÜTZER J (2008) Pain is not a benign symptom among older adults: Comment on Blyth et al “Pain, frailty, and comorbidity in older men: The CHAMP study”. Pain 140 1-2 7. FENLON D, FRANKLAND J, FOSTER C et al (2013) Living into old age with the consequences of cancer. European Journal of Oncology Nursing 17, 311-316.

10. NURSING COUNCIL OF NEW ZEALAND (2013) The New Zealand nursing workforce: a profile of nurse practitioners, registered nurses and enrolled nurses 2012-13. www.nursingcouncil.org.nz/Publications/Reports 11. CARRYER J, HANSEN C & BLAKELY J (2010) Experiences of nursing in older care facilities in New Zealand. Australian Health Review 34, 11-17.

12. MINISTRY OF HEALTH (2011) Medicines care guidelines for residential aged care. www.health.govt.nz/publication/ medicines-care-guides-residential-aged-care 13. HUSBO B, BALLARD C, SANDVIK R et al (2011) Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 343 doi: 10.1136/bmj.d4065 14. NURSING COUNCIL OF NEW ZEALAND (2012) Code of conduct for nurses. www.nursingcouncil.org.nz/Publications/ Standards-and-guidelines-for-nurses

dATe: .........................................................................................

NAme: ........................................................................................

NURsINg coUNcIl Id: ............................................................ desIgNATIoN: .........................................................................

A pRoFessIoNAl developmeNT AcTIvITy pRoUdly bRoUghT To yoU by:

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Nursing Review

RRR LEARNING ACTIVITy:

Reading the article and undertaking this pain management in aged residential care learning activity is equivalent to 60 minutes of professional development. discuss all your answers with a peer/s A: REVIEw ThE pAIN MANAGEMENT pOLICy IN yOuR CLINICAL AREA. 1

Does it address the factors outlined in this article that may contribute to poor pain management for older residents/patients?

2

Are the pain assessment tools referred to in the policy appropriate for older adults, and/or those with cognitive impairment?

B: REfLECT ON ThE pAIN ASSESSMENT/MANAGEMENT fOR OLdER AduLTS IN yOuR CLINICAL AREA. 1

What aspects of pain management are done well? What areas could be improved?

2

What factors within the clinical area contribute to or restrict pain management for older adults?

C: REVIEw ThE CLINICAL dOCuMENTATION Of ONE OLdER AduLT whO IS CuRRENTLy RECEIVING hEALTh CARE SERVICES IN yOuR CLINICAL AREA. 1

What assessments have been undertaken to identify if that person has pain?

2

If appropriate, what strategies have been initiated to manage that pain?

Verification by a colleague of your completion of this activity:

(Signature)

colleAgUe NAme: ............................................

desIgNATIoN: ...................................................

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Retirement

Here come the

baby boomers New research shows that baby boomers want choice and control as they enter old age.

W

e’ve long suspected the baby boomers will be a demanding bunch when they reach old age, and new research has confirmed the notion. According to Victoria University of Wellington researcher Kathy Glasgow, future government policies will need to be flexible to accommodate the diverse needs of ageing baby boomers.

Glasgow, who recently graduated with a PhD in social policy, interviewed mid-life baby boomers around New Zealand to explore their views about old age and compare their expectations and values with current policies for older people.

“A desire for choice and control came through strongly. Boomers grew up through a period of rapid social change, and were exposed to a broadening of possibilities so they expect a choice in how they create their own lifestyles in old age.”

While boomers are expecting to work longer and know they need to prepare financially for their old age, they want to do it in their own way, says Glasgow.

“If there’s any sense of being forced or coerced through policy decision making I think there’ll be strong resistance. Boomers value independence and self-reliance. But like their parents before them, there’s still an underlying sense that it’s the state’s responsibility to care for older people who are in need.”

Creative living options needed

Glasgow says baby boomers expect to live in a variety of housing situations. That could include adapting the retirement village model to reflect their worldview, such as creating eco-style retirement villages or small settlements that are communally managed.

Some people she talked to were planning communal living arrangements akin to the flatting arrangement of their teenage years.

“Flatting was a part of the boomer experience that was different from their parents’ generation, who commonly only left home when they got married.

“My advice is for retirement developers to watch mainstream property marketers more closely, as their housing options without the ‘age tags’ will have greater appeal to boomers in the next few years.”

“There’s also the desire for the coastal lifestyle or bush retreat, but this is tempered with thoughts of wanting to be close to social activities and family.”

With families no longer living as close to each other as they used to, there wasn’t a strong expectation that children would be around or able to provide much support.

“This implies the need to explore opportunities for supporting more creative social networks,” says Glasgow.

Work-life balance crucial

Although many boomers said they were looking forward to reducing work hours, their key emphasis was on work-life balance.

“The underlying values that came through were about choice – being able to choose where they live, who they live with, as well as what lifestyle they led. Flexibility, such as more control over hours and opportunities to work from home, were important too.”

Baby boomers expected to lead an active lifestyle in their older age.

“When you dug deeper, there were some fears about growing old and health was definitely one of them. However, there was also an optimism amongst boomers that they could transform their own experience through leading a healthy lifestyle.”

Glasgow’s research tallies with the views of Australian marketing expert Gill Walker, who explains that the boomer generation wants service, experience and social engagement.

“Boomers want social engagement as that is the secret to youthfulness; they want a

lifestyle with less worries, more ‘me time’, and importantly they want to stay healthy (mentally and physically) so as not to be a burden on their kids or have to go to aged care. Boomers will look to flock with friends, not just family, especially if their family are dispersed around the world,” she says.

Walker thinks retirement village operators may need to think carefully about what they’re offering to the baby boomer generation.

“My advice is for retirement developers to watch mainstream property marketers more closely as their housing options without the ‘age tags’ will have greater appeal to boomers in the next few years.

“Intergenerational developers have a head start, especially with boomers – they just need to build the right product,” she says.

DMF model fading in favour

Walker says boomers typically want to own their retirement residences, and have at least one eye on an improved investment outcome, which means the DMF model has less and less appeal, as they feel both parties should benefit financially.

From a marketing perspective, she says it is vital that for boomers you dial up the experience that they will get.

“It’s about self-approval based motives over social approval-based motives, which appeal to the young.”

Walker gives the example of technology in the home. For boomers, it’s more about the rational benefits of technology, not ‘skite’ technology. Smart technology that controls the temperature of the home, saves money, checks your health, automatically turns on the lights in the corridor when you go to the bathroom at night, is more attractive than home cinema and surround sound.

Ready or not, the baby boomers are on their way and the retirement and aged care sectors should arm themselves with as much knowledge and research available so they are prepared to meet the needs of a generation that knows what it wants.

www.insitemagazine.co.nz | May/June 2015

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Community care

“Many now talk of having “somewhere to go during the week” or “something to look forward to”

Nurturing the social health of older people BEATRICE HALE looks beyond the jargon surrounding healthy ageing and is heartened to discover a wide range of services and providers that cater to the social health needs of older people.

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hat is social health? Connecting with others, enjoyable activities, getting out and about… this is how many older people live. But for the vulnerable frail elderly, it’s not so easy.

We’re told about healthy ageing, ageing in place, and we’ve heard of the restorative model. We’re inundated with catchwords and phrases. The issue is how do we make it happen?

For older people in the community, there is the DIY method of looking round and finding somewhere to go and something to do that fits with their elderly frailty. Or there is the needs assessment, directing the recipient towards services.

Communities and Neighbours (CAN) from Christchurch is a service that focuses on somewhere to go and something to do.

Facilitator Kirstin Dingwall-Okoye describes it as a service that connects older adults with neighbours and wider community connections.

“Our aim is to empower the older adult to live the type of life they wish to live alongside of others. This entails introducing them to individuals or groups, as they desire.

It may be finding that practical expertise in the street, for example, who can trim a tree, get in the bins or share a cuppa on a regular occasion.”

But how do you find out if people are feeling isolated?

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May/June 2015 | www.insitemagazine.co.nz

“Listening… that’s how to pick up clues, hints as to what is really going on,” observed Tracey Faumatua, from Pine Hill, Dunedin.

Manea Te Kia from the Brockville Community Trust Board, Dunedin, agrees.

“You find out what’s really going on for people,” she says.

And that sums up the concept of social health: “what’s really going on for people”.

Getting out in the community

Where do you go from being a listening ear?

Like CAN in Christchurch, Faumatua connects people, with groups, services, and each other. In her role as development social worker, she sends out monthly invitations, picks up those who need it, or organises transport, and takes groups to various venues to ensure outings of interest. She listens, and hears comments, such as “I’m having trouble shopping”. A very hungry group member alerted her to food and shopping problems, so she organised shopping help and Meals on Wheels.

But she also asks them for their input, to help her with the children’s groups, pouring juices, making sandwiches, interacting with the children. ‘Involve older people, use their skills’, is her catchphrase.

A programme that combines the physical with the social is the peer-led Steady as You Go initiative. SAYGO, as it’s popularly known, is offered by Age Concern Otago

in 57 venues round Otago and Southland, with other groups in Ashburton, Thames and Tauranga. These weekly, hour-long exercise classes offer carefully chosen and graded exercises to assist in maintaining and improving mobility.

Far-reaching benefits

A further consequence is that the groups provide companionship for people whose physical problems may isolate them at home.

Many now talk of having “somewhere to go during the week” or “something to look forward to”. The programme has led to car pool arrangements and coffee catch-ups, indicating that the benefits stretch beyond the classes themselves.

Presbyterian Support Otago (PSO) also offers accessible programmes for frail older people in the community. Chief executive Gillian Bremner cites the longstanding PSO volunteer visiting programme where individual volunteers visited older people in their own homes, as companions, as drivers to appointments, to taking people shopping. PSO also offers the Maybank Club programme, which has a varied set of activities for frail older people, some cognitively impaired, many with mobility problems.

Maybank Club coordinator Marilyn Withnall believes the programme’s popularity comes from the variety of activities on offer, the ability to engage with help in crafts, and the get-togethers.

However, Gillian stresses that social health is also important in residential care.

Community care PSO’s newsletter on Valuing Lives describes all the activities offered in its facilities.

Other agencies offer similar services, both in the community and in residential care, and for the former, regular weekly attendance gives something to look forward to.

Companies like Driving Miss Daisy, available nationwide, go beyond just driving older people from A to B by providing a variety of other services, including accompaniment to doctor’s appointments, relaying information to family members, or helping with shopping. Special help is available for those with a walker or a wheelchair. They will even help take pets to the vet.

Mobility vouchers can also help older people with cheaper taxis and transport.

assessment. She felt that she wasn’t alone.

“I was so relieved to get help, my knees shook.”

Max Reid, from Access Home Health emphasised the restorative model, for frail older people. The intention is to ensure older people have improved independence, or maintain their level of functioning for as long as possible. Hopefully, this will reduce the need for support, and thus the cost.

Equally, it is intended to increase the quality of life for older people.

These restorative supports must increase, says Reid, since the cost of supporting older

people living at home is likely to increase.

Older people are living longer and increasing as a proportion of the population, and with smaller families, mobile families, and more women working, older people have to find others to rely on.

Maintaining good social health is an important part of the restorative model.The needs assessment process can help direct older people to services and programmes within their communities that will not only assist them with their daily living tasks but will also give them the social interaction and activity they may so desperately need.

Supportive health professionals framework

Older people can access these initiatives and programmes for themselves, but often the offer of services comes through a doctor’s referral for needs assessment and subsequent services.

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www.insitemagazine.co.nz | May/June 2015

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Clinical

’You only get to die once’

– palliative care gets an overhaul JUDE BARBACK talks to Dr Kate Grundy, chair of the South Island Alliance Palliative Care Workstream about why a ’whole of sector’ approach is needed for palliative care.

E

on establishing better linkages between secondary and primary care, veryone seems to be talking about Dr Atul Gawande at the residential care and hospices. moment. The best-selling author and super-doctor is in New Zealand for a number of speaking engagements.

“There was a groundswell of interest and enthusiasm throughout In his recent book Being Mortal Gawande argues that we – the South Island for collaborating and sharing,” says Grundy. doctors, residential care facilities, hospitals – have become so focused She says while collaboration and innovation was happening in on extending life that we are failing to provide people with Canterbury, in many of the smaller South Island district health end-of-life care that is comfortable and dignified. He sets out to boards it was somewhat lacking. prove that medicine can comfort and enhance our lives to the very “Effective palliative care services have developed across end, providing not only a good life, but a good end to that life.

New Zealand in areas where people have a passion and a voice,” says Clinical director of Canterbury Integrated Palliative Care Services Grundy.

Dr Kate Grundy says Gawande’s visit couldn’t be more timely in She says there is an understanding about what quality palliative terms of helping to raise the profile of palliative care in New Zealand. care looks like. Best practice for palliative care in New Zealand Grundy is tasked with heading up the South Island Alliance has largely been defined by work carried out by the Palliative Care Palliative Care Workstream, a new initiative aimed at taking a ’whole Council and the Ministry of Health. The aim now is to expand what of sector’ approach to palliative care. is working well out to other corners of the sector.

Previously, palliative care in the South Island was accommodated Grundy points to the 2013 Resource and Capability Framework by the Southern Cancer Network, but it wasn’t really gaining much for Integrated Adult Palliative Care Services in New Zealand, which traction there, says Grundy. helps provide guidance to funders and policy makers. The framework “There has always been a very obvious relationship between encourages a ‘hub and spoke’ approach to help share ideas and cancer and palliative care,” explains Grundy, “but this was stopping services throughout the sector. Grundy says there has never been a relationships with other agencies. There needed to be another benchmark against the framework, but the Palliative Care Council is framework that could accommodate palliative care better.” currently working on a survey to enable this.

The framework was already there and waiting within the South The workstream’s efforts in fostering better collaboration Island Alliance, which now accommodates the Southern Cancer throughout the sector will carry a focus on establishing robust Network along with a number of other alliances, including the IT linkages between GP practices, hospices, residential care and Health of Older People Service Level Alliance (HOPSLA). So hospitals. in August last year palliative care made “The South Island has been very proactive the strategic jump from the Southern about IT,” says Grundy. She speaks highly Cancer Network to HOPSLA, marking of the Health Connect South system but “Palliative care is the formation of the South Island Alliance says more needs to be done to include everybody’s responsibility.

Palliative Care Workstream. outlying services, such as hospices and We can’t have everyone Grundy says that while palliative care residential aged care facilities. extends into many other areas, the older “It has taken some time to get hospices being seen by palliative care persons area is a “natural pressure point, due under the radar of IT services,” she says. specialists.” to the ageing population”.

“Residential aged care facilities are a whole different ball game – that needs another Pursuing better linkages conversation entirely.”

With a better strategic fit in place, the workstream members have begun to address Improving public engagement some widely held misconceptions around Another priority for the workstream is palliative care. improving communication and engagement The workstream members believe there with the general public. is a general lack of understanding of what “Palliative care is everybody’s palliative care means, when care becomes responsibility,” says Grundy. “We can’t palliative, and how palliative care interacts have everyone being seen by palliative care with initiatives such as advance care specialists.” planning. Their role is to help the wider Her overall vision for the workstream sector recognise that palliative care sits is for palliative care to be clearly present, alongside other models of care and should valued in all DHBs in all areas, so people be delivered alongside active treatments, can have access as needed.She believes there with the palliative care component of a is no endpoint, as every incremental gain is person’s care becoming more dominant as worthwhile. their illness or frailty progresses.

“You only get to die once. If we get it In endeavouring to achieve this, one of wrong, we don’t get a second chance and the workstream’s main priorities is focusing that’s regretful.”

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May/June 2015 | www.insitemagazine.co.nz

Clinical

Spotlight on...

oral health in older people Research shows a strong correlation between poor oral health and general health, yet the Government refuses to see this as a funding priority for older people in residential care.

JUDE BARBACK looks at where responsibility lies and what aged care facilities should be doing to maintain their residents’ oral health.

Dr

Clive Ross is concerned, and rightly so. It appears oral health in older people isn’t seen as a priority by the Government, despite a growing body of research that shows that dental problems can be the source of general health issues.

Ross, previously the clinical director for the Oral Health unit at Auckland District Health Board, says despite letters to various Ministers and the efforts of the New Zealand Dental Association, oral health in older people is still not being taken seriously enough.

Funding and monitoring

As things stand at the moment, dental care is excluded from the Age Related Residential Care Agreement between district health boards and aged care providers, leaving rest homes to manage the oral health care of their residents and families to fund it themselves.

A 2004 report in the New Zealand Medical Journal published the results of a survey of dependent elderly people in Christchurch and the researchers’ recommendation that “oral health should be considered part of overall health when the Ministry of Health writes service specifications and minimum requirements for rest homes and residential care facilities”.

The Government’s reluctance no doubt stems from the perception of oral health care provision for older people as yet another cost burden on an already stretched health budget.

A 2008 estimate by Counties Manukau DHB for providing one funded dental visit per year for each person aged 65 and over

in its catchment area was in excess of $7 million.

However, if more emphasis were placed on prevention – by provision of regular oral care – the costs would be lower in the long term, particularly as it would also have a positive impact on the overall health of older people, as many studies have concluded.

The call for a change in the policy and monitoring environment around oral care policies in aged care facilities was made again in 2011 by the University of Otago’s Professor Murray Thomson, who believes leaving it up to the sector to adopt it voluntarily will not work.

Poor oral health equals poor general health

When faced with the evidence to support the importance of oral health in older people, it is difficult to understand why the Government isn’t funding this aspect of health and wellbeing.

“The picture isn’t good,” says Ross, of the growing body of research that shows a clear relationship between bad oral health and general health and end of life.

There is international evidence of the links between periodontal disease and cardiovascular disease, diabetes and other chronic illnesses.

The 1997 report Preventive Dental Strategies for Older Populations, commissioned by the National Health Committee, showed that the most common

dental conditions affecting older people, including tooth decay, gum disease and saliva problems, can cause severe limitations in day-to-day activities.

Should facilities take more responsibility?

A 2003 qualitative study based in Dunedin’s residential care facilities found that while staff understood that oral health can influence general health, they had received little training in provision of this care for residents, and generally assumed residents would attend to their own oral hygiene.

Consequently, it typically falls to the resident’s family to address his or her oral health care. However, Ross says maintaining a resident’s oral health often becomes too hard for the family. A trip to the dental practice can take half a day. In many cases, money is not the issue, rather it is arranging for the oral health check that seems to present the barrier.

In other cases, however, the expense is the limiting factor for the family. Work and Income New Zealand (WINZ) only covers emergency dentistry, not basic oral health checks. Ironically, the basic checks are likely to prevent the more serious and costly dental problems.

Ideally, a programme of oral health maintenance should be included in a facility’s service. Maintaining good oral health extends beyond regular teethbrushing, says Ross.

“What we would like to see is an oral care assessment carried out on each resident and then, based on this assessment, an individualised oral care plan.” www.insitemagazine.co.nz | May/June 2015

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FOCUS Deepa Krishnan, the NZDA’s senior oral health educator, agrees.

“What we would like to see is an oral care assessment carried out on each resident and then, based on this assessment, an individualised oral care plan,” says Krishnan.

By way of example, she says that such an assessment and plan might see one resident using high-fluoride toothpaste, which might not be suitable for another resident.

Krishnan says this individualised approach is part of the training and education programme rolled out to aged care staff, however they are not receiving the support from their facility management to implement their training effectively.

In 2010, the NZDA took a look at the oral health training available to rest home staff and realised it was fairly minimal. This prompted the launch of the oral health guide Healthy Mouth, Healthy Ageing, with funding from the Ministry of Health.

Summerset is one aged care and retirement living provider to use the resource to help train its staff on maintaining residents’ good oral health. Brigid London, Summerset’s GM operations, says their clinical team is also developing a practical training session on removing and cleaning dentures.

Buy-in from management an issue

Along with the Healthy Mouth, Healthy Ageing resource, the NZDA rolled out training workshops throughout the country.

The Ministry of Health provides funding for 20 workshops per year for a maximum of 50 participants in each workshop.

Krishnan says the workshops have been very successful but they do not reach everyone.

She says the NZDA is currently applying to the Ministry of Health for more funding to roll out a mixed model of training for aged care facility staff; this could include expanding the workshop and possibly include some in-house training.

Aside from the reach of the current training programme, the main problem appears to be the necessary buy-in from facility management. Krishnan has nothing but praise for the caregivers receiving the training, but she says it is difficult for them to effectively translate their training into practice because of clinical and general managers who don’t see oral health as a priority. This is largely because facilities are not obligated to provide an oral health care programme as part of their accreditation, says Krishnan.

Krishnan and Ross both acknowledge the typically heavy workloads of many care staff in rest homes and understand the competing demands on their time, yet both emphasise the importance of maintaining a resident’s oral health.

Ross says regular oral health checks should be included in a resident’s oral

health care plan, but again, due to the low priority afforded oral health in older people, most facilities do not push this.

In an attempt to alleviate the problem, Ross established a mobile service, Elder Dental, to provide a low-cost, basic dental care service for residents and oral health instruction to caregivers at no cost.

Some facilities are utilising such services, although there is far from a consistent approach, even within organisations.

Summerset’s Brigid London says a number of their villages – but not all – have mobile dental technicians, and some villages also have access to denture technicians who come in and check residents’ dentures for fitting as their mouths change as they age.

Ross notes that some individual Bupa facilities are also facilitating oral health checks, and he points out a few shining examples, noting the Selwyn Foundation as an organisation that is taking a proactive and systematic approach to maintaining the good oral health of their residents.

Yet of others, including many of the “big ones”, Ross says there has been very little uptake.

Ross says the biggest hurdle is educating the facility management that oral health is an integral part of elderly health care, including end of life management. Of most concern is the general lack of understanding around what effect poor oral hygiene can have on a resident’s general health and wellbeing.

He says it often comes down to the level of enthusiasm that the organisation’s clinical director has for incorporating a good oral health programme. Such an ad hoc approach to ensuring quality oral health care is surely insufficient going forward. It seems this aspect of older people’s health needs to be taken more seriously by everyone.

The Health Mouth, Healthy Ageing resource can be found here: www.healthysmiles.org.nz/ assets/pdf/HealthyMouth,HealthyAgeing.pdf

24

May/June 2015 | www.insitemagazine.co.nz

Management

Up close and personal with...

Simon Wallace

JUDE BARBACK meets the new chief executive for the New Zealand Aged Care Association (NZACA), Simon Wallace.

’M

eet’ is not strictly accurate.

Simon Wallace is at the NZACA office in Wellington; I am at my desk in Papamoa. A telephone interview must suffice for now. We joke about the arrival of another Simon onto the aged care scene, as he joins Simon O’Dowd and Simon Challies, two prominent names in the industry. My name is also a source of potential confusion, he says; his wife’s name is also Jude.

Although he’s calling from the NZACA office, Wallace doesn’t finish his role as chief executive at the Tourism Industry Association (TIA) until 26 May before starting at the NZACA a week later.

So why the move to aged care?

“After nine years with the TIA I felt it was time for a new challenge.”

He says he’d seen some major projects through at the TIA – like the 2025 long-term growth strategy, for example – so it felt like the right time to move on.

The tourism industry strikes me as wildly different from the aged care industry. Wallace acknowledges they are very different sectors, but he points out that his new role will bear similarities to his work at the TIA. The TIA, like the NZACA, is the peak private member organisation for its industry.

“My role at the TIA has a strong focus on policy, advocacy and lobbying, on working on the issues that matter to the sector.”

They are both growth sectors, Wallace says. He believes it is important to understand what this growth means to the aged care industry in terms of opportunities for investment and reinvestment.

He says while he has experience with staffing and workforce issues, he knows that he will need to get up to speed with the workforce issues currently facing the aged care sector, particularly the TerraNova v Bartlett pay equity case continuing to play out in the courts. His main focus, he says, is on familiarising himself with the legislation and details relating to this case.

He’s also keen to gain a better understanding of the ins and outs of the Age-related Residential Care contract, of interRAI and other relevant issues.

In spite of the steep learning curve ahead of him, Wallace seems undaunted by the task; he seems eager to get started.

“The Association has a nice feel about it,” he says, “They’ve made me feel so welcome, and I haven’t even started yet!”

That said, he heeds the parting advice of former NZACA chief executive Martin Taylor, that the first year is “really hard”.

“I’m expecting the first year to be challenging,” admits Wallace. “But coming from an industry body, you become thick-skinned,” he laughs.

Wallace is keen to get out and talk to the membership. He’s particularly looking forward to the annual NZACA conference, and says the programme is looking good.

Gaining a good understanding of the role providers play and the challenges they face is essential in building a strategy for the sector, he says.

“I’m not sure if the wider public is fully aware of the incredible growth that is coming this way.”

“My view from the outside is that the aged care industry does a fantastic job providing care that is very complex.

“In the medium to long term I think we could get better at telling the story of the sector, the great things we do and the challenges we face.

I’m not sure if the wider public is fully aware of the incredible growth that is coming this way.”

Wallace is eager for the sector to take hold of its own plan and be industry-led, rather than government-led. He makes the point that the industry’s strategy must be robust in order to withstand potential changes in government.

He is familiar with liaising with Ministers and government officials – he even worked as an advisor to an Associate Minister of Health at one stage.

There is undoubtedly much more to know about the incoming NZACA boss, but I feel I have interrogated him enough – it always feels a little mean quizzing someone on his intentions for a job he hasn’t started yet. Still, I can’t resist a few nosy personal questions for good measure.

When he’s not working,Wallace says he can generally be found on the sidelines of sportsfields, cheering on his two boys aged nine and seven. He’s a keen gardener. He loves overseas travel.

“Although I don’t expect to be doing too much of that in the next year,” he says wryly.

I suspect he is right – no small task awaits him at the NZACA.

edward@activerehabequipment.co.nz

www.insitemagazine.co.nz | May/June 2015

25

Conferences

Meeting Report Home and Community Health Association’s Conference 2015 28–30 April 2015, Auckland

T

he release of the HCHA Deloitte report on the sustainability of the home and community support services sector coincided beautifully with the Association’s annual conference. The report, which confirmed that a lack of a consistent national approach to planning and funding is placing home and community support services under threat, generated media attention.

Conference attendees applauded as the One News segment was shown on the big screens, pleased to see the sector’s plight acknowledged.

It also coincided with the release of the Productivity Commission’s draft report on its inquiry into Social Services, with Commissioner Professor Sally Davenport presenting the Commission’s initial findings. Hon Nikki Kaye was also there to launch the new brochure “There was a very supporting people to move at home. positive buzz at the The AUT Aged Care Workforce Survey findings were also released. conference, and HCHA Julie Haggie said she feedback postwas very pleased with how the conference has conference went. It attracted a record number of attendees, been really positive from across the broad range of – ‘what a great employers, workers, funders, needs conference’ being assessment agencies, IT and other suppliers, and community service an oft-repeated providers. phrase.”

“There was a very positive buzz at the conference, and feedback postconference has been really positive – ‘what a great conference’ being an oft-repeated phrase,” said Haggie. “We had really good feedback on workshop sessions as well.”

Keynote speaker Professor Nicholas Mays from the UK gave a sobering insight into the difficulties faced by the British home and community support sector. He outlined how the Integrated Care and Support Pioneer Programme had shown examples of excellent integration and the challenges in rolling out such examples to the wider sector.

26

May/June 2015 | www.insitemagazine.co.nz

Pahia Turia’s analysis of Whānau Ora, and KPMG’s Liz Forsyth and Ferros Care’s Jennene Buckley’s presentations on the consumerdirected care model in Australia were also well received.

There were some interesting sessions on training and education delivery, with HHL Group’s Eldred Gilbert’s description of a dementia e-learning pilot making use of a free online course (or MOOC). This was followed by PSN Enliven’s Cherie Saunders presentation on changing their approach to focus on the learning needs of support workers, to great success. Careerforce updated

Conferences

HCHA Awards

attendees on the new qualifications for the sector and the role they are playing in helping providers to develop their workforce.

Phillip Patson gave food for thought in his session on the competencies and attributes he seeks from support workers, and the presentation on InterRAI data set off mental lightbulbs. A panel discussion on in-between travel time brought out many questions from the audience and addressed many areas of uncertainty.

The exhibitors were well-supported in break times. Master of Ceremonies Kingi Biddle helped the conference flow smoothly and the conference dinner was excellent. All in all, a first-rate conference for the HCHA: rich in content, collaboration and collegiality.

The highlight of the HCHA conference dinner was the presentation of the HCHA awards, as decided by the judging panel of Katherine Ravenswood, Fiona McDonald-Bates and Jude Barback.

The Workforce Initiative Award, the award for improving service delivery through workforce development, went to Healthvision for their efforts in transforming ACC Level 3 Training Standards using the Healthvision Case Mix methodology. The finalist in this category was Pasifika Integrated Health Care.

The Service Innovation and Quality Award, the award for improving the quality and/or effectiveness of service delivery, went to Geneva Health for its new policy for Vulnerable People Management, which helped improve the management of vulnerable clients being supported in the community. The finalist in this category was Lifewise for their efforts in celebrating clients, their families, and staff through significant dates.

The Lifetime Achievement Award was awarded to Graeme Titcombe.

The award acknowledges Graeme’s role in supporting the achievement of the vision of both HCHA and NZHHA over the past 15 years. He has contributed to or driven many key reports and outcomes for the sector, including the 2003 Quality and Safety Project, the 2005–06 Fair Travel funding injection, the 2006–07 Wage Injection, implementation of Joint ACC/MoH Service Specifications, design of costing models agreed upon between DHBs and the HCHA, and more recently the in-between travel time settlement and the Kaiawhina Workforce Action Plan.

One of the nominations described Graeme as “a passionate advocate for the sustainability of the sector”, and outlined that he had helped to improve conditions for support workers and promote the contribution that the sector makes to the wider health and disability sector.

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For a FREE product sample phone 0800 830 840 or visit www.nestleprofessional.co.nz

www.insitemagazine.co.nz | May/June 2015

27

This article is sponsored by Continence NZ: www.continence.nz

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Untitled-1 28 1 May/June 2015 | www.insitemagazine.co.nz

20/05/2015 12:54:23 p.m.

Aged care

Let’s snoop around... Pohlen Hospital JUDE BARBACK returns to her hometown of Matamata to visit Pohlen Hospital.

I

’m a Matamata girl – or I was, once upon a childhood – so I think I’m on familiar turf when I visit Pohlen Hospital. But I take the wrong entrance and find myself confronted with an array of health service providers – a medical centre, a radiology clinic, a pharmacy, a physiotherapy practice, a dentist – all leased from Pohlen Hospital.

How convenient, I think as I make a hasty exit and try the entrance next door – all those services under one roof.

When eventually I find myself in Pohlen Hospital proper, I voice these thoughts to manager Greg Parker and clinical manager Loraine Jecentho.

Greg agrees that the ‘one stop shop’ aspect of Pohlen Hospital is fairly unique, and a real asset to the community. The hospital itself offers a range of services including maternity care, GP bed care and minor surgeries, but it is its aged care capacity that is the facility’s “bread and butter” as Greg puts it.

Matamata has an older population than most towns, and this is reflected in the need for residential aged care beds, as well as palliative care.

Community ownership model

It is a private hospital owned by a charitable trust, and governed by a Board of Trustees representing the Matamata community. Its name, like many other things in Matamata (for example, the Pohlen Cup, Pohlen Road and Pohlen Park), harks back to one of the town’s early benefactors, Joseph Pohlen.

Consequently, Pohlen Hospital seems to epitomise Matamata. Greg says there is certainly a strong sense of ownership from the people of Matamata, the feeling that the hospital belongs to them.

As a result, Greg says they seldom say no to requests, like letting a family member accompany a resident on an outing at no cost, for example. He concedes that it is sometimes a challenge keeping everyone happy, but says that the communityownership model is overall a very good thing.

“We don’t want for anything,” he says.

The Pohlen Foundation Trust is apparently capable of raising whatever is needed, with a dedicated fundraising team on board. Greg cites many examples of new equipment and buildings that have been the result of the Trust’s astounding fundraising capabilities.

“We don’t want for anything.”

This includes the new palliative care wing, for which Greg shows me the plans. It will include six suites with space for family members to stay. There is scope to expand further still, both out and up.

Greg and Loraine give me a tour of the aged care facility. Of Pohlen’s 23 beds, 19 are allocated to aged care, and the vast majority of these are hospital-level. Greg admits it is often a “juggling act” when it comes to bed allocation and they do the best they can to accommodate the needs of current and incoming residents, and their many different DHB contracts.

Unsurpassed level of care

It is quite different from other facilities I’ve visited. As I walk down the corridors it feels a little dated – after all, the hospital is over 50 years old. However, while it might lack the gloss that other facilities have, the rooms are freshly painted, clean, fairly spacious and sunny. I catch the residents enjoying their lunch and sitting in the conservatory.

But it is the care that is the defining point here. Both Greg and Loraine emphasise the quality of care, saying it surpasses anything they’ve encountered in facilities in which they’ve worked in the past. Pohlen has received awards at previous NZACA conferences, including in 2013, when it took the overall excellence in care award.

’One-stop shop’

And of course the other definitive factor is the ease of gaining access to other services at this ‘one-stop shop’. While there is evidence of much collaboration with Waikato Hospital, I sense that Greg and Loraine are proud to have a hospital that the community can use without needing to go to Hamilton for everything. For example, a resident can

take advantage of the transfusion service at Pohlen rather than have to go to Waikato.

They also make use of the range of available services through forming multidisciplinary teams to assist with residents’ specific needs.

As participants in the interRAI pilot programme, Loraine says they are “up to speed” with the assessment tool, and describes it as useful.

As always, I ask about the TerraNova v Bartlett case and how it could potentially affect them if carer wages were increased without a subsidy increase. Greg says it would be “a killer” and both he and Loraine agree that something, or little things would need to be compromised in that eventuality.

It is raining as I leave the hospital and I dash for my car, thinking how happy the Matamata dairy farmers – my father included – will be with the downpour. As I drive out of the carpark, I reflect on how familiar Pohlen Hospital felt to me, despite never having visited its aged care facility before today. Such is its significance to the community; you can take the girl out of Matamata... www.insitemagazine.co.nz | May/June 2015

29

Research

Key reports released The end of April saw a flurry of reports released, all with relevance to New Zealand’s home and community support services.

Low wages, high workloads and stress outweigh the love of the job for New Zealand’s aged care workforce.

The findings of the inaugural 2014 New Zealand Aged Care Workforce Survey were released at the end of April, revealing that while caregivers generally enjoy their job, it is not enough to sustain New Zealand’s aged care workforce.

The survey’s lead author, Dr Katherine Ravenswood from AUT University’s New Zealand Work Research Institute, says the survey reveals an interesting picture of the typical aged care worker in New Zealand.

“The average aged care worker is female, aged over 45 and is the primary breadwinner in her family, but she earns $15 or less per hour. She sees herself as skilled but low paid and while she generally loves the work she does, her morale at work is slipping.”

The survey gathered responses from almost 900 members of the aged care workforce – nearly 600 from the home and community care sector and nearly 300 who work in residential facilities.

Ravenswood says low pay, high workloads, an ageing workforce and an increasing demand for aged care add up to a concerning picture for the sector.

“Overall, our impression is that although many caregivers love the job and have good management support, the negative aspects of their work outweighs the positives. This should be a major concern for those planning for the future of New Zealand’s aged care workforce.”

The researchers intend to update the information every two years, with the next survey to be implemented in 2016. This will allow the emerging issues to be tracked longitudinally, enabling policy makers, providers and unions to note key trends in the workforce.

The survey can be found at www.workresearch.aut.ac.nz/ agedcareworkforce.

at the Home and Community Health Association’s (HCHA) conference in Auckland at the end of April.

HCHA chief executive Julie Haggie says the lack of a consistent national approach to planning and funding is placing home and community support services under threat as providers struggle to stay afloat. She says that although DHBs have agreed on a national funding model based on client need, until this is implemented the situation will only get worse.

However, the main problem is that current funding levels fall short of what is required for providers to adequately support a rapidly ageing population.

“Home and community support providers are funded almost entirely by DHBs, the Ministry of Health and ACC. That funding just isn’t enough and with no other sources of funding, providers are being forced to cut costs year after year,” says Haggie.

Haggie says the issue has compounded over time with DHB contracts not keeping pace with the minimum wage increases and inflation.

The Deloitte report shows that many providers have responded to insufficient funding by increasing employees’ workloads yet not their pay, leading to high turnover rates.

“Providers would like to pay more so they can attract and keep skilled people, but current contracts don’t generally allow for more than the minimum wage. The Deloitte report shows that all employers are struggling with some now operating in debt.”

The HCHA is heartened by the Government’s recent injection of money to pay for support worker travel between jobs. However, Haggie says that while it has addressed a legal threat faced by employers, it does nothing to weaken the threat of going out of business.

The Deloitte report was commissioned by the HCHA and is expected to be used to support the Association’s discussions with the Government.

Home care services under threat

Commission releases report for improving social services

New Zealand Aged Care Workforce Survey 2014

Home and community support services are under threat because the current funding model for the sector is unsustainable.

This was the main conclusion of a review of the sector conducted by Deloitte, released 30

May/June 2015 | www.insitemagazine.co.nz

A new Office of Social Services and more investment in data technology are among the recommendations proposed by the New Zealand Productivity Commission aimed to improve our social services system.

The Commission released its draft report as part of the Government’s inquiry into the effectiveness of New Zealand’s social services system.

The report includes 81 findings, 47 recommendations and poses eight questions.

The Commission has taken a ‘whole of system’ view, rather than trying to assess the performance of individual programmes, however it includes in-depth case studies on four specific areas: home-based support for older people, services for people with disabilities, Whānau Ora, and employment services.

Drawing from over 130 submissions and over 100 face-to-face meetings, the Commission concluded that while parts of the system were working well, existing arrangements are struggling to cope with the “multiple and inter-dependent problems experienced by many of New Zealand’s most vulnerable individuals and families”.

The Commission found that government agencies generally know too little about what is and is not working well within the system, and find it difficult to reallocate funding away from underperforming initiatives. It recommended a move away from the current top-down arrangements to giving more autonomy to providers and placing more choice in the hands of clients.

Commission chair Murray Sherwin says that while there are “already pockets of successful innovation” new approaches are required to better match services to the needs of clients.

“We advocate for new arrangements that reshape the roles of governments, providers and in some cases clients, to empower clients and give service providers more autonomy,” says Sherwin.

Among the recommendations was the call for a new Office of Social Services to help the Government develop and guide the overall reform strategy, which would see improved commissioning and purchasing capability, more investment in data infrastructure, and better performance monitoring.

The full draft report can be found at www.productivity.govt.nz. Submissions on the draft report are invited by 24 June 2015. The Government will receive the final report by the end of August.

Clinical

Typical day in the life of...

Claire Roskruge, RN

Christchurch-based registered nurse CLAIRE ROSKRUGE is a participant in the Christchurch DHB’s Gerontology Acceleration Programme and is involved in a restorative care pilot for older people within the acute service. INsite asks Claire about her journey into nursing and what she loves about her job.

INsite: How did you find yourself where you are now?

Claire: The path I took to get where I am today was not typical. Looking for something to fill my days after a long bout of illness, I landed on the steps of Christchurch Academy and was put into an aged care course to “fill spaces”. It was here that my instructor saw something in me that I had yet to discover and persuaded me to pursue nursing. It was during my new graduate year on Ward 23 that I discovered my love for working with older adults within the acute hospital environment and began to understand the unique challenges faced by both the patients and staff involved in their care.

INsite: How would you describe your role?

Claire: I am constantly faced with a diverse array of pathologies, much of which is just the tip of an iceberg of comorbidities. This is particularly true amongst the older patients who frequent our ward, who are also faced with a multitude of social, spiritual and economic barriers to recovery. This requires a close relationship with social workers, physiotherapists, occupational therapists and, of course, the medical teams to ensure that all aspects of our older clients’ health are approached in a holistic manner.

INsite: What are some of the frustrations and challenges you face?

Claire: Recognising these risks is both a blessing and a curse, especially as we are witnessing firsthand an ageing population.

Medical wards are renowned for being busy hives of activity and many of our nurses are struggling to keep up with the increasing demands placed on them. All too often we feel conflicted as we attempt to be ‘present’ with our patients whilst completing those ever-mounting tasks that are essential to their care.

”Part of the challenge is to encourage both nurses and members of the multidisciplinary group to re-evaluate their attitude towards ageing and advocate for more of a rehabilitative focus.”

INsite: How did you become involved with the Gerontology Acceleration Programme and the restorative care pilot?

Claire: After completing my new graduate year, I began to feel frustrated that this was to be the status quo and contemplated steering away from medical nursing until destiny again had other ideas. Scrolling through my emails, I came across a note about the Gerontology Acceleration Programme and my interest was piqued!

Since my acceptance into the programme, I have had the opportunity to work in a

residential care facility and rehabilitation ward, whilst also completing a postgraduate paper in gerontology. This has given me a greater understanding and empathy for the challenges faced by our older community and society as a whole, and has spurred my desire to educate and lead nurses within the acute environment. Part of the challenge is to encourage both nurses and members of the multidisciplinary group to re-evaluate their attitude towards ageing and advocate for more of a rehabilitative focus.

One way in which I have been able to do this is to be involved in the restorative care project. This is a pilot initiative being rolled out on Ward 23 that is focused on preventing decompensation and deconditioning. The project will explore using the existing ‘Care Plan – 24 Hour’ document as a generic document for all allied health and nursing staff, which will give visibility to the patient’s care whilst in the acute hospital setting. It will also complement the ‘Frail Older Person’s Pathway’, which provides better support for frail older people both in an out of hospital.

INsite: What do you love about what you do?

Claire: Since my involvement in the Gerontology Acceleration Programme, I have a renewed enthusiasm and passion for my work and appreciation for life in general.

I love being part of something that will hopefully result in a systematic and cultural change that one day will not only impact on my own patients’ care but will also contribute to a better future for following generations.

The Gerontology Acceleration Programme (GAP) is a Canterbury-based initiative that supports the professional and academic development of registered nurses already working in older people’s health who have the potential to be future clinical leaders, specialists or managers. www.insitemagazine.co.nz | May/June 2015

31

Opinion

Last Word... Brien Cree Radius Care managing director BRIEN CREE is concerned that District Health Boards (DHBs) are not passing on superannuation increases to aged care providers and says it’s time for providers to get their funding directly from the Government, and take DHBs out of the equation.

O

n 1 April, the Government increased superannuation payments by 2.07 per cent.

We naturally expected that the District Health Boards, who use super to top up the subsidy on behalf of the elderly in our care, would pass this increase on to the aged care sector.

At Radius we planned to put the super increase towards providing improved levels of care and service to those we look after, as I’m sure was the case with other care providers.

So it was with some dismay, following the superannuation increase, that we received a funding increase offer from the DHBs of 0.7 per cent.

If it wasn’t such a serious issue, it might be easy to think 0.7 per cent is a joke. This does not even reflect the rate of inflation, let alone the 2.07 per cent that superannuitants were given.

Effectively, the DHBs have pocketed the increase at the expense of those to whom the money belongs – the elderly. The elderly in our care have a right to expect that all of the pension that is collected by the DHBs should go towards their care, and not into the DHBs’ coffers, or for other unrelated activities such as elective surgery.

The problem is that the DHBs get given bulk funding by the Government, for healthcare services, and they decide how this money will get distributed. Superannuation is not ring-fenced for those elderly it belongs to; it just gets put into the pot, and then the DHBs work out how they want to spend the funds across all healthcare services.

It’s a real concern that care for the elderly gets put at the bottom of the priority list by the DHBs, despite the fact that the sector is growing all the time as people live longer and the population increases.

It’s for this reason that the aged care sector needs to be funded directly by the Government, not through a ‘middle man’ with its own agenda and set of priorities.

Our primary focus is the needs of the elderly, but the same could certainly not be said for the DHBs – as evidenced by the fact that they are refusing to pass on the super increase that rightfully belongs to those we care for.

The only way we can ensure our sector is appropriately funded and those in our care get the service they need and deserve, is if we are funded directly by the Government.

We simply can’t carry on being underfunded and undermined as a sector – elderly people deserve as much care and respect as those at any other stage of life, if not more. What’s more – if we’re lucky – we’ll all get old one day, so by ensuring that the aged care sector receives the funding it needs, we’re also ensuring our own care in the future.

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.

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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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32

May/June 2015 | www.insitemagazine.co.nz

Strong when wet1-6

Gentle on the budget1-6

A new generation, high performing, silver, gelling fibre dressing for infected, exuding wounds

NEW

With its unique fibre blend, the DURAFIBER™ and new DURAFIBER Ag™ range provides a combination of clinical and economic benefits that support your patient as well as your budget.

For more information please contact your local Smith & Nephew representative, or call Customer Service 0800 807 663 For patients. For budgets. For today.™

™Trademark of Smith & Nephew SN11217 (02/14)

References: 1. Dowler A. DURAFIBER Dressing Physical Properties. Data on file; 2010: report DS.10.056.R1. 2. Dowler A. Testing performed as part of DURAFIBER photoshoot. Data on file; 2011: report DS.11.187. 3. Dowler A. DURAFIBER Ag Dressing Physical Properties. Data on file; 2010: report DS.10.060.R1. 4. Barrett S, et al. Case Series Evaluation: The Use of DURAFIBER on Exuding Wounds. Wounds UK 2012, Vol 8, No 3. 5. Rafiq G. An prospective, open, multicentre study to evaluate a new fibrous silver dressing in the treatment of moderate to highly exuding chronic wounds. Data on file; 2013: report OR- DOF/28. 6. Dowler A. Integrity testing of DURAFIBER Ag in horse serum and ionic solution. Data on file; 2012: DS.12.093.DOF.