INsite May 2016 by NZME. Educational Media

May/June 2016 | $10.95

AGED CARE & RETIREMENT

We’ve got your industry covered I www.insitemagazine.co.nz

COmmunity care

Fragile state:

our home health services TEchnology

interRAI survey reveals a sector’s struggle

POLICY

Dying with dignity the big debate around assisted dying

Dementia

Dementia and decision-making OPINION

“I’m not going into a rest home”

- a son’s perspective

Silver Rainbow

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Costs We have lots of ideas about how to make your service a welcoming place for people of all sexes, genders, and sexualities.

$500 for up to 20 participants at your venue. We also offer workshops for individual staff members at our premises in Greenlane monthly ($50/person). Organisational snapshot for up to 5 hours consultancy ($500) and $80 per hour for any additional hours.

Contact us to find out more: T 09 531 4040 | M 027 700 0432 | E Julie.Watson@affinityservices.co.nz www.affinityservices.co.nz

Ed’s LETTER

I have included a different sort of article in this issue. In amongst the opinions and research of people familiar with the inner workings of our aged care sector are the reflections of Alan, a man whose connection with aged care goes as far as the possibility that his 92-year-old father, Trevor, may require the sector’s services one day soon. What I found interesting about this piece is that for all the sector’s actions in setting up safeguards and systems to ensure everyone receives the support they need, it doesn’t amount to much without buy-in from the person at the centre. Case in point: Trevor agreed that Alan would act as his Power of Attorney, yet in practice Trevor saw this as a mere legality that had no bearing on his ability to sign cheques away to whichever charity came knocking. Endeavouring to maintain Trevor’s independence, the family set Trevor up with a safety alarm, but on the occasions that he has fallen he has forgotten to use it and has driven himself to the doctor. He receives Meals on Wheels, yet continues to cook with poor food hygiene, which often leaves him feeling queasy. And any conversations broaching the subject of transitioning into care are shut down immediately. Trevor probably represents hundreds of older New Zealanders, and Alan their children who are grappling with the ‘what next?’ That stage spent teetering between independence and care is certainly a tricky one. This really drives home the point that our aged care policies and procedures need to be focused on the client at the centre. We need to remain mindful of the people on the receiving end. The new Health of Older People Strategy looks like it is heading in this direction, which is good news. It needs to place the ‘Trevors’ of this country at the heart of any strategic direction for the sector.

Editor, Jude Barback

In this issue...

FOCUS: Long-term care needs

Searching for a death with dignity

Supported decision-making and people living with dementia

“I’m not going to a retirement home”: a son’s perspective

HCSS: a sector waiting for action

HOPS: how it’s shaping up

Good news for older people’s oral health

Living with interRAI

Dealing with dementia

First Silver Rainbow Seal achieved

Our aged care workforce: should we be looking abroad or under our noses?

HET-Careerforce merger good news for aged care

Coming soon: the New Zealand Aged Care Workforce Survey 2016

Taking telehealth into the future

Smart move: technology aiding the older person at home

On the soapbox... Victoria Brown

Let’s snoop around... Rawhiti Lodge Care

Social value and going the extra mile

Spotlight on... Aphasia

Up close and personal with... Leanne MacDonald

RVA Conference set to tick all the boxes

Reducing hospital visits

Last Word... David Wait Editor Jude Barback 07 542 3013 editor@insitemagazine.co.nz Advertising & Marketing Manager Belle Hanrahan 04 915 9783 belle@nzme-ed.co.nz

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

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

General Manager & Publisher Fiona Reid Production Aaron Morey

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May/June 2016 Volume 10/Issue 2 NZME. Educational Media, Level 2, NZME. House, 190 Taranaki Street, Wellington 6011, New Zealand PO Box 200, Wellington 6140 © 2016. 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 2016 1

Policy

Searching for

a death with dignity The Health Select Committee’s inquiry into medically assisted dying has brought to the fore New Zealand’s deeply polarising debate on voluntary euthanasia. JUDE BARBACK takes stock of the arguments for and against, including the NZACA’s strong stance.

“W

hilst numerous medical interventions have lengthened my life, they have now been exhausted, and I endure a life with very little quality, a kind of half-life. I exist.” These are the words of Faye Clarke, who was diagnosed seven years ago with myeloma, an incurable form of bone marrow cancer. In her submission to the Health Select Committee’s inquiry into attitudes towards physician-assisted dying, she outlined the pain she continues to endure and her wish to be given medical assistance to die. Clarke is one of many who supported the petition of former Labour MP Maryan Street and 8,974 others requesting a Health Select Committee inquiry into “public attitudes towards the introduction of legislation which 2 May/June 2016 | www.insitemagazine.co.nz

would permit medically assisted dying in the event of a terminal illness or an irreversible condition which makes life unbearable”.

New Zealand’s preoccupation with euthanasia

New Zealand has toyed with the idea of medically assisted dying for some time now. Over the years, various efforts to change the law have been made through the introduction of various members’ bills. Yet to date, none have proceeded very far. Iain Lees-Galloway’s End of Life Choice Bill (originally introduced by Maryan Street) failed to be selected for 18 months before being withdrawn late in 2013. Former NZ First MP Peter Brown’s Death with Dignity Bill in 2003 failed in a conscience vote at the

first reading stage, meaning the issue did not go before a select committee. A previous bill championed by Michael Laws in 1995 also failed in a conscience vote. An End of Life Options Bill was also published in 2015, but was not submitted to the ballot. Most recently, ACT MP David Seymour submitted the End of Life Choice Bill to the members’ ballot in October last year and is now waiting for it to be randomly drawn from the ballot so Parliament can vote on it. But it was Street’s petition, launched with the Voluntary Euthanasia Society in the wake of the emotive and high-profile Lecretia Seales case last year, that helped the issue gain some traction. Seales, a 42-year-old lawyer and cancer sufferer, fought hard for the right to legally end her life with medical assistance

Policy

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The experience in legalised jurisdictions has not shown any elder abuse associated with it [physician assisted dying] – in fact, the only study done on various vulnerable groups has confirmed lack of abuse.” before passing away naturally in June last year. The petition led to the current Health Select Committee inquiry, for which submissions closed on 1 February this year. Technically, the inquiry is not about any specific legislation. Instead, the committee will examine the issues surrounding medically assisted dying. It will investigate the factors that contribute to the desire to end one’s life, the effectiveness of the services and support available to those who desire to end their own lives, the attitudes of New Zealanders towards the ending of one’s life, and the current legal situation and international experiences. It is the first time these issues have been scrutinised at this level and the closest New Zealand has ever been to considering a change in legislation in this area.

Opening the doors to elder abuse?

Euthanasia has always been a topic that will divide opinion and, unsurprisingly, the inquiry into medically assisted dying has attracted many submissions in favour and many against. The New Zealand Aged Care Association (NZACA) was among those to oppose the introduction of medically assisted dying in the event of a terminal illness or irreversible condition. After canvassing its members, the NZACA concluded that the more proper position for older citizens in care was to receive additional support in the provision of care as they progressed through the natural ageing process, rather than the hastening of their deaths. In its submission the NZACA touched on the practicalities of introducing medically assisted dying, including the impact on staff and staffing. It also raised the fact that as not all facilities would agree to it, residents may be placed in facilities where it was practised, rather than in the facility most suited to them and their circumstances. However, the cornerstone of the NZACA’s argument against medically assisted dying was the vulnerability of older New Zealanders. The association believes it may open doors to coercion and elder abuse. “They may inwardly feel pressured by their desire, or their families’ encouragement, to make a decision to die. This may be motivated,

personally or externally, [by the desire] to leave some inheritance intact. Around 50 per cent of abuse cases handled by Age Concern New Zealand are financially driven.” However, Dr Jack Havill of the Voluntary Euthanasia Society states there is no evidence for elder abuse associated with physicianassisted dying. He even goes as far as describing such abuse as “virtually impossible”, due to the safeguards that would be in place under potential legislation. Certain criteria would have to be met. For example, in addition to the older person being mentally competent and having a terminal disease or irreversible, unbearable condition, two doctors would be involved in looking at the criteria and for signs of coercion and each decision would be reviewed by an expert committee. Havill points out that the Supreme Court of Canada in February last year agreed that medical practitioners are capable of discerning abuse and coercion. “The experience in legalised jurisdictions has not shown any elder abuse associated with it [physician assisted dying] – in fact, the only study done on various vulnerable groups has confirmed lack of abuse.” However, Euthanasia Free New Zealand believes that coercion and abuse in this manner is conducted subtly and over a long period of time. The advocacy group supports the NZACA’s stance, stating that “no safeguards can protect elderly, disabled and mentally ill people from subtle, or not so subtle, pressure to request death”. They state that medically assisted dying would put pressure on people who choose to stay alive, implying that they are a burden on society. “It would make caring for disabled, mentally ill and elderly people optional, instead of the default.”

Is there a place for advanced directives?

While the Health Select Committee’s investigation isn’t about any specific legislation, including the End of Life Choice Bill, there is no denying the inquiry could potentially lead to a law change. As such, in its submission to the committee, the Voluntary Euthanasia Society outlined

specific clauses it believes need to be included in any legislation on medically assisted dying, such as making it available to individuals with “grievous unbearable irreversible suffering” as well as those with terminal illnesses. “To simply have a law allowing [physician assisted dying] only in imminent terminal conditions, as has been suggested by some, would be inadequate. Some conditions such as in motor neurone disease are intolerable to the patient.” It also stated a need for the provision of end-of-life directives. To remove this provision would “remove the autonomy of many patients realising their worst fears after they have become incompetent”. By contrast, David Seymour’s End of Life Bill doesn’t allow for people to sign advance directives; it is only for people who are mentally sound at the time a decision is made to end their lives. Seymour says the difference between his bill and previous ones is that the decision around assisted dying is based on personal choice. “Assisted dying isn’t something that can be done to you, it’s something that you choose and are capable of choosing at the time you choose for it to happen,” he told Stuff. He’s aware that his Bill’s focus may disappoint those who would like to see an advance directive in it.

End of Life Choice Bill

David Seymour says the motivation for his End of Life Choice Bill is compassion. “It allows those eligible to choose the manner and timing of their final days, allowing them to end their life in peace and dignity, surrounded by loved ones,” he says. The Bill proposes that any New Zealander 18 years or older will be eligible for “assisted dying” if he or she suffers from either a terminal illness likely to end his or her life within six months or an irremediable medical condition causing them unbearable suffering. They must also understand the nature and consequences of assisted dying. Euthanasia Free New Zealand believes the Bill is too open to interpretation. It believes much of the language is subjective. The phrase “irremediable medical condition”, for example, is vague enough to cause almost anyone to be www.insitemagazine.co.nz | May/June 2016 3

Policy eligible. Similarly, there is a lack of definition around “terminal illness”. Arguably its biggest concern is that the Bill doesn’t factor in the effects depression can have on such decisions.

The overseas stance

It is not a debate unique to New Zealand. The biennial World Conference on endof-life issues is held in the Netherlands this month, providing a forum for dying-withdignity societies from all over the world to exchange lessons learned in the process of legalising end-of-life choices. The Netherlands is an appropriate venue – the country was one of the forerunners in legalising assisted dying. In 1973 a Dutch physician facilitated the death of her mother following repeated requests for euthanasia. She was convicted, but the court’s judgment set out criteria when a doctor would not be required to keep a patient alive against their will. This criteria was gradually formalised and enshrined in legislation by 2002. Assisted dying is also legal now in Belgium, Luxemburg, Switzerland, Colombia and several US states. Most of these countries extend medically assisted dying protocols to those with unbearable irremediable illnesses – as well as those with terminal illnesses – and allow provision for advanced directives. The US states have provision only for terminal illness. The Supreme Court of Canada overturned a ban on physician-assisted suicide last year and new draft legislation was unveiled in Canada last month on doctor-assisted suicide for adults suffering incurable illnesses or disabilities. 4 May/June 2016 | www.insitemagazine.co.nz

Other countries have taken more cautious approaches. France has recently approved a Bill that will let doctors keep terminally ill patients sedated until death – but has stopped short of legalising euthanasia or assisted suicide. In Germany, doctors are able to provide patients with the necessary drugs for a medicinal suicide, but are not permitted to take any action in the actual suicide. In Australia, former prime minister Bob Hawke revealed his support behind a push to legalise euthanasia. However, Federal Health Minister Sussan Ley has openly opposed euthanasia, instead acknowledging the need to improve end of life care.

Dying well

Ley’s stance is a leaf out of the NZACA’s book. In its submission to the inquiry, the NZACA outlined how the more that members were involved in end of life care the more opposed they were to medically assisted dying. Studies in the UK and Washington State revealed similar trends. The NZACA emphasised that its members are wholly committed to the contentment and welfare of their residents, who need and deserve quality care at the end of their lives. “Our job is to make these people as comfortable and pain-free as possible. At the same time, we also support the emotional and physical needs of the families and whānau of these residents.” Euthanasia Free New Zealand echoes this stance. “We believe true ‘aid in dying’ and compassionate care mean walking alongside a suffering person and their loved ones. We advocate that medical professionals do

everything possible to relieve their patients’ physical and psychological pain, and enable them to be dying with dignity, but without crossing the line of intentionally ending a person’s life. “To do so would be ethically different from other end of life practices, such as switching off life support, do-not-resuscitate orders, or withdrawing futile medical treatment.” The UK’s GW4 Dying Well Network was formed in response to policy failure to “enable good deaths at the end of long lives”. The network talks about the need for“radically new thinking to drive innovative research that can inform philosophy, policy and practice, not only for the frail elderly but for any with high dependency and mental incapacity who cannot die as free and active agents”. The GW4 network has initiated a programme of linked research projects with the potential to challenge and inform future end of life policy. Here in New Zealand there has been a push for end of life care services to be improved. The NZACA has called for the Government to pay rest homes a distinct palliative care supplement, but Clinical Director of Canterbury Integrated Palliative Care Services Dr Kate Grundy says any improvement to funding needs to go hand in hand with an overhaul of how facilities are supported, both by the DHBs and by specialist palliative care services, including hospices. Improving end of life care is on the Ministry of Health’s agenda. Late last year the Ministry published Te Ara Whakapiri: Principles and guidance for the last days of life and is leading a review of adult palliative care services. Matt Vickers, widower of the late Lecretia Seales, welcomes these initiatives. However, he claims that neither addresess all end of life issues and that assisted dying legislation will complement palliative care, rather than compete with it. “It’s those that palliative care can help the least that need assisted dying legislation the most.” Dying with dignity can mean different things to different people. To some it is a nod towards medically assisted dying. To others it is providing people with the best end of life care possible. Preserving the human life or honouring freedom of choice – it was never going to be a straightforward decision. Either way, it is time New Zealanders laid this issue out for full scrutiny and considered the multitude of different views. We are more than ready to have this debate.

Dementia

Supported decision-making and

people living with dementia CHRIS PERKINS discusses some innovative methods of communicating with people living with dementia that can help them to make the important decisions in their lives.

upported decision-making (SDM) is about helping people with disabilities to make their own choices in life. In the field of dementia, we might already be doing this without being aware that what we are doing is SDM. When we ask someone with advanced dementia what they would like to eat or offer a choice of different outfits to wear, we are giving them some control, even if only in a small way. Equally, assisting someone with mild impairment to manage their investments is the same. This contrasts with the old idea that once a person is diagnosed with dementia, then someone else needs to take over the decisionmaking. We continue to push for older people to appoint an Enduring Power of Attorney (EPOA), but it is important to remember that the attorney, even when the EPOA is activated, must continue to consult the person with a disability as much as possible. By supporting someone with dementia to make his /her own decisions we are upholding their human rights, individuality, dignity and self-respect. The importance of people with disabilities having the opportunity to make their own choices and to be involved in all decisions concerning them is recognised by The United Nations Convention on the Rights of Persons with Disabilities (2006). To achieve control over their lives, some people with disabilities need help to make and communicate their decisions. The goal is to move towards the person being supported to make their own decisions and away from someone else making decisions for them (substituted decision-making). This is the background to the hui held 20-21 April 2016 entitled ‘The Conversation: Supported Decision-making’, which was sponsored by the Office for Disability Issues and Auckland Disability Law. This event began the discussion about SDM in New Zealand. At the hui the representatives of a variety of groups presented issues for discussion and the New Zealand Dementia Cooperative hosted a panel to discuss SDM in dementia. Dementia is different from many other disabilities in that it is not a static or stable condition. With progression there is a gradual decline in abilities to remember, reason and communicate. Furthermore, episodes of illness, delirium, pain, poor hearing and eyesight, being unaware of

6 May/June 2016 | www.insitemagazine.co.nz

the time of day or where they are can impact on the person’s ability to think clearly. This means that the support given to a person to make decisions will vary through the course of the condition and from day to day. We need to ensure that the environment and the person’s health is as good as it possibly can be when helping them to make and communicate decisions.

MESSAGE communication

Communication with people with dementia was our first panelist’s topic. Annabel Grant, speech and language therapist at Massey University, shared her system to assist people with dementia to communicate using the acronym ‘MESSAGE’, briefly described below. M - Maximise attention E - Expression and body language S - Keep it simple S - Support their conversation A - Assist with visual aids G - Get their message E - Encourage and engage in conversation

Talking Mats

Grant introduced the ‘Talking Mat’, a visual way for people with dementia to communicate. She also told us about the website www.demtalk.org.uk that offers an online toolkit for effective communication with people with dementia. Psychologist Sharon Brandford followed up by demonstrating some Talking Mats she had used for discussion with people with intellectual disabilities and dementia. Talking Mats help people to make everyday decisions, and taking photos of the completed Mat helps build up a picture of a person’s experiences and choices over time. For best practice in SDM we need to trial communication aids and strategies to augment communication, involve the person in decision-making at all levels and maintain records of their choices. This is an ongoing process that should be implemented long before any major formal decisions have to be made. In that way we develop an understanding of the person’s values and preferences. Providing support is not always straightforward. Richard Worrall (old age psychiatrist, ADHB) told the story of a very independent person who refused input and made her own decisions that seemed very risky. Worrall introduced the concept of ‘openness’ – the degree

Dementia

“

Discussion with people with dementia can be time consuming but ultimately rewarding and new methods of communication can make the process more enjoyable and effective.” to which a person is willing to be supported. Without some openness it is impossible to help people in decision making, though too much openness might leave the person vulnerable to coercion. This presentation introduced the dilemma of what to do when people are determined to do something that makes us very anxious for their safety.

Advance Care Planning

Another way that people can express their preferences is through an advance care plan (ACP). This allows people to make decisions about care should they develop dementia (or other conditions) that make it difficult to decide or communicate. However, Gary Cheung (old age psychiatrist and researcher, The University of Auckland), in a study of capacity to make an ACP, found that over half of his research participants, including apparently cognitively normal older people, lacked this capacity. Clearly, many older people would need support in making an ACP.

The Talking Mat tool

More questions than answers

Any discussion like this raises more questions than answers. Do we only ask people with dementia to make decisions about things that matter to us and not to them? What if they decide to do something we think is risky? How do we balance safety and autonomy? Is the risk to physical safety more important than the risk to personhood when we override people’s decisions? When does persuading, encouraging, cajoling or coaxing tip over into bullying and coercion? What if the person decides they want to do something but the services are inadequate – they want to go for a walk, but the carer is only allowed to give them a shower? And so on… Discussion with people with dementia can be time-consuming but ultimately rewarding and new methods of communication can make the process more enjoyable and effective. To truly respect and value people with dementia we must take the time to reach out and understand them to enable them to make their wishes known and give them our full attention. With appropriate support, they can continue to have control over decisions about themselves for longer than we might have thought possible.

The Office of Disability Issues is building a new disability strategy and would welcome feedback on how disabled New Zealanders and their whānau can live a good life, feel valued, supported and able to participate in their communities. They would like to hear from you on www.jointheconversation.nz before 24 May 2016. Recorded information from the hui will be available from Auckland Disability Law at the end of June 2016. www.insitemagazine.co.nz | May/June 2016 7

Aged care

“I’m not going to a

retirement home”

ALAN HITCHCOCK gives a candid account of the realities of dealing with a parent who is steadily losing independence but refuses to discuss long-term care options.

Alan Hitchcock with his father, Trevor

y mother died without warning. She died while doing a spot of gardening alongside my father, Trevor, at their home. That was in 2011. Dad is now 92. Living by himself, Dad still resides at the same house where he lost his wife. For the most part he is doing okay. He has aged a lot, his hearing is poor, and his balance and shortterm memory are both dodgy. He enjoys reading the morning Herald and still gives the daily crossword a fair go, but he spends a lot of lonely hours looking out the window. I worry about him living on his own and because I live only 15km away, I try and call in on him every day. When I can’t get in, I either

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ring him or my wife looks in on him. My brothers and their wives and families, as well as my children, all of whom live further away, call in on Dad when they can. Soon after the death of my mother, retirement homes were discussed with Dad. My brothers and our wives all had differing opinions as to where Dad’s future lay. We all agreed that at some time he would have to go into care; we couldn’t agree as to when. When I first raised the topic with Dad, I was met with a cold stare and a curt “I’m staying here”. Then to show that the discussion was over, Dad prised back the sun curtains and looked out the window.

Dad lives in a comfortable street surrounded by many friendly retirees and caring families. My brothers and I have organised Meals on Wheels lunches five days a week, a lawnmower man and a house cleaner for him. We have got him wearing a St John Medical Alarm pendant, which he has forgotten to use in the couple of situations where he found himself in need of assistance. After successful eye cataract surgery in 2015, he passed his driving sight test and is also still driving his car. The car gives him huge pleasure and independence – he drives into town for daily visits to the bank and grocery store; he enjoys short drives out into

Aged care the country and often visits Mum’s grave; and on Sunday he drives to church. So why would we change anything? On balance, things are fine today, but what lies ahead? I don’t want to turn up there and find that he has being lying on the floor all night or has burnt himself or put himself or others at risk in any way. The subject of retirement homes that surfaced soon after my mother’s death has resurfaced since with increasing regularity. Or to put it more bluntly, retirement homes are being mentioned more as Dad’s ‘wheels fall off’ at an increasing rate. As a family, we have a number of concerns. As mentioned, his balance is poor and he has had about five serious falls in the last three years, resulting in assorted closed ‘black eyes’, ripped skin and strain injuries. Amazingly, he never reports the falls. I see the damage when I turn up and find him all banged up, sitting in the chair with one of his Boy Scout self-applied bandages and liberal doses of iodine on any wounds. He swears by iodine. He cooks himself an evening meal and also fends for himself at weekends. Friends and family often drop in ‘TV dinners’ and baking. Dad sees nothing wrong with a mince ‘cook up’ on Monday morning and reheating the mince every night for tea for the rest of the week. So it’s no coincidence that by most Fridays he is, in his words, “a bit loose”. In spite of all my food safety advice, he won’t change anything and refuses to make the link. Other things like milk expiry dates and dish and cup washing are also a concern. Dad is not worried by any of this and on one occasion, whilst I was sitting next to him in the doctor’s waiting room, I had to stare ahead trying to pretend that I wasn’t listening to him telling a rather startled stranger, “I’ve always had a cheap set of guts”. Dad is a prime target for charities and slippery cold-callers. Not so long ago he asked me to look through his cheque book to see if he had paid a certain bill. I was staggered to see that hundreds of dollars were going out monthly to many charities that I had heard of and to quite a few that I hadn’t. I challenged him about this. I explained that my brothers and I don’t need his money (and we don’t), but as he doesn’t know what’s around the corner he should save his money better. Dad looked remorseful and promised me that he would rein in his philanthropy. A recent sneaky look showed me that the charities are all still doing very well from Dad’s benevolence. Recently I discovered a pile of unopened SkyWatch magazines in his car shed. After a lot of rigmarole, where I got Dad to nominate

“

All in all, it seems to everybody except Dad that he should soon be making the move into a retirement home. But he just doesn’t want to.” me as his Sky representative, I found that, in addition to the unused SkyWatch, he was paying for Rialto, the rugby channel and all the movie channels – none of which he knew about, let alone viewed. To top it off, a few months ago he walked me into the garage and nervously showed me his newly installed water purification system. “Just under $3,000,” he announced proudly, avoiding my eyes. “Dad, what do you need this for?” I gasped. “Well, the sales girl showed me how my skin was packing up from showering in the rough town water,” he mumbled, still looking away. “Your skin is packing up because you are ninety-bloody-two,” I choked. Recently we have been able to convince Dad that he needs a back-up to his financial (mis) management, and my older brother and I have been given power of attorney to act on health and money issues. The problem now is that it appears he has no intention of actually handing any of the decision-making or signing over; the visit to the lawyers was, it seems, to get us off his back. There are many other signs that Dad should not be living on his own for much longer. Having not mastered his TV remote, he de-programmes his TV on a regular basis and happily rings the local TV firm to send a man round to fix it. His wardrobe is getting tatty; he still loves to wear old ‘cardies’ knitted by Mum 10 years ago. He doesn’t notice or care about food spills on his clothes; his onceloved garden is pretty scruffy. The house is missing out on maintenance and care. As a family we do what we can, but he is fiercely independent, happy with the status quo and resists change and advice on all levels. All in all, it seems to everybody except Dad that he should soon be making the move into a retirement home. But he just doesn’t want to. So do we take control and bulldoze over his wishes and, in so doing, risk wrecking our

relationship with our father, the man who has given us so much care, financial support and love through the years? It is a huge dilemma. Realising that I might have a better chance of discussing retirement homes with him if I did some research, I recently made an appointment with a prominent local retirement home. My wife and I were met by the very professional home manager. She was very understanding of our situation. It seems the reluctant admission by a parent is a problem that many families face. We were shown around the entire complex, looking at the various care options, ranging from residing in villas or modern apartments to care rooms and hospital rooms. We were given and taken through a well drafted prospectus, which clearly explained the services that were available with each living option and the associated costs. There was a range of facilities and activities to be enjoyed. I was surprised and very impressed. As we walked out, we chatted to some of the residents we knew. They seemed very happy, enjoying the companionship and all that was on offer. I made the comment to my wife that I could see myself moving in here down the track a bit. My wife succinctly pointed out that it is hard to bring someone in here if they are kicking and screaming. Clearly, you have to decide early yourself whether you will be prepared to move into a retirement home when it is time. I contemplated this and I realised she was right. With that thought of kicking and screaming in mind, I drove round to see Dad. “I’ve just had a look at the retirement home and I think that ...“ I didn’t get the sentence finished. Dad’s usual poor hearing was working well. “I’m not going there,” he said, quite calmly. With that, he prised back the sun curtains and studied the house across the street. Discussion closed. www.insitemagazine.co.nz | May/June 2016 9

Community care

HCSS: a sector waiting for action The Director-General of Health’s report to the Ministry of Health on the state of New Zealand’s home and community support services (HCSS) describes the sector as being “in a fragile state”. It says “that doing nothing is not an option”. This report was completed in August 2015. Yet still, a sector waits for change.

“I

don’t think people understand quite how fragile the sector is,” says Julie Haggie, chief executive of the Home and Community Health Association. By ‘sector’ Haggie is referring to the home and community support services sector; by ‘people’, she means the Government, which continues to stall on a crucial aspect of an agreement reached between HCSS providers, unions and the Government.

What was agreed

Back in September 2014, the negotiating parties agreed to a two-part settlement. The first part was around establishing national minimum travel payments for community support workers. Many felt the agreement should have included backpay on travel time; however, the unions agreed to forgo backpay on the condition that the second part of the settlement would be met – to regularise the workforce. Part two of the settlement would bring much needed consistency to the sector. As things stand, DHBs vary significantly in their contracting, employment and pay structures. Honouring part two would mean guaranteed hours and workloads for workers. Pay would be linked with training, which in turn would meet the needs of the clients receiving support.

What has happened

According to the settlement this needed to happen within 24 months of signing. Now at month 20, there has been virtually no movement on the part of the Government. Actually, that’s not quite true. The new legislation to allow in-between travel time payments is significant. The Home and Community Health Association has welcomed this, along with the injection of funding to address the specific issue of travel time. 10 May/June 2016 | www.insitemagazine.co.nz

However, to ignore the second part of the settlement is to ignore the larger problems with the sector. As per the terms of the settlement, the Director-General of Health set up an independent body to oversee the regularisation process and review the state of the sector. It reported back to the Ministry of Health in August last year. Yet nine months later, the DirectorGeneral’s report is nowhere to be seen. The Ministry told INsite that it would be made public once they’d worked through the recommendations in the report with the settlement parties.

What the report says and why the Government is slow to discuss it

The report, obtained under the Official Information Act, confirms the sector’s fragility that Haggie mentioned. The first paragraph says the Director-General’s Reference Group “identified clear evidence of a burning platform for change”. It lays bare the fragmented nature of service delivery, the “inefficiencies and significant variation in service provision”, which ultimately disadvantage the person on the receiving end of the support. “There is a lack of focus on the person, and a shift is required to emphasise the person’s needs, prevention of illness, maintenance of wellbeing, reducing unnecessary hospital admissions and improving outcomes rather than the emphasis being on the funders and providers. “Systems and structures are cumbersome, and duplication of effort is evident creating unnecessary stress for people receiving HCSS and inefficient use of limited funding.” The concerning thing about this report is that it is not new news.

The Deloitte report released last year, the recent BERL report and the Human Rights Commission’s report of 2012 all identify the sector’s struggle to develop nationally consistent service models to keep up with growing demand for their services. Residential aged care facility managers are noticing an increasing level of acuity and frailty of residents referred to them from their homes. These days people assessed for rest homelevel care are often much closer to hospitallevel care than ever before. The shift in acuity is due to people remaining longer in their homes, increasingly relying more on the HCSS sector. What’s more, it’s going to increase. The Director-General’s report shows demand for HCSS is expected to increase significantly, particularly for the over-65-years age group, which is projected to grow from approximately 475,000 (12 per cent of the population) to 1.2 million (25 per cent) by 2050. Yet, the Office of the Auditor-General reported in 2014 a lack of confidence that HCSS were capable of meeting this future increase in demand. The 2015 Deloitte report suggested the sector was at risk of becoming unsustainable within the next decade. Worryingly, the Director-General’s report confirmed that DHBs have “little or no additional funding to support the projected demographic changes and increases in consumer complexity that will place significantly greater demands on the HCSS sector”. “Without urgent investment over the short term, combined with a longer-term strategy to address the requirements of the sector, there is a significant risk that people will be unable to access high-quality care,” the report observes. Residential aged care providers have been offered a one per cent funding increase from

Community care

“

The soil for home support is currently bone dry and of variable quality; we are facing imminent crop failure at the same time as being asked to produce more.”

DHBs as part of the Age-Related Residential Care agreement negotiations for 2016–17. While it might seem a paltry increase, Julie Haggie says it is more than home and community support services are getting, yet they can provide their care and support services at a rate that is four and half times cheaper than residential care. The Director-General’s report discusses the need to regularise the workforce, to train the workforce and recognise their training in their pay. It even includes some preliminary estimates to give an indication of what it would cost to ensure the delivery of consistent and sustainable HCSS across the country. Change will not come cheap, and this might explain the Government’s reticent approach on addressing part two of the settlement.

Monopolies forming in the absence of consistency

Meanwhile, as the sector waits for the Government to act on these issues, inconsistencies deepen. Capital & Coast DHB has entered a monopoly contracting agreement with Access Home Health, slashing their HCSS provider contracts to just one. The DHB was probably driven to considering a monopoly situation by the tight funding envelope they have for HCSS. It was likely able to negotiate good terms with Access, for the short term at least. But longer term there is significant risk, a loss of competition and inevitably reduced innovation by opting for a single provider. Will Capital & Coast DHB report efficiencies from their move, prompting other

DHBs to follow suit? This would be very concerning for the sector should this scenario emerge. The writing has been on the wall for some time. In 2013, the Accident Compensation Corporation (ACC) reduced the number of contract holders from 86 to six, leaving many smaller providers to scramble on board with bigger providers or leave the sector altogether. DHBs were showing signs of doing the same. Three years on, Capital & Coast’s decision leaves well-known and reputable providers like Presbyterian Support Central reeling.

Fire-fighting won’t work anymore

The sleepover settlement and the in-between travel settlement have been welcomed by the sector, but it is clear the Government cannot continue this strategy of putting out fires every time things start heading towards litigation. Like the equal pay case, a deeper approach is needed to address the fundamental problems at the core. As Julie Haggie remarks, “The soil for home support is currently bone dry and of variable quality; we are facing imminent crop failure at the same time as being asked to produce more.” The Ministry talks of the need for an “enduring, affordable, sustainable framework” and providing a “roadmap for ensuring a skilled workforce to support New Zealanders”. But until this becomes a reality, it is just rhetoric. www.insitemagazine.co.nz | May/June 2016 11

Policy

HOPS: how it’s shaping up INsite looks at the key themes emerging as the new Health of Older People Strategy moves beyond the workshop phase and begins to take shape.

he new Health of Older People Strategy (HOPS) will sit within the recently published New Zealand Health Strategy, which sets the direction of health services to improve the health of people and communities in New Zealand. The overarching health strategy was developed with the help of sector leaders, independent reports and extensive public consultation, and was informed by other government programmes and initiatives. HOPS is in its design phase. In a series of workshops the Ministry of Health held in October and November last year, they heard the concerns of the public and many of those involved in providing health and social services to older people about areas for improvement. Ministry policy analyst John Roy updated INsite on the next steps per the table below, saying, “Our task following workshops is to analyse all the information we have gathered, prioritise all actions and develop a cohesive, comprehensive and forward-looking strategy to drive improvements for the next 10 to 15 years.”

Most frequently raised points in the HOPS workshops

»» The health system should be truly person centred so that older people and their families/whānau are at the centre of planning for their care. »» There needs to be a greater focus on healthy ageing through improved health literacy, more cross-government coordination in addressing social determinants of health status, particularly for vulnerable population groups, and more promotion of healthy lifestyles through community groups and primary care.

Good news for

POLICY

A new report on the oral health of older New Zealanders confirms what the aged care sectors have known for some time – this is an area of older people’s health that is in need of serious attention.

»» We should invest more in public health initiatives and early detection of emerging conditions to prevent these becoming more complex. »» There are vulnerable populations in New Zealand, especially in the older people group, who have significantly poorer health outcomes than the older population on average, and we need to address these inequities. »» We need more flexibility in some funding, policy and service models to foster innovation to deliver better health outcomes for older New Zealanders. »» We need to better integrate the system for better outcomes of health services. This could include more cooperation between government departments when dealing with vulnerable older people with multiple needs, closer links across community interests and primary care and ensuring that information flows freely through the system and to older people. »» Information technology needs to be used to its full potential. »» Our full health workforce should be better applied to ensure older people receive the full range of care needed to stay well. Some workforce elements could also be better trained in addressing the needs of the older population. »» We need to improve measurement of the effectiveness of our various health initiatives and interventions. »» The quality of healthcare personnel is generally good. »» We need to alter the definition of ‘older person’. Being 65 years of age does not adequately describe the typical picture of the health status of older New Zealanders. »» Older people should have more choice and involvement in their health care. »» Treatment beyond hospital to ensure good rehabilitation and optimal recovery should be more pervasive. »» Information and technology solutions can help older people stay well but it must be user friendly.

older people’s oral health

12 May/June 2016 | www.insitemagazine.co.nz

he release of a report urging critical policy development around older people’s oral health is welcome news to those who have been pushing for improvement in this area. The report, Our Older People’s Oral Health, published in December 2015 and made public on the Ministry of Health’s website in April this year, looks at the key findings of the 2012 New Zealand Older People’s Oral Health Survey.

The findings

According to the report, just over half of all older adults had lost all of their natural teeth. Of those who were edentulous (had complete tooth loss), 73.9 per cent living in residential care and 86.9 per cent living in their own homes wore full

upper and lower dentures to replace their missing teeth. The proportion of older adults living in residential care who were dentate – that is, they had one or more of their natural teeth – was 43.4 per cent; of those living in their own homes, 47.8 per cent were dentate. Just over a third had a functional dentition – defined as 21 or more natural teeth. The researchers describe this as an “encouraging finding”, as the retention of natural teeth benefits people’s overall health and wellbeing. However, the survey also shows that many dentate vulnerable older adults experience oral disease and unmet treatment needs. The report showed “concerning levels” of untreated decay among dentate older adults. Over 61 per cent in residential care and 43 per cent living in their own

Policy homes had untreated coronal decay on one or more teeth. A third had untreated root decay on one or more teeth. Perhaps one of the most concerning findings was that further disparities in oral health exist within this population group, particularly among Māori and Pacific older adults, older adults of lower socioeconomic status, and those living in residential aged care facilities.

Why is the oral health of residents in residential care so poor?

The survey found that residents in aged care facilities have poorer oral health than older adults living in their own homes. They were more likely to have untreated coronal decay and, on average, more teeth with coronal decay; more surfaces with untreated root decay; more likely to require extractions and, on average, required more teeth to be extracted. They were more likely to have heavy plaque and calculus on their teeth. They were less likely to wear complete dentures and less likely to brush their teeth twice a day and to use a fluoridated toothpaste. This could support what other studies have shown – that residents in care experience more physical difficulty in cleaning their teeth. Overall, older adults living in residential care were less likely than older adults living in their own homes to access oral health services, particularly privately funded services, and were less likely to use transport services to access care. They were less likely to have attended a dental professional in the previous year; when they did, it was more likely to be for a problem rather than for a check-up. Interestingly, cost did not appear to be a significant barrier to accessing care for this group, whereas it was for older adults of lower socioeconomic status and Māori and Pacific older adults. The problem is that 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 recommended 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”. There is no doubting that including dental care in the ARRC agreement would have significant cost implications. 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.

“

Oral health in older people wasn’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.” 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 and maintaining a resident’s oral health often becomes too hard for the family. Ideally, a programme of oral health maintenance should be included in a facility’s service and extend beyond regular teeth-brushing to individualised oral care assessments and oral care plans. The New Zealand Dental Association (NZDA) provides a training and education programme for aged care staff. The Ministry of Health provides funding for 20 workshops per year for a maximum of 50 participants in each workshop. The NZDA also supplies a Ministry-funded oral health guide, Healthy Mouth, Healthy Ageing. Since September 2010, 95 training workshops have been held in 19 centres, providing formal training in oral health care for 2,741 caregivers from the aged care sector. A further 20 workshops are planned this year. Deepna Krishnan from the NZDA told INsite last year that they would like to see 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. However, she said one of the main barriers is getting facility managers to support the caregivers in putting their training into practice. Because facilities are not obligated to provide an oral health care programme as part of their accreditation, there is little motivation for managers to prioritise oral care among the many other demands on their time and pockets.

About time

It is clear from this latest report that oral health needs to become a priority. The researchers conclude that with the New Zealand population expected to become older and increasingly dentate, it is critical that policy is developed to address the oral health issues of older adults, particularly in the areas of continued monitoring, prevention and service delivery. It must be of some frustration to those involved with the research that it has taken so long to publish the report, bearing in mind it is based on the findings of a 2012 survey. Dr Clive Ross, previously the clinical director for the Oral Health unit at Auckland District Health Board, is pleased to finally see some movement on this subject. When INsite spoke to Ross last year, he expressed concern that oral health in older people wasn’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. Yet Associate Minister of Health Hon Peter Dunne describes the report’s publication as “timely” given that it complements the new Health of Older People Strategy. In releasing the report, Dunne indicated that the Ministry is now considering where oral health sits in terms of the Health of Older People Strategy and is looking at ways to improve the current situation. “The next stage of consultation on the Strategy will focus on the response to priority issues. The work on the Strategy provides a timely and appropriate vehicle for responding to the report and addressing priority issues related to older people’s oral health.” Dunne says the Ministry is currently considering two options: either looking at ways for improving oral health care within rest homes and community care providers, or greater promotion with GPs and primary care nurses of the importance of good oral health advice to older people. www.insitemagazine.co.nz | May/June 2016 13

Technology

Living with interRAI In the last issue of INsite, the team at TAS offered some reassurance that the sector’s mounting concerns about interRAI would be addressed. However, a recent survey of aged care providers delivers some worrying home truths about the realities of day-to-day life with interRAI.

n 1 July it will be one year since interRAI was made mandatory for the aged care sector. Since its earliest days interRAI has polarised the sector; like Marmite, it was one of those things people seemed to either love or hate. However, more recently the assessment tool appears to be gathering more haters than lovers. A recent survey, conducted by the owner and manager of Glenbrook Rest Home in Waiuku, Peter Mathyssen, confirms that many aged care providers are fed up with the system. The survey was sent to 830 interRAI users and completed by 128. It asked respondents about a range of topics, including the time taken to complete assessments, its ease of use, what they liked about interRAI, and what they didn’t. Mathyssen says the negative atmosphere around interRAI prompted him to do the survey. Other than a few officials, he didn’t know of anyone with hands-on experience in a rest home who had anything positive to say about interRAI. While Mathyssen’s survey revealed some positive voices in support of interRAI, the majority of responses confirmed his gut feeling – that interRAI was not well received by the sector.

Time-consuming

The most common theme emerging from the survey results was how much time interRAI is costing facilities that were time-poor from the outset. The question on how long a full interRAI assessment takes was met with a large range of responses. The shortest time given was two hours; the longest three to four days. The majority of responses hovered around the six to eight hour mark. “I have recently had issues with an interRAI trainer who says an assessment should take 40 minutes,” remarked on respondent. “I find a simple interRAI assessment will take me a shift which is six hours; a complicated one can take two to three shifts.” Lead DHB Chief Executive for Older People Chris Fleming says the length of time a typical interRAI assessment should take is 14 May/June 2016 | www.insitemagazine.co.nz

“

I simply haven’t had time to keep up with all the little tests I get sent to maintain my competency as I have so many other tasks of greater priority.” interRAI survey results at a glance »» 58% of respondents think interRAI is a waste of time or almost a waste of time. Only 15% think it is brilliant or almost brilliant. »» 61% of respondents do not enjoy completing interRAI assessments, only 27% do. »» 66% would NOT continue with interRAI given the choice, only 27% would.

approximately two hours, provided they know the resident well and they know the interRAI assessment well. He acknowledges that there are bound to be variations to this. Some survey respondents voiced frustration at how the time spent on interRAI assessments detracted from their core responsibilities. “I am a sole RN manager at present,” shared one respondent. “The time it takes me away to do the assessment and in the time frame required is very difficult and it takes me away from the resident and has not improved the care given.” “The whole thing just seems so time consuming,” says another. “I am so exceptionally busy as the general, clinical and human resource manager I simply haven’t had time to keep up with all the little tests I get sent to maintain my competency as I have so many other tasks of greater priority, I can’t do these after hours as I have a baby. It seems a lot of additional work on top of what we are already having to do.”

Training still a concern

The lengthy wait for training is still a concern, despite the best efforts of TAS. NZACA chief executive Simon Wallace says he has received a lot of comments about interRAI in recent months, particularly around training and the very long waiting times, sometimes six months, to get RNs on to training courses. “We need to get the training situation fixed because our members have certain obligations in their ARRC agreement with respect to the completion of interRAI assessments and those are at risk unless we get the staff who are trained to do those assessments. In this regard, some NZACA members have received partial attainments in audits because they don’t have the trained staff to do the assessments when required. “This is a flagship policy of government that needs to be supported by training when and where we need it.” TAS has trained in excess of 3,100 Registered Nurses from the 679 facilities across the country and is continuing to train 720 additional nurses per annum. They have also trained 330 facility managers in the use of the software and reporting capabilities. However, Chris Fleming says training is still their biggest concern and TAS is currently exploring options to try and increase the training capacity available. “Ironically, one of the biggest issues is the waiting times for training,” says Fleming. “All facilities reached the target of 1 RN trained per 15 beds, however training demands have continued from two sources, firstly the level of staff turnover in Aged Residential Care, and also many facilities are now choosing to request training for a far higher level of coverage (more RNs trained than previously planned), and this is placing significant demands on the training resources.” Part of the problem is that TAS wants to maintain control over the training process, despite struggling to keep up with demand. Meanwhile, many providers are keen to roll out training themselves, maintaining that this would be a much more efficient solution, especially given the high turnover of aged care nurses. This response from the survey reflected many:

Technology

“

We love interRAI here. It gives a clear picture of where a client is at and what elements need to be focused on in a care plan.” “Many of our nurses will leave if opportunities for jobs within the DHB and in areas other than aged care come up and so we keep ending up at starting point all over again with staff not trained for this.” “My nurses have been on a waiting list since last year,” writes another respondent. “The one nurse we had trained recently has since left, only one other is currently training as no other spaces available for my other nurses.” Concerns were also raised about the costs associated with the training. “We paid an extra 40 hours in last fortnight’s pay to cover nurses completing interRAI assessments. The other negative is that nurses can turnover quite quickly in residential care; they get experience and then get hired by the local DHB (where they don’t have to do interRAI) then we have to train another one.”

Redeeming features

However, while the vast majority held disparaging views about interRAI, there was an abundance of praise – even from those who were not fans of interRAI – for the tool’s ability to help them gain a much deeper knowledge of the resident’s needs. “You get to know the residents very well,” says one respondent. “The residents respond well to the time spent with them.” And a handful of survey respondents were clearly impressed with interRAI. “We love interRAI here,” says one, “It gives a clear picture of where a client is at and what elements need to be focused on in a care plan. We have totally aligned our care plan to the CAPs, which has made a great difference.” Chris Fleming says this reflects feedback they’ve received, which suggests that the facilities that have fully integrated the interRAI process into the way in which they do all of their assessments and care planning are finding that the tool improves quality for both the assessment and care planning. “Where providers are using the interRAI assessment simply as a compliance tool there is great frustration and concern about the tool. “We do not apologise for this as the single most important driver for the implementation of the interRAI tool was improving and enhancing the standard of care being delivered to this vulnerable group of clients.” Mathyssen believes those making policies around interRAI “have no idea” what aged care providers who are using the tool on a daily basis are up against. “There is a large rift between those who make the decisions re interRAI and those who

have to use it in real life. That’s where the problem lies,” he says. However, Fleming says they acknowledge the sector’s concerns about interRAI. He says plans are afoot to commission an independent review of its implementation in aged care from 2011 to 2015. The review will seek objective feedback from the sector. We are about to commission an independent review of the implementation of interRAI in aged care from 2011–2015, which will investigate a range of aspects of the implementation and seek objective feedback from the sector. “Feedback is always helpful and we will certainly consider the issues raised and review and assist where we can. We intend to address concerns and queries from interRAI users through our regular communications with the sector.”

It’s fair to say that the sector expected and tolerated some inevitable teething trouble during the bedding-in phase of interRAI, but is the grace period coming to an end? It would seem there needs to be some much-needed communication between those making the policy decisions around interRAI and those who are required to use it on a daily basis, for the sector to push through these prolonged early days.

interRAI data now available The release of the inaugural National interRAI Data Analysis Annual Report 2014–15 is a step in the right direction to offset the sector’s concerns over interRAI.

he release of the first interRAI data report has answered providers’ concerns that they weren’t receiving any data back despite putting a lot of time and effort into meeting interRAI requirements. The report, prepared by the interRAI National Data Analysis and Reporting Centre in TAS, includes a range of information gathered from the use of interRAI assessment in New Zealand. The report has been described as a “major step forward” in the journey of interRAI in New Zealand. It makes it possible, for the first time, for a large variety of stakeholders in the aged care sector to freely and publicly access interRAI data and information at an aggregated level from a national perspective. It provides information on interRAI assessments and the key features and trends for the year July 2014 to June 2015 and has been drawn from the 19,600 Contact Assessments, 36,900 Home Care Assessments, and 27,200 Long Term Care Facility Assessments completed over this period. While the data has been analysed, the National Data Analysis and Reporting Centre has not attempted to interpret the implications of the information or comment on how it should be used by stakeholders. The intention, as chair of the interRAI New Zealand Governance Board Professor Paul McDonald says, is to encourage “stakeholders in the wider aged care sector to take the opportunity to use the information presented in this report and to start asking the ‘so what?’ questions”. InterRAI is a key focus for the New Zealand Aged Care Association. In its ARRC submission, it called for a more consistent approach to data provision at both the individual and aggregate level to shape future policy settings. The release of the inaugural report goes some way towards meeting these needs. However, chief executive Simon Wallace says it’s not enough. “We welcome the annual report, which offers some early insights, however what we’re really looking for is data relating to individual member facilities.” Wallace says he is looking forward to interRAI staff presenting a range of findings at the NZACA’s annual conference in October. Chris Fleming says TAS is looking to expand the suite of reports over time and respond to sector feedback about what is valuable. “We are happy to receive suggestions at any time from facilities about what data might be useful to support and develop their services.”

www.insitemagazine.co.nz | May/June 2016 15

Dementia

Dealing with

dementia

As the general public becomes more familiar with dementia and what it means, the obsession with cure and prevention increases. But as a society, perhaps we should be looking to truly embrace dementiafriendly communities instead, suggests JUDE BARBACK.

meme popped up on my Facebook feed recently telling me that drinking champagne improves memory and prevents dementia. It was shared widely, with many predictable comments and

‘likes’. Discussions around dementia and Alzheimer’s disease have been cropping up more and more in mainstream and social media. The Herald’s recent running feature on the linkages between rugby and dementia is a case in point. As with cancer, we fear that we may be unwittingly doing something in our younger years that will cause the disease later on. And so we latch on to tenuous research that concludes we should drink more champagne. The sad reality – at least for now – is that even the brightest minds and the most well-funded labs on the planet can’t work out what will totally prevent or cure dementia. Or can they?

Can we prevent dementia?

Professor David Smith from Oxford University is one of the world’s leading authorities on the disease. In February he delivered a lecture at the University of Auckland in which his answer to the question ‘Can we prevent Alzheimer’s Disease?’ was a resounding ‘Yes!’ He busted some common myths – namely that dementia is an inevitable part of ageing and that it is genetically determined – and in doing so, explained that the non-genetic risk factors appear to be broadly similar to those for heart disease and stroke. “That’s a good sign, because we know in the case of heart disease and stroke we can dramatically reduce incidence of these diseases by modifying the risk factors,” he said. He pointed to research led by Carol Brayne that compared the prevalence of dementia in an elderly population in 1991 with the prevalence in 2011. The actual number of cases was nearly a quarter less than the predicted number – a reduction thought to be brought about by the modification of risk factors. Professor Smith also shared findings of his study that showed that B-vitamin treatment for people with mild cognitive impairment with raised blood levels of homocysteine dramatically slowed the shrinkage of particular regions of the brain and therefore the onset of dementia.

No cure on the horizon

Approximately 15,000 older New Zealanders develop dementia each year. That’s 40 every day. And almost twice as many develop mild cognitive impairment, which for half of them will eventually lead to dementia. No wonder we are keen for some wonder drug to emerge – and soon. 16 May/June 2016 | www.insitemagazine.co.nz

However, according to Bupa’s Professor Graham Stokes, a cure is unlikely. In the last few decades pharmaceutical companies have spent vast amounts of money and time on clinical trials all aimed at finding a cure or effective treatment for dementia – and all to no avail. Apparently 103 drugs have reached final phase and all have failed. Inevitably the pharma companies have become reluctant to continue trying to find a cure.

Dementia-friendly communities

In the absence of finding a cure, we need to turn our attentions to creating a society that understands dementia better, one that shows more empathy for those who are living with the disease. Rest homes and special dementia units are generally well equipped. Research has helped facilities make informed design choices so that contrasting colours, flat surfaces, signage, layout and lighting choices will make life easier for people with dementia. Many include sensory gardens and familiar fixtures such as mailboxes, clothes lines, bus stops and garden sheds. Whare Aroha’s exciting new venture to produce New Zealand’s first dementia village with its own shops, eateries and parks will take dementia care to another level. Residents will live in households familiar to them and experience a fully supported life with the ability to roam beyond the immediate boundaries of a typical secure dementia unit. But what about the 60 per cent of people with dementia who are living in the community on their own? ‘Dementia-friendly communities’ rolls off the tongue – it sounds almost utopian to expect society to embrace dementia to the extent that those living with the condition can feel safe and comfortable in their wider community. Yet in Japan, over four million people have already completed training as volunteer supporters for the country’s dementia-affected population, with a goal to have at least six million by 2017. In the UK, the Dementia Friends initiative is aiming to have over four million dementia friends by 2020. The English city of York is the subject of a research and development project, Dementia Without Walls, that looked at the services and facilities which make for a good quality of life, of which health and social care are only one part. Society is already familiar with the concepts of being wheelchairfriendly, or child-friendly, or age-friendly. But dementia-friendliness encapsulates something more; it asks communities to strive towards building social capital and community capacity for all, and in doing so, to value the contribution that each makes.

Aged care

Dementia

First Silver Rainbow seal achieved

On 9 May 2016 Awanui Rest Home in Mt Wellington, Auckland, became the first facility in New Zealand to achieve a Silver Rainbow Seal.

The project outlines the four cornerstones of dementia friendliness as: »» Place – how do the physical environment, housing, neighbourhood and transport support people with dementia? »» People – how do carers, families, friends, neighbours, health and social care professionals (especially GPs) and the wider community respond to and support people with dementia? »» Resources – are there sufficient services and facilities for people with dementia and are these appropriate to their needs and supportive of their capabilities? How well can people use the ordinary resources of the community? »» Networks – do those who support people with dementia communicate, collaborate and plan together sufficiently well to provide the best support and to use people’s own ‘assets’ well? Will we ever reach this point in our communities where we not only have awareness and acceptance of the needs of those with dementia, but also the willingness to actively meet these needs? As we build our knowledge around dementia prevent, projects like Dementia Without Walls are crucial to increasing our understanding of how we can live with the condition in our communities.

Professor Smith’s recommendations for Alzheimer’s prevention »» Stop smoking »» 30 minutes of brisk exercise each day (enough to get you puffing and sweating) »» If you have diabetes and/or high blood pressure, take drugs that effectively treat these disorders »» Increase the Mediterranean elements of your diet, especially your 5+ a day of fruit and vegetables »» Eat fish once or more a week »» Watch your blood glucose »» Make sure your vitamin D and B12 status are good »» If you do have memory problems, get your homocysteine checked. If it’s high, take B vitamins in consultation with your GP »» Keep mentally and socially active.

Silver Rainbow Seal is formal recognition of Awanui Rest Home’s acceptance of LGBTI (lesbian, gay, bisexual, transgender and intersex) residents. The Silver Rainbow initiative has sprouted from research led by The University of Auckland that scrutinised the attitudes of aged care workers and residents towards LGB residents. Its findings led to the development of resources to help educate staff in aged care facilities about homophobia. From there it has grown into a programme of developing awareness and acceptance around diversity in general, with a special focus on the older LGBTI community. Awanui Rest Home is one of the many homes around New Zealand that have embraced the Silver Rainbow initiative from the outset, with management and staff being committed to Silver Rainbow from the moment the resources were introduced. All staff completed an organisational needs analysis and education workshop and a lot of documentation has been changed to be more inclusive. Jackie Jones, Awanui’s manager, says she has found the process extremely fulfilling and hugely informative for their staff. The training has opened up good conversations among the staff, with questions they might never have asked before. Residents’ families have also been very happy with the changes. Jackie wants Awanui Rest Home to be known not only for the Silver Rainbow Seal, however, but also for being an all-inclusive facility where every resident can feel at home and accepted. She likens the Silver Rainbow Seal to a welcome mat – accepting everyone just the way they are. Jackie is very grateful to Awanui’s owners, Mike and Sarah Single, who gave her the freedom to pursue the initiative, and the team at Awanui, who were all willing to embark on this journey. The Silver Rainbow team hopes that more aged care facilities will follow in Awanui’s footsteps – embracing diversity and helping to make the world a better place for LGBTI older adults. For more information visit http://goo.gl/KHpMfO.

Source: Neurological Foundation of New Zealand

www.insitemagazine.co.nz | May/June 2016 17

Education and training

Our aged care workforce:

should we be looking abroad or under our noses?

Migrant workers comprise a significant and growing chunk of New Zealand’s aged care workforce. But with global competition at play, what should we be doing to make our aged care roles more appealing for people both from overseas and in New Zealand?

ike many aged care workers in New Zealand, Mark Alviola, clinical manager at Bupa’s David Lange Care Home in Auckland, is from the Philippines. Although he misses his family, Alviola enjoys the safety that life here offers and believes New Zealand has much to offer health care workers like himself. The Manila Times reported this month that a Filipino caregiver needs only to work around five weeks in New Zealand to earn the equivalent of his annual salary in the Philippines. Apparently, more than 6,000 Filipinos are leaving the Philippines every day in search of better paid work around the globe. New Zealand’s dairy and aged care industries both offer great opportunities for migrant workers.

Why New Zealand needs migrant aged care workers

New Zealand needs migrant workers as much as they need us. As our ageing population continues to steadily increase, so does the need for more aged care workers to support these older people. Increasingly, we need to look beyond our borders for workers to help meet this demand. A 2014 report by Callister & Associates 18 May/June 2016 | www.insitemagazine.co.nz

showed that in the 1990s overseas-born aged caregivers made up approximately 20 per cent of the workforce. By 2006 this had risen to a quarter; by 2013, 31 per cent (in Auckland, 57 per cent) of caregivers were born overseas. Why are migrants filling these roles? Why are more New Zealanders not putting their hands up for these roles? It is no secret, thanks to the work of Dr Judy McGregor and subsequent research like Ravenswood’s 2014 Aged Care Workforce Survey, that the working conditions for aged care workers in New Zealand could be better. The fight for equal pay, which is really a fight for better pay – along with revelations over the uncertainty of hours, high workloads and a lack of support – all hint at a workforce that is not entirely happy. Columnist Bernard Hickey recently shared his thoughts on this subject in the Herald on Sunday. “But the strange and troubling truth is the people who want and need these jobs just can’t seem to get them, or don’t have the skills, or are in the wrong place at the wrong time, or won’t work unless the wage is higher. “We now have more than 300,000 New Zealanders who want a job or more work, but employers are calling for even

more relaxed migration rules to bring in people from overseas to do a mountain of construction, aged care, engineering and hospitality work.” Hickey believes that simply opening up the doors for more migrants is not the answer in the long run. Yet in recent years the government has encouraged employers in the aged care sector to recruit migrant workers. In 2014 the government supported the launch of resources and documents to help prepare workers and employers for employment in New Zealand’s aged care sector. Many aged care employers have embraced the employment of migrant workers. Elizabeth Knox Home and Hospital has taken an exemplary approach. The Auckland rest home employs trained and registered overseas nurses as care partners, pending their New Zealand registration. This allows the nurses the chance to gain experience of New Zealand while improving their job prospects upon completion of their registrations. Andrea Sy, a registered nurse from the Philippines, was one who benefitted from this initiative. She was employed as a health care assistant at Elizabeth Knox while waiting

Education and training

for her New Zealand registration to be completed. Within a year she found employment as a registered nurse. Overseas-trained aged care nurses have also been able to take advantage of initiatives that enable career progression and professional development within aged care. Canterbury District Health Board’s gerontology acceleration programme (GAP) is a good example. The programme involves postgraduate study and ‘job-swapping’ between workplaces, so the rest home nurses experience working in DHB services and the DHB nurses experience nursing in residential aged care. Selwyn, Bupa and others have supported their overseas nurses to put their hands up for the programme in the past.

Mixed messages?

However, a recent government policy tweak appears to slightly contradict its stance on recruiting foreign workers to the aged care sector. Last month the Government announced that employers wanting to hire overseas workers would now be required to start the recruiting process at Work and Income New Zealand to ensure there was no New Zealander who could do the job before turning to the international market. “I can’t help thinking that there are some who might have gone to that [international market] too readily and we have got to make sure that our young New Zealanders and all New Zealanders are selected to do the job before overseas workers are,” Immigration Minister Michael Woodhouse told Radio New Zealand. For aged care, the policy misses the point slightly. Certainly, we would like to see New Zealanders in these positions, but New Zealanders are increasingly turning to other jobs where the pay and conditions are better. Council of Trade Unions president Richard Wagstaff summed it up well when he told Radio New Zealand that while the Government’s changes were positive, employers could not expect people to “pick up sticks and pick up a minimum wage job with no job security”.

The migrant experience

If Kiwis are turning away from aged care, what do migrant workers make of their working conditions? Many, as highlighted above, are overqualified for their positions – typically registered nurses in their home countries settling for caregiver positions here. Often, they tend to see the role of health care assistant as a stepping stone. A 2013 study led by University of Otago PhD candidate Esther Ngocha-Chaderopa showed that it isn’t a bed of roses for migrant workers here either. Her research, based on the management of aged care facilities in Dunedin, revealed that the wellbeing of migrant workers was affected by the stress of dealing with visa requirements, low pay, lack of training and support, and worryingly, discrimination and racism. A quick scan of the global research shows that, sadly, these attitudes towards migrant workers persist in aged care around the world. However, other countries are also grappling with the same challenges of dealing with booming aged care populations and they too are looking beyond their own workforces. Australia, for example, predicts it will need 1.3 million aged care workers by 2050 – a massive jump from the 350,000 workers recorded in 2012. Seventy per cent of staff are first-generation and non-English-speaking. This means that in many cases migrant workers have a choice of where they can seek work. New Zealand isn’t alone in its efforts to enhance pay and conditions for its aged care workforce. At last year’s Careerforce Workforce Development conference, Rod Cooke highlighted low pay and support as issues for Australia’s aged care workforce. So, effectively, New Zealand is competing with the likes of Australia for migrant aged care workers as both countries face a looming shortage. It comes back to needing to raise the profile of our aged care workforce. Progress is certainly being made. The steps towards equal pay in the Health and Disability Kaiāwhina Workforce Action Plan are steps in the right direction. The goal should be creating a vocation that is attractive to all who seek to work in it – regardless of where they come from.

Employee profile: Meet Mark Mark Alviola is the clinical manager at Bupa’s David Lange Care Home in Auckland. INsite asks him about living and working in New Zealand.

INsite: What is your country of origin? Alviola: Philippines INsite: How long have you been in New Zealand? Alviola: Seven years in June 2016. INsite: Was it easy or difficult to find work in the aged care sector in New Zealand? Alviola: In my case, I had already signed a three-year contract with an aged care facility in Rotorua prior to arriving here in New Zealand. They shouldered most of the expenses like airfare, accommodation, and tuition fee for my CAP course [Competency Assessment Programme]. After having that solid three years of experience, it was bit easier to find a job in the aged care sector. INsite: Do you have family with you here? Alviola: No immediate family, just friends and mates from college. Some of them are my housemates. INsite: What do you enjoy about living and working in New Zealand? Alviola: The New Zealanders are very kind, welcoming, and friendly. The scenery is stunning and breathtaking. I love the thought that you feel safe all the time. If you are wanting a more balanced lifestyle, New Zealand’s got the best recipe for that. Furthermore, there are a lot of health care career opportunities for you to grow professionally. INsite: And what has been the hardest part? Alviola: The New Zealand health system is quite different from what I have been used to, especially the aged care sector. In the beginning, it was very challenging and a steep learning curve to adjust to the work environment, systems, and processes. Being away from family is difficult. You have to really do all things here on your own.

www.insitemagazine.co.nz | May/June 2016 19

Education and training

HET-Careerforce merger

good news for aged care

To support workplaces in the transition to Careerforce, the HET employees have joined the ITO. (Left to right) Jennie Cooper, Helen Wilton, Lucille Ogston and Zara Fraser work with Careerforce’s Andrew Saunders on ensuring the process is as simple and seamless as possible

The merger between the Health Ed Trust and Careerforce looks set to strengthen workplace training for the aged care sector.

he merger of the Health Ed Trust (HET) and Careerforce came into effect at the beginning of May and is a win for workplace training in the aged care sector. HET chair John Ryder says, “The merger is good for the industry and Health Ed Trust as Careerforce has the resources and will take education in the aged care sector to a higher level.” For organisations and trainees working with HET, it’s “business as usual”, says Careerforce chief executive, Ray Lind. Careerforce, the Industry Training Organisation (ITO) for the health and wellbeing sectors has the supports, expertise in workforce development, research and evaluation and the strong corporate services that will further enhance the training experience for employers and trainees. “During May we will be in touch with all HET employers to talk with them about a transition into the Careerforce system. In the meantime nothing else changes, other than credit reporting being done through Careerforce,” Lind says. 20 May/June 2016 | www.insitemagazine.co.nz

He reiterates that it is business as usual – trainees and employers can keep using the resources and the HET staff who have also made the transition to Careerforce will remain in their Christchurch office during May. The quickly implemented merger came about after NZQA found HET to be noncompliant in some of its administrative practices and advised them to cease enrolling students or receiving assessments. “Careerforce was dedicated to ensuring all trainees and employers with HET were not penalised because of this and that all workplace training programmes can continue uninterrupted,” Lind adds. As the government-appointed standard setting body in the aged care sector, Careerforce offers a comprehensive stable of competency assessments and relevant workplace training supports. “We know that competence equals productivity and enhanced outcomes. The true value of workplace training is that it is carried out under job conditions, to job standards and to ensure the transfer of learning occurs to meet all job requirements,” Lind explains.

In 2015 Careerforce supported more than 16,000 trainees from more than 1,100 workplaces, an increase of over 20 per cent from 2014. The ITO continues to grow and exceed all targets set by the Tertiary Education Commission. “Through the development of a personcentred, thinking and skilled workforce, the health and wellbeing of every New Zealander will be impacted in a positive way. Incorporating HET into Careerforce only strengthens the availability of workplace training, which will have positive outcomes for everyone in the sector.” One of the key advantages of the merger will be easy access by all employers to the Careerforce team of mobile workplace advisors who work across all areas of New Zealand. This team is supported by another 80 office-based staff in Christchurch, Wellington and Auckland. “We are a person-centred organisation and work closely with all employers to ensure they are maximising their training opportunities now and into the future,” Lind adds. The Health Ed Trust will continue to exist, but will be deregistered as a Private Training Establishment. All training resources and systems (including the ACE programmes) will be supported by Careerforce.

AGED cArE & rEtirEmEnt

We’ve got your industry covered i www.insitemagazine.co.nz

SPEciAL rEPOrt

Medical consuMaBles all you need to KnoW special report INsite is pleased to announce it will be publishing a special focus report dedicated to medical consumables. Medical consumables play an important role in meeting the needs of our ageing population. On a daily basis, clinical managers are faced with making decisions around choosing the right wound care, respiratory or skin care products, continence or ostomy consumables, gloves or protective items. We’d like to give you the opportunity to promote your product via sponsored content to aged care providers, DHBs and hospitals throughout New Zealand. You may wish to share a case study, a product update, supporting research, some customer feedback, or even just good solid information – it is up to you.

your target market is our audience. let us help you reach them.

the opportunity the cost: $4,500 + gst BooKing deadline: 24 June, 2016 puBlished: July 2016 Facts at a glance: • targets owners, managers and clinical managers • delivered to dhBs, residential aged care providers, retirement villages and home health organisations • Multimedia platform • Four print editions per year, 2,500 copies

• The special report will consist of a lead scene setting story written by Jude Barback, Editor of INsite and will include feedback from all paid participants

• Every participant will receive a full page article up to 800 words that provides you with a unique content driven environment to showcase your products and services directly to our industry decision makers • Alternatively you can submit an article which we will edit and sub on your behalf • Every article will include at least one image that you can submit

• A proof will be provided prior to publication for final sign-off. Please note only one set of changes will be accepted.

• The special report – inclusive of your article will not only be published in the August/ September issue of INsite, but will also be published on www.insitemagazine.co.nz in a new Special Reports section which will be marketed via a dedicated EDM to INsite’s newsletter subscribers and will be accessible 24/7 • All paid participants will also receive the opportunity to run rotating banner advertising across the Medical Consumables Special Report section on www. insitemagazine.co.nz for a two month period.

to BooK your special report contact:

Belle hanrahan - agency contact / sales manager phone: (04) 915 9783 email: belle@nzme-ed.co.nz www.insitemagazine.co.nz | May/June 2016

Research

Coming soon:

the New Zealand Aged Care Workforce Survey 2016

Technology

he second iteration of the New Zealand Aged Care Workforce Survey is coming! The first was carried out in 2014 and reported on in 2015. The survey will take place every two to three years to provide longitudinal benchmarking of this significant workforce. It focuses on the aged care sector paid workforce – both residential aged care and home and community health care. The purpose of the survey is to provide independent data on the aged care sector that can inform policy at national and organisational levels. As such, each iteration involves careful consideration of the survey instrument in relation to the changes in the sector and regulatory environment. The research team works closely with a number of key stakeholders in the sector on the survey instrument. The 2014 report, released in 2015, provided information on the workforce in aged care in New Zealand on issues such as work conditions, wages, job satisfaction and occupational health and safety. This has provided data on a national basis that is not provided elsewhere. In 2016 it will focus specifically on direct carers (registered/enrolled nurses and caregivers) as well as managers, and will ask questions on issues such as:

»» »» »» »»

workforce demographics skills, qualifications and training job satisfaction health and safety and wellbeing.

The New Zealand Aged Care Workforce Survey will run over July and August 2016, with the report being published by the end of 2016. Look out for the request to participate in the survey during July and August. An additional aspect of this project to be introduced in 2016 is the undertaking of a more detailed study involving in-depth interviews. In 2016 this part of the project will focus on home and community healthcare workers, the location of their jobs (working in homes with variable contact with an administration office) and their and their clients’ health and safety. It is intended that the interviews will immediately follow the quantitative survey, but will be reported as a supplementary report. The survey is led by Dr Katherine Ravenswood, co-leader of the Wellbeing & Performance Research Group within the New Zealand Work Research Institute with Dr Julie Douglas – both of whom are senior lecturers in management at AUT and researchers within the New Zealand Work Research Institute.

Taking telehealth

into the future

MEI-LIN LOW says addressing the health care needs of our older population will be one of the greatest challenges over the next 10 years. Could technology be part of the solution?

22 May/June 2016 | www.insitemagazine.co.nz

elehealth and its role within health care is high on the agenda for governments and health care professionals on both sides of the Tasman. The ability to deploy telehealth with scale has never been more critical than the present. The health care industry is looking to its future and the role technology is expected to play in addressing challenges like funding and access. The Ministry of Health recently identified telehealth and associated technologies as two of the biggest initiatives earmarked for rural communities as part of its New Zealand National Health Strategy, 2016 to 2026 – not surprising, when you consider that by 2041 almost a quarter (24 per cent) of all

New Zealanders will be aged 65 or older. Not only that, as they get older, New Zealanders are staying active, living longer and as a result, many are choosing to live independently rather than opting for institutional care. In my role I work closely with the health care industry to ensure we are delivering the technologies health care providers will need today and tomorrow. In 2015, Polycom conducted a forward-looking 2025 Healthcare Technology Innovation Survey, which found that addressing the health care needs of our older population will be one of the greatest challenges over the next 10 years.

Technology

“

Telehealth and video collaboration have the potential to transform health care for our older citizens.” Last month I had the pleasure of attending the 2016 Australian Telehealth Conference (ATC) in Sydney and its theme, ‘Breaking barriers, building scale’ was equally meaningful for both the speakers and their audience. The conference saw participants on both sides of the lectern passionately debating and reinforcing the intent to overcome current hurdles to telehealth implementation and adoption. It was also encouraging to note that many of the delegates I spoke with at the event were already providing telehealth services in some shape or form. Additionally, a large number of these providers were looking to take their existing telehealth projects wider within their organisation. A number of key themes surfaced during the event and also during my conversations with attendees, including scalability, technology, incentives, expectations and measurements. I’d like to share some key insights with you.

Scalability

Scale requirements may vary from just a few users to hundreds and even thousands of participants. Whether large or small, health care organisations tend to cover multiple locations, including many remote areas that may not be in top tech shape or have access to good bandwidth. Organisations are also aware that telehealth has to be simple and cost effective enough to scale into small clinics, group homes and even individual patient homes for home health. While some pilots have used web-based video conferencing as telehealth proofs-ofconcept or trials, health care organisations are looking for a range of solutions that suit the various environments they operate in – be it home health, remote clinics, hospital or group home environments. Ideally, video conferencing solutions should be able to connect web-based, room systems, mobile devices and video phones in the same network seamlessly – and preferably be open standard to allow health care professionals to communicate across any platform and any vendor. Another common theme among the success stories shared was the presence of a telehealth programme manager or telehealth coordinator. When applied, the presence of a dedicated individual managing resources and bridging the gaps between practitioners, IT and patients contributed greatly to the success of the telehealth programmes.

Incentives

Obviously, telehealth has not reached widespread adoption, despite its obvious value and benefits. Many participants cited government funding and poor clinician adoption as reasons for slow growth. Without the right incentives (usually monetary) behaviour is unlikely to change soon or change for good. This aligns with Polycom’s survey of health care professionals and the findings in the Healthcare 2025 report. Funding came up tops (21 per cent) as the biggest inhibitor for a more positive health care future. Government policy was also listed as one of the greatest barriers to the adoption of new health care models in 2025. With governments or health care governing bodies ‘holding the cards’ to monetary and policy levers, it seems that telehealth could scale and grow rapidly if health care organisations work closely with them to develop effective models for telehealth implementation.

Technology

Technology, and video collaboration in particular, was recognised as playing a vital role in the success of telehealth by allowing health care professionals to keep in contact with patients more easily and inspect conditions from afar, as well as providing emergency access to expertise. At the same time, organisations were saying that technology is no longer a major barrier. Business-as-usual (workflow), processes, technology management and technology training were regarded as being more critical. The operation and adoption of technology were seen as more critical than the technologies themselves. Providers of collaboration solutions which focus on ease of use and simplifying connections, such as Polycom, were seen to be valued partners in the telehealth journey as health care organisations sought to focus on solving problems and delivering positive outcomes instead of technical bits and bytes. This also aligns with a finding in the 2025 Healthcare Technology Innovation survey by Polycom. Respondents identified technology as the least likely to be a barrier to the adoption of new health care models like telehealth.

Expectations

A large number of participants at ATC wanted telehealth to be incorporated into business-as-usual as they felt this would improve patient willingness to accept and engage with delivery of health care services through telehealth, payment for telehealth consultations and such. There were also calls for telehealth applications that are easy to use like one push dialing to allow a greater acceptance of telehealth amongst older populations, who are not as technology savvy.

Measurement

On the technology aspect of measurement, a number of IT leaders in health care were keen to measure the utilisation, performance and efficiency of telehealth video conferences. Solutions like Polycom RealAccess Analytics provide useful data on utilisation patterns, peak and low telehealth video traffic times, frequent users and the like, which help IT leaders to measure, track and plan support for a telehealth network that should be fully functional 24/7.

The future of collaboration and telehealth

The health care industry is indeed changing – ageing populations, health care reform and rapidly increasing costs are forcing providers to seek different ways of doing things. It was wonderful to hear about the telehealth successes at ATC. Every single organisation that shared their story ensured that they had metrics comparing telehealth consultations, outcomes and billing with non-telehealth statistics. This approach reflects the mindset of business-as-usual in the health care organisations and demonstrates their intention for telehealth to be a viable substitute for in-person consultations. If deployed effectively, I truly believe telehealth and video collaboration have the potential to transform health care for our older citizens, increasing quality of care while reducing costs to create a more sustainable health care model for the future.

Mei-Lin Low is the director of APAC Industry Solutions and Competitive Intelligence for Polycom.

www.insitemagazine.co.nz | May/June 2016 23

Technology

Smart move:

how technology can aid the older person at home Researchers from Massey University have received funding for an exciting new research project that will investigate the impact of technology on the lives of older people at home.

here’s good news for older New Zealanders worried about having to move out of their homes into residential care because of declining health. A new study funded by the Health Research Council of New Zealand (HRC) will investigate how different sources of information from a variety of digital devices could be integrated with information from sensors located in the home, or on a person (e.g. fitness devices), and distributed via social media networks to help monitor and manage the health of older people so that they can live in their homes for longer. The better use of this information will enable patient-centred collaborative care and support by building relationships between the various care providers and the older person, improve communication and information sharing, and support the older person in their self-care, thus enabling ‘ageing in place’. The project has significant potential health benefits for older people by supporting their independence and self-reliance, improving their quality of life, and avoiding the significant health risks associated with institutional care. Dr Richard Whiddett from Massey University and his colleagues Dr Inga Hunter and Professor Hans Guesgen have received a HRC Explorer Grant worth $150,000 for this study, which challenges the conventional understanding of health care as a one-to-one relationship between the patient and the health provider. Current systems of transferring data from smart home sensors tend to rely on a one-to-one relationship; for example, blood pressure readings from the older person to the clinic nurse. Social media networks offer the option of a many-to-many relationship; 24 May/June 2016 | www.insitemagazine.co.nz

for example, between the older person, their family and friends, and health providers. It not only widens the support network for the older person, but also individualises the support system. Smart Houses use ICT in the form of sensor-embedded houses, where the older person can be unobtrusively monitored for health care and disease prevention and can also be provided with mobility assistance, which reduces social isolation, thus improving health and wellbeing. A smart house creates an intelligent environment that can not only monitor and control the environment (e.g. monitoring ambient temperature) but can also track the ability of people to perform activities of daily living such as meal preparation, walking and medication management. In addition, smart environments can recognise significant departures from normal behaviour. The technologies (sensors, recording devices, etc.) that can be used in smart houses and the processing of the data provided have been the subject of much research and development for several years, but smart houses have not been adopted into new models of care yet due to the lack of research into the requirements of the various stakeholder groups. Research is also needed into issues around information inaccuracy, and information privacy and ownership. The project will use focus groups, semi-structured interviews, indepth case studies and prototype development to determine the user requirements for a smart social environment, including the exploration of issues such as privacy and security. The outcome of this project is potentially transformative since it explores new ways of supporting older people to remain in their homes, thus avoiding unnecessary residential care and facilitating early hospital discharge.

Aged care

On the soapbox… Victoria

Brown

VICTORIA BROWN of Care Association New Zealand (CANZ) picks apart the many demands on the residential aged care sector.

see a beautiful city and a brilliant people rising from this abyss, and, in their struggles to be truly free, in their triumphs and defeats, through long years to come, I see the evil of this time and of the previous time, of which this is the natural birth, gradually making expiation for itself and wearing out... It’s perhaps a little clichéd to say that this passage from Charles Dickens’ A Tale of Two Cities is reflective of the aged care sector, but there are certainly elements within it that we should consider. Thirty years ago the aged care sector was in a dire state. One cannot imagine, from today’s perspective, how bad things were then: ancient, dilapidated buildings stinking of urine; poor oversight from the licensing bodies; providers setting their own fees without being questioned. There were no policies and procedures (many of us would be hard pressed to remember just how we kept a check on everyone), just an exercise book for a few notes was all it took – not like today with dozens and dozens of folders needed to hold all the policies now deemed necessary to provide good care. It was this abyss of abysmal care that spawned the new and improved version of aged care through many long years and incarnations. But some providers are questioning whether the expiation that the sector has gone through is now enough and a halt should be called to yet more change and development. Let’s look at auditing. Wouldn’t you think that an auditor who gave a ‘PA’ (Partially Attained) rating to a provider because they had used the wrong contract during the audit would be reprimanded and the provider given an apology and the PA removed? Or we could look at the Age Related Residential Care (ARRC) Services Agreement. Surely time could be called on yet more changes and additions, all of which cost the providers more and more. The equipment list that the sector has to provide never gets smaller – indeed, there seems to be an expectation that whatever changes occur in society the sector will fund from the current fees; for example, the bariatric equipment demand. And what about the new health and safety regulations? These are called Health and Safety at Work, so one could be forgiven for imagining that this piece of legislation refers

to staff issues. But no, not entirely, as it also covers residents’ falls that may have been caused by poor staff handling or issues with equipment and so on. Though it’s great to see that safety at work is taken seriously by everyone, somehow these now need to be reported to WorkSafe New Zealand, as well as the normal agencies we report to! Why? Is it just another way to make money from aged care providers or a serious aim to help improve safety for our residents? I just hope there are no ‘serial fallers’ in your facility – this new regulation will probably attract an extra surveillance audit. Really, you ask? Well, it is starting to look like this might be the case: take the reporting requirements for pressure injuries, add in a ‘serial picker’ who keeps attacking their skin, and which you duly report – this may garner some added attention for your service. And then there’s the Food Act 2014, which came into force on 1 March 2016. Our facility kitchens are audited extensively – fridges, freezers, store rooms, menus, cleaning schedules, temperatures of everything (even to the extent of having to put thermometers in food before plates go to the table) and so on. But is this enough? No. Now we have to register with the local council and have a Food Plan and our kitchens will be inspected by council staff as well. There is a fee for this, naturally – every year. Just imagine the fun we are all going to have when the auditors and the council have a difference of opinion. Guess who will be left trying to sort out any problems? And there has been no mention of interRAI, which has cost the sector so much – training that doesn’t always happen when required and additional RN hours – for really very little benefit to the providers who are putting in all this effort. Not to worry – everyone else will benefit from the sector’s hard work – researchers are salivating over this huge pool of data. Not so much the RNs, who are leaving the sector in droves – probably interRAI is the last straw for so many of these good nurses, who are so desperately needed. But why work in a sector that is poorly paid when the DHBs can offer better money? And try sending a client with dementia to a public hospital – if the ambulance service will even take them, you are lucky. As for ED, even a GP may have trouble negotiating with

“

Will society be content to see older people on the streets in the future as part of the ‘rough sleepers’ group, with nowhere to go and no-one to care for them?” them. Don’t start discussion on anything like some surgical intervention that these residents might need – not interested, they say – not only old, but with dementia, no way! Health dollars are better spent on others. And if they can’t consent (and of course, they can’t) then you are really stymied! So how much more can the sector take of these constant and ongoing demands? All providers work unfailingly to achieve the best outcomes for their residents. They do so much, despite falling incomes and increasing demands. This year the sector received a 1 per cent increase – better than the previous 0.33 per cent, but nowhere near enough to cover the costs of the care that is demanded by the Ministry and their agencies. Very little in the way of extra charges can now be passed on to the client, who may pay part of their fee privately. Though there is the ability to charge for premium rooms and additional services, this is harder for the standalone part of the sector, where the ability to offer ensuite rooms may not be possible. So what to do? More and more people will be needing care in the very near future. If the cost burden is not lightened, how many providers will survive to carry this load? Perhaps this needs to be aired publicly – or will society be content to see older people on the streets in the future as part of the ‘rough sleepers’ group, with nowhere to go and noone to care for them? This is not as far-fetched as you might think – other cities around the world are already seeing this happening. Maybe Abraham Lincoln should have the last word on our behalf: “I never had a policy; I have just tried to do my very best each and every day.” I wonder what an auditor would say to that! www.insitemagazine.co.nz | May/June 2016 25

Aged care

Let’s snoop around... Rawhiti Lodge Care JUDE BARBACK visits a small Matamata rest home close to her heart.

t is the first time I’ve visited Rawhiti Lodge Care in Matamata since my grandmother was a resident there; it feels strange to be back there years later. My granny had always expressed a wish to live at Rawhiti when the time came for her to move into care. In her more independent years she would visit friends there and declared that she liked the homely feel of the place. Rawhiti has lost nothing of that homeliness that so appealed to my granny. It is a beautiful old homestead converted into a rest home. It still bears the grand entranceway and beautiful, big bay windows of the original manor, and feels like one large home, even with the newer rooms, ramps and fittings. I even ring the bell before gaining entry – it feels appropriate. I’m met by manager Hazel Lamberth in the foyer. She is keen to have me visit, eager to raise the profile of Rawhiti. “Tradesmen come here and will say things like, ‘I’ve lived in Matamata my whole life, yet I never knew this place existed!’” she says. “People just don’t know about us.” Tucked away at the end of a quiet cul de sac, it isn’t hard to see how Rawhiti flies under the radar. It is privately owned, one of three facilities belonging to the owners. The home is licensed for 24 people and currently has just 16 residents. Hazel says it is difficult to compete with larger homes in the area that offer a continuum of care. Rawhiti is licensed for Stage 2 rest home-level care, offering a narrow window between independent living and hospital-level care. The assessment thresholds of frailty and acuity appear to be increasing. People are remaining longer in their homes, so that by the time a needs assessment results in a rest home referral, the resident is actually on the cusp of needing hospital-level care. 26 May/June 2016 | www.insitemagazine.co.nz

Hazel says they have had three residents in the last year who have been assessed in their homes as needing Stage 2 rest homelevel care, only to find that they need to be reassessed and transferred to hospital-level care at a different facility within a few months. But not everyone wants to spend their final days in a big, busy facility. Many people – like my late grandmother – crave the intimate, friendly atmosphere at smaller homes like Rawhiti. Yet the smaller homes have to meet the same compliance requirements as the larger ones, with no recognition that they are operating on a significantly smaller scale. And the low level of funding does not help. “There is no doubt the whole aged care sector is underfunded,” says Hazel. “It’s very challenging as there is so much we’d like to be able to do.” But they make do. A raised garden bed, which is planted and looked after by residents, provides seasonal veges for residents’ meals. This was made possible by fundraising from staff and support from local businesses. The gardens and beautiful grounds are maintained by Willy – their gardener who, along with his wife Faye, also works as a caregiver. Hazel, who comes from a district nursing background, knows all about larger rest homes, having managed Ryman’s Malvina Major rest home facility and Enliven’s Woburn Home, among others. She says at larger homes it is difficult to escape the institutionalised feeling; 60 residents can make for heavy workloads and busy, noisy mealtimes. By contrast, she feels that providing individualised care and a familiar home-like environment is more achievable at a smaller facility like Rawhiti.

For example, the home pays for a masseuse to provide hand and foot massages to all the residents once a month. “I think that therapeutic touch is so important for older people,” says Hazel. They cruise the internet as a group, bringing up Google Earth on a big-screen TV and allowing the residents to find their old houses or those of their children all over the world. “They also love checking out the local real estate online,” says activities coordinator Sandy. “They like looking at all the photos of the million-dollar properties, commenting on the decor and furniture.” Sandy says the residents aren’t shy about speaking up – especially when it comes to food. A real effort is made to cook what the residents like. All food is cooked on site and they make good use of the homegrown produce. As a result, Rawhiti recently received an Excellence rating for its food service, of which they’re very proud. The home values the principles of the Eden Alternative and tries to incorporate animals and plants into daily life for the residents. Molly and Sammy, the Rawhiti felines, are testament to this. “We try to make Rawhiti as much like their home as we possibly can,” says Hazel. The residents enjoy regular “tiki tours around town” as well as other activities, like the monthly church service, Friendship Circle outing and happy hour. They also love the monthly visits from musician Mike, who happens to be there during my visit. The residents are enthralled by Mike, who is entertaining them with his guitar and a throng of well known tunes. They are barely aware of my presence as they sing along to White Cliffs of Dover, Ten Guitars and the like – a room full of smiling faces. While I miss my granny’s face among them, I’m pleased to find Rawhiti in good heart.

Community care

Social value and

going the extra mile Policy advisor at the New Zealand Council of Christian Social Services PAUL BARBER discusses two projects aimed at exploring the added value of community-based social services.

t is a huge social achievement of our generation that people are living longer than human beings have ever lived before. Accompanying the gift of longer life are the challenges we face of growing inequality in income and wealth (especially housing) and huge pressures on health and social services that are perceived by some as too costly and inefficient. Oscar Wilde’s famous quote warns us about those cynics who know the “cost of everything and the value of nothing”. It’s this concern for authentic value that has inspired two recent projects aimed at exploring the added value of community-based social services. The second project – Valuing People, Living Well – is due to report its initial results at the New Zealand Council of Christian Social Services (NZCCSS) for Older People Conference in mid-May. This second project has focused on those working with older people in community-based care and support and in aged residential care, following on from the impactful Outcomes Plus report from 2015 that looked at wider social services. The research looked at two interrelated questions: what are the attributes of an organisation that builds social value and what is it about faith-based aged care providers that makes them distinctive?

“

Much of what we learnt applies to any organisation that wants to do well and keep its focus on ‘mission’, yet the work has captured some of the distinctive mix that is typically present in those faith-based agencies. The research found that the organisations studied go above and beyond the minimum mandated requirements and their unique combination of factors forms ‘organisational specific capital’, i.e. the ways they value lives, that contributes directly to social value. It is that social value that, in turn, results in increased quality of life for the older people using their services. This organisational specific capital is also made up of the way the unique characteristics and infrastructures of the community and voluntary sector combine to build the social value of the sector. They are meeting not only contractual requirements set by government but a range of individual, family, whānau and community needs at the same time. This community connectedness emerges as a central finding of the project. Faith-based agencies extend pastoral care beyond the staff member-service user relationship and incorporate family and whānau into events and activities across the continuum of care. This helps to maintain social connections in the community and continuity in residential

Faith-based agencies extend pastoral care beyond the staff member-service user relationship and incorporate family and whānau into events and activities across the continuum of care.”

care settings. This is aided by the natural networks that community-based organisations bring with them to a wide range of other community groups, including childcare, music, craft and young parent groups. A willingness to provide support for older people who could not find it anywhere else, especially those with few resources or complex needs, is another defining characteristic: “We take all comers, we work it out. We’ll take people on no matter what has gone on before.” As faith-based organisations, it is not surprising that spirituality also plays a role in shaping the unique contribution. In the context of an holistic approach to care and support, those in the study talked about spirituality that underpins the everyday work. Not only the Christian faith, but other faiths also find expression. The commitment of both paid and volunteer chaplaincy provides a pastoral dimension at challenging stages in life for many people: “They just seem to go that extra mile… they never rushed and they always stayed just as long as they needed. It was a very flexible arrangement, I think, according to the person’s needs, which varied depending on the week…” The appeal behind this work is for those involved in all aspects of our sector – the policy, funding, management and governance – to recognise this ‘bigger picture’, the wider social value that is present in the web of our communities. This social value must not be dismissed or given lower priority when we debate the future shape of an aged care ‘market’. The value of older people, those who work with them and their communities goes beyond dollars and cents.

www.insitemagazine.co.nz | May/June 2016 27

Clinical

Spotlight on... Aphasia

EMMA CASTLE shares the realities of being unable to fully communicate due to the onset of aphasia.

magine what it would be like to go to sleep tonight and wake up in a foreign country. You would find it difficult to: »» speak the language »» understand what is being spoken to you »» read the street signs »» fill in forms »» convey your needs to others, and be understood. For tens of thousands of people living with aphasia in New Zealand, this is what every day is like.

What is aphasia?

Aphasia, pronounced ‘aye-faze-yuh’ affects a person’s ability to communicate and is caused by damage to the language area of the brain. It is most commonly acquired after a stroke, but can also be a consequence of a head injury or brain tumour. Every day in New Zealand, six or seven people acquire aphasia because of a stroke. While aphasia can affect anyone of any age, two-thirds of those with aphasia are older people. Aphasia can be hardly noticeable or very severe, and you cannot tell by looking at someone that they have aphasia. The effects of aphasia can be devastating for individuals and families and a person’s ability to work, manage finances, and do the things most of us take for granted, like ordering a coffee at a café or shopping for groceries, can become difficult and sometimes impossible tasks.

AphasiaNZ

The Aphasia New Zealand (AphasiaNZ) Charitable Trust, a national charity with an office in Auckland, has been working to support people affected by aphasia since 2007. AphasiaNZ provides information, support services, and resources to anyone affected by aphasia. AphasiaNZ aims to help people with aphasia reintegrate into community activities after acquiring aphasia, and ensure that those with aphasia are not marginalised. Educating people who work in our communities with those with aphasia is also a key aim of the trust.

Ian’s story

One person who has been both helped by, and has contributed to, the work of AphasiaNZ is Papakura man Ian Marshall. Ian, aged in his early 70s, suffered two strokes in 1994 and 1997 – the second affecting his communication abilities and leaving him with aphasia. Ian featured in a 2011 documentary Open Door: Aphasia with three other stroke survivors from Auckland,

and credits his love and passion for cycling as being a key factor in getting him through the tough times and adjusting to life with aphasia. Ian has been a keen and competitive cyclist since the 1960s, competing in 12- and 24-hour time trial races in the UK before moving to New Zealand in the early 1990s. Ian still clocks up approximately 12,000km every year on his bike – more than many of us do in our cars! Living successfully with aphasia also means Ian keeps his mind active – something his involvement in the Auckland Gavel Club for people with aphasia allows him to work on. The Gavel Club gives Ian the opportunity to practise his speaking in the company of others facing similar communication challenges, in a relaxed and supportive environment. In addition to improvements in speech, Ian and other Gavel Club members build confidence, gain leadership skills, and form friendships. When not cycling or practising a speech for Gavel Club, Ian is busy educating others about aphasia and sharing his tips so that people with aphasia can be better understood and supported to live fulfilling lives.

What helps people live successfully with aphasia? »» Keeping physically and mentally active »» Hard work and determination »» Speech-language therapy and technology – iPads and smart devices.

Clinical

Up close and personal with…

Leanne MacDonald

In recognition of International Nurses Day on 12 May 2016, LEANNE MACDONALD, care services manager at Metlifecare’s Pinesong retirement village, shares her thoughts on the challenges and the future of elder care nursing.

eanne began her career working in surgical wards in hospitals, before leaving shift work to become a district nurse. After having her children, she went to work at Pinesong in Titirangi. Once she started nursing in elder care, she “never looked back”.

INsite: How long have you been at Pinesong village? Leanne MacDonald: I came to Pinesong eight years ago as a part-time registered nurse. Over time the role became full- time. I left three years ago to become care services 28 May/June 2016 | www.insitemagazine.co.nz

manager at another Metlifecare village. After a year, the care services position at Pinesong was advertised and I happily returned. I came back to Pinesong because of the strong connections I have with both the residents and the staff. It’s such a joy to be able to support the residents who live in the same community as me.

INsite: Why did you choose to nurse in elder care? Leanne MacDonald: I fell into it – I was at home with two young children and worked

casually as a district nurse in the weekends. When Pinesong was looking for a part-time nurse I was recommended.

hard for them to let that go. I have to make the time for them to learn to trust me and accept the necessary help.

INsite: What is your day-to-day life like? Leanne MacDonald: No day is the same when working in a retirement village, which is part of the reason I enjoy the role. The residents come from a vast array of backgrounds and cultures. It’s such a reward to get to know these people and where they have come from. A lot of my time is spent with the residents and their families. To ensure as much as possible that the residents are getting the quality care they deserve, another major part of my role is to train, coach and grow our home support team.

INsite: What do you enjoy about your role? Leanne MacDonald: Being let into, and a part of, residents’ lives and homes. Some of my role is around palliative care and it’s such a precious thing to support a person in the last few moments of life. I also enjoy the training element – coaching and growing staff so they can do their very best and feel a satisfaction themselves about what they do for other people.

INsite: What are some of the challenges you face? Leanne MacDonald: One of the major challenges is to get the older person to recognise that a little bit of daily support can help them to stay at home longer. Some are very determined and have been brought up during times of hardship and war. They have learnt to be very self-reliant and it can be very

INsite: Where do you see the future of nursing in villages going? Leanne MacDonald: Nursing and supporting residents in a village setting will grow, as the population and percentage of those who are over 65 continues to rise. Residents who come to us want to be able to live independently, but have access to support and care should they require it. Residents also have a voice and they are directing care and making informed choices more, rather than doing what was done before. Already we are seeing technology

Clinical

“

Technology will play a big part in the way we support residents in the future.”

coming into the villages and some residents are making the most of the devices and monitoring their own wellbeing. Technology will play a big part in the way we support residents in the future.

INsite: What do you wish more people understood about your job? Leanne MacDonald: Nursing in a retirement village isn’t just a Monday–Friday role 8.30am–5pm. There is an on-call requirement that requires a high level of commitment and passion. It’s not just a typical job, it takes a certain level of commitment and thinking outside the square. INsite: What has been your proudest moment as a nurse? Leanne MacDonald: My proudest moment was being awarded Metlifecare Clinical Manager of the Year for 2015. It’s a little bit embarrassing actually as I sit back and think, why me? I do know that I aim high and am a bit of a perfectionist and my staff will probably say the same about me. I just love what I do and I’m thankful that I was recognised for that by Metlifecare.

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

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www.insitemagazine.co.nz | May/June 2016 29

Conferences

Alison Quinn

Chris Baynes

Rob Campbell

RVA Conference set to tick all the boxes Retirement Villages Association Conference: 20–23 June 2016 Theme: Technology in our lives

his year’s conference looks set to address every nook and cranny of retirement village operation – from property development to strategic analysis, to incorporating care delivery, to business trends, to marketing, to technological solutions, to media management. The programme appears to have left no RV stone unturned. And, of course, there’s plenty of fun to be had as well. The conference kicks off with the annual golf tournament, while the nongolfers enjoy an Auckland foodie experience. A cocktail party will round off day one as delegates prepare for the business side of the conference. Day two sees keynote speaker Morris Miselowski, one of Australia’s leading futurists, take the stand. Miselowski will discuss some key issues the RV sector faces in the next 10 to 20 years as the generations – from the Baby Boomers (1946 to 1964) to Generation X (1965 to 1981) – reach retirement age. What are the implications for family, culture and society as each generation lives longer, works longer, maintains good health longer, all in the face of emerging technology? Also from Australia, Alison Quinn of RetireAustralia, the largest privately owned retirement village operator in Australia, will share her experience of how the RV sector is performing across the Tasman. In keeping with the conference’s focus on technology, Dr Marge Skubic from the University of Missouri will address delegates via Skype about TigerPlace, an independent living apartment in Missouri that has developed a programme using motion

30 May/June 2016 | www.insitemagazine.co.nz

sensors and sensory cameras to identify potential changes in each resident’s status. Sticking with technology, Eldernet’s Esther Perriam will give a multimedia presentation on what the online world has to offer RV and aged care operators. Minister of Housing Dr Nick Smith will also take the stand on day two, as will ANZ’s Richard Hinchcliffe. Later, Hinchcliffe will also give an update on the bank’s annual survey of the sector. Mark Jeffries will share his vision for MyCare, a new online meeting place for people seeking and providing home care services in New Zealand. Chris Baynes will discuss a residentfocused rating system for retirement villages and how it holds up amongst rating websites that rely on public responses. He’ll also look at the latest Australian digital services and ‘disruptive’ care models. A panel discussion titled ‘Facts, figures and fallacies’ is bound to keep the audience on its toes in the afternoon. The session will be led by Justin Kean of JLL and Michael Gunn of CBRE, who will discuss their retirement village research and trends over the last four years and what the trends might mean for the sector. The much anticipated annual gala dinner is an inevitable highlight of the social programme, with some great entertainment lined up. Black tie is preferred. Summerset chair Rob Campbell kicks off day three. According to his speaker profile, “he believes that he has long since ceased to add to the volume of his SIS file, but still harbours deeply revolutionary views on the world” – and he’s bound to entertain and distract delegates from their hangovers. The CEOs’ forum will involve representatives from some of New Zealand’s biggest organisations. Last year this session focused on how aged care fits into retirement

villages – it will be interesting to see which way discussions go this year. Later in the day retiring Metlifecare CEO Alan Edwards will also address the conference and share some insights into his time at Metlifecare and thoughts about the sector’s direction. The conference’s technology theme comes to life with a presentation by Selwyn’s Sandi Millner and Aidan Craig, which will look at the results of a joint Selwyn Foundation/ Ferros Telehealth pilot for those with chronic illnesses. The techy theme continues with Chris Shaw’s presentation, which will look at how ThompsonAdsett’s strategic alliance with Borderless Healthcare Group is establishing an ecosystem of technology, media and telecommunications where biodata is used to enable the personalisation of both the physical environment and services delivered via smart homes and communities to retirement village and aged care residents. Marketing guru Jeff McGarn, one of Australia’s leading retirement village marketers, will present in the afternoon, followed by the final keynote speaker Guy Ryan, last year’s Young New Zealander of the Year and CEO of the Inspiring Stories Trust. On day four Debbie Mayo-Smith’s masterclass programme and village tour will complete what promises to be an excellent conference.

Date for the diary 2016 New Zealand Aged Care Association Conference: SkyCity Convention Centre, Auckland, 4–6 October Theme: The pursuit of excellence – building on our strengths

Research

Reducing hospital visits INsite provides a sneak peek at research recently published by The University of Auckland showing which interventions are likely to reduce the likelihood of older people requiring hospitalisation. Hospitalisation before and after long-term care

With an ageing population, we can expect to see an increased demand on all aspects of aged care – from home-based support to residential long-term care to acute hospital services. A challenge for GPs and needs assessment teams is making the right call at the right time. Some interesting research has emerged this year out of The University of Auckland that strives to understand what factors place the most demand on acute hospital services. The research, led by Dr Michal Boyd and published this year in Age and Ageing, looks at the rate of hospitalisations before and after residents are admitted to long-term care. The research analysed the hospitalisations of residents 12 months before they entered long-term care and 12 months after entry. Interestingly, and perhaps predictably, the research found that hospital visits increased a few months before people entered longterm care, suggesting functional and medical instability at home was a precursor to being referred to residential aged care. New residents had fewer hospitalisations than when they were at home. Of the 3,363 hospitalisations, there were 2,424 in the 12 months before and 939 in the 12 months after. Most telling was the hospitalisation rate in the six to 12 months before people entered long-term care, which rose sharply with each passing week. These rates dropped off significantly when they entered long-term care and decreased further still six to 12 months after entry. Boyd et al concluded that further research is needed to determine effective interventions to avoid some hospitalisations and possibly even admittance to residential long-term care.

Hospitalisation for the ‘big five’ conditions

Another Auckland-based study published this year in Age and Ageing and led by Dr Martin Connolly looked at whether a nine-month generic intervention – as opposed to a diseasespecific intervention – would have any impact on the rate of hospitalisations for residents in long-term care. The study involved 36 facilities with 1,998 residents. The generic intervention comprised gerontology nurse specialist-led staff education and resident review, facility benchmarking, and multidisciplinary discussion of residents selected using standard criteria. Interestingly, while the intervention didn’t impact on overall rates of hospitalisations or deaths, it did result in fewer admissions relating to what the study refers to as the “big five” diagnoses: cardiac failure, ischaemic heart disease, chronic obstructive pulmonary disease, stroke and pneumonia. Essentially, Connolly et al found that a programme of education, benchmarking and review led by a gerontology nurse specialist can help reduce hospital admissions relating to common conditions like stroke or COPD for older people in long-term care.

Avoidable hospital visits for palliative residents

A third recent Auckland-based study led by Dr Jackie Robinson and published in BMJ,

looked at the extent and cost of potentially avoidable hospital admissions among patients with palliative care needs. Apparently, more than 90 per cent of people spend time in hospital in the last year of life and most people will die in hospital – yet previous research tells us that many of these hospital admissions could have been avoided. Of the 99 patients in the study, 22 were deemed to have experienced a hospital visit that could potentially have been avoided. Robinson et al found that rest home residents were more likely to go to hospital unnecessarily. “Although these admissions are relatively short compared with those whose admissions are unavoidable, any hospital admission impacts on the experiences of patients and families and may contribute to unnecessary hospital expenditure,” the research concludes. References: Boyd M, et al. Age and Ageing 2016; 0: 1–5. doi: 10.1093/ageing/afw051. Connolly MJ, et al. Age and Ageing 2016; 0: 1–6. doi: 10.1093/ageing/afw037. Robinson J, et al. BMJ Supportive & Palliative Care 2015; 5:266–272. doi:10.1136/ bmjspcare-2014-000724.

www.insitemagazine.co.nz | May/June 2016 31

Aged Care

Last Word…

David Wait

New Zealand Nurses Organisation’s industrial advisor for the aged care sector DAVID WAIT says a safe, supportive environment and fair pay are needed to attract nurses to aged care.

ince 2012 new graduate registered nurses have been asked to express a preference for their clinical practice area as part of the Nursing Advanced Choice of Employment System (ACE). The Ministry of Health says on its website that “it is important to understand which clinical practice settings graduates want to work in compared with current and future workforce needs in those settings”. In the first round of the ACE system 0.56 per cent, or seven out of 1,232, graduates, said that aged residential care was their first choice practice setting. That low preference rate no doubt informed the Ministry’s view that one of the key focus areas was the need to improve the appeal of aged care to future graduates. The ACE data for the end of 2015, compiled for New Zealand Nurses Organisation (NZNO) by the Office of the Chief Nurse and ACE, shows that no real progress has been made on making residential aged care attractive to new graduates. Just 1.1 per cent, or 16 out of 1,451, graduates picked this practice setting as their first choice. When we look at the most recent Nursing Council workforce statistics, we can see how important it is to improve the appeal of aged care to new graduates. Currently, 9.3 per cent of all registered nurses work in residential aged care and, of those, 45 per cent are 50 years of age or older. At a time when the need for nurses will peak, a significant proportion of the workforce is on the cusp of retiring. If we are to focus on improving the appeal of aged care, nurses need to have a safe and supportive workplace to practise in and to be fairly paid for the work that they do. In January NZNO conducted research on our aged care collective agreements, comparing rates of pay and remuneration and other conditions like professional development and leave. That analysis shows that while new graduates in aged care can earn a slightly higher base rate than a new graduate working in a DHB, albeit with poorer conditions of employment, after the first year they are likely to earn less and experienced nurses working in aged care will have a base rate approximately 13 per cent less than their DHB colleagues. When other remuneration, such as penal

32 May/June 2016 | www.insitemagazine.co.nz

“

If we are to improve the appeal of aged care, we need to create a safe practising environment and pay people fairly for their work.” rates, overtime and allowances, are considered, a nurse working in aged care is likely to be about 25 per cent worse off than a DHB colleague. It is not just about pay. In 2004 the Old People’s Homes Regulations 1987 and the Hospitals Regulations 1993 were revoked and subsequently replaced with non-mandatory guidelines for minimum staffing levels in aged care. Those guidelines set out staffing levels and skill mix roughly in line with the revoked regulations. The staffing requirements in the Age Related Residential Care Services Agreements stayed in place, but in most cases they require significantly less staff than those set out in the regulations. When NZNO becomes involved in reviews around staffing levels and skill mix, we usually find that the number of registered nurse hours is significantly less than the voluntary standards and the previous regulations. Sometimes registered nurse care-hours have been replaced with caregiver care-hours; sometimes they are just absent. On top of this, we have seen a steady increase in the dependency level and care needs of residents in aged care, best described in the 20-year longitudinal study by Michal Boyd et al. At a time when residents’ needs have increased, the support available to them has dropped. Reduced registered nurse staffing levels have also changed the nature of the work. It is

commonplace for a nurse in aged care to work as sole charge, with limited access to support, directly responsible for the care of a large number of complex residents and responsible for the work of a number of caregiver staff. As the number of registered nurses available has dropped, the role they play in the care of our elderly has become more focused on directing care, with a reduction in the component of direct care delivered by the registered nurse. Registered nurses in aged care can find themselves in a role more akin to the work of a clinical nurse manager in a DHB. This is not a safe environment for a new graduate to practise in and at the extreme end not safe for the many experienced, internationally qualified nurses who are filling the gaps left by the 99 per cent of New Zealand trained nurses who do not choose aged care as their preferred practice setting. NZNO recently supported a nurse whose employer considered referring her to Nursing Council. An internationally qualified nurse, she had received her New Zealand practising certificate one week prior to her first shift. She received no orientation. When things went wrong, the lack of support, the lack of orientation and her lack of experience in the New Zealand aged care setting compounded the issues faced by the nurse and the residents. This is an extreme example, but the lack of support available to registered nurses in aged care is apparent to those working in the sector, and it seems apparent to new graduates. If we are to improve the appeal of aged care, we need to create a safe practising environment and pay people fairly for their work. New graduates know that rates of pay and conditions are less in aged care than other sectors. These rates and conditions have been driven down by years of underfunding and the private sector incentive to increase profit. They know that staffing levels and support are dangerously low. They are voting with their feet and any steps to improve the appeal of aged care will need to address the pay deficit and the failed experiment in removing regulated care hours in aged care.

* Please contact editor@insitemagazine.co.nz for references to this article.

Next issue:

August/September

Nutrition and diet in aged care Diet and nutrition are fundamental topics in aged care, spanning from the home-based sector to rest homes to public hospitals. In this issue, we turn to the experts for their advice and guidance on key nutrition queries. In addition to addressing clinical aspects, we also look at related topics around food delivery, such as residents’ dining experience and whether or not facilities should contract out catering or do it in-house.

See uS At Retirement Villages Association Conference: 20–23 June 2016 theme: technology in our lives

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