Australian approaches to resident classification and quality assurance in residential care

This paper begins with an account of the structure of Australia's residential long-term care program, which was divided into two distinct levels of hostel and nursing home care until 1997. In response to changed policy objectives, a number of measures were then taken to create an integrated residential care system. The main measures were the development of a single scale for classification of resident care need and associated funding to replace two previous separate scales, and the implementation of a new quality assurance system, which included new standards for buildings as well as revised standards for care. I give accounts of these measures and the extent to which they have achieved their intended outcomes before proposing some further developments that could see closer links among pre-admission assessment, resident classification, and quality assurance.     

Vertical Axes on the Long-Term Care Continuum

Abstract

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

Recent Developments in Aged Care Policy in Australia

Summary

A series of major reforms implemented through the mid 1980s sought to contain residential care and expand community care in Australia's long-term care system. While this goal has been maintained, a number of new policy initiatives followed the change of federal government in 1996. This article presents a systematic account of current policy objectives, implementation measures, and outcomes in three major policy areas: changing the balance between residential and community care, targeting in community care, and support for family caregivers. This analysis shows that while there have been shifts in emphasis from time to time, concerted policy efforts over the last 20 years have contained the growth of expenditure on long-term care and realized significant change in the service system.     

Resident councils between lifeworld and system: Is there room for communicative action?

In long-term care facilities, the participation of older people relates to individual care provision (individual level) and to policy decisions that affect all residents in a care organization (collective level). In the Netherlands, resident councils are set up in order to improve resident participation on a collective level. However, our research shows that managers and resident councils are faced with mutual frustration and ineffective interaction. This article investigates the extent to which Habermasian communicative action (herrschaftsfreie Kommunikation) between resident councils and managers in residential elderly care is actually possible by examining the interaction between resident councils and managers in two case studies. We conclude that resident councils find themselves between lifeworld and system. There is communicative action between resident councils and managers, but it is easily dominated by strategic action. Therefore, space for communicative action needs to be deliberately created in order to support resident council participation and influence.     

Changing Needs and Changing Service Delivery for Long-Term Care in Hong Kong

Summary

Both the need for and delivery of long-term care in Hong Kong are shaped by the interaction of the traditional and modern. Rapid social change is affecting traditional family structures and roles in care of the elderly, resulting in increased demand for formal care, which to date has been provided mainly by way of residential care. This growth of demand will escalate with rapid population aging in coming decades. In response to this burgeoning demand, current planning is seeking to reshape the established service system and tackle problems in service delivery in ways that will address the bias towards residential care and improve quality of care.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

A Valued Relationship with Nature and Its Influence on the Use of Gardens by Older Adults Living in Residential Care

ABSTRACT

While there is growing interest in inclusion of gardens and outdoor spaces in residential care facilities for older adults, these spaces are often underutilized despite many identified, evidence-based benefits. A qualitative study of participant observations with behavior mapping, and individual and focus-group interviews, using a grounded theory methodology was used to understand value versus use of outdoor garden spaces. Individual and focus-group interviews were conducted with 32 residents from two facilities. Results revealed that views of nature are fundamentally important to resident well-being, that access to nature influences facility choice, and use of garden spaces is influenced by the way in which individuals prefer to enjoy nature.     

A New Model for Long-Term Care: Balancing Palliative and Restorative Care Delivery

ABSTRACT

Nursing homes have been mandated to maintain or promote the physical and psychological functioning of residents since the enactment of the 1987 Omnibus Reconciliation Act. Although this restorative approach to care has improved outcomes for some residents (Institute of Medicine, 2001 Institute of Medicine. 2001. Improving the quality of long term care, Washington, DC: National Academy Press.  [Google Scholar]), it ignores the reality that all permanently placed residents will die. A new model for long-term care, one that includes a simultaneous restorative and palliative approach to care delivery, is proposed. Palliative care principles provide a guiding framework for changing care delivery. Basic tenets, such as resident and family viewed as a unit of care, interdisciplinary teamwork, and interdisciplinary plans of care, provide a basis for specific operational suggestions. Operational strategies, such as psychosocial and spiritual support for family, resident decision making and participation in goal setting, expertise in aggressive pain and symptom control, and bereavement services following resident death, are described.     

Culture Change in Skilled Nursing: An Exploratory Comparison of a Traditional Home to a New Model

Abstract

The culture change movement has pushed for reform for more than two decades to align policy, the long-term care industry, and resident preferences with regard to care. Evidence from research indicates that culture change has the potential to improve quality in nursing homes. There is no one-size-fits-all way to implement culture change; however, there are key elements and associated concepts and models. A common thread is that they run counter to the medical model, typically found in nursing homes, where care is provided in a hospital-like setting according to the schedules and routines of physicians and staff with little resident input. This qualitative study looks for evidence of culture change in a traditional model of care compared to a newer culture change model, by describing the differences in practices associated with the medical model, person-centered care, and person-directed care between the two settings. Our results indicate that there is evidence of person-directed care in one model of culture change—the Green House home—but not in the traditional nursing home. Future studies should examine other culture change models to compare the differences in the utilization of person-directed care. This information will help to clarify the definitions and concepts of culture change, along with developing best practices for future culture change models.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Administrators and Quality of Care in Long-Term Care Facilities

This exploratory study investigated administrator and facility-related predictors of quality of care in long-term care facilities. Quality was measured using several unmet standards of care identified in the last inspection report of the Ontario Ministry of Health and Long-Term Care (2007). Supplemental data were gathered from surveys mailed to all 602 long-term care administrators in Ontario, Canada, 302 of whom completed the questionnaire. Multiple regression analyses were conducted to test sets of hypotheses linking characteristics of administrators and those of the long-term care facility to quality of care. Education and experience as an administrator in a participant's current position had a moderate positive influence on quality of care; however, negative associations were found between administrator salary and effort devoted to resident care problems and quality of care. In addition, smaller facilities, being located in less populated communities, and administrators with a nursing background significantly affected quality of care in a positive manner.     

Meaning as outcome: Understanding the complexity of decision-making around residential placement in aged care

Abstract

Changes in aged care and health policy have introduced an increasingly complex assessment, resource option, and economic and regulatory context for decision-making regarding relocation to residential care. This paper reports on a study exploring residential placement from the perspective of spouses who place a long-term partner in an aged care facility. It highlights the importance of understanding the meaning of such decision-making for the spouse who remains at home and explores the ways in which the placement is constructed as either a continuation of, or a refusal to, care for a long-term partner. The paper draws out the implications for social work practice and identifies the challenge to merge knowledge of resource packages, care options and financial arrangements with a concern with the processes of decision-making and the emotional and symbolic aspects of such decisions.     

Where can I mourn? Psychodynamic contributions to working in residential child care

ABSTRACT

Loss permeates the experience of being placed in residential child care, yet residential workers are rarely trained to work with young people who are grieving the loss of family and home. This article will provide an overview of psychodynamic theories of mourning, and will discuss how grief work can be facilitated for children and youth in residential child care.     

Chapter 3 Residential Care Facilities for the Elderly

Abstract

Residential Care Facilities for the Elderly (RCFEs), known as board and care homes, are licensed in California and many other states for non-medical care in the community. RCFEs are examined here to provide illustrative issues in the definition of types of long-term residential care. The research examines physical functioning, social supports, and course of residential placement for 109 RCFE residents (mean age 84 years). A significant portion of the residents had personal assistance needs not usually provided at the RCFE level (75% assistance with medication, 52% used walking aids, 29% assistance in bathing). Additionally, a third of the residents had restricted social supports and social activity. Residents report declines in functioning and support as reasons for moving to residential care. Length of residence in the facility (range less than a year to 15 years) was not related to physical functioning or social activity. These findings do not support “aging in place,” within the facility, as the rationale for increased need for assistance in residential care. Implications include the need to maintain the social model of residential care ample for the majority of residents while assuring the availability of a higher need for assistance of a significant portion of the residential care population.     

HIV/AIDS and Home Based Care in Botswana

SUMMARY

The extent of the AIDS pandemic in Africa (and specifically in Botswana), and the lack of institutional frameworks to address concomitant issues, have necessitated the adoption of home based care for sufferers as national policy. The practice is beset by problems, given the severe symptomatic nature of the disease and the general lack of human and material resources to address the needs of patients and care-givers.

A study of one such programme in the Kweneng District of Botswana highlighted gender imbalances, poverty, lack of appropriate skills, over-involvement of the elderly, deficient specialised facilities, need for volunteer capacity building, inadequate income generating activities, insufficient counseling services, and culturally determined cognitive processes as areas requiring urgent attention. It is apparent that the programme needs strengthening through appropriate support mechanisms and that alternative strategies should be devised for those whose circumstances demand them.

The international hospice movement, represented in Botswana, exemplifies a philosophical and service model for multisectoral consideration and implementation on a nationwide scale. The article discusses, inter alia, day care centres and residential units for the terminally ill; a system of highly trained volunteers to work with patients and their families; consistent, skilled nursing services in home based care situations; and halfway houses for training of care-givers as possible solutions to the problem.

The contextualization of such measures will undoubtedly assist in bolstering Botswana's unchallenged record of high standards in governance and social development.     

Activity Engagement in Residential Care Settings: Findings from the National Survey of Residential Care Facilities

Assisted living and similar residential care is an important source of care for elders, including those with dementia. Meaningful activities may help residents maintain function, improve self-esteem, and enhance quality of life. Using data from the 2010 National Survey of Residential Care Facilities, this study identifies the extent of resident engagement in different types of activities; examines the extent to which cognitive status, other resident characteristics, and residential care community characteristics relate to activity engagement; and, among cognitively impaired residents, assesses whether being in dementia-specific settings is associated with activity engagement. Compared with persons without cognitive impairment, those with severe cognitive impairment are less likely to go on outings (79% versus 36%) and talk with family and friends (85% versus 72%). Residents with mild to severe cognitive impairment have higher participation in leisure activities than other residents if they live in dementia-specific settings (73% higher) than those who do not.     

Enhancing the Quality of Care in Residential and Nursing Homes: More than Just a Professional Responsibility

ABSTRACT

This article highlights a range of issues considered essential to improving the quality of care received by older people in residential and nursing home settings. It is argued that improving such care represents a societal as well as a professional responsibility and that remedial action is needed at a number of levels. Five ‘routes’ to achieving quality are outlined, and it is suggested that these are not simply alternatives but that each requires attention if genuine progress is to be made.     

Continuing Competence and Relicensure

Abstract

The purpose of licensing laws is to provide assurance of high quality service and to protect the public from incompetent practitioners. Safeguarding entrance to the professions by licensing examinations is one part of this responsibility which is entrusted to the professional boards. Assuring the continuing competence of practicing professionals is another part and a major challenge to every board of nursing throughout the United States.

A 1979 mail survey identified 18 states which have specific continuing education requirements for relicensure of nurses. In addition, three states have standards of practice incorporated in the rules and regulations governing the nursing profession.

Mandatory continuing education is a first step in the implementation of a system to assure the public of the continuing competency for practice of the professional nurse. It is acknowledgement, with the force of law, that continuous renewal of knowledge is a necessary condition for assuring competence. However, it is not sufficient in itself. Knowledge must be integrated in performance, which is the final test of competency. Thus, other system components that assure continuing competency must be developed and implemented. These include the identification of standards of acceptable performance, and the development and implementation of measures to evaluate practicing professionals and assure that they meet the performance standards. These measures include peer review, self-assessment, and recertification procedures. Successful implementation of a complete effective system will require the collaborative efforts of practicing nurses, their professional organizations, and the state boards of nursing.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.