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April - May 2013 | Vol. 7 Issue 4 | $10.95












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INsite Magazine Vol.7 Issue 4 EDITOR: Jude Barback T: 07 575 8493 E:

In this issue... 4

From home to hospice and everything in between: the challenges of providing a full continuum of care


Passion and vision: leadership in dementia care

ADVERTISING: Belle Hanrahan T: 04 915 9783 E:


Seeking meaning behind behaviour that challenges


Getting maximum from the minimum: exploitation of the age care worker



D: the miracle vitamin


China’s solution: visit elderly parents or they’ll sue

PRODUCTION ASSISTANT: Aaron Morey EDITOR-IN-CHIEF: Shane Cummings GENERAL MANAGER/PUBLISHER: Bronwen Wilkins SUBSCRIPTIONS: T: 04 471 1600 F: 04 471 1080 E: PUBLISHER’S NOTE: © Copyright 2013. No part of this publication can be used or reproduced in any format without express permission in writing from APN Educational Media (NZ) Ltd.

EDITORIAL & BUSINESS ADDRESS Level 1, Saatchi & Saatchi Building, 101-103 Courtenay Place, PO Box 200, Wellington 6140, New Zealand T: (04) 471 1600 F: (04) 471 1080 ISSN 1177-9268 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).


I’VE ALWAYS LIKED the phrase ‘continuum of care’. I like its alliterative quality, and the way the words, when coined together like that, take on a powerful meaning, as if there is no chance of a lapse of care provision in an older person’s journey. However, given the murmurings, and at times roars, of discord from the sector about a lack of integration between health services, it seems appropriate to take a closer look at whether a continuum of care is truly achievable in our current healthcare system. It is a pertinent topic for this issue, for which the focus is on long term care needs. It is difficult to consider care without taking into account the plight of the aged care worker. The pleas from various corners of the sector for more and fairer pay have not diminished and if anything, appear to be gaining momentum. We take stock of what has happened since the Caring Counts report was released. Dementia is also a key theme for this issue. We have become better at keeping older people well for longer, however a consequence of this is an increasing number of people with dementia, with which can often come an increase in challenging behaviours. We look at ways of managing this. We also look at dementia leadership, discussing a knowledge management strategy that can help leaders in dementia care become enablers, rather than directors. As usual, this issue isn’t without controversy, with debates on interRAI and the Retirement Villages Code continuing. We welcome feedback on any theme or article appearing in INsite or ideas for future issues. Also, keep an eye out for our newsfeed emails, through which we strive to keep you informed between issues.





The challenges of providing a full continuum of care


NEWS Snippets and updates from the industry


ON THE SOAP BOX... Victoria Brown


SPOTLIGHT ON... Choral Singing for older people


LET’S SNOOP AROUND... Selwyn Wilson Carlile






LAST WORD... Ian Brown

Jude Barback Editor,

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



Choral health | April / May 2013



LENGTHY WAIT FOR ASSESSMENT AT MANY DHBS The New Zealand Aged Care Association (NZACA) has ruffled some District Health Board feathers for naming and shaming those with long delays in assessing older patients before referral into care. The association released information on the time between a patient receiving a referral and an assessment of their needs. The figures - which include the lowest, the highest, and the average number of days between a referral and an assessment - are for those in rest homes during the quarter ending June 2012. The figures revealed the wait was as long as 79 days for Whanganui DHB, with most DHBs taking around 15 days. However, Whanganui DHB says it believes it calculated waiting times differently to other DHBs, including people who were already receiving short-term care and excluding people assessed in 24 hours because they didn’t have to wait. Whanganui said it also counted every day instead of working days. Taking into account these variables, the DHB informed the NZACA that their actual waiting time was 23 working days. NZACA chief executive Martin Taylor says that even 23 working days, just under five weeks, is still too long. He says ideally a person should be assessed within three days of a referral. An acceptable period would be 10 working days. Bay of Plenty (which reported the shortest wait times of four days), Hutt Valley, Capital & Coast, Auckland, Taranaki and West Coast DHBs were the only ones to come under 10 working days. Another seven DHBs on average take 15 days to carry out an assessment. However, Taylor admits these figures show only part of the picture. The next step is to extract information on how long it takes between assessment and transferring a person into care. An Official Information Act request has been made to obtain these figures, says Taylor.

ST JOHN LOOKS TO REDUCE THE NUMBER OF CALLS TO REST HOMES ST JOHN IS LOOKING to decrease the number of callouts to aged care facilities in response to unprecedented pressure on its ambulance service. St John staff nationally responded to 350,985 emergency incidents last year, up from 309,051 in 2009-10. Callouts to rest homes comprise the biggest group of calls the service received nationally. Some of those calls are inappropriate, giving the examples of lifting a patient back into bed or in the absence of a GP. St John did not have any statistics available to support these claims, however Operations Director for St John, Michael Brooke, says the reality is not everyone needs to be transported to hospital. “Twenty five per cent of our workload could be managed in better ways. If we can manage this workload better, we can concentrate on getting to the lifethreatening calls quicker,” he says. However, Martin Taylor, chief executive of the New Zealand Aged Care Association says rest homes have no choice but to call the ambulance service after hours if there is no after-hours GP cover. This signals a wider problem of having insufficient afterhours GP coverage. “We are legally bound to get our residents in front of a doctor. If there’s no GP cover because DHBs cannot contract with a PHO to provide after-hours coverage, which is their legal responsibility, then we have no choice but to call an ambulance,” says Taylor. Brooke says St John will always send ambulances to high priority calls.

“We are not turning people away; we want them to get the right care at the right place by the right health professional.” While it isn’t turning people away, St John is certainly looking for ways to reduce the number of less urgent calls. The charity organisation is aiming to transport 80,000 fewer patients to emergency departments over the next five years. One system it is trialling is to rank 111 calls under a triage system. A senior paramedic in the communications centre provided advice or referred patients to GPs if appropriate. Another initiative on trial is to send a senior paramedic in a car for less urgent calls to determine whether transportation to a hospital is necessary. However, Taylor believes this scheme is flawed for aged care facilities. In these instances the Registered Nurse at the rest home would make the call on whether the resident needs to be taken to hospital for medical assistance, as facilities have a legal obligation to provide the appropriate care for their residents. St John has also increased its patient part charges in response to the increased demand, with a further increase planned next year. Contracts with the Ministry of Health, ACC and District Health Boards fund nearly 80 per cent of its Ambulance Service direct operating costs. The shortfall is made up from community donations, fundraising, revenue from commercial activities, contributions of volunteers, as well as contributions from part charges.


AN UPDATE ON THE WORK carried out by the Office of the Auditor-General shows that rest home audits are improving. The update follows a scathing report released in 2009, which revealed the audits carried out on rest homes as “inconsistent” and sometimes of “poor quality”. In this report, the Auditor-General felt that since its introduction in October 2002, certification of rest homes has not provided adequate reassurance that rest homes have met the criteria in the Health and Disability Services Standards. It also found that the Ministry of Health, which is responsible for administering the audit process, did not respond quickly enough to address weaknesses and risks in the arrangements. The report listed a number of recommendations. However, the update shows that since the 2009 report, the Auditor-General’s recommendations have been met and progress has been made, with a more rigorous approach taken and a stronger focus on quality of care. The consistency and quality of audits has improved and authorities are in a better position to respond to audit findings. The follow-up report also states that the office is now looking at the future needs of New Zealand's ageing population and how the public sector is planning to meet them, exploring the extent that older people's care and support services are integrated.

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April / May 2013 |


REPEAT REVIEW OF THE AGED CARE SECTOR THE NEW ZEALAND AGED CARE ASSOCIATION (NZACA) intends to carry out a review of the aged care sector next year. With the government unwilling to support the initiative, the association will fund the review itself. Martin Taylor, chief executive of the NZACA says he isn’t surprised Government funding has not been forthcoming as it will highlight the lack of inactivity in addressing many of the issues raised in the last review of the sector, which was carried out by Grant Thornton in 2010, costing the Government $1 million. The Grant Thornton review identified a projected increase in demand which the sector would struggle to meet, due to the cost of building new facilities. Taylor believes little progress has been made since the Grant Thornton review. The problem of lack of profitability was likely to be worse than in 2010, due to increased regulations, building costs, and operating costs and an insufficient increase in sector funding.

SUMMERSET INVESTOR SELLS DOWN AUSTRALIAN PRIVATE EQUITY firm Quadrant has divested 40 million shares, approximately a third of its 56 per cent stake in New Zealand retirement village operator, Summerset. Quadrant will remain a significant shareholder in Summerset, with a 37.2 per cent stake in the company. The company intends to continue its current representation on the board. The underwriting brokers UBS NZ’s co-head Nicholas Ross told the Herald about 95 per cent of the 40 million shares in company were sold locally and they were

However, Chris Fleming, the district health boards’ lead chief executive for health of older people says progress has been made, with new facilities opening in recent years. There has also been significant investment into dementia care by the Government. Fleming has described the timing of the follow-up review as “cynical”, given that it will fall in an election year. However, Taylor says the 2010 review was always intended to be a baseline and the association would look to monitor progress on a regular basis. Next year’s review will repeat the costing survey in the 2010 review in order to track the investment gap. Taylor says it will look at the variances in demographic growth in different regions and the costs of building in those areas. “It will help assess demographic projections DHB by DHB. It may be that people want larger ensuite rooms; we want to establish how much it will cost in individual areas.”

delighted with the speed with which the transaction was executed. UBS reportedly acquired the shares at $2.42 each, valuing the stake at $96.8m. Summerset shares have traded in a $1.50 to $2.68 range over the last 52 weeks. However, the share price took a slight dip after Quadrant’s selldown. After Summerset’s one-day trading halt, the shares opened 3.5 per cent lower at $2.49. Summerset listed on the NZX in October 2011 at $1.40 a share, and has gained 83 per cent over the past 17 months. Summerset is viewing the change in ownership in a positive light. “The board is pleased to have continuing support from QPE [Quadrant] and welcomes new retail and institutional support as we address the many growth

opportunities ahead of us,” says Summerset chairman Rob Campbell. Quadrant’s selldown was not entirely unexpected, as the firm’s agreement not to sell its 56 per cent stake expired at the end of February.


DEMAND FOR NEW AGED CARE QUALIFICATION A NEW SIX-MONTH National Certificate in Health, Disability, and Aged Support (Core Competencies) (Level 3) offered by Waiariki Institute of Technology for the first time in Kawerau is proving popular, with strong interest and 26 enrolments already. The pilot qualification for health and rehabilitation is for students who wish to work in a support role in the health industry. There will be no course fees, an incentive to support the Kawerau community. Depending on the pilot’s success it may be offered at other

Waiariki sites around the region in the future. The classes will be taught at the Presbyterian Church in Kawerau. Meanwhile, the Rural Health Interprofessional Immersion Programme (RHIIP), a partnership between Waiariki, Bay of Plenty District Health Board and Auckland University was launched in March at Whakatane Hospital. The programme aims to bring together students from a range of disciplines including nursing, medicine, pharmacy and physiotherapy.



METLIFECARE RECENTLY DECLARED an interim dividend of one cent per share. That dividend will be paid on 17 April 2013. In a letter to shareholders, Managing Director Alan Edwards informed that Metlifecare has established a Dividend Reinvestment Plan (DRP) under which shareholders may elect to reinvest all or part of their cash dividends in additional Metlifecare shares. “The DRP provides a convenient method for reinvesting all or part of your dividends in further Metlifecare shares free of brokerage charges. Shareholder participation in the DRP is optional. An offer document setting out the terms of the DRP is enclosed.” For shareholders wishing to participate in the DRP for the April 2013 interim dividend, completed DRP Participation notices need to be received by the share registrar by 2 April.

A paper presented to a Communicable Diseases Conference in Canberra looks at two gastro outbreaks at an Australian aged care facility in April and June last year. An apparently healthy fourmonth-old pet puppy was identified as the potential source of infection for up to 15 people. The research identified puppies as a health risk because of the high rate of campylobacter carriage and the susceptibility of elderly residents to infection. It recommended the puppy be excluded from the aged care home until it was a year old, and that puppies not be considered as aged care companion dogs. According to the study, specially trained adult dogs are suitable for use as companion animals for the elderly. | April / May 2013



From home to hospice and everything in between:

THE CHALLENGES OF PROVIDING A FULL CONTINUUM OF CARE Providing seamless care from the home, to residential aged care, to an acute hospital setting appears to be a universal goal. Families want it, the Government wants it, aged care facilities and home support services providers want it ... so why aren’t we quite there yet? By JUDE BARBACK.


ontinuum. It’s a good word, and sounds even better when paired with ‘care’, as it implies continuous, seamless healthcare, at the right level, at the right time. ‘Continuum of care’ is a phrase often associated with aged care facilities and implies the ability of a facility to provide the care needed by an individual at whatever level required, transitioning between the levels with ease. A retirement village, for example, that boasts a full continuum of care to its residents, is one that may have a service for providing care to residents as needed while they are still living relatively independently within their villa or apartment, to the provision of rest-home level care, to hospital-level care. But if we look at continuum of care in its wider societal context, the process of providing care from the individual at home, to residential aged care, to the acute hospital setting is harder to navigate. This is largely because our health system still lacks the level of integration required to deliver seamless transitional care.


New Zealand’s healthcare system is built upon a history of fragmentation that it has struggled to overcome. Jacqueline Cumming provides an interesting overview in her 2011 article, Integrated care in New Zealand which helps to explain why achieving integration is not entirely straightforward. In the mid-to-late 1800s, early governments supported a vast mix of providers and funding models to deliver health services to a rapidly growing New Zealand population. This fragmentation of health service delivery has proven difficult to shake off, despite many attempts to bring about a more integrated health care system through reforms. There was the introduction of the Social Security Act in 1938, which aimed to introduce universal free care for many health services as part of plans to establish a single, national health service, but this did little to dislodge the firmly entrenched user pays 4

April / May 2013 |

system, and major separation in the planning, funding, and provision of services only served to increase fragmentation further. The 1980s reforms saw a renewed focus on integrating planning and funding functions, and public health and secondary care service provision, at a district level, through the establishment of 14 Area Health Boards. The 1990s reforms helped to further integrate planning and funding responsibilities, this time into four Regional Health Authorities. This resulted in a more collaborative and consistent approach to funding services and a greater emphasis on prevention and primary care. However planning and funding was separated from provision; contracting mechanisms were introduced for providers – a system which helped promote competition and in doing so, enabled more choice for users, but also led to more fragmentation as there was less incentive for providers to collaborate with each other. Eventually, by the late 1990s, the four Regional Health Authorities merged into a single, national Health Funding Authority, which set out to develop general practice services into multi-disciplinary teams, or Public Health Service Organisations. Before this plan had time to be realised, the next set of reforms were underway, with the establishment of 21 District Health Boards, which were responsible for funding and provision of hospital service, and funding and contracting for community services, and later, primary care. In 2001, the Primary Health Care Strategy was released, which saw the establishment of 80 Primary Health Organisations, which were held responsible for the health of their enrolled populations, and funded on a capitation basis. However, by the end of the 2000s, there were still concerns that little had actually changed in terms of how services, especially primary care services, were delivered to the user. Care became more focused on the patient, rather than the institution, and alliances were formed to bring together

clusters of PHOs, each alliance aiming to improve coordination of care through devolution of funding and services from District Health Boards into the community as well as improve coordination of services between primary care providers and hospitals.


Cumming believes that, in spite of these reforms, the main challenge lies in encouraging a wide range of providers who currently operate separately at the primary care level – GPs, nurses, pharmacists, physiotherapists, social workers and so on – to work together under a single budget. Primary care services need to better link with secondary care and support services. This was echoed by the Aged Residential Care Service Review, carried out by the NZACA and Grant Thornton New Zealand Ltd and published in September 2010. The review found that through the close integration of health services, this approach makes it possible to improve the resident’s experience, improve provider coordination, and reduce unnecessary services and costs. The review suggests the introduction of aged care services teams, whereby a group of aged care professionals come together with common incentives, tools, and a shared philosophy to provide a full continuum of care services from home and community support, to residential care, to acute hospitalisation, to hospice, and to social work. Many hurdles need to be overcome in the current culture for such an approach to truly work, not least the alignment of operations of different providers and the sharing of financial risk across organisational boundaries. Any barriers to achieving a continuum of care are largely “symptomatic of the healthcare system”, confirms Grainne Moss, Bupa’s General Manager for Rehab and Care Services. Moss acknowledges that in striving for a more integrated system, there is the challenge of balancing the necessary level of specialism with holistic breadth.



reports similar experiences. “We have had instances where the resident has had to be One major obstacle that exists, to varying returned to hospital in less than 24 hours degrees, is a tension and even sometimes distressing for all parties.” mistrust between DHBs and the residential Leach agrees it is “critical” for the operator aged care and home and community support to have a resident assessed correctly so sectors. the right level of care can be provided This was exemplified recently by the immediately when the resident arrives and to reaction of Chris Fleming, the district health avoid premature discharge. boards’ lead chief executive for health of Hall agrees there is an impatience for older people to news that the New Zealand hospitals to discharge. This is no doubt Aged Care Association intended to conduct caused by a pressure on the number of beds a self-funded review of the aged care sector available, a constant challenge for DHBs. in an election year. Fleming describes the The same pressures exist in residential care timing of the review as “cynical”, saying that facilities. the focus should be on finding solutions to “As operators ideally need to run their problems raised in the 2010 Grant Thornton facilities at 100 per cent occupancy to review, rather than on undertaking another achieve some form of financial return, there stocktake. Meanwhile Martin Taylor, chief will ultimately be no excess capacity in the executive of NZACA, says the second review aged care sector, and in many areas it will is “important for all parties”. be challenging to find a place from time to Tensions can also be felt at individual time,” says Leach. facilities. Rachael Hall, manager of Selwyn Due to the high demand, there isn’t really Wilson Carlile rest home in Hamilton a strong feeling of competition among says liaising with the DHB is not always aged care facilities. While larger operators straightforward. She says one particular sometimes have the option of providing problem is when a patient is assessed at a temporary position in another of their Waikato Hospital for referral to a residential facilities until space becomes available, aged care facility, but then there can be a often ‘competing’ facilities that are in close delay of up to a week before the patient proximity of each other will assist each other. is discharged to the facility, without reHall says that when faced with a situation assessment. A week, says Hall, is a really long when more hospital-level beds are needed time when it comes to the health of an older than available, residents can be temporarily person, and often they have regressed in that transferred to a neighbouring facility. time and need to be transferred back to the If necessary, facilities convert beds from acute hospital setting, causing unnecessary rest home-level to hospital-level. Under expense and concern for the resident and their certified level of service, facilities are family. free to do this, as long as they don’t breach Jeremy Leach, General Manager the number of dementia beds allowed of 20 Marketing & Village Operations at Oceania per unit. At times it may not be appropriate,

for example, if a hoist or other specialist equipment that is in the hospital part of the facility is needed. Interestingly, supply and demand patterns are slowly shifting within aged care facilities. Grainne Moss of Bupa says due to the ageing population, the need for rest home beds appears to be dwindling, while that for hospital-level beds and specialised dementia beds is increasing. Moss says that a consequence of keeping older people well for longer, is an increase in acuity of residents both in hospital and dementia care. An inadvertent barrier to providing the appropriate level of care, is often the resident’s family. Many in the sector, including Oceania and Bupa have a “personcentred care plan” which involves family input into the process and helps to manage expectations. Moss says families generally show a preference for the homely feel of rest home rooms, until the resident’s health wanes and then the family desperately wants the reassurance of a more sterile acute hospital room. They will often want acute level care whereas it is often not the best thing, says Moss, especially if the patient has dementia, as it can be confusing and disorientating with the unfamiliar surroundings and all the bright lights and noises. Bupa works with families to develop advanced care plans and talk about these concerns and issues prior to any event. Wendy Taylor, manager of Ryman’s Hilda Ross retirement village in Hamilton, says the assessment process and social worker at the hospital work with the village to help keep families informed of a resident’s changing care needs.


Certainly there do appear to be productive steps being taken towards improving the relationships between DHBs and the residential aged care sector. Hall says there is plenty of opportunity to give feedback, through forums, for example. She says she also has a very good relationship with, the funding and planning manager at Waikato DHB, whom she describes as “very proactive” at following up on incidents when reported. “High quality communication between the operator and the hospital is important; there is no doubt that relationships between key staff help facilitate this,” says Leach. “Our facility managers and admission staff like to work closely with the hospital staff, and in many instances they visit the resident in the hospital before they are discharged into our care.” >> | April / May 2013


FOCUS << Moss agrees, saying she enjoys creative relationships with portfolio managers for aged care for 17 DHBs. She says most of these managers have been in their role for a long time and are knowledgeable, passionate about what they do and take a practical approach to their work. “There are relationships of trust with provider and purchasers, which is a major help in delivering better care.” A good example of burgeoning trust between the DHBs and residential aged care sector can be seen in the work led by Waitemata DHB. Nurse practitioner Dr Michael Boyd, was instrumental in developing the DHB’s Residential Aged Care Integration Programme (RACIP) in which a group of nurses, gerontology specialists, and members of DHBs came up with 18 geriatric issues, providing the basis for the RN Care Guides, now used extensively in care facilities. In addition to advancing aged care initiatives, the development of the programme also helped in building important and strategic relationships between the DHBs and the sector.Boyd says the involvement of the aged care staff from the outset of the programme led to greater ‘buy-in’ for the programme and a greater trust of DHB partnerships. Boyd believes multi-disciplinary teams, including a DHB geriatrician, GP, gerontology nurse specialist,facility senior nurse and pharmacist, are the way forwards for aged care facilities. Research on this topic led by geriatrician Professor Martin Connolly will be published later this year. Although it is disappointing that more funding hasn’t been forthcoming from the Government for residential aged care, Moss believes the Ministry’s appointment of Dr Shankar Sankaran as Chief Advisor, Older People’s Health in March 2011 has been an excellent move. Sankaran’s role is to provide leadership in supporting the Aged Residential Care Services and integrating with primary care to provide specialist support to primary health care professionals. Moss says other DHBs are following his lead with many things, such as conducting medication reviews with GPs. With an 0800 number available for facilities to contact him, he is accessible to the sector. Moss believes Sankaran’s appointment is a practical answer to helping facilities achieve continuum of care. But more can be done. With 34,000 residential aged care beds, compared with 8000 acute care beds, Moss believes the aged care sector plays a significant part. “It needs to get out of the shadows,” she says.


However, it appears there is more to be done to improve the partnership between the home and community support services sector and the DHBs. 6

April / May 2013 |

Better, Sooner, More Convenient Primary Health Care, the Ministry of Health’s policy direction, is aiming to achieve better integration by creating an environment where primary health care professionals in the community work with one another and with hospital-based clinicians to deliver co-ordinated care to people in their own community. While great in theory, many in the sector believe more needs to be done to integrate community care with other health services. Grainne Moss of Bupa is one. “At a strategic level the Ministry has pushed for more integration between primary and secondary care, but there needs to be more integration with community care. Better, Sooner, More Convenient needs to be extended to community services more,” she says. Julie Haggie, chief executive of New Zealand Home Health Association (NZHHA) agrees, saying there is definitely room for improved integration between home support and other health services. “People living at home need to get access to clinical care at home and after hours to reduce the likelihood, frequency, and duration of hospital attendance. There should also be more intensive support to help them rehabilitate after an event such as a fall or stroke,” she says. It is not a unique dilemma.Other countries are also striving to bridge the gap between home-based support with primary and secondary care. The PACE programme in the United States has found some middle ground in its community centres, which give elderly people access not only to health care but to aspects of home-support services such as meals, laundry, bathing, and even transport to the clinic. In New South Wales, the new Hospital in the Home (HITH) programme is becoming increasingly popular with patients and has been deemed to be as clinically effective as in-hospital treatment. Under HITH, patients receive the same treatment as they would in hospital for a variety of acute and sub-acute conditions, allowing them to remain in their own home for longer. The HITH programme also frees up much needed space in the hospital system.

In Australia, there is much concern over rising health costs and emergency departments failing to meet national standards. It is hoped that HITH will help ease the financial pressure on hospitals by reducing bed block by allowing patients to be discharged earlier and cutting inpatient bed day costs. There are similar initiatives underway in New Zealand, too. Don Gray, the Ministry of Health’s deputy director general of policy, points to Primary Options for Acute Care (POAC) as New Zealand’s answer to programmes like HITH. POAC is a service allowing doctors to access investigations, care or treatment for their patient, as an alternative to an acute hospital admission. It includes a range of community diagnostic, therapeutic and logistic services such as GP or nurse home visits, home help, diagnostic procedures like X-Ray and ultrasound, intravenous therapy and even transport to and from primary care locations. The programme works across Auckland, Counties Manukau and Waitemata DHBs. Gray says that in addition to POAC there are a number of initiatives, both under Better, Sooner, More Convenient initiatives and a broader programme to move services closer to home, and develop close links between primary health care, secondary health services and home support services. The Waikato DHB’s START programme and the Canterbury DHB’s CREST programme are both examples of such community rehabilitation initiatives. Gray says there is also now specialist clinical support offered by certain DHBs for primary health and aged care providers. Counties Manukau and Waitemata DHBs are leading the way in this aspect. “[Waitemata] has developed a proactive community gerontology service using health of older people specialists, including gerontology nurse specialists, to provide interdisciplinary reviews, education sessions and phone support to health professionals working in the community and residential care.” Minister of Health, Tony Ryall, in his letter of expectation for DHBs this year stated that DHBs are expected to “work with primary and community care to provide integrated services for older people that support their continued safe, independent living at home”. While this expectation is seemingly being met by various initiatives across the country, it appears some are meeting the task at hand better than others. Older people are to an extent reliant on their region’s DHB’s approach to providing integrated services. Those who fall outside the remits of the DHBs in the wider Auckland region, for example, may have good cause to feel hard done by. The way that many DHBs have pared back the number of provider contracts, placing further squeeze on the sector, indicates a change in focus on home-based care.

FOCUS The recent example of Southern District Health Board failing to include Presbyterian Support Otago as one of its chosen providers, is evidence of the tensions running high between DHBs and providers.


It is interesting to reflect on what is happening in Australia with home care. Australia Minister for Ageing Mark Butler said Living Longer Living Better - Australia’s equivalent policy to Better, Sooner, More Convenient - acknowledged in its long-term forecasting that the nature of aged care was changing, with older people wishing to remain in their homes and communities for longer. Subsequently, over the next 10 years, the Australian government would more than double home care packages across Australia. However, Gerard Mansour, chief executive of Leading Age Services Australia told Australia’s Aged Care INsite that he believes there is more work to be done in getting the balance right. “Social interaction at this time [of life] is critically important we know that - and it’s counterproductive if we allow someone to remain in their own home but they’re enormously isolated,” he said.

As operators ideally need to run their facilities at 100 per cent occupancy to achieve some form of financial return, there will ultimately be no excess capacity in the aged care sector, and in many areas it will be challenging to find a place from time to time. - Jeremy Leach.


In both Australia and New Zealand, and in many countries, modern technology makes it more achievable to provide a seamless continuum of care. Assessment tools, case conferences and electronic medical record platforms are all aimed at facilitating consistent and clear communication across the team. Electronic personalised care plans, used increasingly in the home support sector, allow a multi-disciplinary approach to care and assist with any transitions. However, technology is not always without its problems. While many facilities and operators have expressed enthusiasm for the assessment tool interRAI, many have reservations. Grainne Moss says Bupa is taking a ‘wait and see’ approach to interRAI. Their

caution is based on the experiences of some DHBs who are really struggling with it and have hundreds of interRAI referrals outstanding, meaning that they are not keeping up with the patient as they transition through care. The mixture of enthusiasm and caution towards interRAI is indicative of the push-pull felt in many corners of New Zealand’s healthcare system, as each party strives to push their agenda forward while at the same time collaborating with other parties to achieve the seamless provision of appropriate care at the right time. The love-hate relationships between DHBs and facilities and home support providers, and the variation of services offered from one DHB to another, both hint at the tensions felt in achieving the integration needed to deliver a smooth continuum of care.

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call 0800 277 486 email visit | April / May 2013




LEADERSHIP IN DEMENTIA CARE CAROLINE BARTLE discusses a knowledge management strategy that helps leaders in dementia care become enablers, rather than directors.


ver the last year a group of people and organisations have set about developing the vision for dementia care services. This is the work of the Dementia Cooperative tasked with setting the agenda for change and scoping tasks needed to achieve this. There are six main actions groups which include Network action group, Whanau Carers, Research, Dementia Care Pathways, Advocacy and Workforce Development. I have been privy to being involved in this group, and can attest to the excellent work that has been achieved to date, the legacy of which will shape services. However, as we look to the future we need to explore how this vision will be transitioned into action through leadership. In this article I explore what skills are required to lead and champion change in dementia care services. Alongside the work of the Dementia Cooperative, Careerforce have begun a qualification review. It is hoped that within this some consideration is given to developing our leaders to be courageous, skilled and visionary. However, education is only a small part of what makes a good leader in dementia care as whilst knowledge of best practice is critical, knowledge of how to develop and inspire others and knowledge of how to evolve services within a changing market are all essential criteria. Leadership in dementia care requires passion and vision. 8

Vision to understand how services are now and what is needed to get to where we want to be. A leader needs to have a good understanding of the policy context as well as the evidence base. Leaders need to understand the barriers to improvement and be willing to work creatively around these. Education often is the catalyst as the way we think affects how we feel which affects the way we act. A leader needs to understand the concept of ‘excess disability’; this is about understanding how behaviours and other symptoms are created by living in a poor environment. All too often these symptoms are wrongly attributed to the dementia and therefore are not viewed as being something that can be worked with, minimised or eliminated. Lack of this foresight ultimately leaves people unnecessarily disabled. A poor environment relates to both the social and the physical environment. On a simple level this is a about sensory skills and cognition, and how these are used to interpret the environment. It is also about how a positive social environment can strengthen self esteem, and ultimately positively impact on coping skills and capabilities. Good leaders should be able to support their staff to understand the impact of these and to create an environment which is conducive to enablement. So many people with dementia have told me over the years, “empower us, don’t limit us”. Where we

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operate within the social model of care all of these skills are available to us, and they are powerful where applied appropriately. However, working within a model of psycho-social approaches requires an understanding of the cause and effect of our working practices. A leader needs to see his or herself as a leader and not a ‘manager’; there is a subtle but essential difference in this approach. A leader should see themselves as enabler rather than director. A leader needs to take a truly person-centred approach to their staff team; understanding strengths within the team, delegating responsibilities and encouraging personal reflection in others. All of these skills require a strong knowledge management strategy, and over many years working with different organisations to develop their capacity to become better services, I have created a knowledge management strategy in dementia care PHASE ONE. This framework provides leaders with the tools required to champion change in their services. Policy – This is about understanding national policy and how this impacts on the shape of services. For example, Counties Manukau District Health Board has developed their dementia pathway and the national New Zealand dementia care pathway, which is currently in draft format, is due any day. Understanding this is critical to

how you operate within a fluid environment and in ensuring skilled support is accessible to your client group. Human Resources – This is about adopting a culture of innovation within your services, where mistakes are explored rather than reprimanded. It is about recreating job descriptions so that they capture more of a person centred approach rather than a task based approach, for example detailing how to meet important psychological needs alongside basic care. Having good supervision systems in place is the cornerstone of risk management, safeguarding from abuse and serves well as a vehicle for dealing with the challenges faced with working with this client group. Skilled leaders need to be able to guide reflection appropriately to get support staff to examine their attitudes and actions. Assets – This is about defining the knowledge in your organisation as an asset of value. In many other sectors there is a greater understanding that we live in a knowledge economy, not an industrial one. Knowledge of processes and practices creates profit. Work needs to be done within organisations to catalogue these intangible assests, and be able to determine the return on investment for educational projects. Services – This is about knowledge in services. In this context it is about understanding psycho-social approaches, working in a therapeutic, almost

DEMENTIA rehabilitative way. Owning this and promoting this as part of your service. Understanding what defines your service from others in terms of its outcomes for people who have dementia. It’s about valuable ‘differentiation’ within a competitive environment. Experience – This is about understanding the experience of dementia, or rather customer knowledge. Being able to put in systems to capture this and use this information in the development of services. There are many forms of social media now available to use where we can learn about the experience of dementia, such as the inspirational Kate Swaffer. Organisational memory – This helps to ensure that knowledge is not lost as people move on. Knowledge for example of how to deal with ‘emotional distress’ or specific approaches that work well with individuals. For most organisations this needs to be captured in the service plan or team meetings, however there are now available many more innovative mechanisms to achieve this. Networks – This is about knowledge in networks or relationships, having mechanisms to create knowledge across boundaries. A report carried out by the dementia cooperative makes very interesting reading as it talks about organisations’ capacity to access an evidence base, analyse this and synthesise new knowledge. Making links and using information external to the organisation is critical. Embedding operational excellence – This is about the procedures that operate to capture data and how local policies can hinder or support outcomes. For example some organisations have limiting policies on risk management or how and when to share data, all of this impacts on operational efficiency. In addition, the role that audits play in this process needs to be explored. A leader needs to be committed to change, as nothing stays still. For more information on leadership in dementia care courses delivered by Caroline Bartle, contact Leigh Kelly on +64 9 834 4825, or email info@ These courses will be running in Dunedin and Auckland in June and July 2013.


As the number of people with dementia increases year on year, we need to get better at understanding and managing challenging behaviours that can occur. By BETH McDOUGALL.


any family carers say, “I can cope with what he can no longer do, but I can’t cope with what he has started to do.” It is estimated that currently in New Zealand there are over 48,000 people with dementia and that by the year 2050 there will be 146,699 or 2.7 per cent of the population with a diagnosis. At the Alzheimer’s International conference 2012 it was stated that every four seconds in the world there is another diagnosis. There has been a 24 per cent increase in dementia beds available in New Zealand from 2009 to 2012. The Bupa 2012 census showed that 62 per cent of residents in our care had mild to severe cognitive impairment. All evidence is telling us that our quantity of life expectancy has increased but not necessarily our quality of life. People with dementia have difficulty using words so use other ways to express themselves. Ninety per cent of people living with dementia will experience behaviour that challenges. The behaviours generally only appear at certain stages of the illness and nearly always resolve with time. The more we know about the person and their life story - as in Person First, Dementia Second - the better we are able to understand their ‘new language’ and so are then able to respond meaningfully. Understanding these behaviours requires us to focus on needs to be met, rather than a behavioural problem to be managed. It is important to recognise that behaviours associated with dementia are not bad behaviour on the part of the person; these symptoms are often associated with chemical changes in the brain or by social and environmental triggers – the behaviours are due to the dementia. In residential care our focus is

to minimise behaviour by creating ‘dementia friendly environments’. The purpose of the building does not necessarily match the service that you are now delivering from those walls. Management and staff need to be creative and innovative as to how they set the ambience. Many Bupa homes have established ‘destination points’ or ‘places of interest’ both inside and out where residents are free to enjoy and participate in an activity. Shops, pubs, sewing rooms, offices, nurseries, cafes, painting corners are a few examples of where residents can enjoy their day with some meaningful activity. Memory walks created by a series of photographs from the past local area can be of great interest and a topic of conversation for family members and visitors. These environmental stimuli can provide purpose and opportunities to reminiscence while maintaining dignity for the person and their family. Outdoor areas need to resemble ‘a kiwi backyard’ where residents can sit outside or potter in the garden. Night time lighting can allow a safe place for residents to enjoy the night sky and fresh air to calm restlessness or agitation. Verbal and physical aggression is often presented when personal care is being delivered. In the past this may have been managed by having an antipsychotic medication charted. Staff need to become ‘detectives’ when drilling down to find out the reason behind the behaviour. A recent example of how staff at a Bupa home managed this was to firstly do an analysis of the behaviour. Care staff noted that the behaviour only happened in the shower room and never in the bedroom where personal cares were also carried out. Staff decided to replicate the racing cars and rugby pictures from the bedroom wall

by laminating them onto to the shower room wall. The challenging behaviour was reduced to a minimum and became a ‘win-win’ for both the resident and the staff. Research published in 2011 involved 352 residents with moderate to severe dementia who were randomised into a treatment and control group. The treatment group had their pain managed proactively by being given regular pain relief. The medications used were Paracetamol, Morphine, Bu Trans transdermal patches and Lyrica (used to treat neuropathic pain). Scores for pain, agitation and aggression were measured at the outset and at the end of the trial. Residents in the treatment group had a 17 per cent reduction in their agitation scores with significant reductions in aggression and pain. While this trial has demonstrated that effective use of pain relief may reduce behaviour that challenges and the need for using antipsychotics, we still need to be mindful that any medication given has side effects. Antipsychotics should be prescribed for psychosis and not as a first line approach for behaviour that challenges. By moving from a medical model of care to personcentred care we are helping the resident and their family complete the journey better than we have in the past. We have more challenges ahead as providers of care to meet the needs of those with dementia and those of their families. We are making progress in our understanding and management of behaviour that challenges but the journey is not yet completed. Beth McDougall is dementia care advisor for Bupa New Zealand. References available on request from | April / May 2013





In its decision not to increase the level of funding for aged care, the Parliamentary Health Select Committee said that “positive outcomes, as experienced by residents, are arguably more important than any input measure”. But residents and those who provide their care are inextricably linked, argues JUDE BARBACK.


eet Ana. She is 37. She works as a caregiver at the rest home round the corner from her house, which she shares with her partner and their three schoolaged kids. She earns $14.40 an hour, just over the minimum wage threshold; the average wage of an aged care worker. She has earned roughly the same amount in the five years she has worked there. Her partner earns more than this, but collectively they struggle to afford groceries and to pay their bills on time. Ana generally enjoys her work but resents the low pay, which is a source of constant grumbling among the caregivers. Now meet Mrs. Jones, a resident at the rest home. She is 90 and can no longer walk. Ana is one of Mrs. Jones’ main caregivers. They get on well. Mrs. Jones is grateful that Ana remembers little things like putting a handkerchief up her sleeve, and putting her blind down at the point in the day when the sun gets her in the eye. Sometimes it is easy to forget about Mrs. Jones and her needs amid the flurry of union activity, reports from the Human Rights Commissioner, and talks of a living wage. The attention given to the poor pay and working conditions of aged care workers has shifted the emphasis to Ana. But the fact is, one can’t be considered without the other. They are mutually dependent. If we want older people to be looked after properly, then we need to look after those who are looking after them. This is the overriding theme of Equal Employment Opportunities (EEO) Commissioner Dr Judy McGregor’s Human Rights Commission’s (HRC) report, Caring counts. McGregor famously went undercover as an aged care worker to experience firsthand the long hours for low pay and at times no pay. Her report says the reliance of all New Zealanders “on the emotional umbilical cord between women working as carers and the older people they care for at $13-$14 an hour is a form of modern day slavery”. 10

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The emotive and loaded word, ‘slavery’ has since been brandished by many, including the New Zealand Nurses Organisation, which strongly advocates for more pay for aged care workers. In a petition supported by 10,607 people, the NZNO and Service and Food Workers Union (SFWU) have called for compulsory staffing levels and ratios, fair pay, a single staff training programme and more targeted funding. It seems a case of ‘one step forward, two steps back’, however, with the Parliamentary Health Select Committee’s recent decision not to increase the level of funding in aged care coming as a blow to many who have campaigned hard for change. “The Government’s blinkered approach is morally wrong; they are compromising the quality of care our vulnerable elders receive and are consigning those who care for them to live on poverty wages,” said NZNO industrial adviser, Susan Stewart. The problem with this is that no one wants to take ownership for it. The committee said it “strongly encourages employees and employers to work together to develop fair rates of pay”, which seems to imply the Government is bowing out of any responsibility concerning pay and instead transferring the onus to operators, and the workers themselves. The report further states that the committee acknowledges “the complexity of the funding model and the tension between private and DHB providers”, phrasing that appears to distance the Government from funding models and friction within the healthcare system. In response to the call to improve the ratio of carers to registered nurses, the report says: “…positive outcomes, as experienced by residents, are arguably more important than any input measure and should be given greater priority.” It is unsurprising the report has riled organisations like the NZNO and NZACA and has attracted accusations of being “weak” and “patronising”.

However, if we rid aged care of its emotional connotations and view it purely through an economic lens, it becomes somewhat clearer why Government are in no rush to deliver handouts. In an era of economic recovery and belt-tightening, any top-line spending is presumably done with utmost caution and consideration. While the recent increase of the minimum wage to $13.75, may have been described as “mean” by some in light of a higher cost of living, it is no doubt realistic given the current financial constraints. In some ways the increase to minimum wage is reflective of the Government’s approach to aged care: a nod of support, but stopping short in any meaningful investment. However, given that many aged care workers are earning close to minimum wage, the increase is meaningful. It is often argued

FOCUS leaving for alternative employment, and then, inevitably, she leaves. A new caregiver takes her place. Despite the notes about where Mrs Jones needs to have her call button accessible, and how she needs to be propped up in the morning to relieve her of lower back pain, the new caregiver doesn’t grasp these aspects straight away. And it takes time to build rapport and understand each other. Turnover is a problem in the sector, and it’s not hard to see why. There are many jobs you can do for the same money or slightly more that don’t require such emotional input, such personal work. For example, a job at the local supermarket, even as a trolley wrangler, usually offers over minimum wage. Cleaning, another line of work that often comes under fire for low wages, at least offers more detachment and less emotional input. It appears to be this notion of “unskilled labour” that needs to be addressed. With no regulatory professional body, no minimum training or qualifications needed, caregivers are one of the few unregulated workforces in New Zealand. Earlier this year an opinion piece by Sue Kedgeley in the Herald stirred controversy. Kedgeley berated Ryman Healthcare, Metlifecare and Summerset for their high performances on the New Zealand Stock Exchange. “That’s great news for people with shares in these companies. But it provides little comfort for the 30,000 aged care workers in the sector, many of whom are paid at or just above the minimum wage.” Kedgeley points to the inflated salaries of those who run these companies. “Why can’t some of the profits that are earned in the aged care sector trickle down to caregivers, so that they can earn a decent wage too?” she asks.

case the aged resident in care. “At present, the free market corporate mentality, where profit for a select few at all cost regardless, gained on the backs of low paid workers, is the ultimate aim of administering aged care businesses, [and] is a barrier to improving workers circumstances in the industry! So it’s very unlikely aged care worker participation in profit sharing will become a reality while this one sided economic system of conducting business continues to exist, without some changes and regulation in place to ensure balance and fairness in the equation.” Despite an unregulated environment, most facilities are actively and regularly training their staff, with many working towards level 2 and level 3 training. Tamara Baddeley, a home support worker and SFWU member, told the Caring Counts: Stakeholders Summit held late last year how carers wanted to be paid for their skills and experience. Despite 11 years experience, her level 2 qualifications and a Certificate in Palliative Care, Baddeley is paid $14.80 an hour. Despite the select committee’s verdict, there have been suggestions of progress. The Caring Counts summit was a nod in this direction. Hosted by Judy McGregor, about 90 people involved with the aged care sector, including representatives from peak bodies, civil societies, unions, aged care services providers, district health boards, and the Ministry of Health came together to discuss how to move forward the actions of the Caring Counts report. The sector’s industry training organisation, Careerforce confirms it will incentivise employer interest in training by payments to companies on completion of Level 2 and 3 training. This move is an important step in aligning pay with qualifications. Many organisations do just that,

The Government’s blinkered approach is morally wrong; they are compromising the quality of care our vulnerable elders receive and are consigning those who care for them to live on poverty wages - Susan Stewart that as aged care workers typically do not need qualifications or specific skills to gain employment in the sector, they cannot be expected to earn much more than minimum wage. But once again, in our preoccupation with qualifications and pay brackets, we’ve forgotten about Mrs. Jones again. The fact remains that aged care can’t be rid of emotion. You can’t take Ana and her circumstances out of the equation any more than you can take out Mrs. Jones. The two are inextricably linked. Let’s revisit Mrs. Jones. She is at the mercy of her caregivers. She can’t get dressed, go to the bathroom without their help, or even pour herself a glass of water. While Ana cares about her, and genuinely likes her, she is preoccupied by how little she is being paid, so she gets sloppy about care delivery as she thinks about

Professional investor Aaron Bhatnagar responded to Kedgeley’s piece in defence of Ryman and other large operators. “Not only do Ryman pay above average wage rates, they also have a staff participation scheme for shareholding in Ryman, and they encourage further training and education for staff, some of whom have no formal qualifications beyond the most basic school certification.” Systems that allow workers to receive a proportion of the profits, like co-operative schemes, are often touted as a good way of doing business, with staff more inclined to use the profit sharing incentive to make more effort to improve their own income, as well as that of the business. However, as one Herald correspondent believes, this scheme can only be successful if done reasonably and honestly, with the aim being for a better outcome for the client, in this

of course. Selwyn and Bupa are among those who have initiatives that reward training with pay, and many smaller organisations are also following suit. Some providers, notably Bupa and Metlifecare, have included general support for the Caring Counts recommendations in their collective agreements with the unions. And the old chestnut of travel reimbursements looks to be a step closer to being resolved, too. It appears collaboration is the key to moving forward, but this is easier said than done. When pay rates vary between caregivers in the DHBs and the private sectors, and even from DHB to DHB, common ground is likely to be difficult to find. The push for regulation and fair pay needs to continue if any real change is to occur. Otherwise, Mrs Jones, and not just Ana, will become the real victim of political inactivity. | April / May 2013




With Accident Compensation Corporation (ACC) reporting reductions in claims as a result of falls since its Vitamin D in residential care programme was rolled out, it is now looking to expand the programme to older people in the wider community. JUDE BARBACK looks at the benefits that can be derived from Vitamin D and how prescription across the board will aid both individuals and the economy. To complement the prescribing guidelines on Vitamin D developed as part of the residential care programme, ACC has also prepared prescribing advice for GPs, to assist with prescribing Vitamin D to ‘at risk’ older adults living in the community.



quick poll at my local café revealed most people knew a little about Vitamin D and its benefits. “We’re soaking it up right now,” said one older lady enjoying her flat white in the sunshine. “It gives you stronger bones; stops old geezers like us from falling,” quipped her partner. Indeed, they’re right. International evidence shows that Vitamin D is effective in reducing falls in older people. Vitamin D helps with muscle strength and performance speed as well as bone strength. It enhances the absorption of calcium into the bloodstream which helps prevent osteoporosis - a chief cause of fractures in older adults, especially among women. A fall can be debilitating for an older person, and recovery is often protracted. Falls are also damaging from an economic perspective, too with ACC claims costs generated from older persons’ falls totalling a staggering $11 million annually.

ACC’S RESIDENTIAL CARE PROGRAMME Due to this expense, and the fact that at least two thirds of older adults living in residential care were falling each year, ACC initiated a programme to target the top tier of ‘at risk’ people, through its phased national 12

rollout of the ‘Vitamin D in residential care’ programme in October 2008. The initial target was to achieve prescription of Vitamin D supplements to 70 per cent of residential facility residents nationally by June 2012. Ministry of Health data shows that ACC is on track with its target: Vitamin D prescription rates for older adults living in residential care had increased to 70 per cent by June 2012, and is continuing to grow. Some DHBs have achieved rates in excess of 80 per cent. ACC also looks at whether there has been a reduction in claims to gauge the effectiveness of the programme. Claims for falls in the 65+ age group in residential care fell by 19 per cent in 2011/12, compared with an 11 per cent increase in fall-related claims for the 65+ age group as a whole (excluding residential care). Glenn Donovan of ACC says it is highly likely that increased prescription of Vitamin D in the residential care population contributed to the reduction in fall-related claims. Donovan says ACC also focuses on educating GPs, residential care facility staff, residents and their families, and pharmacists supplying pharmaceuticals to residential care facilities about Vitamin D.

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That ACC is looking beyond residential care to those in the community signals the corporation’s next step with its Vitamin D push. Given that the programme is proving successful in residential care, the inevitable question is, when will it be expanded to older people who are living independently in the community or within retirement villages? Surely it makes sense to help independent older people retain their good health? Often it is a fall which triggers a person’s transition to care. Extending the Vitamin D prescription to those in the community could be the proverbial fence at the top of the cliff, rather than waiting until they are in care, at which time the prescription is more like the ambulance at the bottom. It seems ACC and DHBs are thinking along these lines too, with talks underway between ACC and DHBs about ways to increase Vitamin D prescription among those at-risk older adults in the community. “We’re currently exploring the potential for regional trials to be developed in partnerships with DHBs later this year,” says Donovan. The expansion of the programme into the community would also see ‘at risk’ older adults in retirement villages having access to the supplement. Belinda Keith, manager of Knightsbridge Retirement Village which accommodates residents who live independently, thinks the

move to expand the programme to the community and retirement villages is a positive initiative, although she is sceptical about the level of ‘take-up’ from residents. “We promote medical checks but few residents actually turn up for these. It’s about freedom of choice,” she says. Keith describes the amount of prescription drugs coming into retirement villages as “phenomenal” and says there may be wariness toward the Vitamin D supplement as “just another pill”. However, she believes residents would be more likely to take up the offer of a Vitamin D supplement if it were promoted through an avenue such as the Born Again Bodies classes, which are run by Gary Syme at Knightsbridge. In addition to exercise, Syme also helps educate older people about being healthy.


The “just another pill” argument is certainly valid. With older people often taking many forms of medication, there can be reluctance to add to this count and there has been some scepticism that the Vitamin D in tablet form is just another manmade substance. Syme, a retired pharmacist, dispels this notion. “When the sun hits our skin it generates Vitamin D3 (cholecalciferol) through interaction with a form of cholesterol in our skin. The substance used in the Vitamin D made by the same means - the action of UVB light on cholesterol. Nature has organised the transformation in both cases. “200 to 400 international units of Vitamin D daily was once considered to be plenty, but now doctors are prescribing the equivalent of about 1500 international units a day for people in long term residential care, and some of their other


At the same time, ACC is keen to better understand the impact of Vitamin D on older people’s health. The corporation is part-funding University of Auckland to run a randomised control trial to analyse the effect of Vitamin D on injury and fall rates. The trial will also look at the effect of Vitamin D on cardiovascular and respiratory diseases. Indeed, while more research is needed to clarify the exact relationship, Vitamin D deficiencies are thought to be associated with these diseases as well as with colorectal cancer, mood, cognitive performance, multiple sclerosis and metabolic syndrome. At the 2012 NZACA conference, Rejáne Le Grange suggested that Vitamin D also has particular therapeutic value to those with dementia, helping with circadian rhythms and challenging behaviours. To take an initiative from being good in theory to being good in practice, ACC, DHBs, retirement villages, and providers of home support services will perhaps need to look collaboratively and creatively at ways to educate those living independently why Vitamin D is a good thing. As Gary Syme says, “After all, wherever we are in our lives, we are always in one important form of long term care – our own.”


patients. Why? Because they are at greater risk. They get less sun and are already prone to muscle loss, brittle bones and falling, all of which are reduced by adequate blood levels of Vitamin D. “The unfortunate thing is that we lose our fast twitch muscle first. This is the muscle type that we most need to keep us from falling. Vitamin D can help us maintain, and possibly regain our fast twitch muscle. Vitamin D is stored and released from our body fat – so you will only need a single prescribed tablet of 50,000 units once a month to make a difference.”

VISIT ELDERLY PARENTS OR THEY’LL SUE While people around their world have taken to online forums to express their horror and sadness at the need for a law to make children visit their parents, many have acknowledged that it raises some issues that are prevalent around the world. “The same is beginning to happen here in the US as the older “baby boomer” generation begins to take more and more resources from a much smaller young population. It happened in France 10-15 years ago when I read about morgues filling up during a heat wave as older people couldn’t take the stress of the heat and the younger generation couldn’t be bothered to leave the beach long enough to have a funeral. This is INsite considers the new law in also a product of moral decay,” says one. China which requires children to “Maybe there should be [a law] here in the United States. Many of my friends are neglected by visit their elderly parents. their adult children, including myself. I’ve talked to magine if elderly parents could sue their children mine about it, but nothing changed. I don’t ever ask for for not paying them a visit often enough? their help or complain about my health, I don’t want to This is now the case in China, where the law be a burden,” says another. was amended last year to require adult children However, some on the forums have questioned to visit their aged parents on a regular basis - it whether all parents deserve to have their children visit. provides no express provisions for the frequency or Some felt that victims of abuse should not be expected nature of such visits. The new clause was introduced to comply with China’s law. in response to a growing number of reports of “Let’s get real here,” writes one, “Not everyone elderly parents being abandoned or ignored by their had a loving and supportive upbringing. My parents children. gave me NOTHING but food, clothing, and a roof China’s problem has been fueled by its ageing over my head. I was a farm kid and was worked like a population. Mirroring the country’s rapid full-grown man and beaten like a dog from the time development, its life expectancy has increased from I was a small child. I left home at 17 and have taken 41 to 73 over five decades. Experts claim that by care of myself ever since. My parents are now both in 2050 more than a quarter of the Chinese population, a nursing home 700 miles away from me. It’s hard to already tallied at over 1.34 billion, will be over 65. feel sympathy for your parents when you were never Rapid ageing poses serious threats to the country’s anything to them but free farm labor and a punching social and economic stability, as the burden of bag. Do I ever visit them? Rarely. Do I respect them? supporting the growing number of elderly passes to No. Will I feel bad when the die? No, just relieved a proportionately shrinking working population and that I turned out to be completely different than them, the social safety net remains weak. despite their sad attempt at parenting.” China’s one-child policy has also compounded It doesn’t seem plausible that such a law would this situation, by increasing the burden on the one ever find its way into New Zealand legislation. When child to care for his or her parents. canvassing opinions on the subject, many laughed, Indeed, the traditional extended family, where many shook their heads with incredulity. “What is the elderly parents would live with their adult children, world coming to?” was a response uttered by several. is becoming a thing of the past in China, thanks to However, while China’s demographic situation is three decades of market reforms. As a result, China vastly different to New Zealand’s, the growing ageing is now finding it increasingly difficult to care for its population is of concern here too. One would hope ageing population. the “moral decay” that has afflicted China and made it In the absence of a sufficient number of affordable necessary to instate such a law will never infiltrate New aged care facilities or retirement villages, many cases Zealand. Let it be a cautionary tale. have emerged in China of abuse or neglect of older It was Abraham J Heschel who wrote, “A test of a people at the hands of their children. Last year, people is how it behaves toward the old. It is easy to China’s state media reported that a grandmother in love children. Even tyrants and dictators make a point her 90s in the prosperous eastern province of Jiangsu of being fond of children. But the affection and care had been forced by her son to live in a pig pen for for the old, the incurable, the helpless are the true gold two years. mines of a culture.”

I | October/November 2012 13


VICTORIA BROWN shares her doubts about interRAI.

On the soap box... Victoria Brown


hen I first heard of interRAI, I wasn’t sure what it was all about so I did some reading on the subject and then went to Christchurch to see it in action. I was very intrigued by this and initially felt it could be something good for my facility. But the reality has fallen short of that initial enthusiasm for the tool. There are certainly benefits to the District Health Boards (DHBs) and other agencies to have all providers using the same assessment tool but are the benefits the same for the provider? Or will this be another financial burden that the provider will have to bear once the initial roll-out is completed? When we are made to pick up something compulsorily there is often a risk that innovation goes out the window. And when new ideas are mooted and then mandated for the aged care sector, it is my view as a very small provider of dementia services that any such decisions should be robustly debated and funding secured before any implementation is done. My experience to date has not inspired me with much confidence in what is now a

mandatory system. As the owner/manager of a small facility I needed to be involved as I wanted to understand any cost implications from the introduction of a new way of doing assessment and care planning. Trying to get into the training session was not easy as I am not a Registered Nurse (RN). I eventually did get invited to the training session but this was not the norm. And the frustration continues - as I am not an RN I am shut-out of all communication from the interRAI trainers and have to rely on my RN to forward information to me. My RN was initially trained on the RAI -2 but then had to retrain on the LTCF which meant all of the initial assessments became invalid. This also meant extra time-away from the facility. Then there was a huge hold-up as the workbook was significantly delayed. But probably the worst frustration is the tool itself. We found that we often couldn’t get it to operate properly and had to get a serviceman in. What we found was that this system couldn’t operate when updates occurred and the team had to re-set my computer so that it couldn’t update automatically. Other facilities also had IT experts in to configure their systems at great cost. Whether it will be able to interface with the 4G network or other, newer software

RESPONSE FROM MARTIN TAYLOR Victoria’s views certainly represent the negative opinions of some providers and while we all concede some early adopters have had a rough ride that’s not the case with many others. We all know clinical change within a health sector is hard so it is important to remember why we started this work. The benefits for the elderly are they now have a standard assessment that identifies their needs across the care continuum and will result in better care delivery. For nurses they now have a better support tool for their clinical decision making and care planning. For Facility Managers they now have a clear picture of their residents’ level of acuity and opportunity to intervene to improve service efficiency. Finally, for the sector as a whole we will for the first time ever have robust comprehensive clinical information on elderly residents to support policy development and measure changes in acuity. In terms of replying to some of the claims in Victoria’s opinion piece the following facts need to be understood.

COMMUNICATION »» In the last 12 months the Project has presented at 15 forums around the country.


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Find out about the next one nearest you by contacting »» Regarding the use of the same email address to ask for an Engagement Agreement form. The form helps to understand your ‘readiness’ to participate and will explain how you can get onto the training programme. »» The Project has a lead Trainer in each region with special responsibility to liaise with Facility Owners/Managers. If you do not know who your contact person is find that out by contacting the email address above. »» The Project has a target to train over 2000 nurses in the next 18 months or so. Managers who want to sit in on training are welcome. The majority prefer their senior nurse to take the clinical lead on this new assessment process. »» Communication information especially designed for Facility Owners/Managers is also available through the email address above. »» Facility Owners/Managers with RNs currently engaged in training receive a weekly update on the progress of their nurses. »» Communication opportunities have been made available to Victoria. In addition to the attendance at the training that she refers

systems is still unknown. And the question of who will eventually own and control this huge data pool has never been answered. My RN is only part-time and though she has become faster there is still a time factor which can’t be sped-up just to input data on what seems to be a very slow, unwieldy and old fashioned application– and one that often goes off-line or refuses to do what she is telling it to do. There is a support system but there are significant delays in getting an answer. If she left I would be hard pressed to find another RN trained in this system which would leave my facility residents quite vulnerable and me off-side with Certification requirements. And I question whether the best use of my RN’s time is by having her sitting in front of a computer doing data entry. This task could be, and should be, done by others – ENS, managers and some care staff. The first page which is the admission detail is data – entry only so why should an RN’s valuable time be used in this way? We still can’t make the interRAI give us the “on admission” care plan so that part of the whole admission process has to be done using a care plan that is not part of interRAI. Nor is there any spiritual or cultural component to this assessment system. What I will do when my RN – the only one able to to, she has met with the Project Manager at least twice, has met with the local DHB/ ARC interRAI group on several occasions and had teleconferences with the Chair of the Steering Group and the National Services Manager. She has also attended two interRAI forums in Auckland.

HISTORY »» The 64 RNs who were early adopters (preSeptember 2012) used an early version of the assessment and received bridging training to the new version. All training materials were provided but not in a workbook form. Currently all trainees receive their materials in a bound workbook. »» Support has been patchy for those early adopter RNs who finished training and who can complete assessments without supervision. The Project has begun quality reviews to provide feedback to the RNs and create an opportunity for clinical discussion. The peersupport that is developing among RNs will help as more and more RNs get trained. »» Past assessments did not become invalid because a new assessment is completed and NZACA is managing a programme of reimbursement, on behalf of the Project, to pay facilities for their time for any re-assessments of their residents who were originally assessed on the earlier version.


As the owner/manager of a small facility I needed to be involved as I wanted to understand any cost implications from the introduction of a new way of doing assessment and care planning.

officially access this system – goes on leave and we admit a new client, is something I haven’t figured out yet. The system is designed so that NASC (Needs Assessment and Service Coordination) send their Homecare assessment data to the provider and this populates some of the interRAI. The large backlog in my area, however, means that this is not always possible as the Homecare assessments are lagging badly. And when residents cross DHB boundaries there is no automatic inter-operability between the DHB IT networks which again makes this data transfer impossible. I found this very hard to believe but this has been confirmed by some of the Programme Managers and by my own experience. And if the resident has a respite status then the NASC will not transfer the information via interRAI at all as it will be lost to them completely. A few weeks ago my RN had to do the assessment for a resident we wanted transferred to a higher care level. The NASC couldn’t do it so we had to – the first time in 28 years that there has been no NASC assessment by the NASC assessors. Now, this may be what is intended in the future of interRAI – but there is a cost – to me. And if this is the future, then this needs to be part of the calculations for the introduction of interRAI and there should be no automatic assumption that this is what the sector will do.

is isolated in her data entry phase and the clients and families lose her presence on the floor. The RN is taken for significant periods away from other staff. There are not the joint discussions that used to occur when a new client entered my service. The care staff do not participate as they used to in the care plan development though they are the group that have the greatest knowledge and access to the clients. The RN now struggles to complete her mandated responsibilities. And what of the future? There is a silence over continuing funding for training. Where are the interRAI trained RNs waiting in case my current RN leaves? Where is the extra As a functional assessment system funding for me to increase my RN hours? dementia residents are not a natural fit. And When the HDSS was introduced the sector as some of their medication triggers, as an was told it was “cost neutral” but this was example, a falls risk when they are not and a far cry from the reality. Will this, also, this does not become part of the care plan, be another huge cost impost on the sector my RN has to give an explanation of why in the coming years? And most significant they are not a falls risk. The care plan itself is for me is that no one wants to hear any very untidy and straggly and hard for staff to dissenting voice. No one wants to hear and follow as there are many pages – or part pages address the issues which the sector is facing - to wade through. This is so inefficient that now. I am no Luddite. I don’t fear change or we have made the decision to use our own innovation but we are being asked to enter a care plan. brave new world on faith. And going on past I welcome innovation if there are tangible experiences I feel that the sector should have benefits to my service and my clients. had the right to say “No” before it got this InterRAI so far has not delivered to my staff far. I predict that the providers will wrestle and client group the benefits I would expect. with multiple issues over the compulsory It does not speed up assessments. It does introduction of interRAI in the coming years. not give me a workable care-plan. The RN I hope I am proved wrong.


»» There is nothing to stop a facility writing a care plan “on admission”.

»» Computers have different operating systems and the right system is needed to run the software. This information is provided to facilities when they sign up to training and then again when they take up the laptop reimbursement offer. »» The Project can provide support to your facility IT person and if you do not have one, it will help you get the support you need. There is a helpdesk that runs weekdays from 8 am to 11pm at night. »» Records are transferred regularly across DHB boundaries e.g 20-40 records may be transferred between District Health Boards and/or residential care facilties on a weekly basis. »» Currently interRAI information is held on two systems. One system supports the Central and Midland DHBs regions and the other system supports the Northern and Southern regions. The planned upgrades in April 2013 will see the ability to transfer records between these two systems.

CLINICAL »» A Comprehensive Clinical Assessment (interRAI) is regarded internationally as a ‘best practice’ assessment,it is not data entry.

»» Facility staff, other than the RN, are able to complete admission details on the system, they can get their own log on and training to do this. »» InterRAI assessments are used in over 30 countries. New Zealand, or any, culture cannot be assessed by another culture. So while there is no specific spiritual /cultural component this does not stop the assessor viewing all items from these perspectives or adding items as required by the facility. »» Facilities are free to use any care plan they choose. »» Residents with dementia and other conditions are suitable for assessment. This has been shown in clinical trials and in every day use (interRAI is used in 30 countries) around the world.

THE FUTURE While Victoria is right, that we have not confirmed training delivery after 2015, we have had this as an issue to resolve since day one and are working on a solution. In relation to Victoria’s other concerns, all facilities have to face the possibility of a RN leaving and while we can understand this becomes more critical when a new initiative

is being implemented it is not a reason to stop positive change. In terms of the costs around implementation it was understood from day one that the Government would cover training and software costs, and providers would have to cover back fill costs. Unfortunately, when this was agreed the adoption of interRAI was voluntary so early adopters, such as Victoria, agreed to participate on the projects merits. Since then the Government has seen fit to make interRAI mandatory which is disappointing but does not in any way lesson the benefits of interRAI to all parties. It is also unreasonable to expect a roll out such as this to have answered every question before we begin or even to know every issue that may crop up along the way. While I can understand the frustration that Victoria and others have around interRAI and I am bitterly disappointed with the Government’s mandatory decision and poor project funding, I am also disappointed with providers such as Victoria who have been in the sector for a long time and who cannot see how the benefits of interRAI will change the whole future of aged residential care for the better. Martin Taylor is chief executive of New Zealand Aged Care Association. | April / May 2013


Spotlight on... Choral health S Dr JULIE JACKSON-GOUGH discusses the benefits of singing for older people.

tudy after study, and person after person, attest to the fact that singing is not only good for you, but makes you feel good as well. It is good for your health, good for your posture, good for your oxygen uptake, good for your brain function, good for emotions, and good for bonding with fellow singers. It is not possible to sing without engaging the emotions, so people who sing together are building emotional bonds as well. This bonding has been illustrated in the eight to 80 choir performances that have been run at the Hamilton Gardens Summer Arts Festival for six years now. The bonding between the primary school children’s choir and the retirement village choir members is very special, and this year, with the school and the village being just two blocks apart, there are all sorts of ongoing possibilities of interaction. The children report that they enjoy talking with, and singing with, their ‘buddies’ and the village residents thoroughly enjoy the interaction with the children both in the village and at the school. Singing boosts your immune system. Scientists

tested the blood of people who sang in a professional choir in the city, before and after a 60-minute rehearsal of Mozart’s Requiem. They found that concentrations of immunoglobin A – proteins in the immune system which function as antibodies – and hydrocortisone, an anti16

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stress hormone, increased significantly during the rehearsal. A week later, when they asked members of the choir to listen to a recording of the Requiem without singing, they found the composition of their blood did not change significantly. The researchers, who included Hans Guenther Bastian from the Institute of Musical Education at Frankfurt University, concluded singing not only strengthened the immune system but also notably improved the performer’s mood. And according to a recent study by the University of California, Irvine, singing in a choir just might make you healthier. This study, authored by Robert Beck and Thomas Cesario and published in Music Perception, found that Immunoglobulin A increased 150 per cent during rehearsals and 240 per cent during performance. Singing makes you happy! Researchers at the

University of Manchester have discovered that the sacculus, a little organ in the inner ear, responds to frequencies commonly found in music, and is connected to the part of the brain responsible for registering pleasure. This sacculus is only responsive to low frequency, high intensity sounds, which include singing, and it responds within a few seconds of hearing that kind of sound. So you get immediate pleasure when you sing, regardless of what it sounds like to anyone else. Now if there are no criticisms or put downs


from anyone else to cause you pain, you´ll find the experience enjoyable and get release of good old pleasure-giving endorphins as well.

vocalisation, exerts a massaging effect on the brain and facilitates expulsion of metabolic products into the cerebrospinal fluid. This has led neurophysicists to hypothesise that Singing provides catharsis across the full vocal vibrations cause a kind of cleaning of emotional spectrum. It can give a directly the chemical cobwebs out of the head. A experienced sense of happiness. It’s a mood process as simple as singing might well make lifter and anti-depressant with no side effects. the removal of chemical waste from the brain And it’s not news to health professionals that more efficient. mental and physical health are intimately The Sidney de Haan Centre, attached to linked. Canterbury University in England, has been set up to look at the benefits of the Arts in Singing can prolong your life. Graham Welch, people’s lives, specifically at present with director for advanced music education at singing. Working in Silver Song groups London’s Roehampton Institute, states organised by Sing for your life, the singers “Singing exercises the vocal cords and keeps have been surveyed and interviewed. Large them youthful, even in old age. The less majorities of the participants enjoyed the age-battered your voice sounds, the more you clubs, looked forward to them and felt will feel, and seem, younger.” He says that that singing helped them feel better in when you break into song, your chest expands themselves. Eighty-four per cent of people and your back and shoulders straighten, thus with no previous experience of music valued improving your posture. Singing lifts moods and looked forward to the weekly sessions, and clears the “blues” by taking your mind while 97 per cent of those who had previous off the stresses of the day, as well as releasing experience with music felt the same. pain-relieving endorphins. As you sing along, I conduct an un-auditioned community your circulation is improved, which in turn choir. This email was received from Yvonne, oxygenates the cells and boosts the body’s a choir member, after a rehearsal in 2011. “I immune system to ward off minor infections. would like to thank you for last week’s choir And, “it provides some aerobic exercise for the practice. When I arrived I was just so tired, I elderly or disabled,” Welch says. had had a hectic week with long hours and, A recent German study has shown that at my age (72 years) I was really exhausted. active amateur group singing can lead to When I arrived home just after 6.00 pm I did significant increases in the production of a not want to go out again. But, if everyone protein considered as the first line of defense thought that way, there would be no one against respiratory infections, and also leads there and also, I really enjoy singing. to positive emotional changes. “Given that “I did not think I would be able to every human being is, in principle, capable of concentrate properly. When I returned to developing sufficient vocal skills to participate my car after choir practice, I felt on a high! I in a chorale for a lifetime, active group could have gone on “singing all night”! Thank singing may be a risk-free, economic, easily you, you encourage us and teach us and make accessible, and yet powerful road to enhanced choir practice fun! You have given this choir physiological and psychological well-being.” a really lovely “tone” so that people find us Greg Cohen of George Washington easy to listen to and want to hear more. You University tracked a Senior Singers Chorale have such a variety of songs and atmospheres in Arlington, Va. The chorale singers’ average that it is never boring, as can be when some age is 80 — the youngest is 65 and the oldest choirs sing the same thing for the whole 96. Preliminary data shows the singers suffer concert. less depression, make fewer doctor visits “When I returned home, I did not need a year, take fewer medications and have a pill to take away my headache, as the increased their other activities. headache had gone. The heavy feeling of tiredness over my eyes had gone and I felt Singing can ‘defrag’ your brain. According to invigorated and full of energy. an article in Medical Hypotheses vibration “You have the ability to explain in simple of the human skull, as produced by loud language, and demonstrate music and sound,

Choir singing at the Age Concern Song Fest in Mosgeil in December. Average age early 80s.

so that we can learn to sing correctly and beautifully. It is so much fun to have you, Julie! The time goes so quickly. We leave singing and humming as we go.” Let’s leave the last word to William Byrd, the composer who lived 1543-1623: “Since singing is so good a thing, I wish all men (and women) would learn to sing”. | April / May 2013


Let’s snoop around...

Selwyn Wilson Carlile JUDE BARBACK visits Selwyn Wilson Carlile Home and Hospital in Hamilton


t’s been a while since I’ve been down Grey Street in Hamilton. As I drive to Selwyn Wilson Carlile, I’m struck by what a good possy the rest home is in. Cafes, pharmacies and shops on its doorstep and just the mighty Waikato river between it and the city centre. Back when the home was established, in 1956, perhaps it wasn’t considered quite as central. It was founded by the grandson of Wilson Carlile, a prominent figure in the Church Army. When it was first established, it was a 12-bed care facility, but it quickly grew to accommodate 20 residents by 1962. By 1973, the home was part of a separate trust and by 1981 it had 57 residents. The Selwyn Foundation’s involvement didn’t come until much later. After acting as an advisory board for some years, Selwyn eventually took over the Wilson Carlile home in 2008. The original home, with its bay windows and high ceilings, and architraves still forms part of the facility, which now comprises 20


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hospital-level beds and 40 rest home beds. On the same site sits 10 retirement villas. Rachael Hall, manager of the facility tells me the village is managed by Selwyn’s independent living manager based in Cambridge but its sheer proximity means that the rest home staff look out for the villa residents. “We keep an eye on them,” she says. Upon meeting Rachael, she immediately strikes me as a very competent manager, and a quick quiz of her credentials confirms my instincts. A registered nurse, she spent 19 years in Waikato Hospital, in which time she became Operations Manager. She completed her MBA, not with a career in residential aged care in mind, but soon discovered that the blend of nursing, business and management made her an ideal candidate for such a role. Her husband, who manages Resthaven Home in Cambridge played a key part in encouraging her to pursue the same line of work. Rachael has been at the helm of Wilson Carlile since 2010 and I can see that Wilson

Carlile is a good fit for her. She says it helps having worked at the hospital for so long as she knows who she is talking to and can trust what they’re saying. She admits to feeling frustrated with certain aspects, such as the delays associated with assessing potential residents, but overall finds her role stimulating, varied and rewarding. “At the end of the day, you’re making life better for someone, even if it’s just something small like putting a picture in a frame for them. It’s definitely a feel-good industry,” she says. I can also understand why Wilson Carlile was a good fit for Selwyn – the home’s Christian values are aligned with the foundation’s. Indeed, the chapel, located near the reception, takes pride of place. “The residents and their families enjoy gathering there on Sundays,” says Rachael. It is a nice thought; rest homes can sometimes be rather lonely places on weekends. Rachael tells me that the faith element runs beyond the chapel, and right through to Selwyn’s strategic plan and human resources policies. “It’s

EDITOR’S EYE informs me they are priced at around the $195-210k mark – two of the 10 have remained vacant for some time, suggesting that perhaps the sheen and social scene of larger, newer retirement villages equipped with more facilities may be what the retirement village market is seeking. Back in the home, upholstery samples and the promise of garden renovations suggest an effort is being made to spruce things up. On my tour of the facility, Rachael points out little things she is keen to address – also reflected in the Eden Way an unkempt courtyard, a rather approach we take here, where we pointless space filled with arm look at care from the resident’s chairs and a vending machine, for perspective.” example – and I definitely sense Residents tend to select this is a work in progress. Wilson Carlile on the basis of its However, upon walking Christian values; they have usually around, it occurs to me that come across it through church I’m noticing all the wrong or community connections or things. What I’m missing, is through visiting friends or family that the home has a real sense who have been residents. of calm, the residents here are Selwyn Wilson Carlile occupies happy and peaceful. Instead of its own place in the market. With colour coordinated pieces of its rambling, rough-around-themeaningless art on the walls, edges appearance, it is certainly there are the paintings, scores of no Hilda Ross, no Cascades, them hung outside a resident’s but then it isn’t trying to be. room, celebrating her passion Although it has all the usual and talent. Instead of immaculate components – the recreation gardens, there is the enormous room, lounges, a hair salon, a pumpkin, which the residents visit photo wall featuring outings frequently to monitor its growth to Raglan and the residents’ for the upcoming annual pumpkin Christmas play – it is older and competition. lacks the finesse of its newer, The pumpkin, Rachael tells me, more glamourous counterparts. is a ‘point of interest’, a concept However, as Rachael points out, famed by Dr Hans Becker for not everyone is suited to the likes helping to spark the attention of of Hilda Ross. Price is also a residents as they go about their factor in people’s selection and days. Another example is the wall Wilson Carlile is cheaper than displaying quotes from all over the most. world. “One man with dementia Interestingly, the same market comes to look at it every day and logic doesn’t appear to relate to just stands there and cracks up,” the adjacent retirement village. says Rachael. Despite the location and the Incidentally, there is no relative cheapness of the Selwyn dementia unit, although Rachael Wilson Carlile villas – Rachael says the residents with dementia

are grouped together in the same part of the home. The way the rest home is currently set up does not lend itself to a secure unit, but Rachael doesn’t rule it out as an option for the future. The rest home is divided into three connecting “villas” with a shared dining room, a lay-out that appears to work well. Rachael has made a real effort to ensure consistent care is given to residents with a system in which the same caregiver looks after the same resident. A caregiver is allocated to each villa of the rest home, but in the evenings they share this responsibility, which allows caregivers the opportunity to get to know residents in other villas. “This is working really well,” says Rachael of the system. Staff appear to be a strong point at Selwyn Wilson Carlile. “We have very little turnover,” says Rachael, “Some people have worked here a long time. We have a good core of staff.” There are 48 staff in total, or 33 full-time equivalents. This

includes seven registered nurses including Rachael and Sabya, the clinical coordinator. Rachael says she is grateful for the casual staff members, who help to significantly reduce the home’s reliance on agencies. The approach to staff training has been ramped up in recent years. “It used to be done on an ad hoc basis, tacked on to the ends of meetings, but it wasn’t working,” says Rachael. They now operate a more structured system of two days per staff member, making use of training provided by the Waikato DHB, Alzheimers New Zealand, Health & Disability and other such providers. At Selwyn, pay is directly related to qualifications, giving staff an incentive to complete their training. This doesn’t surprise me. Selwyn Wilson Carlile Home appears to be an honest-togoodness sort of place, true to the original values upon which it was founded. I can understand what attracts residents and their families here. | April / May 2013



RETIREMENT VILLAGES ASSOCIATION (RVA) CONFERENCE 2013: 24–27 June 2013 Marriott Resort & Spa, Surfers’ Paradise, Queensland, Australia


ith the theme, ‘Future proofed & meeting demand - Direction, Community, Challenges’ and an impressive horde of speakers, this year’s RVA conference should not be missed. Held on the sunny Gold Coast, there is also a great line-up of social activities, including the annual golf tournament and the not-to-be-missed Gala Dinner, at which the INsite-RVA Village Manager of the Year 2013 will be awarded. The conference is also a great opportunity for exhibitors to leverage and profile their business to an influential audience. For more information and updates about the conference, please visit http://conference.


Ita Buttrose has twice been voted Australia's most admired woman and is the 2013 Australian of the Year. In 2003 she was awarded the Centenary Medal for services to Australian society in business leadership. She is an outstanding communicator advising both corporate and welfare organisations. Her impressive media career has given her first hand experience in breaking new ground to accommodate the ever changing role of women within the business community. She is a committed contributor to community and welfare organisations and is currently National President of Alzheimer's Australia, Vice President Emeritus of Arthritis Australia and Patron of the Macular Degeneration Foundation. Ita was made an Officer of the Order of Australia for her services to the community, especially in the field of public health education, when she spearheaded Australia's HIV/AIDS Education Program; she received the OBE for her services to journalism, and she is the prolific author of 11 very successful books.


Amanda Stevens is an expert on sales, marketing and customer service - with a twist. She reveals how modern business can create a powerful competitive edge by understanding how consumer psychology drives brand loyalty. Her energetic, humorous and memorable presentation will shift your thinking and give you ideas that increase sales and profits by tapping into the explosive power of the female consumer dollar. Packed with the latest research, entertaining insights and take-away messages, Amanda’s 20

April / May 2013 |

presentation and workshop will provide innovation, motivation and inspiration.


Cameron will provide an update on his views of the current economic climate. He will discuss developments in the financial markets and give valuable insight into the key economic issues and opportunities for New Zealand.


Mike has been an active participant and observer of NZ’s politics for many years and little escapes his notice. Where might the polls be leading the country? Who could form the next NZ Government and what might we expect to see from them? What are the threats and opportunities for the retirement village and residential care industries?


Communicating successfully with the diverse range of mature audiences requires a deeper understanding of strategy, creative, media channels and how best to implement programmes that resonate. We call it “mature thinking”. The audience is not a homogenous group and a “one size fits all” strategy is unlikely to work. Evergreen is one of the first communications agencies dedicated to understanding the nuances of this highly influential and ever-increasing audience. Gill has many years’ practical experience and research in reaching retirement village potential residents and their families. Gill’s presentation will look at some successful campaigns to drive potential residents to your door.


Bernard Salt is a compelling and entertaining speaker employed by blue-chip companies to stimulate thought provoking discussion at conferences, seminars and workshops. He has an understanding of the way in which demographic change shapes consumer markets. He attributes recent trends, and even fashion, to the shifting of the mass market from one stage of the life cycle to another. The Age describes his style as ‘part stand-up comedian, part number-crunching

economist’. A Queensland journalist described him as ‘quick witted and dynamic as a public speaker; he is articulate and holds an audience exceptionally well’. Bernard’s presentation will include information on New Zealand demographic changes that will impact on the retirement village industry.


The radical changes in the insurance industry have caught many operators on the hop. Tim will outline the changes his sector has experienced and will look at the impact they have on the retirement village sector.


In 2012 the Retirement Villages Association of Australia decided to merge with the Australian Property Council to form a new Retirement Living Council within that organisation. Mary will outline the rationale for that decision and discuss some of the key challenges facing the Australian industry over the next year or so.


Allan Pease has been known internationally as "Mr Body Language" since his definitive book with that title became a multi-million seller and the communication bible for organisations worldwide. A born achiever, he began his career in Australia at the tender age of 10 selling household sponges door-to-door, and was an award winning direct salesman as a teenager. By 21, he was the youngest person in Australia ever to sell one million dollars of life insurance and qualify for the elite Million Dollar Round Table. For over three decades he has taught others how to succeed. He teaches skills and techniques in a humorous way that participants never forget. His keynote addresses, books, videos, audio training programmes and his advice on image are sought by business executives, Prime Ministers, television presenters and rock stars. His communications and selling systems have moved companies from one-man bands to multi-nationals. He has written seven number one bestselling books and has appeared on radio and television throughout the world, including his acclaimed top-rating TV and video series on Body Language, which was watched by over 100 million people. His work has been the subject of six BBC science programs.

PROGRAMME DAY ONE - Monday 24 June 2013


Nominations are now open for the INsite/RVA Manager of the Year Award. Does your manager have what it takes? Winning the award carries significant value and enhances the reputation of the winning village. Past Managers of the Year have reported their village profile grew in their local market and their resident waiting lists increased. It’s a win for everyone – manager, staff, and residents. Last year’s INsite/RVA Manager of the Year Award winner, Diana Triplow, general manager of Mary Doyle Lifecare in Hastings, said “My residents kept asking me to enter this competition, so I finally did.” After winning the award, she said she felt “like I’m at the top of my game.” The winner will receive $2000, free entry to the RVA conference and gala dinner, $500 donation to their village’s residents’ Christmas function (or similar), and coverage for the manager, the village, and residents. Resident nomination forms will be available on and very soon. For more information, email RVA Association Manager Mr Ed Thomas Nominations close 10 April 2013 (4pm).


Coach departs the Marriott for the Palmer Gold Coast Golf Course


Tour to Byron Bay and surrounding area departs


Programmed Property Services Ltd golf tournament starts


Play finishes


Buffet lunch in the club house served


Awards in the club house


Depart Palmer Gold Coast course


Golfers arrive at the Marriott


Byron Bay tour arrives back at the Marriott


Trade Me Property opening cocktail party

DAY TWO - Tuesday 25 June 2013 - Programme is still being finalised, but speakers include: Master of Ceremonies: Jim Hopkins Keynote speaker : Ita Buttrose, AO, OBE, 2013 Australian of the Year Cameron Bagrie, Chief Economist, ANZ Speed dating : 10 x 5 minute appointments for delegates with trade show exhibitors Mike Williams, political commentator and former President of the NZ Labour Party 2013 INSite –RVA Manager of the Year Award – the finalists speak RVA Annual General Meeting Evening

ANZ Gala Dinner and 2013 INsite – RVA Manager of the Year Award

DAY THREE - Wednesday 26 June 2013 - Programme is still being finalised, but speakers include: Amanda Stevens - Discover the Secrets of Marketing to the Majority Gill Walker, CEO Evergreen Marketing Bernard Salt, analyst, advisor, commentator, author Tim Grafton, CEO Insurance Council of NZ Mary Wood, CEO Retirement Living Council of Australia Allan Pease, body language DAY FOUR – Thursday 27 June 2013 8am

Masterclass – Amanda Stevens


Masterclass concludes, morning tea available.


Village tours depart


Coach 1 to Brisbane Airport to arrive


Coach 2 returns to the Marriott to arrive



Care Pathway Promoting best pratice for the care of the dying

DATES FOR THE DIARY: • New Zealand Home Health Association (NZHHA)

Home and Community Conference 2013

10-12 April 2013, Rendezvous Grand Hotel, Auckland ‘Squeeze, Stretch and Flex’ Speakers include: Dr Kevin Woods (Director-General of Health), John Hirdes (interRAI), Walter Leutz (integration), Nancy Chapman, Chris Fleming (Lead CEO, Health of Older People), Sheree East, John Parsons, Sandra Hanmer (Healthcare NZ), Hon Jo Goodhew, Barbara Fox Iris, Catherine Swift (Arthritis NZ), Margaret Sanders (CCDHB), Sally Babbington (ACC), Lynda Irvine, Ray Lind (Careerforce) and Jonathan Sibbles (Chiptech).


The Liverpool Care Pathway for the Dying Patient (LCP) is an integrated care path-way that guides the delivery of evidence-based, best practice care of dying patients and their family/whanau, irrespective of diagnosis or care setting.



Venue: St Johns, 23 Carlyle St Dates: Thursday 30 May, 1300-1600 or Friday 31 May, 0930-1230 Cost: $60+GST This three hour Masterclass is suitable for Health Care Professionals who are already using the Liverpool Care Pathway documentation and wish to explore further • Their understanding of the document • Clinical scenarios using the document in practice • Sustainability • Collecting and using audit data from the LCP

Venue: Rydges Hotel, Wellington Dates: Friday 14th June, 0830-1630 Cost: $200+GST till 28 May, after 28 May $250+GST Confirmed speakers: 1. Dr Amanda Landers, Palliative Care Specialist, Nurse Maude 2. Dr Richard Egan, Research Fellow, University of Otago 3. Rev Sande Ramage, Chaplain, Palmerston North Hospital and Writer, Spirited Crone 4. Helen Davidson, Senior Legal Advisor, Health and Disability Commission 5. Fiona King, Funeral Director, Broadbent and May. Open to all Health Care Professionals who have an interest in End of Life care issues. The day will include: Physiology of Registration now open online: Dying - Spiritual & Cultural Care - Legal issues at End of life Multi professional team working

For more information, contact (06) 350 2316

Registration now open online: | April / May 2013



A typical day in the life of … Jo


Jo Wallace shares what she finds rewarding, inspiring and challenging about being the sole RN at Matamata’s Rawhiti Lodge Care.


nce upon a time in a land far, far away ... I joined the team at Rawhiti Lodge Care as their registered nurse. Having spent time in secondary care hospitals in Rotorua and Invercargill, primary care at Matamata Medical Centre, time wearing my other hat in preschool home-based care, it was time to explore long-term care of our elderly. I fell in love with the 1918 lovingly cared-for building and surrounding landscaped grounds as soon as I entered the gate and rounded the corner underneath the grand old trees. The smell of warm fresh baking greeted me as I entered the front door for my interview. Meeting some of the residents and staff that day, I knew that this was the “home” for me and whatever challenges and rewards lay ahead. I have no regrets. My job is mainly the clinical aspects of care. A typical day involves listening to the staff reporting changes in resident’s conditions, responding to the residents’ needs, wound care, giving injections, ordering medications and supplies, checking and updating the communication books, booking appointments, staff training, liaising with pharmacy, updating documentation, helping other staff, and answering the telephone. Depending on how well the residents are determines how busy my day will be. The staff at Matamata Medical Centre are very good to work with in managing the health of our residents. Community services such as podiatry, audiology, optometry, hairdresser and Disability Support Link are integral services to our organisation. I could not do my job so smoothly without them and the quality of the residents’ lives is so much greater with

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their input. I choose not to have status; I muck in just like everybody else. We all work for the residents together. Documentation is a challenge. The introduction of the medical centre’s patient management system to our computer, where only the visiting doctors and nurse ractitioner can document and print all necessary clinical information onsite has really helped this challenge. It is really great to have complete paperwork at my fingertips when it comes to keeping records up to accredited audit standards. Medtech 32 is a real credit to our proactive owners. Time is also a challenge; finding enough hours in the day to fit everything in. It’s a bit like the dishes really - forever evolving and just has to be done! Friendship circle, dress up days, visiting entertainers, residents’ birthdays, Christmas and Mid-Winter Christmas are what I enjoy most. Why? The biggest reward is the moment when a resident SMILES! Bringing joy and happiness to the hearts of our residents is job satisfaction worth more than money can buy. We have a fantastic management team who love to make this happen for our residents. In closing, I have utmost respect for our country’s older folk. Those aged 60 plus fought for my freedom. They have had life experiences and faced challenges that I could only imagine. Their eyes are windows to their souls. Their stories have lessons hidden in them to teach life skills to our generation, if we only take the time to listen to the stories they feel are insignificant. I am so grateful for the special opportunity to share their lives, and so privileged to them and their families for choosing to be with us.

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Last word... Ian Brown Our ongoing correspondence on the revised Retirement Villages Code of Practice sparks further debate.


Having followed your articles on the Retirement Villages Code of Practice (the Code), I am compelled to submit this offering, to assist your readers make their own conclusions. Firstly, though, it is important to note the Act was introduced for the protection of residents and that the Code (when in force) is enforceable as a contract and prevails over any less favourable provisions in a resident’s contract. As, in my opinion, this matter has become so confused, I consider it necessary to go back to the original clause under discussion (clause 21) to establish the original intent of the protection to be provided for residents. The original Code was approved on 25 September 2006, effective 25 September 2007, and included the subject of ‘Fire and Accidental Damage’(clause 21). This subject was covered under the sub-headings of ‘Insurance Cover’ (sub-clauses 1, 2, and 3) and ‘Repair or Reinstatement of Property’ (sub clauses 4 and 5). Under the “Insurance Cover” the operator is required to insure the Village Property for full replacement insurance. If the operator is unable to obtain such cover, the resident must be informed what cover is in fact provided. The ‘Repair or Reinstatement of Property’ states, “The occupation right agreement must provide for repair or total reinstatement by the operator of any residential unit, facility, or other retirement village property if damaged or destroyed. The occupation right agreement must also

clearly state any limitations that apply. (subclause 4) “If the residential unit is not replaced following an insured event, the resident will receive the full sum paid to the operator without any capital or other deductions normally made under the occupation right agreement.” (sub-clause 5) The intent of this clause was to provide protection for the resident in the event of damage or destruction of their residential unit after all, the resident has paid the operator a capital sum equivalent to the “market value” of the unit. However, as has been stated, the Retirement Villages Association (RVA) made application for a judicial review; the operator’s main grounds for this review were its objection to clause 49 of the Code dealing

The intent of this clause was to provide protection for the resident in the event of damage or destruction of their residential unit after all, the resident has paid the operator a capital sum equivalent to the “market value” of the unit. with ‘Refurbishment Cost and Process’. The High Court found no fault with the Code at all and the RVA then had to pursue its secondary objection – and the High Court did find in the RVA’s favour on this point and declared the Code invalid due to process on 19 December 2007.

In June 2008, a “Proposed Code” was issued and a consultation process was undertaken jointly by the Retirement Commissioner and the (then) Department of Building and Housing (DBH). This Code again contained a clause under the general heading ‘Fire and Accidental Damage’. The Insurance section stipulated the insurance cover be for full replacement (similar to the 2006 Code) while the Repair or Reinstatement of Property read: 7. The occupation right agreement for a residential unit that is owned by an operator must: a. provide that, except in certain specified circumstances (if any), if the unit is damaged or destroyed the operator must fully repair or replace it as soon as practicable. b. state the circumstances (if any) when a unit that is damaged or destroyed may not be fully repaired or replaced. c. state the procedure to be followed if the unit is not to be fully repaired or replaced if it is damaged or destroyed. Following the consultation process the Retirement Commissioner must review the submissions, obtain expert opinion and give a recommendation to the Minister. In her review, the Retirement Commissioner stated: “With regard to clause 21 on issues of insurance, I accept the Insurance Council of New Zealand’s view in their submission that the wording is inconsistent and limiting. I recommend the DBH take up their offer to discuss this issue further in order to ensure a workable clause. Some residents supported the reinstatement of clause 21.5 from the >>

TELL US WHAT YOU THINK INsite has been serving the New Zealand aged care and retirement sectors with news and in-depth analysis for several years. Now is your chance to tell us how we can best serve the sector in the future. Complete the INsite reader survey here: By spending just a few minutes giving us your feedback about INsite, you will go into the draw to win a fabulous reading prize pack valued at $300. The plrize pack includes: »» »» »» »» »» »»

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AGED-CARE & RETIREMENT | April / May 2013


LAST WORD << Continued from page 23 2006 Code concerning the distribution of insurance proceeds if a destroyed unit is not rebuilt.” Her recommendation was that DBH and the Insurance Council work with operators and residents to find workable, fair clauses for this section of the Code. This confirms the original intent of the clause under discussion. This intent was further confirmed (by what could be regarded as the official reply on the reason for removal of the 2006 clause) when the DBH stated: “Under the Retirement Villages Act 2003 the Department started work on a Minister’s Code of Practice. During that process, it was considered that the clause (21) was too ambiguous and as noted in a clause by clause analysis provided to the Minister at the time, even where full comprehensive insurance cover is taken out, there are situations where insurance companies do not pay out. The Code cannot place obligations on operators that they may not be able to meet.” The DBH went on to state: “it is worth noting that even if the 2006 clause were still in force today, ‘the full sum paid to the operator’ referred to in most cases, would not be full replacement value of the unit, but would be paid at the indemnity insurance


rate. It is unlikely that this sum would be enough for a resident to buy a new unit outright.” It is also interesting to note that the DBH also included the statement “... it was decided to include the clause used in the Retirement Villages Association Code of Practice.” This supports the views expressed by Rob Wilson, but are directly contrary to statements made by Mr Collyns (‘Last Word ... Rob Wilson’ in the previous issue of INsite.) I also note Mr Collyns is quoted as saying “… the RVA did not comment or request change on the clause as it was written (in 2006) because they believed it to be entirely appropriate”. I ask Mr Collyns, would the RVA therefore support a further approach to the Minister for the reinstatement of the 2006 clause, with slight changes to the wording to remove the ambiguity? This is exactly what the petition from 3,625 residents to the Minister requested. I await any further comment from Mr Collyns and leave readers to make their own decisions as to the veracity of the statements made by the previous correspondents.

RESPONSE: BUILDING AND CONSTRUCTION MINISTER MAURICE WILLIAMSON. Following the extensive consultation carried out in late 2011, I discussed the proposed variations to the Code of Practice with the (then) Department of Building and Housing and the Retirement Commissioner. I agreed to a short period of further limited consultation, after which I considered the final advice and made decisions. I appreciate that the delay caused anxiety for some retirement village occupants. I am pleased with the increased protection provided by the variations to the Code of Practice following a disaster that affected many households in Canterbury and across New Zealand. I will not debate what happened around the Code of Practice under the previous Labour Government. These decisions have been well covered in previous articles and letters. I will make the following points: »» The Government’s aim is a retirement village sector that provides the benefits residents’ sign up to when they enter a village, and enables operators to function with certainty about future operating viability and investment. »» When making the decisions on the most recent variations, I considered a range of advice and views from submitters in reaching my decision. »» The variations will provide increased certainty, and the Code of Practice remains a minimum standard. Many villages have already included the variations and some operators offer better conditions. »» I have asked officials to continue regular discussions with residents and operators.



FOCUS ON: DESIGN INNOVATION IN AGED CARE INsite brings innovation and forward thinking to the fore in this issue devoted to design developments in the aged-care sector. We seek the opinions of architects, engineers and interior designers to bring informed content to our wide readership. We discuss success stories from abroad and their applicability to New Zealand’s care homes, hospitals and retirement villages. Most importantly, we ask “what’s next?” for this aspect of aged care; we challenge popular conceptions and encourage innovative thinking. FEATURES: »» The challenge of being all things to everyone »» Creating dementia-friendly environments »» The importance of gardens to wellbeing »» Green villages: the move towards more sustainable design PLUS: THE REGULARS: ‘SPOTLIGHT ON ... ’ A section dedicated to relevant issues including education and training, therapies, falls prevention, infection control, palliative care, dementia and more. ‘A DAY IN THE LIFE ...’ An insight into the lives of everyone from caregivers to chief executives, residents to retirement village managers. ‘LET’S SNOOP AROUND...’ An insight into the operation of a village or aged care facility. ‘LAST WORD’ Giving sector leaders the chance to air their views on the current status and direction of aged care in New Zealand.

RESPONSE : JOHN COLLYNS, EXECUTIVE DIRECTOR, RVA Mr Brown’s call to reinstate the 2006 Code of Practice clause dealing with repayment to residents if a village is destroyed and not rebuilt is not practical. As we’ve said before, that clause was removed from the 2008 version of the Code following representations from the Insurance Council. It is immaterial what the RVA thought then or thinks now about it; history has moved on and the new clause in the amended Code is the result of extensive consultation with residents, operators and others involved in the industry, including insurers. If a village is destroyed and not rebuilt, residents are paid 100 per cent of their original capital sum. That is unambiguous and provides certainty for operators, residents, banks, and insurers alike. It corrects an unfairness in the 2008 Code and the Association will not be lobbying for a return to the 2006 version. We look forward to working with residents on improving other aspects of the Code, Retirement Villages Act, and regulations.


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