AGED-CARE & RETIREMENT
December 2012 – January 2013 | Vol. 7 Issue 2 | $10.95
WE’VE GOT YOUR INDUSTRY COVERED I www.insitemagazine.co.nz
16 I REGULARS
ON THE SOAP BOX:
SANDRA HANMER 4 I FOCUS ON:
TRENDS IN HOME HEALTH
IS THE SECTOR AT BREAKING POINT?
AND HER NEW ROLE 9I FEATURE
NEW DEADLINE TOO SOON FOR RESIDENTIAL AGED CARE? 2 I NEWS
RVA HITS BACK AT CODE CRITICISM
Do you have questions about living in a retirement village? The Department of Building and Housing provides free independent advice and information for people living in or thinking about moving into a retirement village. Call us free on: 0800 83 62 62 or visit our website www.dbh.govt.nz The Department of Building and Housing is the government agency responsible for overseeing the Retirement Villages Act.
In this issue...
AGED-CARE & RETIREMENT
INsite Magazine Vol.7 Issue 2 EDITOR: Jude Barback T: 07 575 8493 E: firstname.lastname@example.org ADVERTISING: Belle Hanrahan T: 04 915 9783 E: email@example.com
At breaking point? JUDE BARBACK investigates the many challenges facing the home and community support services sector.
BEATRICE HALE confronts the realities facing family carers of older people.
CAROLINE BARTLE discusses home-based support for people with dementia.
What is involved with rolling out interRAI to the residential aged care sector?
PRODUCTION MANAGER: Barbara la Grange
EDITOR-IN-CHIEF: Shane Cummings
GENERAL MANAGER/PUBLISHER: Bronwen Wilkins SUBSCRIPTIONS: T: 04 471 1600 F: 04 471 1080 E: firstname.lastname@example.org PUBLISHER’S NOTE: © Copyright 2012. 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
The realities facing family carers of older people.
SPOTLIGHT ON... Palliative Care
Blended learning the way forward for training in the home-based sector.
IT OFTEN FEELS like the home and community support sector draws the short straw when it comes to aged care. Despite the push to keep older people independent and healthy in their homes for longer, there don’t appear to be sufficient resources available to support these goals. An increasing number of older people are remaining in their homes for longer, yet the necessary support needed to maintain their quality of life isn’t properly supported. This edition of INsite is focused on trends in home health and looks at some of the key issues concerning the sector at present: unclear and inconsistent funding models, national inconsistencies with pay and travel reimbursement rates, pay disparities between DHB and community caregivers, and the squeeze on providers as funders reduce their number of contracts. We also look at the topic of payment for family carers of disabled people, which is currently under the Ministry of Health microscope, and its wider implications for family members caring for older people. Beatrice Hale tempers the political discussion with an insightful look at the realities of caring for a family member. In this issue, we also delve into the world of interRAI and emerge feeling excited about the possibilities. However, one can almost hear the collective intake of breath as the Ministry, DHBs, and aged care facilities embark on the massive task of getting some 2000 nurses started on the training by mid-2014, thanks to the new accelerated deadline imposed by the Ministry for the residential aged care sector. Margaret Owen’s opinion piece on retirement village operating models that appeared in the last issue of INsite sparked some controversy and Metlifecare’s Lynne Abercrombie lays out her response in this issue. This marks the final issue of INsite for 2012, and we look forward to bringing more comment, discussion, and debate to the table next year. Until then, we wish you a safe and happy festive season.
NEWS Snippets and updates from the industry
SPOTLIGHT ON... Palliative Care
ON THE SOAP BOX... Sandra Hanmer
LET’S SNOOP AROUND... Carter House
UP CLOSE AND PERSONAL WITH...Michael Beaumont
A TYPICAL DAY IN THE LIFE OF... Rona Woolsey
LAST WORD... Lynne Abercrombie
Jude Barback, Editor email@example.com
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
LET’S SNOOP AROUND... Carter House
www.insitemagazine.co.nz | December 2012 / January 2013
News NEWS BYTES »»
GREY POWER CONTESTS CHANGES TO TRAVEL CONCESSIONS The New Zealand Transport Authority’s draft plans to remove public travel concessions after 3pm has sparked concern among Auckland’s elderly community. According to North Shore Times Grey Power North Shore says the proposed changes will be detrimental to the 250,000 Super Gold card holders in Auckland, who currently benefit from the travel concessions. Grey Power spokesman Bill Rayner says the move would hurt older Shore residents who have had massive rates increases and rely on travel to beat isolation and loneliness. “The benefits to the older community have been immense; the ability to travel conveniently and exceedingly cheaply has allowed many people to have a greatly expanded social and family life and community contact.” NZTA is seeking to make the changes ‘’on the grounds it is nationally inconsistent and unaffordable’.’ Rayner says that many older people are no longer working yet pay rates and removing the one major concession they receive will be strongly opposed by Grey Power.
GOING DIGITAL In approximately one year, New Zealand television will be completely digital. To aid those who might struggle technically or financially with the change, the Government has launched a targeted assistance package. The package includes a set-top box and the appropriate aerial or satellite dish, which will be installed. Training and technical support will also be provided for a year after installation. It is available to those who aren’t already watching digital television and are either aged 75 and over with a Community Services Card or recipients of a Veteran’s Pension or Invalids’ Benefit, or former Veteran’s Pension and Invalid’s Benefit recipients who transferred to New Zealand Superannuation at age 65 or over.
COMINGS AND GOINGS FROM NZHHA EXEC NZHHA Executive Committee has changed following recent elections. Andrea McLeod (Lifewise) was elected as chairperson and Nicola Turner (Presbyterian Support Central) as deputy chairperson. Those leaving were Kent Youard (Access Home Health), Rod Watts (Presbyterian Support Northern), Trish Neal (Panacea, Chairperson) and Liz Goldie (Healthcare of NZ). Newly elected are Sandra Hanmer (Healthcare of NZ), Pete Carter (Rodney North Harbour Health Trust), Glenys Tremain (Pacific Homecare), and David Chrisp (Access Home Health).
RVA SLAMS CLAIMS OF “HYPOCRISY” CRITICISM THAT THE recent revisions to the Retirement Villages Code of Practice are superficial has been sharply refuted by the Retirement Villages Association (RVA). INsite correspondent Rob Wilson has accused the RVA of “hypocrisy” and “stretching credibility” at their claims to have improved the Code of Practice, when they appear to be reverting back to a former version of the code after the Christchurch earthquakes exposed flaws in the current version. Wilson claims the 2006 Code of Practice stated in part ‘the Resident will receive the full sum paid to the operator without any capital or other deductions normally made under the ORA’. “The RVA, through court action, had this version of the code repealed and the Christchurch debacle was a demonstrable result of the RVA-sponsored amendment to this clause in the 2008 Code of Practice. Now the RVA are claiming to have improved the code by reverting to something near the original,” states Wilson in his correspondence. However, John Collyns, executive director of the RVA, dismisses these claims, calling them “incorrect”. “The clause in question was withdrawn from the 2008 Code by the Department of Building and Construction following representations from the Insurance Council that the clause was ultra vires – in other words, it caught unrelated third parties (the insurance industry) into a retirement village set of regulations and went beyond the enabling powers of the original statute, the Retirement Villages Act.” Collyns says the RVA did not comment or request change on the clause as it was written because they believed it to be entirely appropriate. “The RVA’s judicial review of the 2006 Code had nothing to do with this particular clause but related to retrospectively altering longstanding contracts dealing with refurbishment.”
Collyns maintains that the RVA has consistently said that the outcomes for residents in villages that were destroyed in the earthquake and not rebuilt were unfair, which is why the association has argued for a full repayment without deductions for people in that situation. “Our members rallied to the cause and rehomed around 90 people in villages on terms that were favourable to the residents,” says Collyns. “We lobbied for, and are delighted that, the Government has amended the current Code to ensure residents are better protected.” Graham Wilkinson, vice president of the RVA executive committee, says the revised code has been embedded smoothly. RVA members and their residents are reportedly pleased with the changes. Under the revised Code, owners of retirement village units will be entitled to the original capital sum of their investment following situations like the earthquakes. The variation, which takes effect from October 2013, means deferred maintenance charges will not be deducted from the original capital sum in a no-fault termination situation, such as an earthquake or other natural disaster. However, the move is too late to help those residents affected by the Canterbury earthquakes, such as those at Kate Sheppard Retirement Village in Christchurch, many of whom were left homeless and out of pocket as a result of the disaster. Certainly, the revisions to the Code are cold comfort to these residents and their families. Family members have voiced their approval over the changes to the code but also their disappointment that they cannot be made retrospective. It is thought the new rules will help repair the slight dent to the reputation of the retirement village industry left as a result of the earthquakes and help restore residents’ confidence.
UBLIC PRIVATE PARTNERSHIP P TO TACKLE DEMENTIA
Alzheimers Wellington and Elder Family Matters Ltd have formed a partnership to provide a comprehensive range of education programmes supporting quality dementia care for people living with dementia in the wider Wellington region. The programmes will be available to family carers, paid carers working in residential care facilities, home care agencies, voluntary carers and the general public. The partnership was announced at the inaugural meeting of the Wellington Dementia Community Network on Thursday 6 December. While it is rare for a not-for-profit community-based organisation to partner with a private company, both parties are excited about the potential advantages of the alliance, including aligning approaches to dementia care and enhancing the capacity and capability of staff in both organisations. Alzheimers Wellington manager Nigel Heard says his organisation is “keen to unite with other likeminded providers to make sure people affected by dementia receive an excellent service”. Elder Family Matters general manager Lawrie Stewart believes the partnership will provide consistent training and person-centred approaches to support people with dementia, wherever they live. “While many people with dementia live in their own home, over half of the residents in retirement villages and residential care facilities experience significant cognitive decline,” says Stewart.
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December 2012 / January 2013 | www.insitemagazine.co.nz
SUMMERSET COMPLETES TRIFECTA Retirement village operator Summerset has been recognised as the best retirement village operator in Australasia for the third year in a row. More than 50 retirement village operators across Australia and New Zealand were judged for the award, which was presented to Summerset chief executive Norah Barlow at the 14th Australasian over 50s Housing Awards in Melbourne. Barlow acknowledged what a competitive industry it is. “In this sector, we are constantly driving each other to be more innovative and provide more and more for our customers,” she said. Summerset was established on the Kapiti Coast in 1997 and now has 15 villages across New Zealand. RYMAN’S GROWTH CONTINUES Ryman Healthcare continues to impress investors. The retirement village operator recently posted a 15 per cent gain in first-half profit. Profit reportedly rose to $68.8 million from $59.6 million a year earlier. The operator also increased its dividend, paying a first-half dividend of 4.6 cents a share, up 18 per cent from a year earlier. In the first half, care fees rose 19 per cent to $71.8 million, management fees climbed 19 per cent to $15.7 million, and operating expenses increased over 17 per cent to $64 million. Financial experts attribute the growth to Ryman’s investment in developing its own facilities and say this has been enabled by the operator’s strong cash flows in recent years. BUPA’S EMPLOYEES WIN TRAVEL CASH Cantabrian Libby Cook couldn’t believe her luck when she was awarded a $10,000 travel voucher as part of Bupa Care Services’ employee appreciation programme, ‘Holiday of a Lifetime’. Cook, an Enrolled Nurse at Bupa’s Parkwood, was one of seven lucky employees randomly selected by computer to win travel vouchers. In addition to the major prize, two $5,000 vouchers and four $2,500 vouchers were given out. Cook intends to spend her prize on a bus tour in Britain with her sister, Margaret. “I really enjoy working for Bupa and felt so privileged and honoured to win,” she says.
THE ‘CARING COUNTS: Stakeholders Summit’ was recently hosted by Equal Employment Opportunities commissioner Dr Judy McGregor in Wellington, and 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 attended. The summit was a discussion on how to move forward the actions specified in the Human Rights Commission’s Caring Counts report. The Caring Counts report was a result of McGregor’s inquiry into the employment conditions of aged care workers. It outlines ten key recommendations, including a call for pay, fair travel, and transparency issues to be addressed. It also outlines a time frame for implementing these recommended actions, beginning next year, with completion in 2016. The report indicates that a truly collaborative approach needs to be taken; the time frame specifies who needs to be involved, from the Prime Minister and the Ministry of Health, to the DHBs, to Careerforce, to the aged care providers. The New Zealand Home Health Association was represented at the summit and reports that there was a “general willingness of parties to work together and agreement on transparency in matters such as pay rates and travel policies.” ROBOTS IN DEMENTIA A study by Auckland University shows robots have a positive impact on the lives of people with dementia. For seven years, the university has been studying the use of robots in health care, and this latest research has been using two robots in the dementia care home at Selwyn Village. The two robots have different purposes, with Paro, a “companion bot” designed to look like a pet dog, and the other, Guide, a “health bot”, with a variety of functions, such as reminding people to take their medication. “A lot of our residents had positive responses to Paro, where they would feel a lot calmer by it and their mood would improve,” said clinical nurse specialist at Selwyn Village Isabella Wright to One News. “We’re looking at things like loneliness and depression, but with the Guide robot, we can also look at things like adherence to medication and medicine management and managing longterm health conditions,” said the senior lecturer of psychological medicine at Auckland University, Dr Elizabeth Broadbent.
STAKEHOLDERS UNITE AT SUMMIT
The travel issue is moving closer towards rectification. The Commissioner has obtained a legal opinion regarding the payment of at least the minimum wage for time spent travelling between clients in the home support sector, and this is now available on the Commission website. The issue of equal pay is far from resolved, however, with the Service and Food Workers Union (SFWU) indicating at the summit that it will litigate equal pay using home-based carers as plaintiffs. The union’s point was well made by Tamara Baddeley, a home support worker for over 11 years and SFWU member, who told the summit how carers wanted to be paid for their skills and experience. She is currently paid $14.80 an hour despite holding level 2 qualifications (and working towards level 3), and a Certificate in Palliative Care. However, Careerforce confirmed that they will incentivise employer interest in training by payments to companies on completion of Level 2 and 3 training. Progress also appeared to be made by the revelation that Bupa and Metlifecare have included general support for the Caring Counts recommendations in their collective agreements with the unions.
It is hoped the research will be used to help shape aged care in the future. NEW SENSOR TECHNOLOGIES TO AID ELDERLY AT HOME Radio-frequency identification (RFID) has been around since World War II, and is commonly used today for things like preventing shoplifting and vehicle identification at toll road collection points, but its potential for interpreting human activity has remained largely in the laboratory – until now, that is. University of Adelaide computer scientists are collaborating with those at the University of Queensland and the University of Washington to adapt RFID and sensor technologies to develop novel sensor systems to help older people keep living independently and safely in their own homes. The system will incorporate a network of sensors attached to objects that the person is interacting with in the home. Software will then interpret the collected data, helping to paint a picture of daily life. In this way, the sensors will be able to automatically identify and monitor human activity; this will determine if an individual’s normal routine is being maintained so that timely assistance can be provided if it is needed.
“Our work will be among the first few projects in the world conducting large-scale commonsense reasoning in automatic human activity recognition,” says Dr Michael Sheng, chief investigator for the project, which is being funded over a three-year project. Following laboratory investigations, it will then be trialled in hospitals with geriatric patients.
THE LINK BETWEEN VITAMIN D AND FALLS Studies have shown vitamin D reduces the risk of falls, but researchers at Australia’s Institute for Sport, Exercise, and Active Living are trying to better understand the link. “Studies have shown vitamin D reduces the risk of falls through its roles in bone metabolism, performance, and muscle function,” says researcher Dr Pazit Levinger. “Understanding this link better could help a lot of people but especially those with bad joints who are particularly vulnerable to falls.” The study will also investigate whether osteo-arthritis and other conditions are impacted by vitamin D deficiency.
www.insitemagazine.co.nz | December 2012 / January 2013
At breaking point? With a fragmented and inconsistent approach to funding across the country, the home and community support services sector is struggling to meet growing demand for its services. JUDE BARBACK looks at some of the key concerns facing the sector.
ew Zealand’s ageing population + the Government’s drive to keep older people healthy and independent in their homes for longer = an increase in demand for home and community support services (HCSS). It is a logical equation, yet, according to providers, there appears to be a failure to properly equip the HCSS sector with the necessary resources to meet the rising demand. The Government’s New Zealand Positive Ageing Strategy, which is the responsibility of the Office for Senior Citizens, Ministry of Social Development, has 10 goals aimed at helping to meet the social, economic, and health needs of older people in order to enable them to remain healthy and independent in their homes for longer.
However, HCSS providers are reporting that the recipients of home support services are getting older and frailer, as district health boards (DHBs) concentrate their resources on providing home support to those in most need, leaving those with lower-level needs to cope without these services. Julie Haggie, chief executive of the New Zealand Home Health Association (NZHHA), believes this approach is likely to place a strain on the use of secondary and specialist services. She says support services are not just about keeping people in their homes but helping them to remain as healthy as possible. “Level of health has a huge impact on quality of life,” she says. However, the DHBs’ approach is borne out of necessity. Chris Fleming, lead chief executive officer for the DHB Shared Services Health of Older People Steering Group, says that despite government investment in health and disability, services have increased year on year and DHBs must make funding decisions within the funding envelope available.
SQUEEZE ON PROVIDERS
The limited resources available have prompted some funders to enforce economies of scale by paring back the number of contract holders. The most notable example is the Accident Compensation Corporation’s (ACC) decision in August this year to reduce the number of contract holders from 86 to six, leaving many smaller providers to scramble on board with bigger providers or leave the sector altogether. Yes, it might “better align the service to its overall strategic direction”, as ACC claims, but 4
the reduction in providers is also likely to reduce ACC’s grip on quality control and outcomes. The onus on monitoring these measures will no doubt fall on the shoulders of the chosen six, who will need to monitor the work of the smaller providers to whom they sub-contract. The ‘chosen six’ include four national providers (Healthcare of NZ, Access Home Health, Geneva Healthcare, and Medibank), and two regional contracts (Presbyterian Northern - Auckland/ Waikato and Royal District Nursing Services - Auckland). As for the other 80, two of the largest privately owned providers (McIsaac Caregiving Agency and Panacea Healthcare) have been bought by Healthcare of New Zealand, some providers have already left the industry, and further change and amalgamation is expected. Many providers hold contracts with a range of funders, such as Ministry of Health, DHBs, ACC, or private funders, but with funding reportedly tight across all streams, there is little benefit to this diversity. Some DHBs are looking at reducing contract holders, too, with Capital and Coast DHB taking this step following a service review last year. Southern DHB is reportedly taking a similar course of action this year.
home health services. In the area covered by the Whanganui DHB, funding to the three home care providers is insufficient to meet the cost of the service. “All of us are making losses and we were making losses two years ago. We’re saying we should pull out and just let the service collapse, but morally, we’re not able to do so,” said Graeme Titcombe, chief executive of Access. Fleming concedes that there is no nationally consistent costing or pricing model within the home-based support services area. “The challenge, in particular, for the larger home-based support service providers, many of whom provide services across multiple DHB boundaries, is that, unlike the residential care agreements, which are consistent, they have to face differences of approaches between district health boards. “This does result in variation across the country, an issue that providers have been raising and is being discussed at a national level. However, there is no agreed pathway at this stage. This will mean that there is variation around the country, but DHBs are working with their providers in order to try to enhance quality of services, and this requires a competent and stable workforce,” says Fleming.
LACK OF CONSISTENCY
The variation from DHB to DHB, in addition to the different models used by different funders, has resulted in a lack of consistency and transparency across the sector. For example, the amount paid under the feefor-service model varies across New Zealand, with about a 30 per cent difference between the top-paying funder and the lowest. Haggie says the HCSS sector desperately needs a funding framework that provides more consistency in payment and service expectations across the country. In Dr Judy McGregor’s report on her inquiry into the aged care workforce, Caring Counts, Peter Hausmann, chief executive of Healthcare of New Zealand Holdings Limited (HHL) Group, the parent company for Healthcare of New Zealand, said, “another big discrepancy is the different rates paid by the various DHBs. The variability between them is about 25 per cent. A number of them know we are going to have to top up wages or they are below the minimum wage. The DHBs are funding us below the minimum wage.” Whanganui DHB was highlighted in the report as a particularly problematic funder for
December 2012 / January 2013 | www.insitemagazine.co.nz
However, providers say that a ‘competent and stable workforce’ is becoming increasingly difficult to achieve in the current environment. The NZHHA’s report Making the Most of Home Support Services states that the increasing number of older New Zealanders requiring home support and the increasing acuity of needs of clients are two factors driving the need for more staff, and consequently, more training. However, funding mechanisms in place do not take into account increased acuity or workforce sustainability. The knock-on effect is that providers often cannot guarantee hours of work or offer sufficient incentives for staff to train. As a result, staff turnover is high; Haggie says as high as 30 to 50 per cent in the first six months of employment in some areas. Some providers are finding it necessary to train two people for one job because of the turnover rate.
A key driver of the high turnover rate is the issue of pay disparity between care assistants working under DHB contracts and those working under community care providers, with
FOCUS recommends that DHBs and residential care and home support providers implement pay parity for carers across the government-funded health sector within three years. The Ministry of Health is trying to rectify the imbalance and is in the process of working out what the right level should be.
In addressing pay parity, the issue of travel reimbursement arrangements also needs to be considered. DHB care assistants often have access to a pool car in contrast to the travel reimbursement received by other carers, which is believed to be insufficient to cover the true cost of travel. Apart from exceptional travel situations, DHBs and the Ministry of Health Disability Support Services do not fund travel time. ACC is the only funder that reimburses travel time, and that is at half the minimum wage rate. The ‘Fair Travel Policy’, implemented in 2006, while a step towards recovering vehicle costs of support workers, does not address travel time between jobs. The Fair Travel Policy also does not reflect current petrol prices. As a result, travel DHB assistants typically paid more than their reimbursement allocated to providers from community care provider counterparts. According to HCNZ’s figures last year, DHB funders is insufficient to cover the real costs of workers’ travel. Another barrier to full pay rates for home management are $20 per reimbursement was said to be the cost at which hour upwards and $22 plus for personal care, reimbursement was taxed. community support workers earn $13–$15.50 “Carers are often forced to dip into their own per hour, and hospital support workers are paid pockets, which means they are effectively earning $16–19 per hour. less than minimum wage,” says Haggie. McGregor’s report scrutinised many possible Like pay rates, the amount of reimbursement reasons for the disparity. Professor Matthew Parsons, Chair of Gerontology at The University for vehicle use varies across the country, of Auckland, suggests the housework component according to the rate paid by the DHB and the travel policy in place. completed by community support workers Caring Counts reported various methods of does not entitle them to the same level of pay travel reimbursement. One included loading as healthcare assistants in hospitals. Some 77 cents an hour (with a cap of three hours per DHBs pointed to the “union power” as a contributing factor for the better pay received by assignment) onto client contact time to pay travel expenses, while another is to pay a mileage their workers. Others argue that the degree of responsibility and autonomy and access to direct rate (typically 30c a kilometre) with the first ten kilometres of each day subtracted. Another supervision makes caring in the community variation of this is to exclude travel to the first harder. Regardless of these opinions, the vast majority client from home and travel from the last client of the day in the daily mileage calculation. Still of people within the HCSS sector are pleading others use the travel component supplied by the for a “level playing field” with the DHBs. funder as a top-up to the hourly rate, less tax. However, the aforementioned variation between DHBs themselves will likely make it difficult to find the appropriate rate. WHO ARE THE FUTURE CARERS? To further compound the quandary, there With the question marks hanging over fairness is also considerable variance between what and consistency of pay and reimbursement, it assistants are paid according to their location. is difficult to attract people to the job. Haggie “It is vastly uneven across the country,” says is concerned as to where the next home care Haggie. assistants are coming from. Apparently, assistants working in ‘rural’ areas With many older care assistants now retiring, are paid less than those in ‘regional’ areas. and a high level of turnover among new carers, In her report, McGregor outlines several the sector is facing a real shortage. Obviously, recommendations around achieving fairness in with more people remaining in their homes for this area, notably for the Minister of Health to longer, this is of grave concern. Some areas, like direct the DHBs to develop a mechanism to Canterbury, are said to be in need of community achieve pay parity between healthcare assistants support workers. working in DHBs and carers working in home Haggie predicts that, given the workforce support and residential facilities. She also situation, there is likely to be more focus on
restorative care, retaining independence and possibly reduced household management. “This will put increasing pressure on families,” she says. Interestingly, family carers are under scrutiny by the Ministry of Health at present, due to the court’s decision about the unfairness of payment for family carers of disabled people. Any policy change as a result of the court ruling and the recent consultation period may have implications for the family carers of older people.
The Ministry certainly appears to be taking an active stance on some aspects of home and community support services, yet funding concerns often undermine the good work being done, as appears to be the case in the Ministry’s redrafting of the National Service Specification for HCSS. The aim of redrafting is to accurately reflect the range and level of services being delivered. However, while pleased with the content of the draft, Haggie is perturbed by the lack of discussion around the funding of the application of the service specification. “Significant variation in rates across DHBs means that there is a widening gap between areas where the improved services can be afforded and those where, to a greater or lesser extent, they cannot.” “Simply increasing service specifications that require greater costs for the same or less funding, while dictating inflexible inputs, is not a viable option for either providers or DHBs,” agrees Titcombe, of Access.
COLLABORATION THE KEY
It appears any nationally driven policy to support the HCSS sector is undermined by the fragmented, inconsistent, and unclear approach to funding across the country. Meanwhile, the DHBs are trying to do their best with what they are allocated from the Government. Coupled with a growing demand for its services, the sector is almost buckling under the pressure. No one appears to dispute that consultation and collaboration between providers, funders, and the Government is the way to move forward. Fleming says DHBs should be engaging with the providers within their communities as a part of their service planning and development process. Haggie says there is a need for collaborative contracting. The Ministry appears keen to seek sector consultation on issues like pay rates for family carers and willing to move forwards on some of the recommendations in McGregors’s report. So why have providers, to quote Haggie, “reached breaking point”? Unless collaboration and consultation take into account every aspect, including – and especially – funding, it appears the sector will be unable to progress to the levels required to support the growing numbers of older people remaining healthy and independent in their homes.
www.insitemagazine.co.nz | December 2012 / January 2013
BEATRICE HALE discusses the realities confronting family carers.
Charity starts at home “S
pizzle jitney! Spizzle jitney!”* So said my friend’s mother, as she struggled on to her walker from the dining table. The words meant something – but what? It was up to the caring daughter to work out. She did eventually. And another story: “Oh yes, doctor, I eat well. Mondays, I have some cold meats. Tuesdays, usually fish or fishcakes. Wednesdays, I often go out for a meal. Thursdays, I try to have a pie, and on Fridays, it might be fish and chips.” But there was not a word of truth in this. I know because it was my mother talking to her doctor when I took her to visit him. On the same visit, I said to the doctor, “I would like to have a talk with you.” My mother said, “You’re going to talk about me”, to which I replied, “Yes, remember, Mum, I did say I needed to talk with your doctor. I can see more of the difficulties you’re having than you can.” Result? A mammoth pout, shouldershrugging, cold anger. But I had to tell the truth, and so I persisted, “She can’t dress herself properly. I found her trying to get two legs into one trouser leg this morning.” Mum and I eventually laughed about it. But it wasn’t really funny. Just like “spizzle jitney”, it really wasn’t funny. It was heartbreaking.
WHO ARE FAMILY CARERS?
Family carers for older people range from daughters, daughters-in-law, and sons to spouses, to nephews, nieces, aunts, and uncles. Sometimes, such carers involve grandchildren as well, who ‘keep an eye on’, or who ‘run errands and visit’, and of course, report on their visits to their parents. The living arrangements vary, too. Spouses live together and sometimes older people live with sons and daughters. Sometimes they share homes with their siblings. But often, the older person lives on his/her own, with no one immediately to hand to call on for help.
WHY IS FAMILY CARE AN ISSUE?
Three-score and ten? Not now! Peter Laslett, the British historian, divided the older population into third age and fourth age. The third age, beginning with retirement, is one of activity, and energy, certainly employable, and maybe still partly employed. Today, we are looking forward to a significant increase in this third age ageing population, who will live longer than the former Biblical threescore and ten. At the same time, though we have improved our lifestyles and are becoming more active and energetic, we still face incapacitating illnesses and disabilities, despite the improvement in medicine and technology. We still struggle with specifically ageing diseases such as Parkinson’s, stroke, and Alzheimer’s, though indeed, these can affect 6
December 2012 / January 2013 | www.insitemagazine.co.nz
younger people, too. And this fourth age, of illness and disability, may continue longer than before because of medical care, so that we need help and care for longer. Traditionally, the needs of previous generations were usually met by informal family care, with minimal formal home care and institutional responses such as residential care and hospital care, which provided the care needed when there were no families or when family members were unable to care. Currently, however, residential care is now more specialised than previously, caring for much frailer older people, while those less frail are given home care with care workers provided by the agency of their choice – visiting once, twice, or more during the week – to help with activities of daily living. More care is provided in the community and families are usually in the forefront of that care, with the backup of home care workers.
not being able to care for my mother, who had cared for her own mother. Other families are likely to experience spousal separation and family reconstitution, and women are more likely to be in paid employment, usually outside of the home. For many, this means that they are unable to care for older members. Such changes contribute to the need for more formal home support for older people. At the same time, it might be that the needs of older people may be often greater than families can manage. Such social trends, in the form of changing family structures, higher labour force participation by middle-aged women, the emergence of ‘sandwich’ generation caregivers, who care for children with disabilities – perhaps their own spouses, too – and the geographical dispersal of families all affect the potential supply of care within families. However, families do care.
BECOMING A CAREGIVER
Families themselves are changing. The Organisation for Economic Cooperation and Development talks about a falling birth-rate. With fewer children growing up, who will care for the older people? Families today are more mobile and geographically dispersed. For myself, having moved from Scotland to New Zealand, I relied on my brother and sister-in-law to provide immediate care for Mum, which they did well and willingly. Nevertheless, I felt very guilty at
Why do people care? From my social work days, I remember vividly older people saying “Well, I promised to look after him/her in sickness or in health” and “I took him/her for better for worse”. Daughters would say, “My mother looked after her mother/father”, giving a history of generational care which meant, for them, there was a strong duty to look after frail parents. And many would say “I don’t want strangers looking after my mother/father”, believing that the intimate knowledge and
CONSULTATION PERIOD FOR FAMILY CARERS Ministry of Health v Atkinson was a landmark case. Earlier this year, family carers took court action against their ineligibility for payment for providing disability support services to their children. The court decided that a policy that means family carers are not paid for providing support to their disabled family members is discriminatory under the New Zealand Bill of Rights Act. The Ministry of Health chose not to appeal the decision and has instead started trying to rectify the situation. The Ministry is now considering the submissions made during the consultation period on ‘paying family carers to provide disability support’. It is hoped by family carers, and those they care for, that the consultation period and subsequent government decisions will result in a clearer and fairer policy regarding pay. In addition to considering public opinion, the Ministry will need to factor the legal and cost-
related implications of such a policy change. It will need to consider quickly – a working policy needs to be in place by May 2013 to avoid further legal action. Whatever the outcome, the new policy is expected to have implications for family carers of other groups, such as older people receiving DHB-funded support. The New Zealand Home Health Association (NZHHA) thinks that any new policy should aim for paid family carers to fit into current funding and service models that involve wage payments to workers, such as individualised funding and/or employment of family carers through Home and Community Support Service agencies. The association is also of the opinion that the new policy should avoid set rates for family carers and take into account things like annual leave, superannuation, qualifications, and training.
Similarly, the New Zealand Medical Association, in a letter to the Ministry, outlined its view that the level of care and support required by the disabled person should be consistent with the two-step NASC system currently operating: Needs Assessment followed by Service Coordination. The consultation document also raises questions about accountability, with some claiming what goes on in a family shouldn’t be put under scrutiny and others suggesting family carers should be subject to auditing and have to comply with the Standards. The NZHHA has suggested there are other factors that need to be taken into account in policy development, such as a dispute and mediation process and enhanced respite for family carers. The association also believes more resources and mentoring would be needed to aid any transition to a new model.
FOCUS and noises get easily interpreted as obstacles for social interaction at home” (p.14). But we don’t maintain ‘continuity of self’ as carers, do we? We change and absorb the caring role into our selves. We become carers.
affection of families meant that they can care better than anyone else. But even with the best of intentions, and a family history of caregiving, few of us are prepared for the onset of giving care.
A useful way of understanding the process of caregiving is to consider it in stages. Caregiving can creep up on you, as Dot McCaw, first president of Carers New Zealand, said frequently. Or it can begin with a bang, after someone suffers a stroke or an accident, for example. Then there is a second stage when grief, bereavement, and bewilderment happen all at the same time (“This can’t be happening to us, to me.”). This is often a time of raising questions and searching for answers, and of looking to others for guidance and perhaps mentoring. It is also often a time of considerable despair when families realise that the relationships within the family are changing: a spouse or adult child takes more authority, with some difficulty. An example of these changes came from the wives in the early days of a carers’ support group. New members, said Jenny, talked of ‘we’... “we do this”, “we did this”, “we will ..” But deeper into the caring role, it became ‘we/I’, as in “we used to do this, but I do it now”. And then with further caring, it became ‘I’, with the wife becoming the sole decision maker. Caregiving is a time to relinquish some roles, to reconsider how to live a different life, and it is a time, above all, of recognising the losses and of grieving and bereavement. The third stage of the process we offer is that of reconnection, where the grieving and bereavement don’t go away but become absorbed into the process of change and care, where relationships with health professionals enter into the family network, where friendships may change because they can no longer be sustained in the same way, and activities are different
because there is limited time to maintain them. Sometimes carers can feel quite alienated, isolated, and lonely. This is a time to actively seek out any support groups either in the neighbourhood, or on the Internet, looking up Carers New Zealand, for example, and listening to carers’ radio.
MEANING OF HOME?
We talk of community care, living at home, and ageing in place. But we have to ask: what happens in our homes? In a recent book, The Age of Supported Independence, the authors identified changes in space, changes in time, and in relationships, all of which had a major impact on the family member as carer: “I used to think my house was not my own but the place was set up like a hospital anyway, and I used to have wheelchairs [for my husband], walking frames, seats and bed with frames up the side, and lifts – you know, overhead lifts, things over the top – and there was no room to turn around ... I had no space. I lost my space.” Changes in space can be microcosmic, as in altering the position of a chair, or macrocosmic, where a family member will alter the layout of the house and/or rooms to accommodate the needs of the person with a disability. The disability becomes visible with the presence of grab-rails, ramps, or a wheelchair, perhaps. A hospital bed is introduced, or a former lounge room is changed to become a bedroom, where showers and toilets are fitted with grab-rails and raised toilet seats, where the wheelchair takes a prominent place at the front door. Quotes from authors Saarenheimo et al. (2004) suggest that the home can be thought of as a ‘shell of the self’ and they observe that “changes in the domestic order can be interpreted as challenges to maintaining the continuity of the self”. In this respect, the ‘signs of illness’, such as the presence of special hospital furniture, care equipment, or particular odours
Such changes are inevitable, and most of us recognise and accept them, but there are other issues that need to be dealt with. Becoming a caregiver might mean giving up a job; how then does the carer survive? It might mean such constant attendance on the person with disability that the carer’s health suffers. What can be done about that? It can mean isolation from friends who have their own and different lives to lead. Invisibility is also issue. As one man commented, “People come to see her, not me. I just open the door, and they walk in and go straight over to her. I might just as well not be here.” Practically, there are different benefits in New Zealand to assist the carer. Carers New Zealand’s website offers a series of entitlements and where to access them. Constant attendance can be alleviated by respite carer and carer support. Both of these are available through the Needs Assessment service, accessible when the older person was assessed to receive home care and also accessible through the general practitioner. Such respite and carer support will make sure that the carer has four weeks a year of ‘holiday’ – not much, and more would be better. As they say in aircrafts, “Put on your own oxygen mask first”. If you don’t take care of yourself, then who will take care of the other person? In terms of isolation and invisibility, if the carer is unable to meet with friends because of the different paths each is taking, why not join a carers’ support group where carers meet to discuss their own situations and receive information and help from others, to listen to speakers on topics of their choices, and also to make new friends and have fun. Grieving over the losses is the biggest issue: what used to be, compared to what is now. Support groups can help by empathising, sharing, and understanding.
HUMOUR? DR WHO?
Sometimes, to combat the grieving, we use humour, don’t we? Recently, when working on my latest book, Voices of Family Carers, I’ve been thinking about carer identity. Carers are skilled people who change their worlds to help the person they care for: they change their homes, their time frames, their social lives ... and they learn more on the job of caring than we realise. Carers are highly skilled people. Let’s not forget that. And we need to stand up and be counted to make sure that we get the support we need to care for the people we love. *from the book Salmon Salad and .... by Samantha Mozart.
www.insitemagazine.co.nz | December 2012 / January 2013
CAROLINE BARTLE discusses what constitutes good home-based support service for people with dementia.
Dealing with dementia
at home T
he demand for care for individuals with dementia in their own home is set to increase. Factors that are driving the growth in the sector include: »» an increase in the number of people developing dementia – there are currently about 43,000 people with dementia in New Zealand but this is set to increase to about 77,000 by 2026 »» drive for early diagnosis – identifying a higher number of people in need of support »» Pharmac’s decision to fund anti-dementia drugs such as Donepezil »» funding limitations – funding care in the community being the cheaper option. The cost estimated in the economic impact study in 2008 set this financial cost of caring for dementia at approximately $712 million, of which $272 million is within the residential sector and $100 million in the hospital sector. This cost could be reduced by better preventative models of care and a wider variety of support models in the community, including better respite services. Within the dementia strategy (2009), there is a strong emphasis on exploring different models of care and support. Services within home health need to be brought up to date and to evolve to cope with the increasing demand. Maintaining a person in the community requires clear ideals about managing risk in the face of diminishing capacity. It involves treading the fine line between risk, rights, and responsibilities. It is
about ensuring that as a service we are not too risk averse but instead recognise the role that risk assessments play in enablement. It involves understanding the dialects of the condition, the interplay between health, psychology, and the social environment. It involves utilising the best of aids, adaptations, and assistive technologies. The use of assistive technologies in New Zealand is developing. Assistive technologies can enable a person to stay in their own home for longer. They are used for a whole range of purposes but play a strong role in minimising risk or promoting independence. Technologies range from low-tech to high-tech. However, there are complex ethical considerations in their use, specifically where the use of an aid replaces human contact or where they create an overthe-top ‘big brother’ approach. Some of the things that define a good home-based support service for people with dementia include: »» strength-based care plans that include life histories, which are actively used to inform care practices »» staff well trained in the area of dementia care, able to spot early symptoms and differentiate between the things that cause confusion that is not dementia »» good communication between other support staff, allied health professionals, the person with dementia, and their family/whānau
December 2012 / January 2013 | www.insitemagazine.co.nz
»» a good understanding of the role of other support services and how to access them »» a robust risk management plan, including risk management of staff as well as clients »» consistency of staff – poor consistency can be confusing for a person with dementia »» a person-centred approach to care, including real involvement in assessment and reviews »» appropriate time allocated to visits to meet the whole range of needs, not just physical needs »» a balanced approach to managing rights and risk, and understanding that a diagnosis of dementia does not automatically deny a person from making their own choices about taking risks in their life »» all staff understand safeguarding protocols and can define what constitutes abuse and how to report it »» strong leadership and management – services are headed up by individuals who are well skilled and well trained in dementia care. Keeping a person in the community has wider benefits than purely economic. In the face of failing memory, the richness of the environment serves as a good tool to reinforce and identify important aspects, which impacts ultimately on self-esteem. Home-based support services may not be the best option for everyone and the person with dementia must be central to the decision-making process.
The Government’s decision to accelerate the time frame for the roll-out of interRAI to all residential aged care facilities has met with mixed reactions. JUDE BARBACK looks at why there is such a strong drive for the clinical assessment tool and what it is hoped to achieve.
arlier this year, Associate Health Minister Jo Goodhew laid two new deadlines on the table for the residential aged care sector: by June 2014, all facilities will be participating in the rollout of interRAI, and by June 2015, it will be mandatory in residential aged care. The decision has provoked some concern from the New Zealand Aged Care Association (NZACA). The association feels there is not enough time and funding allowed for the effective implementation of interRAI.
THE INTERRAI STORY SO FAR
InterRAI stands for ‘international Resident Assessment Instrument’. It is an electronic clinical assessment tool that is being used by the Needs Assessment Service throughout New Zealand. Basically, it is a tool that provides a comprehensive clinical assessment of needs, which is then fed into the development of tailor-made care plans. The tool is expected to help provide, for the first time in New Zealand, detailed objective statistical information about older people in care; the hope is for this information to better support policy development and implementation. The need for a validated assessment process dates back to the introduction of needs coordination in 1994, which was reinforced a decade later by the Guideline for Specialist Health Services for Older People. The guideline, which suggested assessment of older people needed to be comprehensive, multidimensional, and standardised across New Zealand, led to an evaluation of assessment tools used throughout the world. The interRAI Home Care assessment was
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thought to be the best tool available that met the criteria of the guideline. InterRAI was developed by a collaborative network of researchers in over 30 countries, and the result is an internationally recognised assessment tool that is designed to assist nurses in aged care facilities to provide quality care for residents. The roll-out of interRAI for assessing needs for home-based support services was completed in June this year, with all DHBs now using interRAI for their community clients. Following the success of a pilot programme using interRAI in residential aged care in Canterbury and the Bay of Plenty, the Ministry of Health and the district health boards (DHBs), with the involvement of the NZACA, started to roll out interRAI in residential aged care last year. “This is a positive move to build on the good work being done by aged care providers and ensure people in aged care facilities across the country are getting a consistently high standard of care,” says Minister Goodhew.
WHY MAKE IT MANDATORY?
Ministry of Health, Deputy Director-General Policy, Don Gray says the mandatory nature of the programme from June 2015 will ensure each aged care resident in New Zealand receives a Comprehensive Clinical Assessment at least twice a year or when their health status changes. The Ministry believes this will help ensure continuity of care across the sector and create a level playing field for all providers. “The Ministry recognises that most rest home providers already provide a high
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standard of care for residents. However, one of the biggest advantages of making interRAI mandatory is that all of the approximately 700 residential aged care providers nationwide will be using just one standardised assessment tool. “This will mean standards of care can be benchmarked with data collected nationally and used to give an indication of the quality of care in facilities across New Zealand,” says Gray.
Gray says the Government is asking providers to get engaged in the roll-out of interRAI a year in advance of its June 2015 deadline because, as with any new system, interRAI brings with it some challenges. “It is hoped this shorter time frame will help place providers in a better position to train staff earlier and learn the new assessment in a systemised way together, which is important in an area as challenging and critical as clinical change,” says Gray. However, the NZACA has criticised the Ministry’s decision. “It is no longer a partnership,” says chief executive Martin Taylor. While the NZACA remains supportive of the interRAI project – Taylor is a cosponsor on the project’s steering group – the association believes the sector is not ready for the tool to be made mandatory on the terms laid out by the Ministry. “It is disappointing that something so positive has now become a regulatory compliance burden as a result of being made mandatory and having the time allocated to roll out this initiative shortened substantially,” says Taylor. >>
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www.insitemagazine.co.nz | December 2012 / January 2013
<< WHAT DOES INTERRAI is trained to become the lead practitioner, who will then be TRAINING INVOLVE? The NZACA’s concerns are justified: the roll-out entails training around 2000 Registered Nurses to understand the assessment tool and how to use the web-based assessment software. All facilities need to be participating in training in approximately 18 months’ time. Given that only a small percentage of these nurses have received training so far, it is a big task ahead of the sector. However, the Ministry has put in place a number of training approaches to help meet the varying requirements of providers. The interRAI project team will ensure that a nurse in each facility
supported by interRAI trainers to roll out the training to other nurses in the facility via “classroom days”. The lead practitioner supervises assessments. If a facility would rather not have a lead practitioner, interRAI trainers will provide the training directly to the facility. Training can also be rolled out to groups of facilities. Following this approach to training, the Ministry expects training to take on average one day a week during the six to eight week process, outside of three classroom days. InterRAI competency, which includes classroom learning,
supervised experience completing assessments, and a competency evaluation, takes between 50 to 55 hours for staff to achieve. In return, providers are expected to play their part in terms of making their staff available for training. “We encourage providers to contact their local trainer through DHB Shared Services as early as possible so they can discuss what is required,” says Gray. There are currently seven dedicated interRAI trainers spread around the country. However, Gray says this will increase significantly in the coming months. The Ministry says there will also be ongoing support provided for aged care facilities as they introduce
interRAI. Such initiatives include a phone-in support desk, access to online self-paced learning, a ‘buddy system’, and the quality review of assessments so nurses get feedback to support learning. “Feedback from facilities who have already adopted interRAI has been positive and we believe it will provide better assurance about the standards of patient care and safety in aged care facilities,” says Gray. Facilities that haven’t yet received interRAI training appear to be keen to get on board, too. Sharon Owen, manager of Carter House in Te Puke, says her staff are looking forward to receiving their interRAI training and are awaiting more information.
InterRAI trainers tell it like it is
INsite chats with interRAI trainers, Joop Wieringa and Lynda Wheeler, about training, costs, challenges, and why they think interRAI is going to be so beneficial to the sector. INsite: What stage are you at with training? Joop: At the moment, we are training the second group, Registered Nurses from Bay of Plenty, Waikato, Lakes, and Tairawhiti DHBs, with between 4-11 in each group. INsite: What does the training involve? Joop: The RNs have two days in the classroom after they have completed an online training module, and then they attend a third day’s classroom session a week later. All trainees have to do a minimum of five assessments and they have to complete 10 online evaluations to get to an accepted competency level. Trainees then are required to complete a final competency interview at the end of their training and also have to pass an annual review. INsite: How quickly are RNs grasping the training? Joop: The training is mainly around how to use the tool, as most of the RNs have good clinical assessment skills. The training is focused on how to use this comprehensive and complex electronic assessment tool. When interRAI was introduced, I saw this as a major quality improvement initiative for residential aged care. Trainees can pick it up quickly but need to get used to the tool, and we have found that it can’t be learned in an hour as there is a high level of complexity.
INsite: Do you anticipate any challenges with training process? Lynda: The early post-training stage is always difficult as staff move through the change process and become familiar with the coding and specificity of the tool. Recording an assessment on a computer, using SMART goals, and interpreting the assessment outcome measures and CAPs is a significant part of the training and ongoing support provided nationally to facilitate this process. INsite: Do facilities have to bear many costs associated with the training? Joop: The facilities fund the costs for relieving staff for the three days training and the time for completing the assessments – about 53 hours. The Ministry of Health and DHBs have put quite a bit of money towards the introduction and training of interRAI. They fund the training facilitators, pay for the training materials including manuals, pay for the interRAI licenses and annual licensing fees, and reimburse the residential aged care facilities the costs of a laptop computer. INsite: Did you expect any resistance to making interRAI mandatory? Lynda: InterRAI had been a mandated introduction, so naturally there was some staff resistance to change. When they were asked after using it for some time, they reported that although interRAI assessments
December 2012 / January 2013 | www.insitemagazine.co.nz
increased the burden of paper work, this was easily outweighed by the benefits in better resident outcomes and focused care plans. INsite: What can we expect based on international experience with interRAI? Lynda: InterRAI is based on international evidence and is used extensively in other countries particularly in the United States and Canada. The evidence certainly from the States – which has been using it for some 20 years now – is that after using it for two to three years there was a decreased hospital admission rate from facilities, as triggers were identified early and facility staff were able to manage these factors in house. The Evaluation of RAI impact on Facilities paper (More et al., 1997) also noted decrease in ADL decline, decrease in cognitive decline, and decrease in urinary continence decline. There was no increase in mortality. There was an increase in advanced directives use, increase in behavioural management programmes, and an increase in activity involvement. INsite: Will interRAI bring about consistency across New Zealand? Lynda: There is standardisation across the country and that certainly has made a difference. When somebody [from home-based care] moves into a residential facility that is using the Long-Term Care Facilities (LCTF) [assessment], we are able
to transfer the client’s previous assessments (Home Care – HC) into the LTCF office, so residential staff can view the information gathered about the resident, providing them with a wealth of background information. Staff can easily see what has changed for the resident and what has remained the same. This means that for the resident and staff they do not have to ask the same questions and repeat the same background material for every assessment from the community into a facility. It is really about the information going with the resident from the community, into a residential care facility, into hospital, and back again. Or from facility to facility. When someone moves away from Tauranga to Hamilton, for example, we can easily transfer their complete file. INsite: Do you anticipate interRAI will help facilities to better manage their workloads? Joop: Often the issue of work load is subjective because it is not always easy to identify hard evidence to support staff claims. Now with interRAI, it is very easy to provide objective data. Lynda: During the research phase of the LTCF one facility had three wings in their rest home. In one of those wings, the care staff stated that their wing carried a heavier workload in the morning and they did not have enough staff. When I separated the collective data from the facility LTCF assessments into the three wings, looking at the acuity levels between
TECHNOLOGY Jenny Crawford, manager of Oakdale Rest Home in Cambridge, is supportive of interRAI, as it is a nationally driven initiative. Like Carter House, the staff at Oakdale are waiting in anticipation of hearing more.
COSTS OF TRAINING
Taylor points out that the training costs associated with getting the sector interRAIready in time for the deadline are likely to be problematic for many providers. “Before [providers] could decide whether and when they wanted to accept these costs – now they have no choice,” he says. the wings, it was very clear that they did have a highly dependent group of residents in that one wing. So the change made was they altered the care staff allocation to provide the wing with the greater acuity level more care staff from the other wings for an hour each morning. So it was not about increasing costs; it was simply about redistributing the staff into the area where the need was greatest. INsite: Does interRAI take a holistic approach to assessing an older person’s needs? Joop: What interRAI is really about is providing a snapshot of a person’s functional ability. So the assessment gives you straightaway both a clinical and social picture of the person, so the person completing the assessment can see what needs to be wrapped around a person so that they can stay at home or improve or prevent decline or function at maximum ability in the residential care facility, or in a rehabilitation facility. Lynda: There isn’t anything not considered. It covers all domains of a person’s life. It is an amazingly comprehensive tool. INsite: What do you perceive as the main benefits of interRAI? Joop: There are many benefits from interRAI, and particularly for the older person. This is because the comprehensive assessment tool doesn’t allow those using it to miss any areas of the assessment. Every time someone does an assessment they have to complete the full comprehensive assessment and are
According to the Ministry, the Government has invested more than $10 million over four years (2011-2014), which will support the roll-out into residential aged care. The Ministry will cover the cost of the interRAI software, a laptop to use the programme and initial interRAI training. However, Taylor is critical of the funding allocation. “When DHBs rolled out this initiative, they trained only about 700 Registered Nurses on a budget of $12.5 million over four years. In comparison, we are being expected to train almost three times that number for $10.8 million dollars and complete that training in less time.” guided through the tool so there are no parts missed. The assessment outcomes trigger care issues, which can be transferred to a care plan so that the carers know what to do to improve the quality of life and the quality of rehabilitation for the older people. Lynda: The triggers that are produced at the end of the assessment highlight issues specific to that resident, which allows the facility RN to consider what course of action is required for that particular person. This will become part of an active targeted care plan with timed goals of intervention. So you are always looking for both the triggers that maintain someone where they are or for any functional improvement and reversibility for each individual resident. One of the other benefits for the residential care sector in using the long-term care tool is that it should facilitate the decision-making process around the change in need levels for a resident. This process is currently being developed. Joop: Another benefit of interRAI is that because it is an online tool many services will have access to it so there will be less duplication than we have in the systems we use now. Additional benefits of interRAI for the facility will be for the manager to have a good understanding of the levels of complexity of care and they will even be able to see the departments/wings with the greatest need and adjust the staffing levels to address the needs of the residents.
HOPES FOR INTERRAI
Despite concerns over costs and timing, Taylor says NZACA “is committed to making this quality initiative a success for elderly New Zealanders”. To be a “success”, the assessment scores produced by interRAI need to be used effectively to produce fair and optimal outcomes for older people. Given that the tool will now be mandatory across the board, encompassing DHBs and the residential aged care sector, in theory interRAI should result in a consistent approach to care placements across the country. So if an older person assessed by the tool under one DHB receives the same interRAI score as another person under a different DHB, both should receive the same level of care or have the same access to residential care. Providing a robust, standardised approach to a continuum of care is what interRAI is all about. Dr Brigette Meehan, interRAI project leader, describes it as a
“very satisfying assessment process to be involved with” as it looks beyond a person’s current status to his or her future, presenting opportunities to modify any risks he or she may face. She also praises the holistic nature of the assessment yielded by interRAI. “Sometimes, there’s an assumption that because you have one health condition it somehow protects you from getting another. But what happens if you have arthritis and then have a stroke? InterRAI is designed to look less at a person’s conditions and is much more about how they manage in their daily life.” There is certainly much enthusiasm for interRAI, from the Ministry to the nurses. Assuming the Ministry, DHBs and facilities can work within the tight time frames and budget – which shouldn’t be understated – the initiative stands a real chance of success.
www.insitemagazine.co.nz | December 2012 / January 2013
Blended learning the way forward CAROLINE BARTLE discusses the advantages of a blended learning approach for training in the home-based support service sector.
he Home and Community Support Sector (HCSS) Standard has evolved to reflect current thinking around user empowerment and personcentred care. This is underpinned by a strong ethos that these standards will help to improve practice to enable services to provide care to more complex needs, which is in synergy with the Government’s plans to increase services within this sector. The outcomes in the HCSS Standard are underpinned by key principles, many of which echo the person-centred philosophy. However, to achieve these outcomes at ground level, substantial training and development is required to enable support staff and services to be able to respond to complex needs, including cases with varying capacity issues. One of the key objectives of the new standards is to enable training requirements to be better linked to the new standard. However, despite the regulations in place, there is no definitive guide to the minimum training requirements for the health and community sector other than those imposed by local Ministry of Health 12
contracts. The HCSS Standard does discuss competency mapping to identify gaps. However, there is no specific requirement in place to meet minimum requirements for national qualifications. Arguably, the lack of definitive guidance in this area leaves service providers at risk of poor interpretation of the standards or in danger of barely meeting minimum competency requirements. Standard 3.2 deals with induction and training directly, and throughout the document there are references to how specific training will help to support the achievement of a number of standards: consumer rights, informed consent, cultural competency, privacy and dignity, and discrimination and abuse, to name but a few. This is a potential minefield for organisations looking internally to develop independent training programmes that are not delivered against national standards, or as part of a qualification. In the absence of specific requirements, many organisations use national qualifications to benchmark their training delivery and to develop appropriate pathways. However, the diverse
December 2012 / January 2013 | www.insitemagazine.co.nz
nature of the home-based support service sector means that, at times, the scope of these frameworks does not meet the range of training needs required to deliver a truly person-centred service – one that not only creates a safe platform for practice and supports rights and person-centred thinking but also adopts a philosophy of ‘enablement’. Bespoke training of this nature is in short supply and traditionally very expensive to deliver. There are still a high number of untrained care and support staff working in the sector. Many of these speak English as a second language, and their role, compared to that of a residential establishment, is largely unsupervised. The support role carries significant responsibility, particularly when supporting individuals with complex needs, on top of capacity issues, making them extremely vulnerable. All of this makes training complex, yet profoundly important. One of the main difficulties facing the sector is in staff retention. However, developing a national benchmark for career pathways in this sector is key to supporting staff retention. Another difficulty facing the sector is the lack of affordable and flexible training solutions. Solutions are needed that will meet the complex demands of work patterns, a wide scope of needs, and ever-emerging roles.
Much can be learned about how we tackle these challenges by exploring the available theories of knowledge creation. Nonaka and Tekeuchi (1995) suggest that knowledge manifests in two ways: explicit and tacit. The explicit aspect is knowledge that can be easily shared between others and includes information that has been codified and articulated, information that can be easily transferred in manuals, books, and presentations. Tacit knowledge is more commonly referred to as ‘know how’ and is more about practice; it’s in the doing. Examples of this include learning how to ride a bike, knowing how to knead dough, or being able to carry out practical aspects of care. Qualifications tackle this element by separating competence and knowledge. Competence is practised, of which knowledge informs. However, the key driver here is how do organisations turn explicit knowledge into tacit knowledge in an affordable and meaningful way? What is the process? Nonaka and Tekeuchi’s answer to this is in the SECI model: socialisation, externalisation, combination, and internalisation. Put simply, there has to be interaction with others in debating, practising, reflecting, and adapting. Many of these ideas are already implicit in the way most service providers operate. There are already a degree of mentoring,
Perhaps it’s time to start thinking more broadly, using blended packages such as e-learning, coupled with internal systems of reflecting, debating, and practising? Perhaps being creative and flexible in our learning approaches will truly drive outcomes? reflecting in supervision, team meetings, informal discussion in the review of service plans, and so on. The learning here takes place within the context of practice. However, there are also many misconceptions around what taught sessions (the more expensive option) are able to achieve, with many providers mistakenly thinking that the learning takes place here, using this method as almost a ‘tick box’ approach. This is because taught sessions traditionally allow room for discussion and individuals get a chance to simulate the more practical tasks. Yet, delivery styles are far from consistent, with some people opting for more didactic styles (because of limits in time) and others opting for more constructivist or humanistic type approaches. One could argue that even with the most facilitative approaches, taught sessions are not universally the best option for knowledge creation, and perhaps there needs to be a more joined-up approach between guided learning and practice? Perhaps it’s time to start thinking more broadly, using blended packages such as e-learning, coupled with internal systems of reflecting, debating, and practising? Perhaps being creative and flexible in our learning approaches will truly drive outcomes? E-learning, a low-cost and flexible alternative, might ensure more affordability for developing internal knowledge-creation systems and more investment for communities of practice to meet and discuss. Setting up organisational goals around knowledge management will ensure sustainability. Quick, expensive ‘tick box’ approaches are unlikely to engender sustainable results. There is no substantive research into the benefit of training and development in the home-based support service sector. However, a small-scale study was carried out in 2005 (Smith, Kerse, and Parsons) to determine the impact of a healthcare assistant
education programme on the quality of care for older people living in a residential home in Auckland. This study, although small, evidenced how training can impact on outcomes, particularly where there were complex needs. However, the variables at play are highly debatable within any context of study of this nature as factors outside of the training influence heavily on the transfer of knowledge to practice. Leadership practices such as good supervision, team meetings, and creating a learning culture, all impact on learning outcomes. The benefits of training to the home-based support service sector, need to be considered across several domains: the moral and ethical basis, the wider social benefits to communities, as well as the economic benefit. The economic benefit can be viewed in terms of reductions in admissions to residential services, as well as reducing home-based support services and primary care through rehabilitative or ‘enablement’ approaches. Reducing the cost of training is a key consideration. Organisations need to look closely at cost versus outcome. In measuring outcomes, simple end-of-course evaluations should not be used in isolation. Models such as Kirkpatrick’s four levels of evaluation model provide a good framework for the scope of evaluation. The four levels of Kirkpatrick’s evaluation model essentially measure: » reaction of student: what they thought and felt about the training » learning: the resulting increase in knowledge or capability » behaviour: extent of behaviour and capability improvement and implementation/ application » results: the effects on the business or environment resulting from the trainee’s performance. A study was commissioned by Careerforce (2010/2011) on the costs of delivering the
Foundation Skills Training. The size of the study means that it is difficult to draw any reasonable conclusions from this. In addition, completions did not feature in the research. Completion/achievement is now driving the funding model and therefore needs to be a key factor in any analysis of learning outcomes. However, the study did highlight some interesting issues for consideration: » there is wide variation in the type and cost of training » the median cost for classroombased training was $1,330 per trainee » employers incur a range of costs when undertaking workplace-based training: direct costs such as tutor time and outsourced administration of the programme, travel costs for tutors, workbooks, resources, and venue hire, and indirect costs » costs decline as the number of trainees increases » classroom-based training was completed in half the time that
non-classroom-based was (20 weeks) » indirect costs (such as back-fill costs and staff replacement) were approximately 90 per cent higher in classroom-based training. What all of this tells us is that a blended approach is required, one that considers the formal and informal, the knowledge and the competence, and the cost versus outcomes. A blended approach is required to accommodate complex work patterns, and reduces backfill costs and other indirect costs, such as travel. In solution to this Amida (Access) in conjunction with 3 Spirit eLearning are launching this month the first of a suite of e-learning programmes to support a blended, low-cost approach to this sector. The first unit to be available is the 23920 ‘Demonstrate a knowledge of dementia, person-centred care and communication for a person living with dementia’, one of the four units available on the limited credit programme.
www.insitemagazine.co.nz | October/November 2012 13
Spotlight on... Palliative Care INsite talks to Hospice New Zealand about the realities of palliative care.
2. An ageing population. We are seeing an increase in chronic conditions that have a palliative care need. 3. Collaboration between health providers. This is currently happening at a national level with Hospice NZ, the Ministry of Health, and the Palliative Care Council working together. Moving forward, we need to work within our regions and collaborate with the palliative care community. Locally, we need to work together to ensure everyone who needs palliative care gets the support they need at the right time. 4. Awareness of hospice services. This is always a challenging area of our work as often people are unaware or unsure of what services hospice provides – or believe certain misconceptions about what palliative care is about.
INsite: What does palliative care typically involve? Hospice NZ: The World Health Organisation (WHO) has defined palliative care as ‘the active total care of patients whose disease is not responsive to curative treatment’. Palliative care affirms life and regards dying as a normal process, neither hastens nor postpones death, and provides relief from pain and other distressing symptoms. It integrates the psychological and spiritual aspects of patient care as well as offering a support system to help patients live as actively as possible until death. Palliative care also extends to patients’ families, offering a support system to help families cope during the patients’ illnesses and in their bereavement. Palliative care therefore recognises that cure or long-term control of disease is no longer possible and is therefore concerned with quality rather than quantity of life. Caring for people with life-limiting illness includes an understanding of the physical, psychological, cultural, spiritual, intellectual, and social dimensions of care. Palliative care
must be based on a philosophy that each person is a unique individual with unique needs. Everyone must be treated as a whole person. Excellent communication and a team approach is the key to effective palliative care and in meeting the needs of people with lifelimiting illness. Nurses, carers, physicians, and all members of the interdisciplinary team are like different musicians playing together in a symphony, whose movements are orchestrated by the needs of the person. INsite: What are the biggest challenges in palliative care? Hospice NZ: From a national perspective the challenges we face as an organisation are around: 1. Workforce pressures. With workforce shortages existing and looming even larger – for example, palliative care medical specialists – we are going to have work in innovative ways, supporting our colleagues in primary and aged residential care to ensure people get the care they need irrespective of their setting.
Many people believe hospice is about a building, when in fact, it is a philosophy of care. The majority of hospices have inpatient facilities where people go for respite, symptom and pain management, or during their last days – but in fact, the majority of people are cared for in their homes in the community. Our goal is to help people make the most of their lives, to live every moment in whatever way is important to them. Depending on when our services are sought, living every moment can take on a different meaning. It might be going to watch a sporting or cultural event; it might be time with family and friends, through to holding someone’s hand or feeling the sun on their skin through a window. The most important aspect is that we celebrate that that person is alive and ensure they are receiving the care and support both they and their family need. The hospice philosophy extends beyond just the physical needs of a person and extends to their emotional, spiritual, and social needs as well. Everything we provide is completely free of charge. INsite: What does the HNZ Fundamentals of Palliative Care education programme entail? Hospice NZ: In 2009, a Ministry of Health national stocktake into palliative care service provision identified the need for nationally consistent education programmes to support generalist palliative care providers.
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December 2012 / January 2013 | www.insitemagazine.co.nz
To address this need, Hospice New Zealand developed a nine-part learning series: The Fundamentals of Palliative Care.It was completed in late 2011. This education programme was designed to assist member hospices to support and educate residential care staff members who are working with residents requiring a palliative approach to their care. It is available to anyone working in aged care facilities, regardless of their designation.It is truly an interdisciplinary education resource. The programme consists of nine learning packages, a participant workbook for each package with pre- and post-learning activities and teaching presentation notes. A certificate is awarded to the participants for each learning package following completion of a post-learning reflective evaluation. A collaborative teaching approach can be undertaken utilising the skills of gerontology educators/nurse specialists/ doctors and those of the specialist palliative care team to impart knowledge – this may be the educators, grief counsellor, doctor, or any member of the interdisciplinary team with the most appropriate knowledge. In this way, we bring together the best knowledge and skills from both gerontology and palliative care to support the care of our older people. The programme is presently provided free of charge to remove barriers to the provision of training and is provided on-site at the residential care facility. The nine learning packages cover the following topics: 1. The Essence of Palliative Care 2. Ethical issues in palliative care 3. Pain and Symptom Management 4. Palliative care for people with chronic illness 5. Palliative care for people with dementia 6. Communication skills 7. Last days of life 8. Loss and grief 9. Caring for Ourselves. In 2013, we hope to develop the learning packages for home care and acute hospital care.
FREE PHONE 0800 734 223
A practitioner’s reflection
CHRIS MURPHY, Community Liaison and Educator – Palliative Services, Mary Potter Hospice, Wellington shares her thoughts on how hospices can work alongside aged care to care for residents with palliative care needs.
ollaboration and partnership is the key to providing a shared care approach to older adults and their families, whether they are living independently or in a provided care setting. The blend of expertise and experience across the staff at the aged care facilities and the visiting hospice staff means the range of needs of the residents are met appropriately. It is important that the specialist hospice staff respect the work of the nurses and GPs as they may have known the resident and the family and whānau for a number of years. We aim to add value and expertise to enhance the care already provided. The support that can be available to staff includes specialist clinical assessments and visits, a 24/7 telephone specialist support and advisory service, and an education service. Specialist multidisciplinary community teams provide specific advice on the management of care and symptoms for residents experiencing complex issues. They also assist with referrals and transition for specialist and complex palliative care, if necessary. There is a wide range of educational opportunities delivered by hospices and available for staff working in the aged residential care setting. Workforce issues, such as staffing, varying knowledge and experience, and the ability to provide backup to release staff for training, present a number of challenges, and we have
had to accept that one size does not fit all. Education is provided at a range of venues including on-site at the care facility. The style of delivery ranges from a short informal session at the report handover to oneday intensive workshops delivered at a formal venue such as the hospice education centre. We aim to deliver at various times to capture staff working shifts and to capture bigger numbers, including breakfast and evening meetings. The topics provide knowledge and skills to work with people requiring a holistic palliative care approach: physical, social, emotional, cultural, and spiritual. The presenters involve many members of the hospice clinical staff. Regular meetings with management assists with planning a service that meets the needs of staff and promotes a safe delivery of palliative and end-of-life care. There are many benefits for residents and their families from a good hospice/care provider partnership. Older people may face a number of health issues as they approach the end of life. Associated problems and symptoms also increase and these can be managed and supported by the expertise of their care workers. However, this requires a range of skills and expertise. The aim is to support older people to remain in their place of choice and to avoid moving them to an unfamiliar setting at the end of life.
In many areas, the care staff and the visiting GPs are the primary providers of palliative care and end-of-life care in an residential aged care setting. The facility staff and GPs are supported by the local specialist hospice palliative care service. The blend of expertise and experience across the two services ensures that the resident’s needs are met appropriately. Collaboration and partnership is the key to providing this shared care approach for older adults (and their families), whether they are living independently or in a care setting. It is important that the spThe knowledge of experience of the nurses and medical staff is variable as it is just part of their work. Many need further knowledge and skills, and many need to recognise and access the support to deal with the issues they face as they work with people who are dying. The family and whānau may experience issues of loss, grief, and bereavement. Specialist counsellors and social workers may be available to provide care and support to the family and whānau or advice to the onsite staff. GPs are supported by the Medical Consultants in Palliative Medicine. Symptom management can be very complex when a resident has age-related issues such as dementia, and a collaborative approach to medical prescribing is essential. This can be provided through assessment visits or via the telephone on a 24/7 basis.
www.insitemagazine.co.nz | December 2012 / January 2013
On the soap box... Sandra Hanmer Each issue, INsite seeks opinion on a contentious issue concerning aged care and retirement. FRESH EYES, FAMILIAR CHALLENGES, AND SIGNIFICANT OPPORTUNITIES Two months into her new role as chief executive officer for Healthcare of New Zealand, experienced community and integrated health system advocate SANDRA HANMER shares her initial insights on how we can work together to achieve improved health outcomes and greater individual wellbeing.
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’ve been a part of the Canadian health system for over 25 years, and like New Zealand, there has been much evolution in the way that health and disability services are provided. Starting somewhat afresh in New Zealand, it’s been natural to draw comparisons between the Canadian and New Zealand health and disability systems, many of them positive. Both countries greatly value the health of the population, and each has a shared focus of developing the supporting processes and systems to improve people’s health. Both are mindful that the health status of an individual includes health and other social considerations such as nutrition, housing, and employment. Health is not viewed in isolation. Another fundamental similarity is that both face some significant challenges and opportunities in terms of adapting the existing system to effectively respond to the increasing demand for high-quality, integrated health and disability support services within limited financial and human resources. So the good news is New Zealand’s health system is not alone. What is happening here is very similar to what is happening in other jurisdictions. New Zealand’s immediate advantage is its size. We can take a more direct population health approach and hopefully see improvements in health status over a shorter period of time. With a population of 4.4 million, as opposed to Canada’s 33 million, we have the capacity to trial and implement new health innovations that have direct and immediate benefits for far larger portions of the population. This is not to say, however, that when looking for solutions to the challenges we face across health systems we can simply apply a ‘one size fits all’ approach. The challenge for both systems is to continue to create sustainable long-term solutions. At present, both countries talk of having a health ‘system’, but often what we have are disparate parts and services that people move between – sometimes seamlessly, sometimes not. Another key challenge is that both countries are experiencing shortages in health leadership, specialists, and an ageing health workforce across all disciplines. However, with these challenges come opportunities. Across the New Zealand health and disability sector, there is the potential for significant sharing of knowledge and for New Zealanders to be
December 2012 / January 2013 | www.insitemagazine.co.nz
innovative, creative leaders in transforming our services to meet the needs of our population. Our focus must be to balance learning from and contributing to global policy, while delivering effective, personalised solutions at the local level. New Zealanders have a real willingness to do this. In addition, there are some very strong resources to draw upon, including first-rate tertiary academic institutions and excellent health specialists, secondary care health providers, and primary care networks. We need to ask ourselves how we can better use health ICTs and other resources available to enable us to further integrate and transform the way we provide health and disability services. We also need to empower individuals to ask what role they must play in improving and managing their own health. Change is constant so the time to embrace it is here, both globally and within New Zealand. We have a unique opportunity to influence and evolve our health system to ensure more people receive the right care in the right place, at the right time, by the right people. It’s no coincidence the key goal shared by both countries is to establish a more integrated health system that people can navigate through smoothly, with the right support along the way. Over the last four years, New Zealand has been a leader in the transformation of the health and disability sectors that favour integrated community-based services. Ultimately, our success will depend on our ability to work together, to empower the people we support and to use technology to continue to integrate and improve people’s experiences of the health system. Only then do we succeed in achieving improved health outcomes and enabling people to enjoy greater long-term independence and wellbeing. Sandra Hanmer has held several leadership roles in Canadian tertiary, secondary, community, and primary health organisations, including founding CEO of the Waterloo Wellington Local Health Integration Network, president and CEO of COTA Health, and CEO of the Victorian Order of Nursing. Hanmer recently relocated to New Zealand and is now CEO of Healthcare of New Zealand, an organisation providing community-based home support, nursing, and disability services to more than 18,000 people throughout the country every day.
arter House is buzzing from yesterday’s Melbourne Cup antics. A couple of residents pass through the entrance foyer boasting cheekily to reception staff about their wins. I wish I’d been there to see the residents and staff wearing their hats, tipple in hand, shouting at the horses. I can only imagine the frivolity in June when the home celebrated its 35th birthday. “We have a lot of fun,” confirms manager Sharon Owen, who is clearly passionate about aged care. “I’m a real sook when it comes to the elderly,” says Owen, a registered nurse for 23 years who has been managing aged care facilities since 1997. “They’ve loved, they’ve looked, they’ve seen, and have all that experience to offer.” There are 64 residents at Carter House: 17 in the secure dementia wing, 18 in the rest home and 29 in the hospital. Carter House has 26 retirement village units, which surround the facility. Anglican Care (Waiapu) Ltd, a not for profit organisation, has owned Carter House since 1994. The village residents integrate seamlessly with those at Carter House. Many like to volunteer to help with activities like housie and bowls as well as join Carter House residents for ‘happy hour’. Village residents are given first priority for beds in the home, helping to provide a smooth continuum of care. I like this aspect of Carter House – the way it doesn’t pigeon-hole its residents into various categories of care. The large common lounge, dining, and games area located midway between the rest home and hospital wings provides a hub for residents of varying levels of care. Today, Trixie, the home’s two-year-old Maltese cross, is the centre of attention in the lounge. Trixie is a working dog; her job is to be affectionate to residents and provide a sense of calm. She sits aboard a resident’s walker and is taken for a lap around the room while everyone, myself included, gushes. Poor Trixie is recovering from a recent attack from another dog, an injury that saw her make the front page of the Te Puke Times. Owen says the local vet has been so generous in aiding Trixie’s recovery. This isn’t the first time she hints at the close ties Carter House has with the Te Puke community. When three All Blacks visited the town during the World Cup last year, Carter House residents were among those in the grandstand to meet them, shamelessly using the rest home’s name to form a connection with Daniel Carter. Ninety per cent of the 75 staff are from the Te Puke area. “My other passion is my staff,” says Owen, who believes Carter House would be nothing without its fantastic team. She believes training is important to keep staff motivated and helps give them a personal sense of achievement.
Let’s snoop around...
JUDE BARBACK visits Carter House in Te Puke, Bay of Plenty.
They use the ACE programmes, but also draw on Ruth Thomas’ (Midland Regional Dementia Behavioral Support and Advisory Service Coordinator) expertise for bespoke training on mental health issues when needed. In the entrance foyer, a staff qualifications board is testament to the emphasis placed on training. Owen says she is “excited” about the roll-out of the interRAI tool to all aged care facilities and is unfazed by the training it will involve, as by the time it is integrated into Carter House, any issues would have hopefully been addressed. In fact, Owen strikes me as a team player. She is enthusiastic about the collaboration with other aged care providers in the region. “We’re such a diverse group, we all have something different to offer,” she says. She is also hugely supportive of the relationship Carter House has with the Bay of Plenty DHB. The DHB’s mental health department manages the waiting list for the home’s dementia unit, which helps to prioritise those who require this sort of care the most. This arrangement suits Owen as it takes away the burden of deciding who should go into the dementia unit, for which there is high demand. I sense Owen is particularly proud of the dementia unit and its strong diversional therapy team. Upon our visit, I’m particularly taken with the dementia unit’s garden, with
its promise of purple as the lavender and agapanthus get ready to bloom. In true Spark of Life fashion, the garden also has a pitch for golf putting, a clothes line, a mail box, and bus shelters. The interior of the unit is equally stimulating, with textured wall art, photos, and residents’ paintings displayed in common areas. While some of the dementia unit residents’ rooms have been recently painted, others are in need of redecorating. Owen says they barely can afford the time it would take to repaint, such is the level of demand. If they were to renovate, it would be to extend the dementia unit, she says. I’m a little surprised there is no mention of any plans to upgrade the resident rooms in the rest home. Like many older rest homes, the bulk of Carter House’s rooms are without ensuites, with the exception of seven rooms – previously manager’s quarters – which all have ensuites and decks. Owen says some residents go on a waiting list for one of the larger rooms, but when one becomes vacant, the resident often chooses to remain in the smaller room with the shared bathroom. I can’t help but wonder if future residents and their families will continue to take this view or whether Carter House will, in time, look to provide ensuites for all its rooms. For now, however, the status quo appears to be working. While Carter House may lack some of the lustre and polish of newer homes, it has a sense of homeliness that only time can bring to an aged care facility. The residents appear happy and comfortable in their surroundings. Some facilities I have visited give the sense that residents are not allowed in the reception area for fear of spoiling the ambience; at Carter House, the residents furnish the foyer with their presence and laughter. Today, the bowls team is congregating there and they are eager to be part of the photo. Residents, staff, and manager are all obliging with a “cheese” for the camera, and I hope I have captured the camaraderie and care that epitomises Carter House.
www.insitemagazine.co.nz | December 2012 / January 2013
Up close and personal with...
INsite chats to Michael Beaumont about the establishment of ACITVANZ (Aged Care IT Vendors Association of New Zealand), a new organisation aimed to bring together businesses that provide techn ological solutions to the aged care industry. INsite: Whose idea was it to form the new association? Beaumont: The
association was initially formed in reaction to the interRAI implementation, as we were concerned about the information that was being circulated in regards to the interRAI roll-out process. Secondly, it is important that our customers (the various facilities and healthcare providers) are well informed and aware of the changing face of IT in the aged care sector. This can be better achieved through having one voice. INsite: What is your role in the association? Beaumont: Together with Richard
Reddecliffe, we are trying to formulate the key objectives that ACITVANZ will advocate for, on behalf of the vendors and their customers. Secondly, it is to formulate a strategy to achieve these various objectives. The next stage will be to establish key relationships with various organisations that will enable us to meet these objectives.
INsite: Why was there a need for a new association? Beaumont: Aged care is a very significant
part of the New Zealand health scene. Businesses that provide technological solutions to the aged care industry of New Zealand needed a voice with a specific aged care focus, separate from other health and IT organisations. Several of our members are also members of the NZ Health IT Cluster but see ACITVANZ as being more of a niche organisation that can focus specifically on the needs of the aged care industry rather than the all-encompassing health environment of which that industry is a part. Aged care providers have different reporting and financial requirements and operate in different regulatory environments. Changes to these reporting requirements and structures have a huge impact on both aged care providers and their supporting vendors in terms of providing technical solutions to the aged care industry. The new organisation aims to offer a single voice regarding the business impact on vendors and their clients of such changes. 18
INsite: What barriers does ACITVANZ hope to overcome for its member companies? Beaumont: Having a single voice means that
ACITVANZ can work to support IT capability in aged care facilities such as basic IT skills and decision making (IT governance) – there is an advantage for all stakeholders to have an IT-literate user base in aged care. The member companies will benefit as key information can be disseminated from various organisations to ensure that IT vendors can anticipate rather than react to change. Having a single voice means that all vendors large and small can have access to government and non-government organisations. Through the association, feedback can be given to the key people and decision makers so that needs of the vendors can be understood when decisions are made. We aim to work with government and non-government agencies to ensure that changes in technology or requirements are rolled out using a positive and well-managed approach. The needs and requirements of the aged care sector can be better understood so vendors can provide current and future clients what they need.
INsite: How do you think it will make a difference to its member companies, competitors, and the aged care sector? Beaumont: The aged care sector will benefit
INsite: What is the next step for ACITVANZ? Beaumont: When we have finished defining
different government and non-government agencies can understand the real impact that the decisions that are made at a high level have on the business and aged care providers that must implement the directives of different agencies. By having a single voice, we can ensure that the various vendors operate ethically on a level playing field so that the aged care providers can make the best informed decision when it comes to purchasing an IT solution and that all relevant vendors are kept in the loop in terms of industry changes that affect us all. The new association, by communicating directly with key organisations, can better understand changes in reporting, financial, and clinical requirements so that we can be better prepared and better service our clients when change occurs rather than finding out about change late and on an ad hoc basis.
as vendors will better understand various regulatory requirements and can anticipate changes so that the disruption caused by changes will be minimised. The sector will also benefit as we can work with government and non-government agencies as a voice for our clients to ensure that all their considerations are known before change occurs. This ensures that the regulatory agencies can focus on the successful implementation of projects with all parties working towards the same goal.
December 2012 / January 2013 | www.insitemagazine.co.nz
REACTIONS TO ACITVANZ: Chris Fleming, Lead Chief Executive Officer for Health of Older People: “I am pleased to see this New Zealand Aged Care IT Vendors Association come together. Over the past year, we have been working with the vendors to find solutions that enable their IT solutions to work in an interoperable manner with the Comprehensive Clinical Assessment tool (interRAI), which is being rolled out across aged residential care. It is vital that the systems work together to ensure the most effective and efficient processes that avoid duplication can be adopted by all.
the complete organisational structure of ACITVANZ, we will look at improving the way that technology is utilised in the aged care sector. This will help to ensure that the aged care facilities and providers benefit from the technological advances in the marketplace. FOUNDING MEMBERS OF ACITVANZ: » » » » »
Netsoft Vcare Leecare HSA Global Momentum Healthware » Infogeni
» » » » » » »
PeoplePointAptean ecare Time Target Press Ganey i.on my care Care training online QPS Benchmarking
The ability to engage with a single association as we move forward to find the solutions will make progress and communication easier for all.” Martin Taylor, Chief Executive, New Zealand Aged Care Association: “We are very supportive; it gives the steering group one point of contact and shows a maturing in vendors where they can put aside commercial competitiveness and discuss common issues and agree on the best solution.”
A typical day in the life of … Rona
INsite chats to a shopping service co-ordinator for Age Concern.
o you know an older person who can no longer drive themselves around? Who has no family support nearby and who does not have the finances to call a taxi to go grocery shopping? That person is exactly who I help on a daily basis. I believe I have one of the most rewarding jobs around: I am the shopping service coordinator for Age Concern Hamilton. We have a band of nearly one hundred precious volunteers who either shop with their older clients for an hour each week or undertake relief shopping for us. The majority live in Hamilton, but we also have volunteers in most of the Waikato rural towns. The shopper uses their own car to collect his/ her client and take them to their nearest supermarket. Assistance is given to reach products, read labels, carry grocery bags, and even unpack and put away the shopping at home if necessary. Our shopping service makes such a positive difference in our clients’ lives: not only does it allow them to keep well-stocked with nourishing food but also to enjoy a regular social outing. In some cases, our service makes the difference between an older person being able to stay in their own home versus moving into a full-time care facility. Many of our volunteers and clients form close friendships and both look forward to their weekly trip to the supermarket … and sometimes a cuppa afterwards! In the past few years, I have been running my own businesses at home – small group cooking classes and a guesthouse. However, at the start of this year, with our three children all grown up and out on their own journeys, we decided to sell up our rural lifestyle property and move into town. I wanted to try a bit of voluntary work, and (with the help of Mr Google) I found Age Concern. When I enquired, I was told of a part-time job coming up in their office. I really was in the right place at the right time! I live in the beautiful town of Cambridge and travel through to Hamilton to be at my desk by 9am. There is usually an assortment of messages for me by the time I get there; perhaps one of my volunteers is unwell and I need to organise a relief shopper, or sometimes, I will just get in my car and take the client to the supermarket myself. There may be a new referral from Disability Support Link that requires me to contact the older person to explain what Age Concern can help them with. I then send out the paperwork for signatures and ring around our volunteers who live in close proximity to see who might like to take on a new client. Some
of our dedicated shoppers have two, three, or more clients – what gems they are. If I have applications from new would-be volunteers, I will process these – we carry out police checks on all our applicants and their vehicles must be registered, WOF’d, and insured. I also meet with them for a chat and informal training session – they have guidelines to follow, and I run through any difficult situations which may arise during their work. As well as pairing up clients by location, I
all rub along very well together in a relaxed environment. Usually, we are all heads down/ bottoms up and busy, but we do try and stop for a quick lunch, a bit of a gossip, and set the world to rights! We are enthusiastically supported by the Age Concern Council members. Working for a non-profit service organisation certainly makes mine a ‘feelgood’ position. We are there to help people, many of whom can be feeling quite
Assistance is given to reach products, read labels, carry grocery bags, and even unpack and put away the shopping at home if necessary.
also try my best to make good personality matches. Fortunately, our shopping service receives a level of funding from the Waikato DHB. This support requires us to keep comprehensive financial records, and part of my day is spent administering these databases and reimbursing our shoppers a little for their vehicle costs. I work alongside eight other great ladies in our office in the Celebrating Age Centre in Victoria Street, Hamilton. We have a manager, two administrators, two visiting service co-ordinators, a field worker, an elder abuse and neglect co-ordinator, and a nutrition and health education facilitator. We
vulnerable. The clients are usually really appreciative of everything we do for them and the volunteers love being able to give back to their community and form friendships with someone of another generation. Of course, when you work among older people, you inevitably have some very sad days when you hear that one of your clients has been admitted to hospital or has passed away. But even at these times, it is a privilege to be a ready listener for the family. Through my work with Age Concern, I have definitely learned to be a more patient person. I have discovered that everyone has a story and we enrich our own lives by taking the time to hear it.
www.insitemagazine.co.nz | December 2012 / January 2013
Last word... Lynne Abercrombie DIFFERENCE IN OPINION
In the previous issue’s ‘Last Word’ column, Margaret Owens expressed her views on village operating models, advocating for a pastoral care model over a service model. Here, Metlifecare’s LYNNE ABERCROMBIE offers a different opinion on the subject.
argaret Owens’ article in the Last Word in the October/November issue of INsite was an interesting read that certainly provoked some dismay and debate in our team. The views expressed reflect a historic and polarising view of an industry that has evolved and continues to evolve in a climate of ever-changing social expectation and health policy reform. Having moved beyond the disappointment that such views might still be held, we have taken some time to reflect on what our own model looks like. The increasing expectation within social policy to develop strategies and processes that will allow older New Zealanders to remain in their own home, living as independently and safely as they can, is well documented and widely discussed in the sector and broader community. As key stakeholders in the industry, we should be united in providing viable and attractive living arrangements that can assist in that process. The model by which any provider chooses to operate should be guided by that operator’s business values and the desires of the community in which they operate. The two models that Owens proposes each have their merits, and arguably, a place in the industry, but to suggest they are the only models that currently operate, or indeed, that a pastoral model with a strong focus on “doing for” is the best model, is wrong. Metlifecare operates a model that has been developed and refined over many years in the industry and in response to our residents’ and prospective residents’ feedback. We choose a model that empowers our residents to make decisions about their lives.
Values that underpin this model are shared and demonstrated by all staff, led by the village manager. We value a partnership with our residents built on trust, integrity, and a generosity of spirit that ensures a day-to-day relationship that is fulfilling and meaningful. Within the context of that relationship, residents are empowered to live their lives as they choose – independently, with support and assistance or receiving high levels of care. Where they receive that support and care is again a partnership decision in which the wishes of the resident are paramount, albeit that at times they need to be guided by matters of safety and affordability. Contrary to the statement that residents in the “service” model (which by definition Owens would suggest we operate) are less connected to the village, Metlifecare’s recent annual independent research on residents’ satisfaction demonstrated overall 98 per cent level of satisfaction with the services offered and an increase in the sense of feeling connected to their village and relationships with staff and others. The Baby Boomers to whom we will be selling in the future are an informed and empowered consumer group. There is a place in our industry for a range of business models, but we would suggest that underpinning any successful model in the future must be a partnership between resident and manager that recognises the right of the resident to make choices that suit them as an individual. Lynne Abercrombie is General Manager, Operations of Metlifecare Ltd.
RESIDENTS’ WISHES at Christmas
Have you or your staff been fulfilling the wishes of your residents in wondrous ways? WOULD YOU LIKE TO BE REWARDED WITH $1000? If so, INsite would love to hear from you for the INsite/NZACA Residents’ Wishes competition!
December 2012 / January 2013 | www.insitemagazine.co.nz
PARTICIPATE IN THE INsite READER SURVEY TO WIN By spending just a few minutes giving us your feedback about INsite, you will go into the draw to win a fabulous summer reading prize pack. See page on right.
THE PRIZE PACK INCLUDES COPIES OF: » Brazil (Michael Palin) » Quotable New Quotes » The Ultimate Vegetarian Collection » Touchstones: A Memoir » Dear Heart » The 20th Century in Poetry The prizes are courtesy of New Holland Publishers, Random House, and Hachette NZ. For more information on these great books, visit: » www.newhollandpublishers.co.nz » www.randomhouse.co.nz » www.hachette.co.nz AGED-CARE & RETIREMENT
The theme for this year’s INsite/NZACA competition is “A resident’s wish fulfilled”. Send us your fabulous photos of how you or one of your staff members met the needs of your residents this year. It could be anything: organising a social event, offering extraordinary personalised service, or perhaps a field trip with a special purpose. If you fulfilled the wish of one of your residents, we want to know about it!
Entry information »
Send up to five photos (high resolution), with captions of 50 words of less. Prize money: $1000
Entries via: » »
Email: firstname.lastname@example.org Post: INsite/NZACA Residents’ Wishes competition, PO Box 200, Wellington 6140 Entries close 15 January 2013 Entries published in INsite’s February/March 2013 issue
AGED-CARE & RETIREMENT
READING INsite How did you come to read the magazine? It was sent to me directly It was in a pile in a common area Online Other (please specify) ........................................................................................................................................ ........................................................................................................................................
How many other people read your copy of the magazine? None 1 2
On average, how long do you spend reading INsite? 1–5 minutes 5–15 minutes 20+ minutes How would you rate the articles in INsite? Excellent Good Average Poor Very Poor
What topics are you most interested in? [multiple answers] Profiles of aged care workers Interviews with aged care leaders/leader opinion Infrastructure and design ICT and procurement Dementia/Alzheimer’s disease Care tips/advice Clinical tips/advice Management or business tips/advice Colleagues’ activities outside work Other (please specify)
Who would you like to see interviewed in INsite? ........................................................................................................................................ ........................................................................................................................................
What do you most dislike about INsite?
Have you visited the INsite website in the past three months? Yes No
What aspects of aged care are you most interested in? [multiple answers] Rest homes Retirement villages Home-based care Other (please specify) ........................................................................................................................................
What sections in the magazine do you enjoy most? [multiple answers] Focus (themed articles) News A Day in the Life (following one worker’s day) Q&A (feature interview) Spotlight on (discussion on a specific topic/idea) Last Word (an expert’s opinion piece) Other (please specify)
How do you look for work in the aged care sector? INsite magazine INsite website Newspapers TradeMe website Seek website Other [specify]
What is your annual income? Under $30k $30–50k $50–80k $80–$100k $100k+
What story topics are you most interested in? [multiple answers] Retirement villages as a business Long-term care needs Design innovation in aged care Nutrition and diet in aged care Infection control and wound care Trends in home health Other (please specify)
What is your age? 18–34 35–44 45–54 55+
Are there any new sections you would like to see in INsite?
Are there any other products or services you would like to see in INsite?
What is your gender? Male Female Transgender/other
What do you most like about INsite?
Would you recommend INsite as a good read to someone else? Yes No
WORKING IN THE SECTOR Do you believe aged care workers are paid appropriately? Yes No Do you believe you are paid appropriately for your skills and experience? Yes No Which peak body best represents you? New Zealand Aged Care Association Retirement Village Association New Zealand Home Health Association Service and Food Workers Union Other [specify] ........................................................................................................................................
Do you have any comments on the state of rest homes in New Zealand? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
Do you have comments on the state of retirement villages in New Zealand? ........................................................................................................................................
How many conferences do you attend each year? None One Two Three Four or more Do you have any other comments? ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
Thank you for your time. Rest assured that your information remains confidential and will not be given to any third party. To enter the prize draw, write your details below and send your survey marked ‘INsite reader survey’ to: Post: Box 200 Wellington 6140 Fax: 04 471 1080 Email: email@example.com Your name: ................................................................................................... Job title: ............................................................................................................ Postal address: ......................................................................................... Email: ................................................................................................................... Phone: ................................................................................................................. Mobile phone: ..........................................................................................
www.insitemagazine.co.nz | December 2012 / January 2013
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