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HEALTH’S EMERGENCY REPORT WARNS OF EMERGING CRISIS
SHORTSIGHTED GERONTOLOGICAL & ILLOGICAL NURSING
HSE SERVICE PLAN 2014
IMMENSE SATISFACTION IN CHANGING LIVES
Book of evidence highlights requirement for immediate State action
Tadhg Daly, Chief Executive Officer, Nursing Homes Ireland “Planning is bringing the future into the present so that you can do something about it now”, American writer Alan Lakein once wrote. It is an apt truism that has been further brought to bear for the Irish long-term residential care and wider health sector arising from the recent publication of Health’s Ageing Crisis: Time for Action – A Future Strategy for Ireland’s Long-Term Residential Care Sector. The BDO report’s publication coincides with a critical and definitive moment in time for long-term residential care in Ireland. Its findings make compelling reading for those operating in our sector, the wider health service and for a Government aiming to make ‘Ireland the best small country in the world to grow old’. The first sentence of the report’s executive summary encapsulates the critical crossroads our sector finds itself at: “The provision of residential care for our ageing population is rapidly heading for crisis; however this is a situation that can, with the appropriate actions, be avoided.” For our sector, a series of long-standing key issues remain unaddressed. This report now provides independent timely analysis. Readers of NHI News will already be aware the HSE in its National Operational Plan 2013 warned of a “significant national deficit of long stay beds by 2016”. The Fair Deal review that Department of Health stated would be completed before year end 2012 remains outstanding. Last May a HSE presentation outlined glaringly the stark scenario facing the State in the provision of public long-term residential care, when costs of €1.68bn were outlined to maintain current provision and a 20% public presence within the sector. As the report acknowledges, at a time of straitened financial circumstances we must ask the question is this the best use of scarce public resources. In November 2011 – over two years ago – Minister Reilly told the Oireachtas Health Committee“we have to ask why 50% additional costs pertain in public long-term institutions and facilities for the care of the elderly which do not apply in the private sector, and have to examine and address that”. The terms of reference for the Fair Deal review, published June 2012, commit “to examine the overall cost of long-term residential care in public and private nursing homes. While the updated fees (Fair Deal) agreed between HSE and all private and voluntary nursing homes are publicly published on a consistent basis – the most recent being February 2014 - it remains an outstanding issue that public nursing home fees are not subject to the same transparency, with the most recently published dating back to March 2011. The weekly cost of public nursing home care is 3 years out of date – what are the HSE hiding? The HSE committed to NHI February 2013 it would publish up to date fees for public units within weeks, advising a review of capacity had looked at costs of such homes, but the commitment remains
01 — NHI NEWS
outstanding. In May 2012 the HSE published its report advising consultation process in respect of the future of community nursing units in the Midlands. As illustrated, since it has assumed office, this Government has failed to act with required urgency to grasp and address the very serious issues facing the provision of nursing home care. The crisis is on our doorstep. The 2013 Operational Plan stated under supply of long-term residential care beds is already an issue in urban centres. This is evidenced by the unacceptable, and avoidable, issues concerning increased numbers on trolleys in our acute hospitals. NHI commissioned BDO to conduct this essential independent analysis to bring together objective research and evidence to inform of the growth in requirement for nursing home care, assess public policy surrounding long-term residential care, provide recommendations and to outline consequences of inaction. BDO analysed key statistical independent data, national and international reports, government commissioned reports and reviews. Health’s Ageing Crisis is a vital and crucial contribution to debate and policy planning surrounding longterm residential care and wider healthcare delivery. Key stakeholders inputted to BDO’s body of work, including the Department of Health, HSE, HIQA, NTPF, IMO. The debate surrounding requirement for nursing home care is often skewed. Only one in 20 persons aged 65+ requires long-term residential care. Understandably this increases to around four in 20 persons for our 85+ population. Looking at the population projections, BDO points to the CSO analysis that the population aged 85+ will increase 46% by 2021; this is 7 years away - yes only 7 years. “The level of frailty and complexity of the medical needs for those of that age increases, prompting a greater and often essential need for residential care,” the report states. “The evidence is clear. The need for nursing home care increases within the older age cohorts…In short, demand for nursing home care from those segments of the population whose care needs can only be met in a long-term residential care setting is forecast to increase substantially in the short to medium term.” This is a warning our Government cannot ignore. Health’s Ageing Crisis forewarns of the implications for State of failure to implement appropriate policy. Ireland already has one of the lowest numbers of long-term beds per 1,000 of the population when benchmarked against comparator countries, the analysis informs. It refers to Government commitment to develop an integrated care model that treats patients at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. It points to Sweden, where acute capacity was reduced, but long-term residential care capacity was increased, with 7.5% of population aged 65+ receiving long-term care in residential homes and 9.5% formal care at home. BDO’s analysis warns of consequences of diversion of funding to support persons requiring long-term residential care, outlining it will result in much higher social and economic costs now and into the future. “Even if the government and its agencies are successful in developing alternative or complimentary models of care for our older population, the increases in the cohorts of our 85+ population, whose complex care needs can be best met in a nursing home, will continue to generate strong levels of demand for nursing beds,” the report states.“It is clear that the current Fair Deal Budget is inadequate in the context of an ageing population, with associated higher dependency levels. The report quotes Age Action Ireland concern at diversion of Fair Deal 2014 funding. It stated: “We are extremely concerned that the switch in some of the funding from nursing home supports to community supports which the HSE is planning will be insufficient to meet the needs of the sickest of older people who will be affected…Older people whose needs are not met in the community will
CONTENTS NHI NEWS News from Nursing Homes Ireland, the representative organisation for the private and voluntary nursing home sector.
HEALTH’S AGEING CRISIS The Government’s current short-term approach with respect to policy and funding for the residential care needs of our ageing population will, if continued, result in a much higher social and economic cost in coming years, the BDO report Health’s Ageing Crisis: Time for Action states.
READ ALL ABOUT US The fundraising endeavours of residents and staff of a Dublin nursing home, who took to the streets to raise money and support those affected by Typhoon Haiyan in the Philippines; a proud resident of a Co Cork nursing home becomes a first-time author; 2013 saw visits to Ashford Castle, Knock & publication of a new magazine in a Co Mayo nursing home; Coral Haven in Co Galway celebrates its 10th anniversary.
DATES FOR YOUR DIARY NHI Members note key dates on the NHI calendar for the year 2014.
NEWS UPDATE Nurse prescribing raised in the Oireachtas and national audit shows shorter stay in acute hospitals for persons with dementia admitted from nursing homes.
HSE SERVICE PLAN 2014 NHI & Age Action are warning of the consequences for the wider health sector of the €35m cut to the Fair Deal budget for the year 2014.
QUALITY IMPROVEMENT GRADUATION NHI Members were amongst the first Irish graduates of a course in quality improvement science that was jointly run by HIQA & IHI.
MY NURSING HOME LIFE NHI’s Director of Nursing / Person in Charge 2013 Award Winner advises of the emphasis that is placed upon continuous professional development in nursing home care.
NHI ANNUAL CONFERENCE 2013 The Department of Health is favourably disposed to bringing key stakeholders in the provision of long-term residential care around the table to plan for requirement, the NHI Annual Conference heard.
BEST PRACTICE At Moorehall Lodge Ardee the approach is to live in the moment and capture the essence of it by using visual triggers to stimulate recollections and make emotional connections. It was the inaugural NHI Care Awards Innovations in Dementia Care Award winner.
ART & DEMENTIA As the Creative Director for dementia specific programs and an artist, Michelle Burns truly believes in the therapeutic nature of art. For those with dementia, the expression it affords provides them with a new voice, the Creative Director at Senior Access, an Adult Day Programme in San Rafael, California, writes.
NHI CARE AWARDS 2013 Glitz and glamour at the annual celebration of nursing home care: the NHI Care Awards 2013
NHI ACKNOWLEDGES SUPPORT OF
Thanks to all supporters of NHI, many of whom are featured in this newsletter. Please note, NHI is not responsible for third party services advertised in this publication. Inclusion in this newsletter does not endorse, recommend or imply any approval of the suppliers listed in this publication.
be admitted to acute hospitals while others will be left struggling at home on ever-lengthening waiting lists for a nursing home bed”. BDO’s warnings are stark: “Diverting money from the Fair Deal to support home care packages (a sector that remains unregulated) will only further increase the delays in securing longterm residential care for those who need it most. The net weekly cost to the Exchequer of private nursing home care is averaged at c.€750 (excluding the resident’s contribution) per resident versus a weekly cost of c.€6,000+ in the acute hospital sector. This means that for every 1,000 of the population who cannot access nursing home care and therefore must remain in acute care, the State is incurring a cost of up to €6m per annum.” NHI has warned the Government it cannot‘bury its head in the sand’ concerning the very serious issues it is faced with in respect of long-term residential care. This independent analysis highlights lack of a clear policy and national strategy for the long-term care of our older population and cites current uncertainty around future funding arrangements for nursing home care. The nursing home sector does not exist in isolation. It is integral to a proper functioning health service. Failure to address the issues outstanding will have very serious consequences for our acute hospital sector and impact negatively upon wider population. Health’s Ageing Crisis is a crucial body of research that cannot be ignored. This report outlines in stark terms the crisis that is imminent. The issues highlighted are of national importance and will impact upon wider health sector and Irish society. It warns the time for action is now and offers a series of considered recommendations. A key message is with the appropriate action and policy crisis will be avoided. NHI and the care provided by our members are a key part of the solution. The appropriate action and policy will ensure older persons are provided with appropriate care in their local communities. Our sector does not exist in isolation and is essential to health service delivery and must be central to Government plans to reform our health service. Health’s Ageing Crisis outlines in stark terms massive cost implications for the State if it fails to plan with immediacy for our residential care requirements. I echo the comments of Robin Webster, Age Action Ireland CEO, who stated at Health’s Ageing Crisis launch the report must be given consideration in the context of a national debate. NHI is now focussed on bringing its findings and recommendations to stakeholders and wider public attention. This report can provide the momentum and impetus to escalate required action to meet our older persons care requirements. We cannot and must not prevaricate any longer. As the report title states – ‘Time for Action’.
Tadhg Daly, NHI CEO
NHI NEWS — 02
NHI UPDATES Committed to excellence in care www.nhi.ie
NHI calls upon Government to heed ESRI acute hospital report findings Two-thirds of extended stays in acute public hospitals in 2012 were by older persons, the ESRI has reported. The extent of older persons utilising acute hospital services and high level of dependence placed upon these health settings to meet their healthcare requirements has been outlined by the latest report by the ESRI into activity in acute public hospitals. The Activity in Acute Public Hospitals in Ireland 2012 Annual Report was published 10th December and key ﬁndings included: P Two-thirds of the total extended stay days in public hospitals in 2012 (66.7% - 657,614) were by persons aged 65+. 10,140 of the stays during the year were by persons aged 65+. P
Over half the total acute stay days were by persons aged 65+ (50.2% - 1,086,927). 34.7% of the such stays were by persons aged 65+ (167,378).
The 65+ age group represented 36.4% (511,145) of total discharges in 2012. This represented a 6.4% increase on 2011 number and 5% increase since year 2008.
Persons aged 65+ accounted for the largest proportion of total bed days (47.3%), which was an increase of 1.9% on the 2011 ﬁgure
Persons 65+ accounted for 1,744,541 (39.7%) in-patient bed days in 2012.
4.6% (23,121) of in-patients were discharged to long-stay accommodation (national total – 497,875)
Nursing Homes Ireland warned the Government that it cannot ignore the ESRI-identiﬁed need for increasing care services for an ageing population. NHI said that the Department of Public Expenditure and Reform is represented on the ESRI Council and should take note when allocating health resources. “If ofﬁcial reports produced by public institutes over the years had not been ignored then the recession may not have been so severe, so it’s time to stop ignoring these reports,” said Tadhg Daly, NHI CEO said. “Too many reports get ignored in this country and it is pointless having these institutes if nothing happens at Government-level about their reports.” “It is fantasy for the Government to simply wish older persons will be able to stay in their own homes when it is evident there is considerable dependence being placed upon acute hospitals to provide them with care,” said Mr Daly. “The nursing home sector has a very signiﬁcant role to play in alleviating the pressures upon acute hospitals and to consequently bring signiﬁcant reductions to health spending.” “Older persons must be able to access the support of the Fair Deal scheme in a very timely manner. Any cut to the Fair Deal scheme further increases the numbers awaiting the specialist care of nursing homes and in turn leads to further increases in numbers being cared for in the inappropriate settings of public hospitals. The cut to Fair Deal in the 2014 Service Plan poses a serious threat to the positive developments in respect of A&E and hospital waiting times.”
Welsh First Minister at Five Nations Care Forum Welsh First Minister Carwyn Jones attended the most recent Five Nations Care Forum Meeting that NHI was represented at. The Care Forum brings together representative organisations for Northern Ireland, England, Scotland, Wales and the Republic of Ireland to explore matters such as care delivery, registration, regulation and government policy, and to identify common areas of concern. NHI is the forum member organisation for the Republic of Ireland. First Minister Jones spoke with Tadhg Daly, NHI CEO, and Owen McGartoll, NHI Chairman, at the conference that took place in Cardiﬀ last October. Mr Daly and Mr McGartoll informed of the private and voluntary nursing home sector in the Republic of Ireland and regulation and policy. Speaking at the conference, Minister Jones praised the work of Care Forum Wales, which celebrated its 20th anniversary in 2013. www.fivenationscareforum.com Pictured from left, are, Tadhg Daly, CEO, Nursing Homes Ireland; Bridget Warr, Chief Executive, United Kingdom Home Care Association; Robin Sidebottom, Vice Chair, Scottish Care; Christine Thompson, Independent Health and Care Providers; Wales First Minister Carwyn Jones; Mario Kreft MBE, Chair, Care Forum Wales; Nigel Newman, Senior Business Development Manager, Boots UK; Des Kelly, Executive Director, National Care Forum; Martin Green, Chief Executive, English Community Care Association.
03 — NHI NEWS
NHI presents to Oireachtas re End of Life Care NHI presented to the Oireachtas Joint Committee on Health and Children’s Public Hearings on End of Life Care in Leinster House on 5th November. Mary Burke, Chairperson NHI National Nursing Committee, appeared before the Committee to discuss end of life care in nursing homes and offer recommendations in respect of providing such care. NHI's recommendations brought to the Committee included: P The role of GP in providing services to residents in nursing homes is clariﬁed and that this is done in tandem with a full review of the GP contract and education for GPs involved. P
Registered Nurse Prescribers working in private healthcare facilities are issued with a prescription pad and enabled to prescribe residents with Medical Cards.
The HSE publish the ﬁndings of the QPSA (2013) audit on Primary Care Team Services and outlines the actions taken to address the deﬁcits in service provision.
A formal mechanism for GPs to communicate with out-of-hours services is implemented without delay
The development of a Department of Health led Forum/ Expert Group on long-term care.
The role of the GP in providing services to residents in nursing homes is clariﬁed and that this is done in tandem with a full review of the GP contract and education for GPs involved.
There is an increase in the number of Geriatricians nationally to improve access to diagnosis and chronic illness management in the nursing home thereby reducing unnecessary hospital admissions. An extension and replication of Connolly Hospital out-reach service is the preferable option.
Consideration be given to the prioritisation of palliative care patients on the Fair Deal waiting list to facilitate death in a more appropriate place.
Legislation pertaining to Advanced Care Directives is implemented in Ireland and its publication is accompanied by a general public awareness campaign and specialised education for healthcare professionals.
There is a public awareness campaign and tailored education for health care professionals prior to enactment of the Assisted Decision Making (Capacity) Bill.
NHI procurement partner wins national award For the third year running, First Choice Purchasing was a winner at the National Procurement Awards. First Choice Purchasing partners with NHI to deliver the group purchasing scheme that is exclusive to NHI members, delivering cost savings and beneﬁts to members in the day-to-day running of their business. Pictured receiving the Excellence in Private Procurement with SME’s Award is Eoghan Donnellan of First Choice Purchasing and Edward Heﬀernan, Associate Director with Morgan McKinley. NHI Members can sign up for the scheme and can do so by mailing Eoghan Donnellan at edonnellan@ﬁrstchoicepurchasing.com or by contacting him at 086 2295638.
Above: Mary Burke, Chair NHI National Nursing Committee, is pictured, right, at P Immediate action is taken to address the Leinster House ahead of her presentation deﬁcits in ‘Adaptation’ and ‘Return to Practice’ to the Oireachtas Health Committee re nursing programmes. End of Life Care with, left, Paul Gregan, Primary Palliative Care Initiative, and, You can read NHI's submission to the Committee centre, Mary O’Dowd, Institute in respect of End of Life Care via the news section Community Health Nursing. of the NHI website, www.nhi.ie.
NHI features on Drivetime RTE Radio 1 re access to therapies Health Policy Analyst Sara Burke brought to public attention an unpublished HSE Audit of Primary Care Team Service provision that revealed the majority of nursing home residents do not have access to essential therapies provided by the HSE. Ms revealed details of the HSE audit on her health slot on Drivetime, RTE Radio 1, on Thursday 21st November. She informed therapies such as speech and language therapy, OT, physio, and dietetics are essential for the health and wellbeing of older persons in nursing home care and make a huge difference to their quality of life. However the HSE audit states just a third of residents in private and voluntary nursing homes have access to these HSE provided services, whereas half of those in public homes can access. When she queried the HSE in respect of the audit ﬁndings, she advised she was informed emphasis is on providing such services to people in the community. Ms Burke said this emphasis is proving to the detriment of older persons in nursing home care. She informed the Fair Deal scheme does not encompass
such essential care and despite the vast majority of nursing home residents holding medical cards, they cannot avail of services they are entitled to in an appropriate time. Tadhg Daly, NHI CEO, responded to Ms Burke's report on the show. He informed residents in nursing home care have complex needs and are high dependency and such therapies are re-enabling and life-saving. He said the challenge is to engage with stakeholders to ensure residents can avail of such services and older persons in nursing homes must be capable of accessing such services in a short timeframe from the comfort of their home - the nursing home. He advised of a "postcode lottery", whereby access can differ signiﬁcantly for residents in nursing homes within short proximity to each other because of differing HSE authorities. He said the HSE has a responsibility to ensure persons in such care have timely access to these life enabling and saving therapies. Mr Daly said the ongoing Fair Deal review presents further opportunity to address this critical issue.
NHI NEWS — 04
NHI partners jobs programme to support disadvantaged jobseekers NHI is partnering the STEP Supported Employment Nursing Home Pilot Programme, an initiative designed to support disadvantaged job seekers to gain skills, experience and qualiﬁcations to meet the increasing demand for workers in the elderly care sector. The programme started in February and commenced with six months focussing on work experience placements at St Mary’s Nursing Home, Merrion Rd, Dublin. The participants are being supported by a job coach, a facilitator from Southside Partnership, work buddies, a project assistant and project manager, in union with the nursing home staﬀ and residents. Fifteen months will be spent working towards a HIQA qualiﬁcation with work-placements provided through open training college in Goatstown. Tadhg Daly, NHI CEO stated: “Private and voluntary nursing homes provide wide-ranging employment in urban and rural communities across Ireland. With innovative support frameworks such as the STEP Supported Employment Nursing Home Pilot Programme their role in enabling job seekers develop skills and secure gainful employment can be enhanced.” The programme was launched by An Tánaiste Eamon Gilmore on 11th February at St Mary’s Centre, Dublin.
Pictured at the launch of the programme are, from left, Claire Hopkins, Open Training College; Mary O’Halloran, STEP Supported Employment; Teresa Mallon, Menni Services; An Tánaiste Eamon Gilmore; Sarah Togher, Irish Association of Associated Employment; Tadhg Daly, NHI CEO.
NHI Members show intergenerational solidarity as gesture of support for Filipino colleagues NHI Members raised over €17,000 to support the people of the Philippines who were visited by the great tragedy that was typhoon Haiyan. The tragedy brought great sorrow and distress to people working in NHI Member homes who are members of the Filipino community. The €17,000+ raised through the fundraising efforts and generosity of NHI Member homes staff, residents and visitors has been presented to UNICEF to support its relief efforts on the ground in the Philippines. NHI’s Member support of the NGO that saves and protects the lives of children is a statement of intergenerational solidarity. The fundraising of older persons living in Irish nursing homes and staff providing them with care is supporting children who are now homeless and extremely vulnerable to life-threatening diseases because of the impact of typhoon Haiyan. Speaking at the cheque presentation, Peter Power, Executive
Director, UNICEF Ireland said: “I would like to sincerely thank Nursing Homes Ireland and its members for supporting UNICEF Ireland’s humanitarian work in response to the devastating typhoon which caused so much destruction in the Philippines. “Many members of the Filipino community here in Ireland work in nursing homes throughout the Country and we are grateful for their support. The money raised will go directly to UNICEF’s lifesaving work in the Philippines as we help the millions of children and families who have lost everything to recover from this disaster.” Tadhg Daly, NHI CEO said: “I thank Members for your generosity in supporting the NHI Philippines Relief Fund and showing solidarity with your colleagues during this time of sorrow, distress and worry. Our Filipino colleagues are dear friends and bring great care and compassion to residents living in nursing homes.”
NHI Philippines cheque presentation Pictured at the cheque presentation in The Marlay Nursing Home are, from left, staff of the nursing home Teresita Cruz, Ronaldo Bundoe, Ailen Lumires, Dulce Valmonte, Colette Clabby (Director of Nursing), Tadhg Daly, CEO of Nursing Homes Ireland, Peter Power, Executive Director UNICEF Ireland, Ed, Julien Wardag, Rolando Patolilic. The Marlay Nursing Home staff, residents and visitors contributed generously towards the Philippines Relief Fund.
05 — NHI NEWS
Prominent health & finance speakers to feature at NHI Members Seminar 2014, as Members gather for AGM – 9th April 2014, Galway Leading health policy analyst Sara Burke and renowned economist Dr Alan Ahearne will speak at the NHI Members Seminar 2014, as Members will travel to Galway for the Seminar and company AGM. Both events will take place Wednesday 9th April at the Ardilaun Hotel, with Seminar registration from 9am and the AGM commencing at 2.30pm. Speakers of particular interest for private and voluntary nursing home proprietors have been lined up by NHI to speak at the Members Seminar and they include Sara Burke, journalist, broadcaster and health policy analyst, who has a weekly health slot on RTE Radio 1’s Drivetime. Sara also writes a fortnightly column for the Medical Independent and is a part-time research fellow in the Centre for Health Policy in Trinity College Dublin. Dr Alan Ahearne is Head of Economics at the National University of Ireland, Galway. At the AGM he will speak to NHI Members re the economic outlook for SME’s and moving on from the recession. He will speak about cost of capital, interest rates, wages and inﬂation. Dr Ahearne is a Member of the Commission (that is, the Board of Directors) of the Central Bank of Ireland. He is also a member of the Central Bank’s Audit and Risk Committees. Prior to taking up his role with NUIG, he was Senior Economist at the Federal Reserve Board in Washington, DC, where he worked for seven years. At the Fed he advised Alan Greenspan, Ben Bernanke and other Fed Governors on developments in the global economy. He was the principal economist at the Fed covering the Japanese and Chinese economies. He served as Special Advisor to former Minister for Finance, the late Brian Lenihan, from March 2009 to March 2011.In this role, he advised the Minister on
economic, budgetary and ﬁnancial policy in responding to the economic and ﬁnancial crisis. Among other things, he played an advisory role in relation to the three budgets during the period, the National Recovery Plan, the creation of the National Asset Management Agency and other measures to address the ﬁnancial crisis. NHI Regions have put forward a series of diverse motions for discussion and ratiﬁcation at the 2014 AGM. Members will be informed further of other speakers in the near future and NHI advises it is imperative that you book in advance for the Seminar / AGM. You can book by mailing firstname.lastname@example.org or contacting head ofﬁce at (01) 4292570. You are asked to advise who will be representing your nursing home at the AGM/Members Seminar.
Leading health commentator Sara Burke will address NHI Members at Members Seminar 2014
Nursing Homes Week 2014 NHI is delighted to announce Nursing Homes Week 2014 will run from Monday 16th to Sunday 22nd June. The 2014 celebrations will follow on from the very successful inaugural Nursing Homes Week 2013. Once again a series of events and activities across the country will celebrate nursing home life and the excellent care provided by NHI Members in Irish communities. Residents, their relatives and friends, staﬀ and extended communities will come together in celebration during Nursing Homes Week 2014. The role of the nursing home sector in healthcare delivery, job facilitation and enabling person-centred, life-changing and enhancing care will be promoted during the week. Support material and further information will be provided to NHI Members in advance of Nursing Homes Week 2014 and we will once again be encouraging all to join in the celebrations. Below: Nursing Homes Week 2013 celebrations at St Attracta’s Nursing Home, Co Mayo
NHI NEWS — 06
HEALTH’S AGEING CRISIS
Diverting Essential Nursing Home Funding Will Have Huge Cost The Government’s current short-term approach with respect to policy and funding for the residential care needs of our ageing population will, if continued, result in a much higher social and economic cost in coming years, the BDO report Health’s Ageing Crisis: Time for Action states. The NHI commissioned report estimates that for every 1,000 people who cannot access nursing home care due to the State’s strategy, the cost to the Exchequer will be €273 million annually in addition to the immeasurable impact on people and their families. Health’s Ageing Crisis: Time For Action, A Future Strategy for Ireland’s Long-Term Residential Care Sector presents independent research and evidence to lead the debate on public policy in respect of current and future requirements for long term residential care. Derry Gray, Managing Partner BDO, said Government, Department of Health, the HSE and related agencies must engage constructively with the nursing home sector to prevent a crisis and to ensure that nursing home capacity is able to meet future demand. “Recent decisions by Government to divert money from nursing home care to alternative home care packages and other community facilities will be counterproductive and ultimately result in considerable waiting times for residential care.” “This will consequently increase pressure on acute hospitals adding further to the numbers of delayed discharges within that sector,” Gray added. “Unfortunately such issues are already evident within our acute hospital sector. From a capital and operational funding perspective, encouraging and supporting the private and voluntary nursing home sector to develop the bed capacity needed to meet the current and future requirements of our ageing population represents a more effective use of limited Exchequer resources. A clearly deﬁned role for the nursing home sector, in the context of a new and emerging continuum of care model, should form a key element of future health care strategy.” The BDO report also notes that, unlike other elements of older care provision, nursing homes provide high levels of specialised care and operate within what is a highly regulated and safe environment. “Uncertainty around the ﬁnancing of Long Term Care under the Fair Deal scheme and the absence of a formal cost model threatens sustainability of current provision and continues to temper investor sentiment, acting as a barrier to investing in the nursing home sector,” said Tadhg Daly, Nursing Homes Ireland (NHI) CEO. “Signiﬁcant capital investment in the nursing home sector is now urgently required. The political expediency associated with cutting ﬁnancial support for the Nursing Home Support Scheme (Fair Deal) runs the risk of real long-term damage to Ireland’s capacity to care for our growing ageing population. Older persons must be afforded opportunity to access nursing home care in a timely manner and failure to ensure this will have serious consequences for their health and wellbeing. Furthermore, a key weakness in terms of the provision of the entire range of older people services in Ireland is the absence of regulation of or national quality standards for assurance in other older care settings, primarily homecare,” said Daly. “Inaction is no longer a policy or solution - the ﬁndings in this report very much emphasise the time for action is now.” “Government policy and funding must provide a sustainable basis for the delivery of high quality nursing home care and allow for on-going investment in new capacity and service development. The private and voluntary nursing home sector is a vital part of health service provision, a notable employer, contributing signiﬁcantly to local economies and is the most cost efﬁcient provider of long-term residential care for our ageing population,” added Daly.
07 — NHI NEWS
The BDO report stipulates that bed capacity within the nursing home sector is no longer keeping pace with increasing demand for long-term residential care. Ireland has, relative to other European countries, an extremely low number of long-term beds per 1,000 of the population. But critically, economic and funding constraints have in recent years been compounding this deﬁcit, warns the report. The report ﬁnds that demand for nursing home beds is now exceeding supply in parts of the country, with the gap rapidly widening. Analysis conducted as part of the study predicts a shortfall in the number of nursing home beds of approximately 4,000 beds in two years (2016) and 8,000 beds by 2021. The implications are clear, according to the report. People in need of residential care, because they can no longer be cared for at home, will be forced to remain in or seek care within an acute hospital setting. This will have an inevitable wider impact on demand for acute hospital beds and over-crowding throughout Ireland’s accident and emergency departments. The report notes that the costs of providing care in an acute hospital are a multiple of between ﬁve and eight times the cost of providing nursing home care, either publicly or privately. The report also highlights the vital role currently played by Ireland’s nursing home sector which provides long-term residential care for over 27,000 people including public, private and voluntary beds. The report estimates that approximately 22,000 people are directly employed by the private and voluntary nursing home sector, contributing over €170 million annually to the Exchequer through direct taxation paid. The objective of the report was for an NHI commissioned independent, fact-based review of the Irish nursing home sector. The report’s analysis was based on publicly available data and literature and included primary research, which took the form of extensive engagement with key stakeholders throughout the nursing home sector, older persons care and wider health sector. Read a comprehensive analysis of the report and its key findings and recommendations in this issue of NHI News.
HEALTH’S AGEING CRISIS: TIME FOR ACTION
A Future Strategy for Ireland’s Long-Term Residential Care Sector
Prepared by BDO
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t 1 Patient, 1 Bottle, 1 Day t GMS Approved www.fresenius-kabi.com Date Dat eo off Preparation: Preparation: Feb Feb 2013. 2013. EN/2kcal/002.13 EN/ 2kcal/002.13 References: 1. Raynaud-Simon References: Raynaud-Simon A: Clinic Clinical al pr practice actice guideline guideliness fr from om the F French rench He Health alth High A Authority: uthority: nutritional suppor supportt strategy strategy in pr protein-energy otein-energy malnutrition in the elderly. elderly. Clin Nutr 2011, 2 011, 3 30:321-319. 0:321-319. 2. Hubb Hubbard ard GP. GP. A ssystematic ystematic rreview eview o off c compliance ompliance tto o or oral al nutritional supplemen supplements. ts. Clin Nutr 2 2012,31:293-312. 012,31:293-312.
READ ALL ABOUT US! What activities are taking place in your home? How are residents fullling their lives? What celebrations are taking place? Read all about us! oﬀers NHI Nursing Homes the opportunity to publicise the wide-ranging activities that are taking place in homes across the country. It provides an excellent opportunity to publicise nursing home life in the positive light it should be seen in and members are encouraged to make us aware of what is going on. You can send any articles or pictures of interest to email@example.com.
Nursing Homes big push to support Philippines Residents and staff of Cairnhill Nursing Home in Foxrock, Dublin, took to the streets to raise money for the victims of Typhoon Haiyan, the exceptionally powerful hurricane that displaced an estimated four million people in the Philippines.
raving the cold, staff pushed residents in their wheelchairs around neighbouring streets to the local shopping centre of Cornelscourt. “Armed with our banner, we shouted and shook our baskets to get the attention of passer-bys and people in their cars to give us whatever they could afford,” Lisa Fitzgerald, activities co-ordinator at the nursing home explained. “It warmed our hearts to see how generous people are, even in these tough recessionary times. We were greeted with smiles and encouragement. The Gardaí also kindly agreed to help us out and they created space on the road for us to walk. We are also very grateful for the generosity of the staff of Cornelscourt Shopping Centre who provided us with tea, mince pies and cake when we stopped to have a much needed break.”
09 — NHI NEWS
A number of staff in Cairnhill Nursing Home are Filipino and Lisa described them as very respected and valued. “They have made Ireland their home and they have become our friends,” she said. “When Typhoon Haiyan hit the Philippines on November 8th it left thousands of people dead and forced millions from their homes. It broke the hearts of the Filipino staff to see their people suffering such a tremendous loss and being so far away from their home brought feelings of great sadness and helplessness. We knew at Cairnhill we had to do something to help and so the idea of a charity Wheelchair Push came to mind. We are delighted we got to contribute in some way and it brought us all a little closer together. We have raised €3,000 and we are over the moon about that.” See NHI News section re: Philippines Relief Fund.
Proud Bill sees dream come true as debut novel published The publication of Bill O Donnell’s novel The Small Kingdom is a lifelong achievement for a gregarious gentleman in his late 80’s. On finding it impossible to continue living in the community, Bill made his home at Deerpark House Nursing Home in his beloved Bantry. He settled in very quickly and found himself at ease and having time to look towards completing the novel he started 30 years previously. Being very involved in activity sessions such as creative writing and life story, Bill met with likeminded people and one of these was Tom Weld, who was facilitating sessions. With Tom’s support, encouragement and his research on printing possibilities, things started to happen. Bill was a publican for 55 years at the very well known and loved Anchor Bar in Bantry. His story-telling and people loving skills served both him and the community well over the years. The now completed novel draws on Bills intimate knowledge of the lives of the seafaring people of the special part of the world that is South Cork and is laced with wonderful authentic detail. Bernie Cronin, Activities Leader comments: “It is written with humour and rare warmth, and with great story-telling skills, honed during his worldwide travels and in five decades of running the ‘most happening’ public house in Bantry.” Where better was there to hold the book launch than in his beloved bar setting amongst his family and friends. Bill, with the help of the activities team at Deerpark House, set about creating his guest list for the launch. “A great evening was had where 50 guests toasted Bill’s achievement over cheese and wine, as Bill signed his book; his dream had come true,” Bernie adds. “Demand being so great, a second print was needed. A contented Bill read from his novel to great applause and admiration from his family and many friends, in his beloved Anchor Bar.” A portion of the proceeds from the sale of the book will go to the Irish Lifeboat Association, a worthy association close to Bill’s heart P
Bill O’Donnell, resident of Deerpark Nursing Home, Co Cork, sits proudly with his novel ‘The Small Kingdom.’
Resident born in year of lock-out celebrates Anna May Egan, a resident of Ashford House Nursing Home celebrated her 100th birthday on 17th December 2013. Her day in the Co Dublin nursing home began with visits from relatives, friends and local clergy. Then a special Mass for Anna May was celebrated in Ashford House by Fr Manoj Ponkattil and this was followed by a wonderful birthday party during which Anna May was presented with a letter of congratulations signed by President Michael D. Higgins. Anna May was born in 1913 – the year of the Dublin Lockout. King George V was on the throne in England and September 1913, one of the most famous poems of William Butler Yeats, was published. It was the year when suffragette Emmeline Pankhurst was jailed and another suffragette Emily Davison ran in front of the King’s horse at the Epsom Derby and was killed. P
The staff of Ashford House celebrate with birthday girl Anna May Egan
Anna May celebrates with staff members Dinah Dio Clarito and Fe Balazo.
NHI NEWS — 08
READ ALL ABOUT US
Castle, museum and arts: a year of activity at Mayo Nursing Home 2013 was a very exciting year for the residents and staff at Brooklodge Nursing Home; it was certainly a very busy place, writes Ann Cummins, Director of Nursing. With the help of our artist Pam O’Connell, the residents produced an art book and a calendar displaying their beautiful artwork. Brooklodge Nursing Home is situated very close to Ballyglunin Railway Station where the opening scenes of The Quiet Man were filmed. With it so close in proximity, we decided to take a trip to Ashford Castle in Cong , Co. Mayo, and witness where all the outdoor scenes were filmed. This was the highlight of the year for the residents and staff. They enjoyed silver service dining in the George V Dining Room and this was followed by relaxation, chat and card playing in the drawing room. During the year our residents also visited Knock Shrine and took a tour of Knock Museum. This brought back many memories of turf fires, churns and ploughs. Mary Roche, a local lady, came and made
11 — NHI NEWS
butter the old fashioned way with a churn and our residents helped out. Some declined – saying they did enough churning in their day! It was a year one of our activity coordinators produced our first bi-annual magazine Siamsa, showcasing our ongoing activity. Our Christmas Mass and party on 8th December was extremely enjoyable, with residents participating in the readings of the Mass and the choir. Afterwards the families, staff and residents enjoyed dancing, singing and entertainment from local musicians and dancers. Annagh Hill Boys and Girls National School and Cahergal National School visited the nursing home before Christmas and entertained the residents with music, dancing, and gymnastics. Everyone had a wonderful time. Throughout the year our residents help out with feeding the hens, collecting eggs and we also have ponies during the summer in the fabulous gardens surrounding the nursing home. We hope to continue our good work in 2014 and ensure our residents are living in a home where they are happy P
READ ALL ABOUT US
10th Birthday celebrations at Coral Haven 2013 saw Coral Haven Nursing Home celebrate its 10th birthday. A highlight of the Co Galway-based nursing home’s 10th anniversary year was a day of celebration on 21st June. The occasion was marked by a Mass celebration and was followed by the official launch of Coral Haven’s new website, www.coralhavengalway.ie. The website was launched by the Mayor of Galway, Councillor Terry O Flaherty. Also in attendance was Minister for Training & Skills at the Department of Education & Skills Deputy Ciaran Cannon. Coral Haven was proud to present long service awards to three members of staff who have been employed since its opening in 2003. Music and entertainment was provided in a marquee by Stephen McCormack, Matt Keane and Irish and Sean Nós dancing was courtesy of Emma O’Sullivan. Coral Haven is a 60 bed nursing home under the ownership of Joe and Bridie Corcoran. It provides employment to 68 staff. Coral Haven has enjoyed great success over the years, producing very high standards of care and obtaining excellent outcomes from HIQA inspections. During its ten years it has continually Pictured are the celebrations from left: Mayor of Galway Councillor Terry O’ improved and enhanced the variety of services available to Flaherty, Minister of State Ciaran Cannon, Proprietors Joe & Bridie Corcoran, residents of the home P and Director of Care Siobhan Finnerty.
DATES FOR YOUR DIARY NHI Upcoming events of interest April
Quality and End of Life Care Education Day NHI will deliver a Quality and End of Life Care Education Day in conjunction with the Irish Hospice Foundation. The Education Day will take place at Moran’s Red Cow Hotel and is designed to support Members in meeting HIQA’s thematic inspection requirements.
NHI AGM & Members Seminar 2014 The NHI AGM & Members Seminar 2014 will take place Wednesday 9th April in Galway. The venue is the Ardilaun Hotel. The line-up of speakers for the Members Seminar includes Sara Burke, journalist, broadcaster and health policy analyst, and Dr Alan Ahearne, Head of Economics at the National University of Ireland, Galway.
NHI Education Day: Revised Care and Welfare Regulations: Exploring the Impact for Nursing Homes NHI will run an Education Day Thursday 15th May in Citywest Hotel, Co Dublin, titled: Revised Care and Welfare Regulations: Exploring the Impact for Nursing Homes. Further details will be announced in lead up to event. NHI Annual Conference 2014 NHI will again bring together an excellent line-up of speakers to discuss key issues pertaining to healthcare and care provision.
NHI Care Awards 2014 in association with Homecare Medical Supplies The excellent care provided in nursing homes across Ireland will once again be honoured and recognised at this prestigious national awards ceremony. www.nhicareawards.ie
NHI NEWS — 10
THE LATEST HAPPENINGS IN THE CARE SECTO R
Signiﬁcant increase in numbers affected by Alzheimers Alzheimer's Disease International (ADI) has announced that the number of people living with dementia worldwide in 2013 is now estimated at 44 million (estimated at 35 million in 2010) and will reach 76 million in 2030 (estimate was 66 million) and 135 million by 2050 (estimate was 115 million). Recently published research entitled ‘The Global Impact of Dementia 2013-2050’ reports a 17% increase in global estimates of people living with dementia, compared to the original ADI estimates in the 2009 World Alzheimer’s Report. The Alzheimer’s Society of Ireland (ASI) stated: “A key part of planning and being able to cope with the crisis coming down the tracks is the introduction and implementation of a National Dementia Strategy in Ireland, which would bring Ireland in line with other key European partners including the UK, France and the Netherlands.” Currently The Alzheimer Society of Ireland is working closely with the Government and other key stakeholders to create the ﬁrst National Dementia strategy which will be launched in the ﬁrst quarter of 2014. “We are looking for a strategy that shows political leadership on dementia in support of the thousands of people in Ireland currently living with Alzheimer’s or waiting to access services,” said Gerry Martin, CEO, The Alzheimer Society of Ireland. The Society states today in Ireland there are 41,700 people with Alzheimer’s and dementia. In less than 10 years the ﬁgure will have reached 70,000 and by 2041, will be at 140,000 due to our ageing population. The overall cost of dementia care in Ireland is just over €1.69bn per year. However if funding is ring-fenced to implement the Strategy currently under development, it will enable savings without resorting to further cuts on badly needed hours of care nationwide, ASI has stated.
Single Assessment Tool to commence late 2014: Minister Lynch The ﬁrst phase of implementation of the Single Assessment Tool (SAT) will commence in late 2014, Minister for Older Persons Kathleen Lynch has informed Dáil Éireann. A minimum of 50% of all new entries to the Nursing Homes Support Scheme, Home Care Package and Home Help Schemes will be assessed by the SAT in the last quarter of 2014, Minister Lynch informed Dáil Eireann 19th December. Full implementation of SAT will be in place by the end of 2015, she added. Deputy Billy Kelleher, Fianna Fáil spokesperson on Health, asked the Minister for Health when it would be rolled out. He also asked the Minister if he will provide the ﬁndings of the review of the fair deal scheme to assess its applicability to other sectors such as the disability and mental health residential sectors.
National audit shows shorter stay in acute hospitals for persons with dementia admitted from nursing homes The ﬁrst national audit of the quality of dementia care has highlighted people with dementia admitted from nursing homes to acute hospitals have the shortest length of stay in hospital. It also found that 35% of people who were admitted to acute hospital with dementia were discharged to nursing homes. Co-principal investigators on the audit were Professor in Geriatric Medicine Des O’Neill and Dr Sean Kennelly, Clinical Senior Lecture in Medical Gerontology from Trinity College Dublin along with Dr Suzanne Timmons and Paul Gallagher from University College Cork. Professor O’Neill and Dr Kennelly are members of both EngAGE, Trinity’s Centre for Research in Ageing, and the Trinity College Institute of Neuroscience. The audit showed Ireland does not yet have standardised care for dementia in acute hospitals and highlighted poor access to diagnostic and support services. It highlighted inadequate assessment of cognition, delirium, mood, and behavioural and psychological symptoms, in people with dementia during their admission, and where assessed and discovered, issues were not highlighted on discharge. People with dementia admitted from nursing homes were least likely to have cognitive and social assessments. The average length of stay for a person with dementia admitted from home and discharged to a nursing home was 59 days, compared to 22 days for a person admitted from home and discharged home. Only 43% of the people with dementia had a standardised cognitive 15 — NHI NEWS
test recorded in their healthcare records and this dropped 20% to those admitted from residential care. 30% were assessed for indicators of delirium, 14% were assessed for recent changes in mood and 20% received a social and environmental assessment. The report highlighted over a third of wards - 35% - had unﬁlled nursing vacancies and 26% had unﬁlled healthcare assistant vacancies. Only 69% met their agreed minimum stafﬁng levels. While the majority of wards - 96% - reported they had some level of access to liaison psychiatry, 26% had no access to psychiatry of old age services. The results also highlighted a signiﬁcant lack of psychology services (91% of wards had no access), specialist continence services (66% of wards had no access), and social work services (47% of wards had no access). In 2013, the Irish National Audit of Dementia audited 35 acute hospitals in the Republic of Ireland, interviewing the senior hospital managers and geriatricians; directly observing the environment/ interviewing the clinical nurse manager of 77 wards, and reviewing 660 healthcare records of people with dementia who had been admitted to the hospitals. The Irish National Audit of Dementia is a joint initiative carried out by the Centre for Gerontology and Rehabilitation, University College Cork, The Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght Hospital Dublin and the HSE Quality and Patient Safety Directorate.
Nurse prescribing in nursing homes raised at Oireachtas hearing The Department of Health has stated it supports, in principle, nurse prescribers in private nursing homes having access to primary care prescription pads, subject to robust governance and accountability structures being put in place. The Department informed of its stance arising from representation by Senator Jillian Van Turnhout at the Oireachtas Health Committee in respect of the issue at the quarterly committee meeting on 16th January. Senator Van Turnhout asked “the reason for the HSE Policy that Registered Nurse Prescribers who work in private healthcare facilities including nursing homes are not issued with prescription pads”. She asked if the Minister would agree that this discriminates against qualiﬁed registered nurse prescribers working in private facilities and may impact on patient care by preventing timely symptom relief for residents with medical cards living in private and voluntary nursing homes where access to a GP may not be immediately available; and if he has plans to ask the HSE to change this?” In a written response the Department of Health stated: “The Department supports, in principle, nurse prescribers in private nursing homes having access to primary care prescription pads, subject to robust governance and accountability structures being put in place. The provision of nurse prescribing services in nursing homes would greatly enhance continuity of care from the hospital sector through
to the nursing home sector. Medicines legislation currently in place does not differentiate between prescribing by nurse prescribers in public or private setting. Nor does it deal with reimbursement under the Community Drugs Schemes of prescriptions by nurses. The issue of reimbursement through the Primary Care Reimbursement Service (PCRS) is a matter that will be progressed through engagement with the HSE by the Primary Care Division in this Department.” The matter was raised at the Debate and Dr Siobhán O’Halloran, Chief Nursing Ofﬁcer at the Department stated: “With regard to nurse prescribing, there is a legal and regulatory framework in place. It has been in place since 2007. We currently have 650 nurse prescribers and 425 in training. There is no doubt that the introduction of nurse prescribing in the nursing home sector can yield the same beneﬁts as in the acute sector, where it is more prevalent. It can also yield additional beneﬁts in terms of continuity between the acute and nursing home sectors. There is an issue at the moment with nurses accessing primary-care prescription pads for the purpose of reimbursement of medical card patients that we need to resolve. In resolving that issue, we also need to ensure that the governance of that issue is robust. In this regard, the Department, through engagement with the HSE, will progress the matter and any other matters that may be slowing down the expansion of this in the nursing home sector.”
NHI NEWS — 14
HEALTH’S AGEING CRISIS: TIME FOR ACTION
High social & economic costs for State because of failure to plan: BDO report On 11th February the BDO report Health’s Ageing Crisis: Time for Action – A Future Strategy for Ireland’s Long-Term Residential Care Sector was launched. This timely and essential body of work will be of crucial importance in informing ongoing debate surrounding the care requirements of our older population. It will be utilised by NHI to bring to stakeholder attention urgent necessity to appropriately plan for our ageing population’s long-term residential care requirements. residential beds or approximately 70% BDO was commissioned by Nursing of current capacity in the sector. Homes Ireland to conduct extensive In short, the demand for nursing independent analysis and rigorous home care from those segments of assessment of the Irish long-term EXECUTIVE SUMMARY the population whose care needs residential care sector, the ageing HEALTH’S AGEING CRISIS: can only be met in a long-term demographic and our older TIME FOR ACTION residential care setting is forecast to population’s projected healthcare A Future Strategy for Ireland’s increase substantially in the short to requirements. The report presents Long-Term Residential Care Sector medium term.” independent research and evidence to The report presents three lead the debate on public policy in supply scenarios to project forthcoming respect of current and future requirement. The scenarios are based requirements for long term residential on demand projections arising from care. Its conclusions inform of very analysis of three main data sources for stark consequences for older people key demographic assumptions: and the wider health sector because of current planning and policy deﬁcits. It m CSO Census of Population 2006 & will be of crucial importance in 2011 informing ongoing debate m CSO Population & Labour Force surrounding the care requirements of Projections 2011 – 2046 our older population. m Towards the Development of Predictive Extensive engagement with key Model of Long-Term Care Demand for stakeholders throughout the nursing Northern Ireland and the Republic of home, older persons care and wider Ireland (CARDI). Prepared by BDO health sector was undertaken by BDO. All scenarios are based on Engagement included the Department additions of new private beds and of Health, HSE, HIQA, NTPF, IMO, and incorporate: individual nursing homes. “The m Notwithstanding aspirations, there purpose of the research is to help is unlikely, based on international inform national future strategy for evidence, to be any signiﬁcant aged care provision and to provide reduction in the % of 65+ who require guidance as to what may represent appropriate future policy responses long-term care and directions, speciﬁcally with regards to the future role of Ireland’s m The signiﬁcant increase in population 85+ and their requirement nursing home sector,” the report states. for nursing home care m Public sector continuing to struggle to maintain existing provision The following is a synopsis of the report outlining key areas of analysis. m Voluntary sector struggling to maintain existing bed numbers REQUIREMENT m Private sector adding beds but below requirement International healthcare planners plan on the basis that 4.5% of Their projections are as follows: population aged 65+ will have a requirement for long-term residential m Scenario 1 projects requirement to increase by 4,208 to 2016 and care. Health’s Ageing Crisis emphasises: “the demand for residential care 7,986 to 2021. increases signiﬁcantly in the older age cohorts, with research m Scenario 2 projects requirement to increase by 5,759 beds to 2016 demonstrating that approximately 17% of those aged 85-89 and 28.9% and 10,913 to 2021. of those aged 90+ require long-term residential care”. m Scenario 3 projects requirement to increase by 3,531 beds to 2016 “Over the next seven years, CSO forecasts point to Ireland’s and 6,058 by 2012. population aged 65+ increasing by approximately 200,000 people or SUSTAINABILITY approximately 38%,” the report states. “Of particular relevance to the long-term residential care sector, those in the 80-84 age group are While recognising the ﬁnancial difﬁculties facing the State and forecast to grow by approximately 20,300 people or 29%, while the emphasis on enabling persons avail of home and community care, the numbers of people aged 85+ will increase by 26,800 or 46%. This will report states the “demographic and international evidence is clear”. increase the levels of frailty and the complexity of those who now and “There is increasing demand and need, in Ireland, for long-term will in the future require long stay residential care. Based on these residential care being generated by those cohorts of the population forecasts, BDO have estimated that the 85+ segment of the population whose needs can only be met in a long-term residential care setting.” alone will generate demand for approximately 18,947 long-term There are two key factors that are likely to play a key role in
19 — NHI NEWS
determining and inﬂuencing the role of Government in long-term residential care, Health’s Ageing Crisis states: the ﬁnancing of nursing home care – Fair Deal at present, and capital investment required to maintain and grow public care. “There is clear evidence to suggest that current government policy with regards to the provision of older persons care services is being driven only by ﬁnancial considerations rather than with the objective of providing the most appropriate care for those that need it most,” it states. It points to compelling demographic, national and international evidence to outline urgent requirement for appropriate policy planning including: m Our low number of long-term care beds per head of population; m Faster growth rate of 65+ population by comparison with our EU neighbours; m The doubling of our 85+ population in coming decades and increased requirement for nursing home care amongst that age cohort; m Unrealistic objective of reducing percentage of population 65+ (4.5%) requiring nursing home care; m Lack of investment in public bed provision, with €834m required just to meet HIQA physical environment standards and a further €850m to maintain 20% public provision; m Fulﬁlling Government healthcare objectives will result in increased demand for nursing home care. “The lack of a clear policy and national strategy for the long-term care of our older population, combined with current uncertainty around future funding arrangements poses one of the biggest challenges to the long-term sustainability of the nursing home sector,” it states. Based on estimates and future population projections, it estimated the cost of the funding of Fair Deal, based on current approach, will reach €1.20bn by 2021. It excludes capital costs and investment required for public homes to meet HIQA physical environment standards (€834m) and to maintain public provision at 20% (€850m). With the HSE National Service Plan 2014 stating there will be no new additional resources to invest in older person services, the report questions where money will come from to meet capital funding requirements. Diverting money from Fair Deal to home care and other elements of care will result in increased waiting times for residential care and add further to increasing demand being placed on acute hospital sector, adding further to numbers being delayed discharge it states. “The HSE’s own ﬁgures estimate the cost of a hospital stay per night at €800-€900 amounting to a conservative total cost of at least €540,000 each night the 685 patients remain in hospital,” it adds. “This equates to approximately 720 weeks of nursing home care. Private nursing home care provides a more cost effective and appropriate form of care for these patients and if used effectively can result in signiﬁcant cost savings for the HSE and Department of Health.” It states the net weekly cost to the Exchequer of private nursing home care is averaged at c€750 (excluding resident contribution) per resident versus a weekly cost of c€6,000 in the acute hospital sector. “This means that for every 1,000 of the population who cannot access nursing home care and therefore must remain in acute care, the State is incurring a cost of €6m per annum,” it informs. “The comparable cost of accommodating the very same population in appropriate private nursing home care is €750,000. The cost savings and beneﬁts to the Exchequer, on an annualised basis, are enormous.” Given the signiﬁcant capital investment required to maintain and grow public bed provision, the report questions if the Government should look at alternative models of care, citing public private partnerships, joint ventures, incentivising private sector. FINANCING NURSING HOME CARE The ability of the private and voluntary nursing home sector to make the investment now required to meet current and future capacity
requirements is entirely dependent upon bank funding and equity investment, Health’s Ageing Crisis states. Uncertainty regarding long-term funding arrangements (Fair Deal) and a challenging lending environment are cited as two key factors adversely impacting on investor sentiment and capacity to make essential capital investment that is urgently required. It is also creating much uncertainty for existing operators and is causing some to question their ability to continue to operate. HBC analysis published in 2007 for Age Action Ireland informed a “fair price” per resident per week for nursing home care of €1,101 in the Greater Dublin Area and €994 for homes operating outside it. “It is important to note that these estimates were made in 2006 and are pre the establishment of HIQA,” the report states. “They are therefore not reﬂective of the additional costs that have been imposed on nursing home operators as a result of meeting the requirements of a more regulatory environment. Nor for that matter do they take account of general inﬂationary cost increases that have occurred in the intervening period. When the various cost components and recommendations of HBC are considered, it is clear, based on rates currently being negotiated by the NTPF, that there is a gap between the actual cost of providing care, based on 2006 costs, and the current fees.” The report informs the State is paying between 58% and 103% more per resident in a public nursing home than the comparable fee paid to a private or voluntary home. It references Minister for Health Dr James Reilly questioning why 50% additional costs pertain to public nursing home care and the Comptroller and Auditor General highlighting the anomaly. Stating care requirements and dependency levels of some residents in public nursing homes may be higher than some residents in private homes, the report asks can or should the State continue to afford to pay between 58% and 103% more for care. “In discussions with banks and other funders to nursing home projects, what came across clearly is that notwithstanding the favourable demographic factors and an overall positive perception of the industry, their willingness to invest in the sector is tempered by the signiﬁcant inﬂuence and control the state exerts over the sector,” Health’s Ageing Crisis comments. “In particular concerns have been raised regarding the funding and future of the Fair Deal, and the current process by which the NTPF sets rates with individual operators. Uncertainty with regard to the fees negotiated between the State and the nursing home operator undermines the conﬁdence of ﬁnancial institutions, equity investors and nursing home operators and has contributed to the slowdown in investment in the sector and as a consequence the number of new nursing home beds entering the market. “Reductions in the budget for the Fair Deal and recent decisions to divert monies from the Fair Deal to support home care packages can only further add to this uncertainty. In order to fund new nursing home projects, our research has indicated that banks are actively seeking upwards of 30% equity investment and short ﬁnancing periods. “It is clear from our research that the process adopted by the NTPF in negotiating and setting Fair Deal rates with individual nursing home operators does not factor in capital costs or capital repayments. The current methodology is focussed on meeting the cost of care only. As a result the ﬁnancial returns available to nursing home operators and funders are not as attractive as are available in other sectors, and considerably below the 12% proposed by Laing and Buisson as representing an acceptable return. Securing funding for new projects is one issue, but should not be considered in isolation. Another important consideration is the ability and capacity of all nursing home operators to invest in and maintain the existing longterm residential bed provision.” Referring to NHI’s Annual Private Nursing Home Survey 2009/2010, it highlights the “onerous costs”, “capital costs” and “major structural redesign” that private and voluntary nursing home
HEALTH’S AGEING CRISIS: TIME FOR ACTION
for the elderly. Although funded operators will face in complying and by the Government, the number meeting HIQA requirements, of other older person’s services advising of the €834m expenditure (Home Help, Home Care existing public nursing homes will Packages) are provided, at what is incur in this respect. “This a signiﬁcant cost in what is an expenditure is on-going, but does unregulated market.” Referring to not contribute to increasing the Government commitment to number of beds in the system and develop an integrated care model may in fact lead to reductions in bed that treats people at the lowest numbers, as operators are forced to level of complexity, the report reduce overall capacity to meet states it is vital “all patients are standards in terms of room size, assured of and beneﬁt from the layout and occupancy,” it states. same levels of protection enjoyed “This has serious implications in by nursing home residents”. terms of the sustainability of the The report provides a cost of existing public bed provision, and Derry Gray, Managing Partner BDO, outlines the key findings care comparison analysis, the potential knock-on effects to and recommendations emanating from Health’s Ageing Crisis examining hourly and weekly both the private nursing home at its launch at Stephen’s Green Hibernian Club, 11th February costs identiﬁed by PA Consulting sector and acute hospital sector in analysis of the Irish home care should overall bed provision be market, which found the average hourly rate charged by private sector reduced.” to be estimated at €21. “Assuming the provision of home care ﬁve days “With continued downward pressure being exerted by the NTPF a week for eight hours a day, this equates to a “weekly” cost of €1,178 on the rates paid under the Fair Deal, banks, equity investors and for HSE/Non-Proﬁt home care services, and a weekly rate of €840 for operators remain reluctant to invest in the sector,” it adds. “This is home care services provided by private providers,” it states. “These because the signiﬁcant investment that is required to provide complex costs are only marginally below the weekly costs of public and private care to some of our most vulnerable members of society, meet strict nursing home care. Again it is important to emphasise that nursing regulatory requirements and generate a reasonable ﬁnancial return is homes operate in a highly regulated market, providing full nursing currently not available or recognised in the current NTPF home care 24 hours a day seven days a week to those cohorts of the negotiation process.” population who have been independently assessed as requiring The report states Fair Deal, when originally conceived, was nursing home care. Even if some of these people could be cared for designed to meet requirements of residents with high and maximum through the provision of home care support, it is highly unlikely, based dependency but in the determining fees the NTPF has not used costing on their care needs and dependency levels that this care could be models to inform the process. It refers to “clear evidence” that provided at rate below that paid within a nursing home setting.” demonstrates the dependency levels of nursing home residents are increasing and historic and existing data may underestimate actual CAPACITY levels. “In keeping with the concept of “money follows the patient” and When benchmarked against comparator European countries, Ireland the rolling out of a single assessment tool, a strong argument can now has one of the lowest numbers of long-term beds per 1,000 of the be made to move towards a move towards a framework of population aged 65+, it states. Only Italy with 16 per 1,000 and Spain individualised payments, based on the needs/dependency proﬁle of with 21.3 have fewer. the resident, which truly reﬂect the actual cost of meeting the care Ireland is now catching up with other European countries in needs of each nursing home resident,” it adds. terms of population ageing and the percentage in older age cohorts, “The demographic evidence could not be clearer,” the report the report states. These changes are evident in increasing demand for states. “The demand for nursing home care is now, in a number of long-term residential care. “While capacity in the nursing home sector, locations, beginning to outstrip capacity. The HSE National particularly in the private sector, grew rapidly in the period 2003-2009, Operational Plan 2013 states “Based on population projections, there recent years have been characterised by a signiﬁcant slowdown in the will be a signiﬁcant national deﬁcit of long stay beds by 2016”. This is development of new nursing home beds, and there is now strong supported by BDO’s own research which shows that by 2016, there is evidence to demonstrate that the demand for long-term residential likely to be a shortfall of up to 4,208 beds. The ability of the private and care is exceeding capacity in many locations throughout Ireland,” the voluntary nursing home sector to make the investment which is now report warns. required to meet current and future capacity requirements is entirely Over the last three years the level of net additions has largely dependent upon bank funding and equity investment. been driven by private providers but the level of additions has fallen “In discussion with banks and other funders, what came across to approximately 339 per year on average, which has largely come in clearly is their positive perception of the industry,” it states. “However the form of incremental additions to existing facilities. their willingness to invest in the sector is heavily tempered by the Health’s Ageing Crisis points to demand in nursing home care in a ability of potential operators to develop, register and proﬁtably operate number of locations outstripping capacity, referring to HSE National new nursing home developments given a near monopoly purchaser Operational Plan 2013 informing of “signiﬁcant national deﬁcit of long of service and limited ability to recover costs from the provision of stay beds by 2016”. It informs of Department of Health and HSE policy additional services or enhanced offerings.” objective and desire to provide approximately 20% of overall long-term HOME CARE residential bed capacity, stating it is not clear the extent to which it is a realistic or achievable objective, “given the signiﬁcant ﬁnancial and Health’s Ageing Crisis informs of the nursing home sector being now one operational challenges that exist in terms of bringing some of the of the most regulated sectors before adding “care standards and current capacity up to HIQA’s physical environment standard by regulations are not evenly applied across all older people services and supports, with the home care sector, for example, currently unregulated”. 2015…Unless signiﬁcant new additions are made in areas of high“The HSE’s Service Plan for 2014 places even further emphasis on demand, it will be difﬁcult to raise the level of effective supply – and this developing and supporting community and home based care supports will require some form of targeted capital support.”
21 — NHI NEWS
CONCLUSIONS The report's conclusions include: m Nursing home care provides a more appropriate and cost effective form of care, not only for those in our population that need it most, but also for many people currently cared for within the acute hospital system. Deﬁciencies in long-term residential care supply contribute to delays in discharging people from acute hospital beds, resulting in increasing delayed discharges and contributing to the situation of over-crowding which is prevalent throughout accident and emergency departments. This has knock on effects throughout the acute hospital and wider healthcare sector. m The level of private sector investment required to provide the number of new nursing home beds needed by our ageing population will not happen unless greater clarity is provided in relation to the funding and ﬁnancing of long-term care. m Given the HSE’s own cost estimates, it is highly unlikely that the State will be in a position to fund the cost of not only maintaining the existing provision of public nursing home beds, let alone maintain its 20% share of total supply in the future. This will result in substantial shortfalls in nursing home beds relative to market need. At a time of straitened ﬁnancial circumstances, the question that must be asked, is this an appropriate use of scarce public resources? m Further falls in current nursing home bed supply are inevitable if the deadline for meeting HIQA Standard 25 on the physical environment is to be met. This has drastic implications for overall nursing home bed provision, with ﬁgures from the HSE suggesting that it could result in the loss of 3,000 public beds alone. The private and voluntary nursing home sector will not have the capacity or ability, in the short-term, to make up this shortfall. m It will therefore fall back on families or the acute hospital sector to meet the care needs of those urgently requiring but unable to access appropriate nursing home care. This has signiﬁcant socioeconomic and ﬁnancial cost implications. m There will always be a cohort of the population (particularly those aged 85+) whose care needs can only be met in a long-term residential care setting. Within Ireland this cohort of the population is growing rapidly. Domiciliary/home care (which is currently unregulated) is not always appropriate or suitable to meeting the care needs of this population. A sustainable and viable nursing home sector has a key role to play in avoiding adverse outcomes for our older population.
m Gaps in long-term residential care are not just an issue for our older population. Shortfalls in nursing home beds will impact on the availability of beds within the acute hospital sector. This has implications for all requiring acute hospital care. m The lack of a clear policy and national strategy on the long-term care of our older population, combined with current uncertainty around future funding arrangements poses one of the biggest challenges to the long term sustainability of the nursing home sector. RECOMMENDATIONS The report brings forward the following recommendations: m It is vital that the Government, policy makers and key stakeholders come together to map out the future of nursing home care and implement an appropriate framework to meet the signiﬁcant growing requirement for it. The nursing home sector has a key role to play in developing this strategy and offers a real solution to the challenges created due to an ageing population. Nursing home operators must be afforded the opportunity to shape this strategy. m Careful consideration must now be given to identifying how the State can support or encourage new investment in nursing homes in areas where there is clear evidence of strong demand for long-term residential care. m The development, by the NTPF of a clear and transparent pricing policy/model which provides a fair price for patient centred care, must be undertaken as a matter of priority. m Operators who are dissatisﬁed with the rate proposed by the NTPF must be afforded the opportunity for fair right of appeal independent of the NTPF. m It is vital that the government addresses as a matter of priority how the €1.68 billion investment required for public homes to meet HIQA standards and maintain provision is to be made and how it proposes to ensure that all public nursing home beds can become HIQA compliant by the July 2015 deadline. m A model and appropriate budget for funding nursing home care that recognises the costs of providing resident centred care, but which is sustainable in the context of an ageing population, must be developed as a priority. m It is vital that the Fair Deal for nursing homes remains intact. Efforts to increase the level of funding to other older care services or provisions must not be at the expense of a reduction in the overall funding available to those requiring long-term residential care. Download the report at www.nhi.ie under the publications section.
Left: Robin Webster, Chief Executive Age Action, warned at report launch Health’s Ageing Crisis must be considered in context of national debate and national action plan Right: From left Senator Colm Burke, Age Action Chief Executive Robin Webster, and NHI CEO Tadhg Daly discuss report
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HSE SERVICE PLAN 2014
HSE Service Plan 2014: Illogical and shocking cut to Fair Deal Move will have consequences for older persons health and impact negatively upon wider health sector NHI has stated it is shocked and appalled at the enormous cut in 11,372 were provided up to the end of September this year,” he stated. support that will be provided to people requiring nursing home care in Mr Daly further commented: “It is laudable that the Government 2014. The HSE Service Plan 2014, published 18th December, is is committed to supporting older people to remain in their homes as projecting a reduction of 939 – 1,702 persons to be supported by long as possible. However, the recently published ESRI report Nursing Home Support Scheme (Fair Deal) to year end 2014. informing of activity in public hospitals (Activity in Acute Hospitals in The projected outturn for numbers to be supported by Fair Deal Ireland 2012 Annual Report) highlighted older persons’ requirement for in 2013 is 23,000 and the expected activity by year end 2014 is 22,061. continuous, specialist care over an extended period. The ESRI By comparison with numbers supported by the scheme at end of projection for signiﬁcant growth in requirement for nursing home October – the HSE’s most recently available ﬁgures published at time care is backed up by the Centre for Ageing Research and Development of publication of Service Plan – 1,702 fewer persons will be supported. in Ireland (CARDI) which has previously issued a warning this Service “Such a drastic cut to the scheme that enables older people avail Plan is ignoring: “Even with greater emphasis on care at home and of the specialist care of nursing homes is very difﬁcult to countenance,” more resources provided to realise it, the demand for residential care Tadhg Daly, NHI CEO commented. “It is illogical and short-sighted and is going to increase signiﬁcantly in the next decade.”* will result in 900 – 1,700 fewer persons being supported by Fair Deal Requirement for nursing home care is growing considerably. At in 2014. It will unavoidably lead to an increase in the number of older the end of September 745 persons were Fair Deal approved but persons presenting at our already awaiting payment. Minister for Older stretched and overcrowded acute People Kathleen Lynch informed the hospitals. We have real fears this very Dáil 13th November a further 523 signiﬁcant cut to Fair Deal will have persons were awaiting Fair Deal very serious consequences for the funding approval. health and wellbeing of older people. “The cut will undoubtedly We are shocked by the drastic nature of result in longer waiting times for Fair the cut in support.” Deal,” Mr Daly added. “For an older NHI has expressed person in a hospital or home setting, it disappointment and extreme concern is crucial they can avail of the specialist for older persons requiring nursing care provided by a nursing home home care arising from the €35.5m within a short timeframe. If this is not million cut contained within the enabled, it can have very serious “Older people whose needs are not met in the community will be Service Plan for the Fair Deal 2014 consequences for the person’s health admitted to acute hospitals, while others will be left struggling at home on ever-lengthening waiting lists for a nursing home bed,” budget. and wellbeing. Older people approved Eamon Timmins, Age Action Ireland The cut to numbers supported by for Fair Deal have been assessed by a Fair Deal is drastic when you look at multi-disciplinary team as requiring “A cut of this magnitude will bring to bear great distress and angst for older persons requiring the support of Fair Deal,” Tadhg Daly, the numbers that were supported by the dedicated care nursing homes NHI CEO the scheme at the end of the October – provide in their local community. the most up-to-date ﬁgures available “The severe and drastic from the HSE at time of publication of measure further underlines the critical the 2014 plan. Some 23,763 people importance of bringing key were supported by the scheme at the stakeholders together through a end of the month, it stated. This would consultative commission to plan reﬂect a reduction of 1,702 persons. appropriately to address the care Age Action Ireland said the cut to requirements of older persons. NHI Fair Deal will result in acute hospitals reiterates its call for responsible policy and community-based supports that and planning to be brought together are already under pressure facing even through the immediate establishment greater pressure in 2014. “Older people of a Department of Health-led whose needs are not met in the Commission on Long-Term Residential community will be admitted to acute Care. This has already received the hospitals, while others will be left struggling at home on eversupport of key health, policy and older person representatives. We’re lengthening waiting lists for a nursing home bed,” Eamon Timmins, living longer and this is increasing considerably our requirements for Age Action spokesperson warned. “There is a considerable gap between the specialist care provided by nursing homes. We must plan those who will beneﬁt from these initiatives and those left waiting for immediately for this. a nursing home bed as a result of these changes. What is not clear in “A cut of this magnitude will bring to bear great distress and this plan is what is going to happen to the 700 to 1,700 people who will angst for older persons requiring the support of Fair Deal. Denying not get a nursing home bed next year and how they will be cared for.” access to the specialist healthcare of nursing homes will bring to older He said the planned provision of home care packages and home help people in 2014 great distress, worry and concern. This smacks of a hours for 2014 has remained at the same levels budgeted for 2013 failure to see the wood from the trees in respect of health planning.” “While the HSE plans to provide 10,870 home care packages in 2013, *Future demand for long-term care in Ireland, CARDI, October 2012
25 — NHI NEWS
NHI criticises Fair Deal cut as large numbers await hospital bed Early 2014, the Irish Nurses and Midwives Organisation (INMO) reported substantial number of patients on trolleys and trolleys in wards awaiting admission to a hospital bed. On January 7th its daily trolley and ward watch report informed 359 patients were on trolleys in emergency departments. This represented a signiﬁcant increase on the numbers on the corresponding number for the previous year, which was at 284 patients on 7th January 2013. 102 persons were on trolleys on hospital wards, resulting in a total of 467 persons waiting on a hospital bed. The ﬁgures made national news and Tadhg Daly, NHI CEO commented: “Very regrettably we are not surprised by the media reports highlighting the increase in persons on hospital trolleys awaiting admission to a hospital bed and are concerned this will be replicated in the news throughout 2014. The reports speciﬁcally highlight hospitals are reporting an increase in admissions of frail elderly persons. Given the substantial cut to this year’s Fair Deal budget contained within the HSE Service Plan 2014, unfortunately we believe this occurrence will be repeated in the year ahead as more and more older persons will present to acute hospitals because of inability to access nursing home care. We’re facing into a year in which 939 to 1,702 fewer persons will be supported by Fair Deal. Many of these older persons will have no other option but to remain within the acute hospital sector or present at their local ‘A & E’. For many older people in 2014, they will be waiting a number of weeks and likely months to avail of Fair Deal funding to enable them access the specialist, continuous care of nursing homes. This will have a very signiﬁcant impact upon the wider health sector and our acute hospitals in particular. It is not too late for Ministers Reilly or Lynch to halt this crude and illogical cut to the scheme - a measure that will only bring distress, concern and hardship to older persons. We call upon the Government to put older persons healthcare requirements ahead of health budget arithmetic and ensure the Fair Deal scheme 2014 is appropriately resourced.” Mr Daly spoke on Morning Ireland, RTE Radio 1, in respect of the crisis. He informed listeners the substantial cut to the Fair Deal 2014 budget was illogical and shortsighted and regretably NHI's fears re its impact were coming to fruition very early in the year. He described HSE announcement it will fund extra beds within the community to alleviate the overcrowding within hospitals as an acceptance of the shortcomings of its 2014 Service Plan. Good work in alleviating overcrowding will come undone if there are not enough beds in the community to support older persons healthcare requirements, he stated. Mr Daly reiterated NHI's call for the establishment of a forum to plan for the signiﬁcant increase in numbers growning older and their healthcare requirements. Other media platforms also reported NHI’s comments and you can listen back to the Morning Ireland interview and see other media coverage in the news section of www.nhi.ie.
NHI NEWS — 32
QUALITY IMPROVEMENT GRADUATION
Nursing home graduates honoured at HIQA graduation NHI Members were amongst the first Irish graduates of a course in quality improvement science that was jointly run by the Health Information and Quality Authority (HIQA) and the Institute for Healthcare Improvement (IHI).
90 staff from ten pilot sites of six nursing homes and four acute hospitals received their graduation certiﬁcates at a ceremony in Farmleigh House, Co Dublin, on 6th February. The graduates undertook the course on a voluntary basis to learn about increasing the quality of care they provide. Participating nursing homes included Tara Winthrop Private Clinic, Co Dublin, and St Luke’s Home, Co Cork. Marie Kehoe-O’Sullivan, Director of Safety and Quality Improvement with HIQA, said: “This collaboration between HIQA and the IHI is the ﬁrst time that the IHI has worked in partnership on a national level to roll out this online programme and it represents an important, concrete step in supporting quality improvement in Ireland’s health and social services.”
St Luke’s Home graduates, from left, Eileen Ferguson, Fiona O’Mahony , Sally Rodgers, Catherine Carey, Colette Culver
27 — NHI NEWS
Course participants were nurses, pharmacists, health care assistants, doctors, physiotherapists, dieticians, bed managers, administrative and management staff. They were given access to speciﬁc knowledge, skills and methodologies that have been proven to effect positive change in health and social care in other countries. The participants were provided with quality improvement knowledge and tools to design and implement new quality improvement initiatives, measure how well they were meeting the standards, implement changes needed and provide evidence of their progress. “HIQA has a responsibility to support quality improvement in Ireland’s health and social services by providing education in quality improvement and this partnership with the IHI delivers
that,” Ms Kehoe-O’Sullivan added. “It began for the ﬁrst time last year, with participants completing a minimum of 16 modules in order to achieve the HIQA/IHI Certiﬁcate of Completion in Patient Safety, Improvement Capability, Quality Cost and Value, and Person and Family Centred Care. We congratulate the ﬁrst graduates and we will continue to work with the IHI to promote a better experience for patients and residents in Older Person services and their families and deliver improved outcomes from our health and social care services.” The Institute for Healthcare Improvement (IHI) is a based in Massachusetts and a leading innovator in healthcare improvement. Above: The proud graduates celebrate at Farmleigh House
Pictured at the HIQA/IHI graduation are, front row from left, Rena Galvin, Adrienne Stack, Mary McCormack, Catherine Dunleavy, Vikki McGinn, Dr Tomasz Tomasiuk, Bincy Joseph, Rosamma Jacob – all Tara Winthrop Private Clinic, and Treacy Cooper, HIQA. Pictured back row, left to right, are Brian McEnery, HIQA, Dr Ambrose McLoughlin, Department of Health, Marie Kehoe O’Sullivan, Director of Safety & Quality Improvement, HIQA.
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MY NURSING HOME LIFE
‘A huge privilege with huge responsibilities’ Sinead Beirne fulfils the Director of Nursing/Person in Charge role at Annabeg Nursing Home, Co Dublin. The Co Leitrim native stresses the most important ‘qualification’ any person needs to work in care of the elderly is to ensure your heart is in the care you are providing. She outlines her qualifications, the role she fulfils and responsibilities, and would advise trainee and graduate nurses to learn the life lessons that come with nursing in the nursing home sector. Sinead was the Director of Nursing/Person in Charge award winner at the NHI Care Awards 2013.
What is your job title?
Director of Nursing/Person in Charge at Annabeg Nursing Home. What was your view of gerontological nursing prior to you taking up the position within Oaklodge Nursing Home?
I qualified as a Registered General Nurse at St Vincent’s University Hospital. I worked in oncology for many years. This was a very difficult and emotional area to work in and as a result I decided nursing might not be for me so I returned to college to commence Certified Accountancy. After two years of ‘number crunching’ I returned to where my heart was and returned fulltime to nursing. While funding my accountancy studies I worked as an agency nurse mostly in Care of the Elderly and this was where I got a true taste for Gerontological Nursing and I’m happy to say I’ve never looked back since. I am currently undertaking a Certificate course in Care of the Older Person in a residential care setting. I have completed a Diploma in Management and Employee Relations and Certificates in Palliative Care and Dementia. I have also completed other An Bord Altranais accredited courses while working in care of the elderly. I would stress that the one ‘qualification’ any person needs to work in care of the elderly is the natural ability to work with your heart. If your heart is not in it then nursing is not for you. It’s all about caring. It’s about appreciating that you are a huge part of each residents’ day and a huge part of their life. We make their day and let us not forget that we are working in their home so our mood, our attitude, our sense of caring, our communication skills have a huge impact on each residents day. Did you work elsewhere prior to fulfilling your role at Annabeg?
I worked in the Oncology Unit at St Vincent’s University Hospital and was a student nurse re-employed at St Vincent’s University Hospital. One of my strongest memories is while a student nurse working in the oncology unit the Ward Sister at that time asking ‘which nurse is from Leitrim?’ I whispered ‘I am’ to which she said ‘I’m not sure what words you said to Mrs X but you really gave her encouragement and hope; Well done’. I was absolutely delighted and tearful. I absolutely love nursing and the fact that I made an impact on that person’s life was overwhelming. Needless to say oncology nursing is difficult and quite an emotional area to work in and thereafter I entered the gerontological area of nursing. My first role was as a director of nursing was when I was 29 and I have remained in this role for the past 12 years. What attracted you to employment in the nursing home sector?
While working in the acute sector I was completely frustrated by the red tape when trying to implement changes in practice and care. I suppose I found it difficult when the answer was always “no” or simple suggestions or ideas had to go through various committees that seemed to take forever to respond. I’m the type of person who if I see an area of care that can be improved upon and it is realistically achievable I want the changes made immediately and working in the nursing home sector allows for change. Residents come first and if changes can improve care or quality of service then immediate action is taken. Gerontological nursing is truly rewarding and I feel privileged that I work in this area. Another big attraction to this area was the emphasis on continuous professional development. It is to the fore in every nursing home, with nursing skills and experience on par and above those working in the acute setting. Nurses are more exposed to emergency situations without the backup that is available in the acute setting and therefore must make decisions using their clinical judgement and knowledge. The high standard of care in the nursing home sector must be highlighted as it is truly immeasurable. I feel very proud to be a part of this nursing sector. Staff are more open to change and teamwork is crucial. It is also a ‘no nonsense’ field of care. You work with your heart and don’t just leave. You get to know your residents and you build relationships that are inseverable. The bond becomes very strong - almost like they are your second family. The people we care for are amazing people with amazing legacies and a generation from which we can learn a lot. It would be remiss of me not to mention the attraction flexible working arrangements. A lot of consideration is given to staff rostering in this sector. At Annabeg staff never work more than two consecutive days and have every second weekend off. Days off are rostered around annual leave to ensure staff get extra time off and maximumise their Annual Leave. So one week’s annual leave gets turned into 12 days leave from the facility. Caring for your staff is crucial and eliminates issues such as sick leave and high staff turnovers. Being ‘family friendly’ is also key to a happy team. Happy staff equal delivery of a high standard of care which equals very happy residents.
29 — NHI NEWS
Has your perception of the sector differed from reality?
What are the challenges presented in your employment?
Absolutely. The nursing home sector can come in for very negative coverage from media and there is significant generalisation around the quality of care provided with ALL nursing homes often tarred with the same brush. The Leas Cross report did massive damage to the sector but it is up to each individual nursing home to prove themselves in relation to the excellent standard of care it provides and prove media wrong. Many older persons living at home are cold, lonely and barely cook for themselves due to being alone and perhaps due to financial constraints. After the death of a partner some may not cook for themselves, may stay in bed to save on heating bills and become very lonely. I’ve often been told ‘it’s the night-time I dread’. People come and go during the day but everyone goes home and they’re home alone and it’s a long night. And many of these people don’t sleep well because they might be fearful. Compare that to residents in care facilities who are truly well cared for. Their hygiene needs are met, they are warm, have an extensive menu choice and they are constantly entertained and offered activities. They live in very clean and homely facilities with no security issues or laundry and cleaning worries. These residents have choices. They make the rules. They dictate how their day should run and are very much empowered by the residents’ forum in the nursing home. After all the facility is THEIR home not ours. Residents are very much consulted on their care. I compare working in the nursing home sector to areas of care that colleagues of mine work within and the contrast is startling. The nursing home sector is certainly more proactive in areas of risk management, health & safety, fire safety, infection control and continuous professional development. Staff are exceptionally well trained and very confident in emergency planning. There is also `no profession discrimination or distinction between those employed. All team members are treated as equal, with all staff receiving the same training- with slight variances for nurses. Each profession employed have crucial roles to play in delivering an excellent service and a very high standard of care. Nurses do not lose their skills while working in this area but rather become more confident and stronger in dealing with different situations as they are more exposed to reality and have to make informed decisions. Working in the nursing home sector allows for a more organised, productive day where risks are minimal due to the high standards of care and systems in place. Due to the high level of organisation and accountability there is certainly less occupational stress and a more confident, empowered team. Happy staff ‘deliver’ happy residents and that’s what it’s all about. If you have unhappy residents then there are ‘system’ failures. I firmly believe that if we stick to the basic principles of ensuring excellent care, the rest will follow. If you fail on basic care principles then you have a problem that inevitably leads to bigger problems. Often that can be forgotten in other areas of care.
One of the biggest challenges is perhaps getting the balance right between ‘paperwork’ and delivering care. While I advocate the changes in our regulations and the improvements they have brought I do feel that we now spend too much time on documentation which could be spent on our residents and this saddens me. The question must be asked if it looks good on paper, what is the reality on the ground? Another challenge in this sector is undoubtedly funding. Funding must support our sector in improving upon the excellent standards of care we are striving to provide. One of the most frustrating challenges in the nursing home sector is our constant battle with A&E departments and a flippant attitude at times towards residents who come from the nursing home sector. On many occasions staff have to challenge A&E decisions to discharge residents back to the nursing home without proper assessment. There is also a frustration residents are not being assessed as the most appropriate healthcare setting and being referred to overcrowded A&E units.
What are your responsibilities?
Where do I start??! Most people would run a mile from the role of Director of Nursing due to the level of responsibility attached to the role. But one must not panic about these things and my rule of thumb is to never forget the basic principles of care. I instil this into staff. If you fail on that then you run into problems such as pressure sores or malnutrition eventually leading to higher mortality rates. All any resident wishes for is to be well cared for, to be respected, to be listened to, to be treated with dignity & respect. Without this you have nothing and no other frills or marketing ploys make up that huge shortfall. In my role you are entrusted with peoples’ lives. This is a huge privilege but also brings a huge level of responsibility. Unlike the C.E.O of a large firm, my responsibility is for people with pulses, not a product. Therefore there is no room for error, there is no room for mistakes. How do I gauge the level of service I and my team provide? One of the most important key quality indicator’s is number of complaints received. This gives a clear guidance to system successes or failures. And are the residents happy? If not, then why not? Engaging with residents on a one-to-one level is vital and there is no better way to do this than by taking time out with them. It is not achieved by popping your head in now and again in an official capacity. Other areas of responsibility include ensuring compliance with the National Standards for Older Persons in Residential Care Settings, compliance with the Health Act, nursing home regulations, fire regulations, health & safety and employment law. Auditing is a large part of my role, as is meeting with residents and their families to review their care. I also have overall responsibility for staff training and ensuring continuous professional development. My role also involves functioning as a ‘bed manager’. While it may sound exhaustive, there is an exceptional team behind me. If you lead by example you reap the rewards.
Is there a typical day?
Absolutely not! Every day is different and time flies. It is great to get up and head to work and love your job. What are the most pleasing aspects of your work?
It is hard to sum up. Some real examples for me include m When you get the opportunity to take a resident out who hasn’t been out in society for
many years that’s immense job satisfaction! To experience the look on their face and to see their delight, it truly wrenches the heart. You cannot measure the satisfaction and joy on being able to make that impact on someone’s life. m Making residents wishes come true. If it’s attainable then I will pull out all the stops
to grant that wish. Achieving it and seeing the residents reaction delivers immeasurable satisfaction. m Receiving cards with words of thanks can be very emotional and a little reminder of
why you care and why it’s worth it. m Caring for people terminally ill is a privilege and probably the most important care you
will ever give. m Planning entertainment, outings and surprises give me a particular sense of
satisfaction as I like to think outside of the box. Sometimes it’s not always about budget and there are ways around it. What advice would you provide to any trainee/graduate nurse considering employment within the Nursing Home Sector?
I would say go for it! You will attain nursing skills and experiences for life. You will become more confident and stronger in clinical decision making. You will become an excellent mentor and leader. You will not work in the shadow of others. Your continuous professional development will expand immensely. You will have pride in the care you deliver and you WILL care. Your standard of care will grow. You will have less occupational stress. You will have a very fair roster and your bank account will be healthier. And you will enjoy your job! You will learn lessons from life from those who have truly lived life.
My Nursing Home Life affords persons working within a nursing home setting the opportunity to discuss their role and advise the wider public of what it entails and employment within such a setting.
NHI NEWS — 22
NHI ANNUAL CONFERENCE 2013
Forum receives positive response from Health Secretary General The Department of Health is favourably disposed to bringing key stakeholders in the provision of long-term residential care around the table to plan for the requirement for such care, Dr Ambrose McLoughlin, Secretary General of the Department of Health stated at the NHI Annual Conference in November. The decision to establish a forum as requested by the NHI will ultimately be a political one, he said.
r McLoughlin was speaking at Shaping the Future of Nursing Home Care, on 7th November at Citywest Hotel. He delivered the opening address and participated in a question and answers session with the conference chair, broadcaster and historian John Bowman. Over 400 representatives of the nursing home and health sectors attended the conference. During the question and answer session, Mr Bowman referenced NHI’s long-standing call for the Department of Health to bring key stakeholders in the provision of longterm residential care together through the establishment of a ‘Forum on Long-Term Residential Care’. Mr Bowman asked “why there is not a more formalised relationship between this sector [private and voluntary nursing homes] as one of the key stakeholders in a forum to help develop public policy”. “I certainly will give very close scrutiny to the request of NHI and I have had discussions at political level,” Dr McLoughlin responded. “This is essentially a political decision. There are complexities in this because of issues around competition law, EU law and how we handle these; we have to be very careful and do have a huge challenge in this area.” He added: “Now we mightn’t call it a ‘forum’ but I think you can take it Minister [for Older Persons] Lynch
Dr Ambrose McLoughlin (left) addresses the conference audience during his discussion with John Bowman, event chair. will be disposed to putting an entity in place, it is ultimately her decision and a matter for her. It will be grounded on the basis of cooperation and collaboration.” In respect of the review of the Nursing Home Support Scheme (Fair Deal), Dr McLoughlin said “it is very important we get this review right”, adding, “it’s going to be the basis
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on which we will plan signiﬁcant investment decisions”. “Do you accept that the people here at today’s conference in this sector cannot be expected to be making investment decisions if they do not have certainty about the policy in the middle term,” Mr Bowman asked. “I accept that and the problem that we face as a Department is that until we stabilise the situation in respect of the health budget and our colleagues across Government do the same it is very diﬃcult for us to be certain about the numbers and the monies that will be available,” Dr McLoughlin replied. “But you can take it that we are in dialogue with the Department of Public Expenditure and we do hope to see a stimulus package approved by Government in the near future and I’m conscious of the fact that there needs to be some commitments made by Government in the medium and long-term in terms of funding long-term care. I would say there won’t be a decision on this until early in the new year but there will be a decision probably early to mid-2014.” The Secretary General said the Department is “working closely” with the HSE to develop an overall plan regarding future public provision of long-term residential care. “The plan will reﬂect both national and regional requirements and will have regard to the current severe ﬁnancial constraints, restrictions on public sector staﬃng and recruitment and the ongoing need to meet service and safety standards, all of which pose challenges for community nursing units across the country,” he added. He encouraged delegates to look to emerging technologies to support them in care provision and said there’s great opportunity for small and medium industry in Ireland to partner with the nursing home and health sectors. Questioned in respect of key issues facing the sector, Dr McLoughlin encouraged private and voluntary nursing home operators to look at how they can extend their services by utilising their expertise in home settings.
NHI Care Awards
2013 A night of glitz & glamour For a full list of winners and more pictures log on to: www.nhicareawards.ie
Award winning Moorehall ‘butterflies’ stimulate recollections At Moorehall Lodge Ardee the approach is to live in the moment and capture the essence of it by using visual triggers to stimulate recollections and to make emotional connections for the person in care. It was the recipient of the inaugural Nursing Homes Ireland Care Awards Innovations in Dementia Care Award. hen Moorehall Lodge Ardee recently received the NHI award for Innovations in Dementia Care, it marked a milestone in a journey that began with the proverbial single butterfly flapping its wings. Moorehall Lodge Ardee is part of the family-owned Moorehall Living Group, an innovative business where people flourish in a caring environment that seeks to constantly push new boundaries in the care of older people. Moorehall Lodge Ardee (MHLA) was established in 1998 by Michael and Tanya McCoy as one of the first purpose-built nursing homes in the north-east. By 2000 a household caring model specifically for people with dementia was opened. Moorehall Lodge Drogheda was then opened in 2012, featuring a further two households specialising in dementia care. Over the past four years, MHLA has undergone a physical and culture change resulting in a remodelling of the layout of the building and the approach to care. There are no longer signs of staff uniforms, badges, signs, notice boards, nurses’ stations. It now has four households, each with its own front door, kitchen, living space and private bedroom areas. With the support and commitment of staff, families and residents, care provision has been transformed. “The journey undertaken by staff, residents and their families to achieve the status of Ireland’s first accredited Butterfly Programme centre has, we believe, brought a new dimension to dementia care,” says Carol McLoughlin, Director of Care. “We all live in the moment – moments matter. For everyone with or without a dementia what we have now is so important. Our approach is to live in the moment – capturing the essence of that moment using visual triggers to stimulate recollections and to make emotional connections for that person. We’ve recognised that we cannot yet ‘fix’ dementia as a condition but we can certainly improve our approach to care. Our fantastic staff have embraced the challenge to change the way we care for people living with dementia.”
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Bright Butterflies Central to Moorehall Lodge’s approach to implementing the Butterfly Programme is a belief that people with dementia function primarily at an emotional level rather than at a thinking and logical level. If you take the example of somebody needing to use the bathroom, it takes around 37 different instructions from the brain for someone to recognise the need to use the toilet, get up and fully go through the process. Moorehall Lodge’s experience is people with dementia have a reduced and impaired ability to go through those 37 processes. What they do possess, though, is the ability to emotionally process things. “Some may have the ability to say: ‘I need to go to the toilet’, but may not be able to remember where it is or what to do next,” says Carol. “They can become quite agitated by not knowing what to do. We have found that by communicating emotionally, reading body language and recognising the person's emotional state, it's possible to help that person through that kind of day-to-day activity whilst at the same time retaining their dignity. “Our view is that if the person caring for that person is tuned into that individual they can stay a step ahead, look for facial expressions, look at the way someone is sitting, and see maybe that they are becoming agitated. Taking this approach allows staff to read the signs and not explicitly say, 'come on and we'll go to the toilet', which can cause distress. Instead they reframe the interaction by saying something like 'let's go for a walk', and then guide the person safely to the bathroom.” Often people don't understand that the person with dementia doesn't have the ability to interact with the world in the way they used to. This idea of connecting with people on an emotional level - getting into their world - means that we can achieve real improvements in their quality of life, Carol says. Moorehall Lodge staff learn to act as ‘butterflies’, she adds. Dressed brightly to hold attention, they flit in and out of people’s “moments,” making constant connections and reaching the places within their mind that will trigger off memories and ideas.
Central to staff training is the use of memory boxes. “Each member of staff is asked to bring in six things that are connected to strong memories in their own life,” says Carol. “We then ask them to pull something out of the box and explain why it's significant to them – why it triggers memories. More often than not these memories are surrounded by emotions which when accessed can lead to a stronger sense of self. “Moving on from this, training is focused on understanding how the same process works with residents. For example, if a resident had been a teacher or a builder, then there are plenty of items associated with each profession outside their bedroom or living room that they can come and go past, touch, wear and enable them live in the moment. These items are hugely significant to people with dementia as they trigger powerful memories. It can be something as simple as a towel, or a football jersey; these items trigger strong emotional connections for that person.”
Unified Support Walking into the dementia-specific households in Ardee, you might think that the communal areas can seem chaotic – with rummage boxes, domestic items, musical instruments, work items from residents’ past careers and a lot of colour and sound being features. But this atmosphere brings great calm and peace to the residents and their families who recognise that the moments of happiness that the Butterfly Programme brings, Carol explains. For her and the Moorehall Lodge Ardee team, the great success of the approach to dementia is how it has involved the families and staff at every step, creating a unified atmosphere of support.
Clockwise from left: ...
The Butterfly Programme featuring staff and residents interacting in Moorehall Lodge Ardee Visual triggers stimulate recollections and make emotional connections
Moorehall Lodge’s approach to dementia care has been the subject of national awards, media coverage and Ministerial visits, but satisfaction comes in smaller forms for Michael McCoy: “For us, success is measured in quality of life – both for our residents, their families and our staff. For me, a smile says is all.” For more information in respect of the Butterfly Scheme visit www.butterflyscheme.org.uk
Best Practice is a feature in NHI News that focusses on best and innovative practices in nursing homes. Nursing Homes are invited to make us aware of practices the wider public should be aware of and can contact email@example.com if interested in contributing an article P NHI NEWS — 24
ART & DEMENTIA
Creating an enriching & expressive environment As the Creative Director for dementia specific programs and an artist, Michelle Burns truly believes in the therapeutic nature of art. For those with dementia, the expression it affords provides them with a new voice, the Creative Director at Senior Access, an Adult Day Programme in San Rafael, California, writes.
rt allows the individual to communicate visually what is difficult or impossible to communicate verbally. It provides a safe place for expression of feelings and is a wonderful way to rekindle memories from the past. The creative process provides an avenue to address therapeutic concerns such as gross and fine motor skills, engagement and cognitive functioning. Art can also be a very effective tool to address psychosocial issues such as autonomy, independence, peer connections and self worth. These were all things I witnessed with our artists and, as our creative program grew, I saw art effect another change. Art was providing opportunities for staff to work with our members in unique ways. They found that the artistic process became an opportunity to build a deeply meaningful connection with the artist. This became a shared journey that was much more than just a ‘time-passing’ activity. In the moments of collaboration, staff members developed a deeper understanding of where the individual was, both physically and mentally. Instead of fixating on an individual’s decline and how that would affect the ability to accomplish a task, they focused on what the individual was capable of. They learned to reframe direction or explanation in a constructive
and encouraging way. Most importantly they learned to use art as a common language that focused on the positive experiences of the artist’s journey. By diminishing the perceived loss of abilities, a natural buffer was created that opened eyes to surprising talents and skills that remained. Art is an integral part of an innovative dementia care program, but projects can be challenging to execute successfully. The key is to find the balance between overly simplistic projects that risk infantilizing and projects that protect the adult sensibility. Approaching art as a process rather than as an outcome keeps artists from feeling overwhelmed, while still providing satisfying outcomes. This process is achieved through simple steps that are modified to meet the individual artist’s needs. Supporting staff by training them to understand the process of these steps and how to implement them creates an enriching experience for everyone. The artists can thrive in an environment that uses dignity as its core philosophy and staff members gain valuable tools to help individuals enjoy meaningful activities. This paradigm shift focuses on building relationships as the cornerstone of best practices in care.
International Dementia Care Conference Ms Burns will be speaking at the 6th International Dementia Care Conference in Dublin. Entitled Supporting staff as enablers of change: Towards flourishing dementia care cultures, the conference takes place in the Crowne Plaza Hotel Dublin on Monday 28th and Tuesday 29th April. Early bird rates are now available. To book , call 01 260 8138 or visit www.sonasapc.ie
Proﬁle: Michelle Burns Michelle Burns is the Creative Director at Senior Access, an adult day programme, and is a dementia art specialist with other centres in San Rafael, California. With a series of third level qualiﬁcations in this area, she has contributed to university curricula and produced guidelines for community organisations working with people with dementia. Ms Burns has presented her innovative approach to arts and dementia at international conferences and delivers training workshops to caregivers, healthcare professionals and people living with dementia. Her publications include a handbook outlining expressive art projects to use in dementia care settings and an article in the recently published book The Gifts of Autism and Alzheimer’s. In curating and contributing art created by people with dementia at exhibitions in art galleries and museums in San Rafael, Ms Burns has been instrumental in increasing public awareness and understanding about dementia in the community.
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work space life
Mater Adult Hospital: ward furniture supplied to over 200 rooms
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Published on Mar 19, 2014
Published on Mar 19, 2014
NHI News Spring 2014 focuses on the findings and recommendations emanating from the NHI Commissioned BDO report Health's Ageing Crisis: Time...