Additional funding for access to medical services for residents of aged care facilities
Caring for the frail elderly living in residential aged care requires doctors to spend a significant amount of time managing and organising the ongoing care of their patient. This includes discussing the patient's care needs with the nursing staff, maintaining medication charts, completing various forms, discussing care and treatment with the patient's relatives, liaising with pharmacies regarding prescriptions, and taking after hours telephone calls from nursing staff. There are no Medicare rebates payable for this work. For many doctors, having made the investment in their surgeries, it is not financially viable to visit patients living in residential aged care, particularly when they have a waiting room full of patients. The AMA's proposal for additional funding for access to medical services for residents of aged care facilities addresses this by recommending that the Australian Government provides specific funding to approved residential aged care providers to allow them to enter into service agreements with medical practitioners to provide ongoing medical care to residents in a particular facility. Voluntary agreements between doctors and approved providers could be negotiated on a case-by-case basis and would complement Medicare rebates for medical services provided to residents of aged care facilities.
All Australians have a right to medical care when they need it. For older Australians living in residential aged care, access to ongoing medical care and supervision is fundamental to ensuring they receive the best possible level of care as they grow older.
As the population ages, the trend towards rising dependency levels for residents in aged care will make it imperative that these residents have access to appropriate medical care.
There are currently few obligations on providers of aged care to facilitate access to timely and high quality medical care and supervision for all residents on an ongoing basis.
Approved provider responsibilities
Under the Aged Care Act 1997 (the Act) approved providers have responsibilities for the quality of the aged care they provide through their aged care services. Approved providers must comply with standards set out in the Quality of Care Principles 1997.
Under these principles, approved providers of residential care services must provide assistance in obtaining health practitioner services by making arrangements for health practitioners, including medical practitioners, to visit residents.
The Aged Care Accreditation Standards are standards for the quality of care and quality of life for the provision of residential care. The Accreditation Standards as set out in Part 3 of the Quality of Care Principles 1997 currently don’t impose adequate assessment criteria in regard to access to medical care. As a consequence, this requirement is met in a very adhoc way across the sector and is not sufficiently monitored or scrutinised as part of regular accreditation reviews like other important service and care requirements.
The accreditation assessment process currently does not closely monitor what formal arrangements are in place for an aged care facility to obtain medical care for its residents. Nor do the accreditation criteria demand that a residential aged care facility provides appropriate physical infrastructure for medical care to be provided on site. For example, very few facilities support the delivery of palliative care or provide an adequately equipped clinical treatment room that affords patient privacy, and contains sufficient medication imprests, and appropriate medical stocks (such as catheters, sterile gloves, wound dressing materials), as well as good information technology for patient records and medication management.
The AMA believes it is incumbent upon approved aged care providers to ensure that medical care for aged care residents is equal to the standard of medical care enjoyed by the rest of the population. This includes:
- accreditation arrangements and monitoring processes that ensure medical care and supervision of residents is provided on an ongoing basis;
- access to adequately equipped clinical treatment areas that afford patient privacy and information technology to enable access to medical records and to improve medication management; and
- access to sufficient number of registered nurses to monitor, assess and care for residents and liaise with doctors.
To achieve that, the provision of medical care must be an integral part of aged care. The AMA proposes that the Accreditation Standards be strengthened in this regard to provide greater certainty to residents that medical care and medical supervision is available to them on an ongoing basis.
Enabling approved providers to arrange medical care
It is appropriate that approved providers of aged care are properly supported by Government to ensure their residents have access to medical care. The Aged Care Act provides for the Commonwealth to give financial support to approved providers, through subsidies or grants, for the provision of aged care.
The AMA believes the Government must provide specific financial support to approved providers to ensure residents can access appropriate medical care. Approved providers would use this financial support to:
- provide appropriate settings for medical care to be delivered; and
- recruit and retain medical practitioners to encourage them to provide medical services to residential aged care facilities through a variety of arrangements.
These should be voluntary local agreements negotiated on a case by case basis between doctors or practices and individual approved providers. They will not be between the Government and a doctor.
Agreements could, for example, include, but would not be limited to:
- a lump sum payment for a doctor to provide medical care and supervision to residents on an ongoing basis over an agreed period of time;
- a payment made to a doctor when agreed services are provided;
- an additional service payment paid by the RACF on behalf of its residents for each service that is provided to a resident of the facility over and above the MBS payment for that service; and
- a longitudinal payment that is made when an individual doctor has provided services to residents of the facility over a period of time.
All of these options would involve voluntary agreements over and above the MBS fee for service payments which would continue to be claimed for each medical service provided to a resident in a RACF.
Excellence in the provision of medical services for residents would also assist RACFs seeking to diversify into subacute and step down care.
Agreements could also be made between geriatricians and other medical specialists and approved aged care providers, and could potentially cover both medical care as well as research and training in the RACF. Excellence in the provision of medical services for residents would also assist RACFs seeking to diversify into sub-acute and step down care.
An arrangement between an individual doctor/s and an approved provider would be structured in such a way as to ensure it did not threaten the primacy of the doctor-patient relationship. Nor would it negate or preclude the right of an individual resident to choose to be treated by their own doctor outside of such an arrangement.
Additional Commonwealth funding to RACFs for this purpose would be subject to the provision of evidence that the aged care facility continues to use the funding for this purpose.
More nurses in residential aged care
The AMA recognises it is also necessary for the accreditation standards to be improved in respect of ongoing nursing care of aged care residents by specifying a minimum acceptable staff ratio between registered nurses and patients in aged care facilities. Having appropriate numbers of qualified nursing staff in aged care facilities will ensure that residents’ health is properly monitored, those residents requiring medical attention from a doctor are identified quickly and doctors can provide the most efficient and effective medical management of the resident in the facility when the resident needs them, working alongside the nursing staff in the facility. Good medical care under this model will also reduce the number of instances of hospital admission by residents of aged care facilities.
As stated above, new agreements between RACFs and doctors will reflect incentives and remuneration over and above existing payments under the Medicare Benefits Schedule (MBS) which will still cover medical services provided by the doctor. The AMA will continue to pursue Medicare items that reflect the complexity and the significant amount of clinically relevant non face to face time involved in providing medical care and medical supervision to residents of aged care facilities.
The AMA recommends that access to ongoing medical care and supervision of residents in aged care is enhanced through :
- accreditation arrangements that more closely monitor and guarantee that aged care residents receive medical care and supervision on an ongoing basis;
- access to adequately equipped clinical treatment areas that afford patient privacy and information technology to enable access to medical records and to improve medication management;
- specific financial support to approved residential aged care providers to allow them to enter into local agreements with medical practitioners to ensure residents can access appropriate medical care;
- access to sufficient number of registered nurses to monitor, assess and care for residents and liaise with doctors; and
- MBS items that better reflect complexity and the significant amount of clinically relevant non face to face time involved in providing medical care and medical supervision to residents of aged care facilities.
Published: 14 May 2009