Sins of the system visited upon the elderly

6 minute read

If we are serious about quality aged care in the community – keeping people in their homes – why is it not easier to bring primary care to them?

It maybe slightly crazy but I can’t see any other way.

I’ve decided I’m going to give up one of my afternoons in the surgery to just do nursing home and home visits, in particular, home visits on my very elderly patients .

I’m sure plenty of you do this already, and others will be much more efficient than I am at regularly squeezing in one or two visits routinely into a day’s schedule. But for me, the demand is outstripping my capacity and I need make a change before I miss something serious.

The problem is, of course, that I’ve been at the practice for just that critical length of time whereby a number of my older patients who were active, vital and independent a decade ago are now getting old, sometimes very old – and if they’ve also experienced illness, misfortune or misadventure they have become increasingly fragile.

These patients have been my patients for many years. They always used to present to the surgery and I know they would still like to in theory, but the reality is they are not strong enough or safe enough to come in unaccompanied, and for many organising someone to bring them is too difficult. I need to go to them.

All this seems logical right? So where does the crazy part fit in?

Well, in my book home visits and nursing home visits tend to be an exercise in frustration. And I’m not just talking about the logistical challenges such as negotiating the treacherous front path, or waiting the obligatory 15 minutes at the front door waiting for Fort Knox to become penetrable.

We all know, the system does not support this type of service.

In particular there are no incentives, either financially or otherwise, to encourage GPs to take on these out-of-office visits. In a busy practice, the decision to swap an afternoon of face-to-face office consults with a series of consecutive home and/or nursing home visits does not make economic sense.

Obviously that’s not the reason I’m doing it, but it is a bit pathetic isn’t it?

Today, in Australia we live in a society where elderly people are – quite rightly – encouraged to live in their homes as long as they are able. As much as authorities would like us to believe that this push comes from some altruistic noble principle, we all know that the bean counters have worked out it is much cheaper to keep an older person in their own home and support them with some services than to have them enter an aged care facility.

And so we have the proliferation of home care packages and the burgeoning industry associated with the provision of services for the elderly recipients of these packages.

Don’t get me wrong. It’s a great idea – and so many of my patients would be lost without the help they receive courtesy of these home care packages.

But when they set all this up did someone ever consider that these people’s primary medical care needs were likely to increase in accordance with their level of home care package and maybe the home delivery of GP services should be supported along with extra hours of a cleaner or someone to help prepare meals?

I know, I know. It’s a different pool of money. It’s a different administrative body. It’s state vs federal, health department vs housing department … But you get the gist!

I think my annoyance really hit a peak after reading a recent BMJ paper, written by Australian researchers – uninterestingly titled “Quality and safety indicators for home care recipients in Australia”.

In a nutshell, they looked at various indicators that were associated with good health outcomes and linked them to the different levels of home care packages.

The principle of accountability makes sense, of course. We know people on a level 4 home care package need a lot of support, so how are we going at delivering that support? Finding objective indicators was obviously a challenge and the researchers certainly came up with some interesting ones. Aside from hospitalisations, falls and fractures (which seem reasonable) they also looked at whether they’d had a chronic disease management plan or a home medicines review.

“Concerningly, utilisation of chronic disease management plans and home medicines reviews were lower in those receiving level 3-4 HCP, despite having more complex care needs and increased potential for suboptimal medication-related care and service utilisation” the researchers wrote. 

Maybe, just maybe, it’s because these “HCP” packages don’t come with a provision for increased access to good, regular primary care. As they become less mobile these patients probably haven’t seen a GP often enough to get a chronic disease management plan done!

Everyone recognises that these elderly patients need more and more support to live at home – why isn’t it inherent that an at-home regular GP visit be subsidised and supported as well?

According to this paper, approximately one-third of Australia’s aged care budget is spent on the provision of home care services, of which half is on home care packages. And by 2050, it is estimated that 80% of aged care services will be delivered in the community.

Surely it makes sense, if they are serious about delivering quality aged care services, to provide for the delivery of primary care at home – they can’t just rely on the pathetic Medicare rebate they usually allocate that seems to assume these patients only differ from our surgery patients geographically. The demand is soon going to outstrip the supply.

The frustrations of home visits and nursing home visits are unlikely to be fixed by any one initiative or any single rebate rise. But I think something is going to have to happen soon or else there is going to be an inequity of access to good quality primary care, and it’s our society’s most vulnerable who will suffer the most.

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