Aged Care Royal Commission: my submission to the Ministerial Roundtable on the Terms of Reference
Sept 27, 2018
Notes for presentation to the Ministerial Roundtable on the Terms of Reference for the Royal Commission into Safety and Quality in Aged Care. Sydney, Sept 27, 2018
By: Ngaire Hobbins APD, for the Dietitians Association of Australia
Firstly, thank you Minister Wyatt for the opportunity to be part of this important discussion. A summary of these notes will be presented in my 2 minutes available at the meeting on Sept 27; here I offer an expanded rationale for that short presentation.
I note the draft TOR are as follows:
· The quality of care provided to older Australians, and the extent of substandard care;
· The challenge of providing care to Australians with disabilities living in residential aged care, particularly younger people with disabilities;
· The challenge of supporting the increasing number of Australians suffering dementia and addressing their care needs as they age;
· The future challenges and opportunities for delivering aged care services in the context of changing demographics, including in remote, rural and regional Australia;
· Any other matters that the Royal Commission considers necessary
We submit the following:
1. In the draft TOR point 1, the word ‘care’ does not adequately cover provision of quality food and nutritional support.
Care implies delivery of compassionate, hands on assistance and nursing/medical attention; but the ability of aged care services (including community care) to ensure quality, appropriately nourishing food that actually makes it into the mouths of every person in residential or community care, is more than just ‘care’. That requires a combination of professional understanding of the nutritional needs of older people, a deep understanding of the processes involved in preparing appropriate food (much more than just cooking meals) and an ability to critically analyse and direct the systems in place to ensure prompt delivery of appropriate, nourishing, quality food to every person requiring it. ‘Care’ does adequately cover those requirements, neither does it reflect the essential involvement of an appropriately qualified, Accredited Practising Dietitian.
Currently, providers are only required to have a dietitian assess the menu and to attend after a nutrition issue is identified for an individual resident or client. The menu assessment can be done ‘off site’ and still be acceptable under quality standards; but, in terms of assessing the real nutritional adequacy of the food and food service systems, at least one full day site visit is essential, so this is completely inadequate. In addition, most case management systems ‘trigger’ a dietitian referral following 2 or 3kg weight loss; for a frail, elderly person that is often too late to be able to turn the problem around. As well, that referral visit does not allow time to determine the capacity of the kitchen, food service and care staff to deliver the nutritional prescription given. The Royal Commission must address food service and nutritional support of residents/clients together, under an additional TOR.
Proposed additional TOR:
“The quality of food and nutritional support from Accredited Practising Dietitians provided to older Australians and the extent of substandard food and nutritional support”
2. The use of the word ‘challenge’ in points 2,3 and 4 is not appropriate. This term, in relation to older Australians, reinforces ageism, implies that our elders are burdensome and as such, is disrespectful.
In place of ‘the challenge of’ : “The responsibility (or capacity?) of government (and aged care providers) to support and provide high quality care and nutrition to Older Australians” ….and those living with disabilities in residential and community care.
3. There is an urgent need for the Royal Commission to consider the impact of the funding model currently being used in terms of the quality of life it might deliver for those in care. The current model encourages disablement and disability. While it is appropriate for many residents to have higher levels of assistance funded, there are also many others living in residential care especially, who can gain significant benefit from proactive nutritional support combined with physical activity initiatives and social inclusion programs. If, for example, people are adequately fed (especially ensuring protein intakes are achieved, which requires dietitian involvement in recipe and menu development) and have access to professionally designed and individually directed physical activity programs (including gyms and other strategies to incorporate resistance exercise into regimes), their swallowing ability can be improved or maintained so that they do not require moving to higher level texture modification in their meals (thickened fluids and puree for example). This is of immense benefit to quality of life as well as nutritional status, since it is well documented that the move to higher levels of texture modification is associated with reduced nutritional status for many residents. But providers currently access additional funding for the provision of texture modified meals, while there is nothing in the current model that provides for gym programs or for pro-active nutritional involvement in aged care.
Proposed additional TOR:
“The capacity of the current funding model to support the ongoing quality of life and reablement of older Australians and the extent to which the current model provides a disincentive to the government’s stated intention to encourage reablement in older Australians in care, including those living with dementia or disability”
4. And finally, the draft TOR offers no clear outcomes. Discussion of ‘challenges’ and ‘opportunities’ is not enough to allow the Commissioner to make specific recommendations to ensure the Royal Commission achieves better quality of life and health outcomes for older Australians and those with disabilities supported in care.
Proposed wording in point 4:
(Instead of “the challenges and opportunities for delivering….”)
“The means by which government and aged care providers will deliver high quality aged care and nutrition services in the context of changing demographics including in remote, rural and regional Australia”