Response to Department of Health’s Proposal for a new residential aged care funding model – consultation paper

CPSA welcomes the opportunity to comment on Proposal for a new residential aged care funding model – consultation paper and supports the development of an aged care funding tool that explicitly references residential aged care staffing levels. CPSA is concerned that the proposed model, the Australian National Aged Care Classification (AN-ACC), has been developed on the basis of care practices funded and shaped by the current Aged Care Funding Instrument, which may compromise the effectiveness of AN-ACC. CPSA urges that the introduction of AC-ANN be delayed until the Aged Care Commission has made its final report to the Governor-General and the Government has responded to its recommendations.

CPSA provides its comments as direct responses to the questions asked in the consultation paper.

1. Are there any risks or benefits of the proposed funding model that have not been identified?

What has not been identified and dealt with in the proposed funding model is that the model has been developed using current residential aged care staffing levels. It has been tacitly assumed that those staffing levels are adequate in the delivery of safe, quality care.

While the issue of staffing levels in residential aged care was already contentious before the institution of the Royal Commission into Aged Care Quality and Safety, Commission hearings thus far have confirmed that staffing levels cannot be assumed to be generally satisfactory. However, the 50/50 split between shared costs and variable costs is based on the assumption that typical staffing levels are satisfactory.

CPSA notes that no information on staffing levels in residential aged care are published either in aggregated, de-identified form or more specifically for individual providers or services. In fact, the RUCS does not appear to have considered the issue of the adequacy of staffing levels in the facilities at the time it gathered data at all.

As noted as part of the RUCS, one of the limitations of ACFI was that it “does not focus on what drives costs of care”.[1] The RUCS acknowledges that staffing is the principal cost driver, and in fact RUCS bases its residential funding proposal mainly on staffing costs. It is clear that, while staffing costs may not drive ACFI, ACFI does drive staffing levels, because ACFI funds salaries and wages in residential aged care.

As a result, there are is a very important and significant risk for the proposed funding model, AN-ACC.

The RUCS Report 1 describes how the data was collected to enable to calculate the split between shared costs and variable costs. This was done by meticulously recording what actually happened on the residential aged care wards of the aged care facilities selected for the exercise. However, what actually happened on these wards was funded by ACFI. By using this method of data collection on which to base AN-ACC, the proposed AN-ACC risks inheriting the ills of ACFI.

If the Royal Commission were to recommend a change in staffing levels in residential aged care and if that recommendation were to be adopted by Government, AN-ACC cannot guarantee that it accurately funds the staffing levels then required. It is highly likely that the Royal Commission will find that what is classed as variably-costed care under the RUCS requires increased levels of staffing, both in terms of numbers as well as qualifications. In other words, the 50/50 split between shared costs and variable costs would be unlikely to be realistic in a scenario where staffing levels are increased significantly to cope with the true demand and need for variably-costed care.

The RUCS did not collect information about time spent on specific care during night shifts: “… all time on night shift was defined as shared time that would be costed equally across all residents.”[2] Inherent in that approach and decision is the assumption that nothing much happens during night shifts. The Royal Commission has heard evidence that night shifts are typically understaffed and that staff during night shifts struggle, or rather fail through no fault of theirs, to provide the variably-costed care required. The Royal Commission has also heard evidence that oral healthcare – an area of care typically required to be provided at night – is a neglected, and in many RACFs an absent area of care provision. Just meeting the variably-costed care at night time alone would likely throw out the 50/50 split between shared and variable costs proposed by the RUCS.

The Royal Commission has also heard that staffing levels during morning and afternoon shifts are typically inadequate. In evidence concerning care provided at Bupa Willoughby, the Commission heard that food would be served to a resident but no one would be available to make sure the resident ate that food. Malnutrition rates in RACFs are high and this mostly due to RACFs not having sufficient staff assigned to ensuring that meals are not just served but also eaten.

Likewise, if the Royal Commission were to make findings related to the widespread, inappropriate prescribing and administering of psychotropic and anti-psychotic medications, behaviours like wandering and day/night reversal would need to be managed by carers, posing a significant demand on their time across day, afternoon and night shifts.

The undesirable inheritance from ACFI to AN-ACC would not necessarily be limited to the staffing cost component, but could also extend to other costs such as equipment and supplies. For example, ACFI also drives the rationing of continence pads in residential aged care, an item that should not be rationed. This may well lead to a recommendation by the Royal Commission to the effect that continence pads should be provided when needed without any rationing. Lifting of rationing would then also lead to an increasing demand on staff time so that residents can be assisted with incontinence pads.

It should be noted that CPSA is not critical of the RUCS’ methodology or AN-ACC’s structure. However, it is becoming increasingly clear with each day of Royal Commission hearings that residential aged care is in crisis and that some assumptions on which the AN-ACC is based are wrong.

2. Are the proposed resident assessment and classification processes appropriate? If not, why not?

CPSA does not have the expertise to comment.

3. Are the proposed reassessment triggers appropriate? If not, why not?

It seems very restrictive to have only two clinical triggers plus a necessarily arbitrary time trigger for re-assessment. Ideally, re-assessment should be done on the advice, and at the request of the Director of Nursing of a facility.

4. Are there other factors that should be considered for inclusion as reassessment triggers?

See comments under 3.

5. Should the Commonwealth consider the introduction of reassessment charges for services that trigger unnecessary reassessments?

Punitive charges for reassessments that do not result in a change in case-mix classification may cause residential care services to be reluctant to apply for reassessments and this reluctance would be a negative for consumers, whose interest it is to receive proper and properly funded care at all times, including when their circumstances change.

It is noted that the proposed two clinical triggers for reassessment are unlikely to be gamed by service providers, while the arbitrary standard period for reassessment trigger constitutes an open invitation for gaming, and one that will be used for every resident at every opportunity.

6. Should there be a requirement for reassessment in the proposed funding model?

See comments under 3.

Questions 7 – 11

CPSA does not have the expertise to comment.

12. Do you support the development of a best practice needs identification and care planning assessment tool for use by residential facilities?
13. Do you support a requirement for care planning assessments to be undertaken at least once a year for all residents, with outcomes discussed with residents and carers?

CPSA supports the development of a best practice needs identification and care planning assessment tool for use by residential facilities. This should be undertaken regularly and as needed for all residents, with outcomes discussed with residents and carers.

[1] Report 1: The Australian National Aged Care Classification (AN-ACC), Australian Health Services Research Institute, February 2019.

[2] p13, Report 1: The Australian National Aged Care Classification (AN-ACC).