A panel of GP and nurse practitioner outreach services representatives has argued that aged care providers should not be required to secure GPs for their residents – but conceded a care coordinator role could be a useful tool to ensure residents receive health care services in residential care.
For just under two hours, Senior Counsel Assisting Peter Gray QC tested a range of propositions on the panel: Dr Troye Wallett (pictured below), a GP and aged care consultant with GenWise Healthcare, which provides mobile GP services in residential care and the community in a number of states; Dr Paresh Dawda (pictured above), a GP and Director and Principal of Prestantia Health, which provides a similar outreach service based in the ACT; and Susan Irvine (pictured further below), an RN and General Manager of Home Nurse Services, which has 35 Nurse Practitioners (NPs) across a number of states and territories, namely:
That there should be blended payment arrangements for health care services in aged care (and a funding program to pay for the model), such as a general practice receiving an annual payment based on the recipient’s or group’s health needs with fee for service payments for complex or after-hours attendances and performance payments based on factors such as immunisation rates or diabetes management planning:
All three were in favour of this proposition.
Dr Dawda argued no payment model is fit for purpose on its own so a blended payment model is the best option. He pointed to the US and the UK where alternative models of provision for aged care have been set up that includes primary care.
This “pot of money” is used to deliver care to the person that best meets their needs.
“Within that are elements of risk sharing that have to be negotiated but also there’s a built-in incentive there around if they are efficiencies of scale that are achieved and savings realised and agreements around how those savings could be utilised, for example, a case for investing potential savings in further enhanced service offering is not uncommon,” he told Mr Gray.
Dr Wallett also supported the idea, but added it would require a review of the Medication Benefits Schedule (MBS) because GPs are currently not remunerated for many aged care items such as handovers or writing medication charts and the MBS doesn’t incentivise proactive care.
That the MBS be amended to support comprehensive health assessments of aged care recipients every six months:
Again, the panel gave this idea the thumbs up. All agreed that there should be a provision for a team care arrangement and for nurse practitioners to be involved in assessments.
That the Commonwealth fund a scholarship program to increase the number of nurse practitioners in exchange for them working in aged care, particularly in rural areas:
Ms Irvine gave this the tick of approval, saying her team estimates another 600 nurse practitioners are needed across Australia to provide medical care.
The RN also advocated for a $1 per day per resident finding model to be paid through aged care facilities to nurse practitioners to provide high-level nursing support and supplement the non-billable items that NPs do in aged care.
That multi-disciplinary outreach teams (i.e. flying squads) of specialists be implemented with dedicated funding to provide outreach services to aged care facilities:
The group was supportive of this idea, but Dr Dawda cautioned the Senior Counsel on the divide between the state and Commonwealth-funded series and the need for an integrated approach.
“I would strongly urge the Commission to consider not only having it go through local hospital districts but also primary health networks and think about a sort of co-commissioning type of model, and that way it puts an emphasis on multidisciplinary teams in an integrated way rather than in a siloed way,” he stated.
He argued this would require both a shared record system (the importance of data) and clear delineation of the roles and responsibilities of each party to ensure residents don’t fall through the gaps.
Dr Wallett also pointed to the need to extend the MBS items for telehealth consultations with specialists to provide more incentives.
That the Royal Australian College of General Practitioners (RACGP) amend its accreditation standards for general practices to allow GPs which practise exclusively in aged care facilities and at home to be accredited – specifically the requirement that general practices maintain a physical presence and certain equipment at facilities:
Unsurprisingly as both work at mobile services, the GPs agreed this would be a positive step.
However, the pair were less supportive of new draft standards developed by the College that are currently under consultation which contain a list of measures that facilities should do to support GPs.
Dr Wallett says while he would like to see basic internet access, basic access to printers, and access to the facility’s notes as minimum requirements, other measures such as access to a consulting room should be an issue for the facility and the GP to discuss.
“I think some GPs that come into aged care facilities will require a clinic room with everything set up there for them,” he said. “Some GPs would be very happy to walk in with their computer and their own equipment and deal with residents that way. So, I think one needs to be cautious of mandating things that some that might not fit into both the GP or the RACF.”
Dr Dawda was in accord.
“In my conversations with directors of nursing, for example, at residential aged care facilities, I think I’ve quoted one of them in my statement which was along the lines of, you know, ‘Please don’t give us anything more to do. We just can’t cope.’ I think there’s a real risk of unintended consequences,” he said.
Ms Irvine suggested a service agreement between the GP and facility would be a better option – and Commissioner Tony Pagone was intrigued by the idea.
“How do you envisage the agreement to look like?” he asked. “Would it be just a matter of each of the aged care facilities being more or less required to guarantee that they would make available something for GPs visiting? Is that what you had in mind?”
“No,” she replied, “I think on an individual basis, so a mutual conversation, as Troye suggested, between the – what the GP is thinking that they need to require, and don’t forget we don’t have to have one GP visiting an aged care facility and we visit one aged care service in South-East Queensland that has 55 GPs visiting that facility.”
Dr Dawda had concerns about this model however – namely, that it would turn off some GPs.
“I worry about having service level agreements, as it becomes a transactional, rather than a transformational system,” he said. “Introducing a third party … with the purpose of clarifying accountabilities where there’s no – no exchange of moneys, for example, between the two parties, could potentially be detrimental and may actually put some GPs off providing services to residential aged care, so I think, again, there’s a risk of an unintended consequence.”
Like previous hearings, the Commissioner wanted more detail.
“If you’ve got some ideas, now is a good time to tell me,” he joked.
Dr Wallett argued it could be as simple as facilities providing a service agreement to a GP with their minimum service requirements and asking if they can meet those.
“I’m sure we could come up with a list of five or six or seven things that would be required on a MOU, not dictating the answer to them but at least the questions,” he stated.
That the extent of aged care providers’ responsibility to obtain primary health care for residents should be clarified; that providers should have a requirement to engage GPs for their residents; and residents should have a care coordinator to help them in accessing health care services:
Dr Dawda was again cautious about making providers responsible for securing primary health care for residents. He also raised concerns about a care coordinator, arguing that while any group could fill this role, it should still sit within general practice.
“I think we need to be responsive to what the local context is, what the local needs are, what the workforce issues are locally and availability of workforce,” he said.
Dr Wallett was on the same page.
“The requirement to engage primary health care practices, I agree, is problematic,” he said. “I think that, again, it adds a burden to the aged care facilities which are overburdened already.”
He was more enthusiastic however about the idea of a care coordinator.
“To me it sounds like it needs some nutting out and thinking about to where that person sits and how that can sit and where and how that would work. But from a working GP point of view I like the idea of being able to walk into a facility, finding the care coordinator who will tell me all about my residents, find the pressure wounds we heard about before, phone specialists and get them and do all that kind of thing, so I think it is a good idea.”
Unsurprisingly, Ms Irvine was all for nurse practitioners filling the care coordinator role.
“They have the ability to, you know – they speak the same language as doctors, they can talk to the specialists, they can talk to all the aged care, they could talk to families,” she said. “They have the time to talk to families and look at those issues.”
That aged care and home care providers should have the ability to add their care plans to the My Health Record (MHR) system:
Dr Dawda said very few aged care providers are using MHR and agreed it should be encouraged – and taken further.
“I think it’s about secure information exchange with the plurality of providers that are involved in the resident’s care, and so we should be looking at digital communication in a secure way with all those providers and certainly My Health Record should be a component of that,” he said. “But I don’t think My Health Record is a two-way communication tool, and therefore I don’t think should limit ourselves just to My Health Record.”
He pointed to the interoperability framework due to be released by the Digital Health Agency (DHA) next year as a potential way forward.
Ms Irvine also agreed it was a good idea – but noted many aged care providers still don’t use digital systems and the poor communication between aged care and hospitals as potential barriers.
“Would you agree, however, Ms Irvine, that ideally every aged care facility in the country should have access to digital systems?” Commissioner Lynelle Briggs asked.
“Absolutely,” Ms Irvine replied. “But we have some of the largest providers and listed companies in the country who are not.”
“And that is surprising, so one would be expecting those providers to upskill in this area, do you imagine?” the Commissioner went on.
“I would hope so,” said Ms Irvine.
If you are a provider that is still relying on a paper-based system, I would seriously be re-thinking it right now.