Catherine Scott

Sundale Ltd

Auditing in aged care aims to improve the quality of care by reviewing care delivered against defined criteria and implementing changes based on the results. 

Internal quality audits are undertaken against the Aged Care Quality Indicators, and the external accreditation and certification measures compliance with the Aged Care Quality and Safety Standards. 

Providers need to regularly review clinical practice levels of activity, processes of care and outcomes, and benchmark performance data with external sources and other similar health service organisations. 

Having systems in place supports:

• Monitoring variation in practice against expected health outcomes,
• Providing feedback to care team members on variation in practice and health outcomes,
• Reviewing performance against external measures,
• Clinicians to regularly take part in clinical reviews of their practice,
• The use of information on unwarranted clinical variation to inform improvements in safety and quality systems, and
• Recording the risks identified from unwarranted clinical variation in the risk management system.

Undertaking audits and being accredited does not eliminate all risk to residents experiencing harm or adverse health events. It highlights the presence of safety and quality systems that support safe and reliable quality care are in place and risks of harm are identified and managed. 

The reasons for undertaking auditing and seeking accreditation include the following:

• Compliance
  • Receiving a certificate of attainment,
  • Licensing implications, and
  • Funding and contractual requirements.
• Verification
  • Verifies that the provider is authorised to provide care,
  • Reassures our residents, their families, and the broader community, and
  • Authenticates a provider’s claims of highly reliable care.
• Quality
  • Demonstrates consistency between a provider’s words and actions,
  • Represents safety and efficacy of practices, and
  • Fosters positive health outcomes for residents.

Audits involve the entire organisation and generally represent four key steps:

• Understanding the Aged Care Quality and Safety Standards and Quality Indicators,
• Ensuring there are people, resources, and support to give effect to any required changes,
• Using a combination of internal and external auditing resources such as the Aged Care Quality and Safety Commission, and
• Completing regular self-assessments that bring together a provider’s evidence showing how they meet the above standards.

During internal audits and external accreditation, a process of triangulating evidence takes place whereby written evidence is compared against what is observed to be occurring in practice and then verified through resident, family, and staff engagement for confirmation.

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.

Phillip De Bondi

South Australian Virtual Care Service (SAVCS) - SA Health

Background

The South Australian Virtual Care Service (SAVCS) was established in December 2021, offering the South Australian Ambulance Service (SAAS) direct access to Emergency Department (ED) trained clinicians via a virtual consult. The intent was to avoid inappropriate transfers to the state's emergency department by effectively bringing the senior clinical staff to the patient via video conferencing.

SAVCS data demonstrated that approximately 16% of all referrals to the service from SAAS came from Residential Aged Care Facilities (RACF). It was observed that this cohort often had significant delays with waiting for transport to the hospital, waiting at the hospital, and waiting to be transported back home. Evidence from the 2019 Royal Commission into Aged Care noted that residents do not always achieve good outcomes by attending a hospital and that thousands of inappropriate ‘000’ calls come from RACF.

SAVCS saw an opportunity to provide direct access to the SA Virtual Care Service senior clinicians for residents residing in aged care to improve the timeliness of care delivery and reduce the need for residents to move to access care and to better support RACF staff. The virtual consult allows people who know the resident best to discuss the scenario with SAVCS’s urgent care staff directly. Virtual consults allow staff, family, and friends to be included on the call regardless of their geographical location.

Service Development Timeline

• June 2022: A co-design workshop was held with key stakeholders, including SAAS, Primary Health Networks, Aged Care providers, and SAVCS, to develop the pathway.

• July 2022: Engaged with a Pilot Provider to roll out the pathway to their sites.

• August 2022: Engaged with Early Adopter Providers to ensure the initial success of the pathway was not unique to the Pilot Provider.

• October 2022: Opened the SAVCS pathway to all RACF across SA.

Outcomes

At the time of writing, SAVCS has had 1,318 virtual consults with RACF residents across South Australia. 84% of RACF residents will have their care managed with alternate pathways to a traditional emergency department, including offering care in place (66%) of residence without needing to be transported at all. The consulting time for a SAVCS consult is 43 minutes (median) and is far less than the traditional pathway of involving SAAS, transport to ED and time to access, and assessment of bricks-and-mortar ED while avoiding the risk of hospital-acquired complications. SAVCS is safe, with no significant incidents since inception.

Future

We are progressing with the expansion of the pathway to get more RACF to utilise the service. Whilst over 80% of aged care providers have registered to use SAVCS, 40% remain to utilise the service. SAVCS plans to improve this with continued engagement and co-design with our RACF partners. SAVCS is working with partners on opportunities to understand and further support upskilling of RACF nurses in gaining experience in acute assessment. The direct interaction between onsite referring clinicians and SAVCS specialist clinicians is a unique offering to SAVCS.

For more information, please contact: Phillip De Bondi at Phillip.debondi2@sa.gov.au

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.

Dr Claire Gough

ARIIA, Flinders University

Aged care services are a critical aspect of society given the increasing age of our population. Older adults are entering the latter years of life with more chronic conditions than before and often require assistance to live independently in their own homes or move to residential aged care facilities. In recent years, there has been a push for reablement to be integrated into aged care. Reablement is a person-centred approach that aims to empower older people to regain skills and independence, moving away from the traditional ‘passive care recipient’ to an ‘active participant,’ encouraging ownership and self-driven independence. [1] Reablement has the potential to improve an individual's quality of life, as older people are supported to regain their independence, this may reduce long-term care needs, and subsequently the workload of the aged care workforce.

In August 2023, the ARIIA Knowledge and Implementation Hub (KIH) will be supporting ARIIA’s Innovator Training Program (ITP) to provide a specially themed ITP program on how to integrate reablement approaches into aged care service delivery. This topic was nominated by the aged care sector as a high priority issue via ARIIA’s annual national survey. This need corresponds with the Australian Government’s recommendations for reablement to be integrated into aged care services to improve the quality of aged care delivery [2, 3] This reablement-themed ITP will be delivered over 10-weeks via online learning modules and co-design workshops that aim to assist participants understand a specific problem around the integration of reablement in their service, find a best-practice evidence-based solution that they can adapt to their situation, and plan a measurable outcome for change. To support the program, the KIH have carried out an environmental scan to identify resources that may be useful to support care workers increase the independence of older people in their care. These resources can be found on the ARIIA website here, and are supported by the ‘Rehabilitation, reablement, and restorative care’ priority topic which can be accessed here.

This ITP program is an exciting opportunity to inform the aged care workforce and support the independence of older adults receiving care. To expand on this body of work and inform future approaches in this space, the KIH will be holding a round table at the end of 2023 to determine the state of play for reablement in aged care. These discussions will involve key stakeholders and aim to identify barriers to reablement approaches in the day-to-day delivery of aged care and ways to facilitate reablement to achieve best outcomes for older people.

If you are interested in being involved in these round table discussions, please email KIH@ariia.org.au

1. Maxwell H, Bramble M, Prior SJ, Heath A, Reeves NS, Marlow A, et al. Staff experiences of a reablement approach to care for older people in a regional Australian community: A qualitative study. Health Soc Care Community. 2021;29(3):685-693.  
2. Department of Health and Aged Care (Australia). Commonwealth Home Support Programme: Program manual 2023-2024 [Internet]. Canberra, ACT: DoHAC; 2018 [updated 2023 Jun; cited 2023 Aug 2]. Available from: https://www.health.gov.au/resources/publications/commonwealth-home-support-programme-chsp-manual
3. Royal Commission into Aged Care Quality and Safety. Final report: Care, dignity and respect - Volume 1 summary and recommendations [Internet]. Canberra, ACT: Commonwealth of Australia; 2021 [cited 2023 Apr 16]. Available from: https://agedcare.royalcommission.gov.au/publications/final-report-volume-1  

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.

Dr Chad Han

Caring Futures Institute, Flinders University

Pre-frailty and frailty are clinical syndromes that increase an older adult’s risk to higher dependency and are associated with lower survival rates. [1, 2] This is especially important as many older adults already live with multiple chronic conditions such as metabolic diseases and cancers, that make them vulnerable. Frailty (physical) can be described as a syndrome when three or more of the following conditions are present: low physical activity, slow walking speed, unintentional weight loss, weak grip strength, and self-reported exhaustion. [2] Frailty (inclusive of domains other than just physical) can also be defined as deficits in cognition, general health status, functional independence and performance, social support, medication use, nutrition, mood, continence etc. [3] Pre-frailty, as its name suggests, is a state prior to the spectrum of frailty, though a consensus of its definition is underway. [4]

There is a high prevalence of pre-frailty and frailty in Australia. In a cohort of 329 hospitalised older adults at Flinders Medical Centre in Adelaide, more than half (n=220) were either pre-frail or frail, according to the Edmonton Frail Scale. [5] The acute stress of hospitalisation makes it harder for older adults to ‘bounce back’ as they get discharged [1]. There are ways to alleviate that. Multifaceted interventions combining exercise and nutrition as part of management strategies are recommended by The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group for pre-frail and frail hospitalised older adults. [6] However, the sustainability of these treatments is questionable, and involving a more collaborative partnership approach with patients may be equivalent as existing models but better reduce burden on healthcare resources.

The INDividualized therapy for Elderly Patients using Exercise and Nutrition to reduce depenDENCE post discharge (INDEPENDENCE) pilot program was developed by a group of researchers at Flinders University involving dietitians (Professor Michelle Miller, Dr Alison Yaxley, Dr Chad Han – as part of his PhD with College of Nursing and Health Sciences, Flinders University), a physiotherapist (Dr Claire Baldwin) and a physician (A/Prof Yogesh Sharma). The novelty of this program was the adaptation for pre-frailty and frailty of a chronic condition self-management model developed by Professor Malcolm Battersby, initially for self-management of conditions such as diabetes. [7] The pilot randomised controlled trial, recently published in Clinical Interventions in Aging, showed promising results on the preliminary effectiveness and acceptability of such a self-management hospital-to-home program. [8]

The trial highlighted that this self-management model was well received by participants, having an average participation in activities/visits of above 90%. [8] There were significant improvements in the Edmonton Frail Scale at 3 months (after the active support ended) and a legacy effect at 6 months (3 months after active support was removed). To understand more about the barriers and facilitators to this program, participants of the intervention group were also interviewed. The barriers and enablers we identified highlight the unique and individualized needs of older adults which can aid or hinder adherence (manuscript under preparation).

Intentions, Social influences, Environmental context/resource, and Emotions served as primary barriers towards adherence to both exercise and nutrition components. For example, a participant shared how depressive mood could prevent her from eating better and moving: ‘Now I hate getting out. I just like staying in my bed. I think the earlier I get up, the longer the day is.’ Common enablers for both components included Knowledge, Social identity, Environmental context/resource, Social influences, and Emotions. For example, the acknowledgement of benefits of exercise encouraged a participant to keep doing her exercises: ‘And I knew it was going to build up stamina and give me strength again. So there was a big incentive.’

Want to know more about the INDEPENDENCE pilot program?

• Watch Chad and Barbara (a participant on the INDEPENDENCE program), as they chat about research and the INDEPENDENCE pilot program: https://www.youtube.com/watch?v=zgVLrwdO5NI
• The idea behind this INDEPENDENCE program was also presented at the Asia Pacific finals of the 3-minute thesis competition: https://vimeo.com/632502129

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.