Our Submission to the Royal Commission into Aged Care: "Physiotherapy in Residential Aged Care"
Written by Simon Kerrigan, February 18, 2020.
Physiotherapist’s have the potential to be the most crucial staff members at any residential aged care facility. They are trained to be evidence-based practitioners in exercise prescription, complex pain management, cardiorespiratory care and a broad range of rehabilitative services. Unfortunately, the current aged care system has created an environment whereby physiotherapists are encouraged to be ineffective, which has driven many professionals away from the industry.
Key Issues:
The Aged Care Funding Instrument (ACFI)
The ACFI and in particular pain management claims (12.4a/12.4b), have created a system which diminishes the role of physiotherapists. Physiotherapist’s are encouraged to spend the majority of their day massaging residents or applying electrophysical agents such as TENS machines or Ultrasound in order to create a financial return. As these pain management claims can be delivered by a broad range of “allied health” clinicians, the result is that each of these distinct professions has been grouped into one category. A key example of this, is that most external providers of physiotherapy/pain management services will actively recruit for a “Physiotherapist / Occupational Therapist or Chiropractor”. There is a distinct lack of knowledge as to the actual scope of these professions.
As pain management claims accrue a significant amount of points in the complex healthcare domain, there is an expectation from aged care providers that these claims will continue regardless of the residents “need”. Again, this is driven by the financial return. As such, residents may continue to receive massage therapy or an electrophysical agent such as TENS despite not having ongoing pain.
Furthermore, the ACFI is well known to promote disability and disincentivise services which improve function and quality of life as these will lead to a decrease in funding levels. As such, Physiotherapist’s are typically actively encouraged not to provide treatments or programs which will achieve improvements. Alternatively, organisations will create expectations around treatment list numbers which mean that there is simply no time to complete anything other than claimable massages.
Whilst gym-based exercise equipment would provide great benefits for older residents, a physiotherapist’s typical equipment stock is usually limited to sorbelene cream and a TENS machine, as these are the only tools required to deliver funded treatments.
Effective Pain Management
Unfortunately, the ACFI has created a perception within residential aged care that Physiotherapist’s are primarily massage therapists. It is widely accepted in the academic literature that massage is not an effective method of treating chronic pain. Massage is a passive modality, which creates a focus on the pain area. Meaning that the receiver may experience some temporary relief, however the underlying cause of the pain is never addressed.
In terms of electrophysical modalities, the literature is clear that all electrophysical agents including TENS machines, ultrasound, interferential machines and dry needling work as a mechanism of placebo and are no more effective than “sham treatments”. These should not be prioritised as funded modalities and don’t serve the best interests of our older adults.
Peak industry bodies such as the Australian Physiotherapy Association and the Royal Australian College of General Practitioners have released statements in recent years confirming that exercise-based interventions and education are two of the most effective methods for managing chronic pain. Unfortunately, as these interventions are not funded, they are rarely delivered.
Ageism & Ignorance
It is widely accepted within the aged care system and in the general community that older people cannot improve. This could not be further from the truth. Physiotherapist delivered exercise programs have been proven to improve bone mineral density, symptoms of arthritis and other chronic pain conditions, musculoskeletal strength and function, cardiorespiratory health, diabetes, brain health and cognitive function, quality of life indicators, mental health, Parkinson’s Disease and other neurological conditions, obesity and falls rates.
Physiotherapy in residential aged care is unique in the sense that Physiotherapist’s are able to work with their older clients on a daily basis as they work within their homes. As such, the opportunity to achieve significant improvements through supervised and structured sessions is greatly improved. Particularly when taking into consideration that residents are consistently admitted into residential aged care after experiencing a period of significant functional decline due to an acute illness or fall.
Falls Prevention
Passive/extrinsic modalities to falls prevention are regularly prioritised over more active/intrinsic methods of managing falls in residential aged care. Passive/extrinsic methods include things like sensor alarms, low-low beds and supervision charts. Whilst these can form an important part of an effective prevention strategy, what’s regularly neglected is the evidence-based approach to falls prevention provided by physiotherapists.
Jenny Hewitt et al. (2018) in a study conducted in 16 residential aged care homes with 221 participants found that with 50 hours of strength and dynamic balance training over 25 weeks (2x1 hour sessions per week), that falls rates could be reduced by up 55%. This would not only be an excellent outcome for residents, but it would also create a huge cost-benefit for the healthcare and aged care systems.
Documentation Requirements
Documentation systems for pain management claims are typically laborious and offer very little detail as to the effectiveness of treatments. These treatments are consistently completed as bulk entries, as there is no onus on providing treatments which are effective. They serve to meet the “requirements” of the ACFI as opposed to creating an accurate record of what’s happening with the resident and how they are responding to any given treatment. Significantly, whilst these records lack value, they also take important time away from providing hands-on or supervised treatments with residents.
Due to the increased scrutiny on providers to meet progressively higher care standards, the focus has continuously shifted towards documentation in an attempt to “show” how they are meeting the standards. As such, key pieces of documentation such as care plans have become so long that they are not indigestible and thus redundant. In order to make a minor change to a resident’s care plan, a physiotherapist may need to update a physiotherapy assessment, a mobility and transfer assessment, create a progress note and update a paper-based mobility chart for the resident’s room. In an attempt to satisfy quality standards, unrealistic review schedules are also implemented including time-frames as short as every 3 months. These reviews occur regardless of whether there have been any changes to the resident’s function or care needs. Whilst it’s widely recognised that an effective referral system from managers, team leaders and RN’s would be sufficient, the fear of failing accreditation regularly takes precedent and forces providers into making these unrealistic expectations into set policies. Again, every minute completing unnecessary documentation is time taken away from residents.
Multidisciplinary Teams & Professional Isolation
Unfortunately, multidisciplinary teams are almost unheard of in residential aged care. A sole physiotherapist is regularly assigned with the task of managing the needs of 80 or more residents. This includes managing the physiotherapy aspects of the admission process, completing falls reviews, ongoing assessments, a broad range of referrals, equipment prescription, hospital discharge planning, rehabilitative and exercise programs (if time allows and is supported by the home), falls committees and family conferences – among other things.
Due to the tendency for homes to employ one clinician only, many physiotherapist’s experience professional isolation and a lack of professional development. Putting aside the obvious limitations of physiotherapy practice, this alone causes a significant turnover over clinicians and a regular disruption of services. It is worth noting that these feelings of professional isolation are even more prevalent in rural and remote areas.
The Reliance on Overseas Trained Clinicians
Unfortunately, due to the negative perception of aged care within the physiotherapy profession, the aged care industry has become reliant on overseas trained clinicians who enter the workforce on “Limited Registration”. External providers will regularly use these clinicians without providing the necessary levels of training and supervision due to gross shortfalls in staffing levels. The aged care industry has become reliant on this workforce in order to support their pain management claims in particular.
Looking to the Future
The future of physiotherapy in residential aged care does not look bright. The R-ACFI’s proposal for a “physical therapy subsidy” – which redirected pain management funding into evidence and exercise-based interventions – was widely celebrated within physiotherapy circles. Unfortunately, with the completion of the RUCS and the proposed AN-ACC system, the physical therapy subsidy appears to have been shelved.
Furthermore, it appears that the AN-ACC will offer no direct funding for allied health services. Whilst there is speculation that the new care standards will encourage providers to provide physiotherapy services, history would tell us that if it isn’t funded, it won’t be delivered.
We are likely moving towards a system where Physiotherapist’s will be contracted for a limited number of hours per week to complete new and follow-up assessments, post-fall reviews and referrals. They may be asked to develop or contribute to exercise based initiatives, which will likely be delivered by unqualified staff under the guise of a “physiotherapy-aide” or “allied health assistant”.
Whilst the ACFI limits the scope of a Physiotherapist’s practice, it at least gave them a “foot in the door”. With the right application, a clever approach and a supportive provider, Physiotherapist’s are still able to achieve outcomes for their residents. If the proposed new funding tool is implemented, it would mean that many residents’ ability to access these services would be significantly diminished. Those who can afford to pay for services will reap the benefits, creating an even bigger divide between the “haves and have-nots”.
What Should We Do?
The aged care system could be improved by funding services which have the potential to improve function and quality of life. Clinicians should be encouraged to empower residents to set goals, implement evidence-based treatments and show effectiveness through outcome measures.
To do this, we would need a shift in mindset which recognises that people aren’t necessarily entering aged care to experience a gradual decline. Part of this would involve re-defining the role of residential aged care.
From our perspective, the aged care system should have the goal of sending residents home. If we strived towards this goal, at the very least we would reduce the burden of care on staff, the provider and the aged care system as a whole. We would also create a much more positive and respectful environment which celebrates and encourages resident’s abilities.