Hip fracture patients denied rehab when returning from hospital to aged care

Written by Caroline Egan, HelloCare, October 30, 2020.
View original article here

Older people in hospital recovering from a hip fracture are being sent to residential aged care on the misunderstanding they will receive physiotherapy rehab once there.

But in reality, the government only funds physios in residential aged care to provide massage services, so called ‘4B’ pain management, which do not aid in hip fracture recovery at all.

Matters are even worse for older people with cognitive decline, who are often not even considered for rehabilitation due to the belief they can’t follow instructions.

The problem of older people returning to aged care homes from hospital raises a fundamental question: what is the purpose of residential aged care? Is it a place where older people can thrive, or is it a place where older people go while the medical profession and families wait for them to die?

Physio the best chance for rehabilitation after a hip fracture

Physiotherapy is the best treatment for older people who are recovering from hip fractures, said Gustavo Duque, Professor and Chair of Medicine, Australian Institute for Musculoskeletal Science at The University of Melbourne.

Alongside physio, older people recovering from a hip fracture should be up and walking from day one, says Simon Kerrigan, Physiotherapist and Director of Guide Healthcare.

Given the importance of physio to the recovery of older people who have had hip fractures stabilised in hospital, patients are often returned to residential aged care on the understanding that physio services are provided in aged care homes.

But in reality, Mr Kerrigan told HelloCare that though physios do come into aged care homes, residents do not receive the physio treatment they need to recover from a hip fracture, due to the way aged care funding is allocated.

Professor Duque agreed. “One-to-one appropriate and effective physiotherapy” after hip fracture is “not widely available” in Australian aged care homes, he said.

Aged care homes only funded to deliver massage

Aged care homes are funded to deliver physiotherapy under the ‘4B’ subcategory of ACFI, which targets pain management.

The 4B ACFI subcategory delivers funding for aged care residents to receive 80 minutes of one-on-one physio a week, but the only treatment physios are supposed to deliver is massage or the use of an electrophysical machine, such as an ultrasound.

In practice, what often happens is that physios come into the home and simply spend the whole day massaging residents from the “4B list” of those who qualify for 4B ACFI funding, Mr Kerrigan told HelloCare.

“Physios are given these lists where they see people so that the 4B numbers are maxed out to the point where their whole day is spent massaging people. They really don’t have any time to do anything else,” Mr Kerrigan said.

Yet massage is “completely inappropriate” for the rehab of a person after they’ve had a hip fracture, but “there’s no funding for rehab,” Mr Kerrigan said.

“As far as tailored, individual rehab, that becomes something that just puts extra stress on [the physio],” he said.

Allied health services in residential aged care are lumped together, he said, with no distinction between physio, occupational therapy, chiropractic or podiatrist services. They all provide massages under 4B.

“It’s all because of ACFI and this pain management model which says allied health professionals can offer this treatment,” Mr Kerrigan said.

As a result, physios have become reluctant to work in aged care homes, he said, because the work is repetitive and does not yield positive results.

Bedbound for three years after hip fracture

Mr Kerrigan recounted a situation where he spent a week working in an aged care home, and noticed that six of the residents were in bed for the whole week. The care staff explained to him they had all had falls and suffered hip fractures. 

Some of them hadn’t been out of their beds for three years

After explaining the fractures would have been stabilised surgically in hospital and there was no reason the residents couldn’t weight bear, Mr Kerrigan got the residents up on their feet the very next day.

“There’s very few cases where the medical team won’t decide to stabilise [a hip fracture]. It’s only if someone’s very frail or very unwell,” he said. 

Mr Kerrigan didn’t work with the home for long. He reported them to the Aged Care Quality Agency, the regulator at the time, and though his complaint triggered an inspection, the provider passed all 44 quality standards.

“I was horrified,” he told HelloCare.

Older patients with cognitive decline overlooked for rehab

Access to physiotherapy is not the only problem faced by older people recovering from hip fractures. Some doctors and nurses believe patients (or residents) with cognitive decline will not be able to follow instructions in rehab, and so they do not recommend rehab for this cohort at all.

“A significant proportion of aged care residents are not appropriate candidates for rehab due to their baseline functional or cognitive status,” said Professor Duque.

But Mr Kerrigan doesn’t agree. He says some aged care residents with cognitive decline do better than others because they can sometimes be less anxious about pain, and sometimes they are more likely to want to get up and walk straight away.

Of course, it depends on the level of decline, but certainly patients/residents with cognitive decline should not be automatically discounted for rehab, he said.

The exceptions: proactive homes, family to advocate

It depends on how proactive the aged care home is the level of rehab older people receive when they return from hospital after a hip fracture or similar, said Mr Kerrigan. 

“If you go into a home where the physio is very proactive, the organisation is trying to improve function, they’re trying to get people moving again, then there’s a good chance that they will get half an hour, three of four times a week, of rehab, getting them up and walking again, or trying to get them moving,” he explained.

Supportive organisations prioritise the residents, they run rehab clinics, they support group exercises, they run falls prevention and cardio respiratory rehab programs.

Mr Kerrigan pointed out the importance of the care workers in this process. It often falls to the personal care workers to ensure that residents are up and about, walking twice a day, he told HelloCare.

Proactive homes “prioritise the people with the most needs, instead of the people who need the most points under ACFI,” he said.

The only other hope for residents is a “pushy family” who get a physio to come in to provide the extra support. These services are paid for by the family, Mr Kerrigan said.

“It shouldn’t be that way,” he noted.

Residents don’t recover without rehab 

Mr Kerrigan said the problems experienced by residents rehabilitating in aged care homes after hip fractures is symptomatic of “broader problems” within the sector. 

The recovery of residents from strokes, prolonged hospital admissions and respiratory illnesses – or any other reason there has been a deterioration in function – also suffers from physios not being funded to help with rehab in residential aged care. 

In all these instances, physios are again “boxed in” to fit within the ACFI-funded 4B model. Aged care homes aren’t funded to provide any more care outside those perimeters. 

Without the correct rehab, there is a risk residents will never return to their health prior to the incident.

“I’ve seen it first hand. There’s not enough good clinical staff on site” and “providers too often take the view ‘we’re not a rehab facility’,” Mr Kerrigan said, adding that not all homes are this way.

Professor Duque said aged care homes should be funded to provide more physiotherapy services for rehab. 

“They don’t have to remain on site,” he said. “Mobile units providing those services would be the optimal approach.”

What is the purpose of aged care?

The issue goes to the heart of a central question about residential aged care.

Professor Joseph Ibrahim, Head of Health Law and Ageing Research at the Department of Forensic Medicine, Monash University, asked “What is the purpose of a residential aged care service?” in a submission to the Royal Commission into Aged Care Quality and Safety.

Are they “places where residents thrive”, as Professor Ibrahim suggested? 

Or are they “a place where frail old people receive basic health and other care, while staff, health professionals and family… wait for them to die”.

Mr Kerrigan echoed Professor Ibrahim’s comments. “This is an issue around what is aged care, and what is the role of the physio,” Mr Kerrigan said.

“It’s a problem… Unless there’s a family member of somebody who’s really going to advocate for that person who’s returned, there’s a high risk they’re not going to get the rehab they need.”