When I started in aged care, I never had to do a CAPD [continuous ambulatory peritoneal dialysis], PEG feeds, and now hospitals try and get people out earlier and only want acute people in there. They are leaving more care to us in the nursing home.
...
Unstable diabetes, people with colostomies, complex dressings, complex pain management programmes, people coming straight after theatre that need rehabilitation. It's a lot more intense now than it used to be.
97 The NSW College of Nursing submission to the Productivity Commission in November 1998, relied upon by the Association, discussed the issue of early discharge. The submission observed:
Discharge one or two days post surgical hip replacement or repair of a fractured neck of femur is not uncommon. This in itself demands a high level of skill and resources, but combined with the aforementioned concomitant disorders, with or without dementia, the required level of skill and resources, human, technological and other, rises markedly.
98 In relation to the extent of increased acuity, the Association explained the RCS is the tool used by the Commonwealth to determine funding for each resident. It provides a measure of resident dependency. It provides for eight levels, four "high care" and four "low care". The level of each resident is determined using a bundle of 21 indicators, including such matters as continence, behavioural issues, communication skills, and technical and complex medical procedures required.
99 The Association referred to statistics that showed as at June 2002, almost two thirds of residents in residential aged care facilities were classified as "high care" (i.e., RCS 1-4). Within the high care group, the number of RCS 1 (the most dependent category) has increased by 35.9 per cent during the period from 1998 to 2002. During the same period, it was submitted, the proportion of residents requiring assistance with specific needs has also increased significantly.
100 The Association referred to other evidence supporting the extent and effect of increased acuity. This included various submissions by the New South Wales College of Nursing, ANHECA, ACSA and the evidence in these proceedings. Oral evidence by Ms Susan Owens, the Director of Nursing at Eric Callaway House, was as follows:
With their co-morbidities, they do not only have dementia. I have five with at least five different diagnoses. We have diabetics, Parkinson's, Pitts' disease. We have cancers. We have residents that because they are living longer and are of a greater age have horrific skin irritations. We have colostomies or one colostomy. Our other colostomy passed away over Christmas. We have cardiac disease. We have lung disease. We have asthma. We have peripheral vascular disease. We have one amputee and all of them need full nursing care.
101 The Association referred to the evidence of Mr Peter Allen, the Director of Nursing at Wollongong Nursing Home, who observed:
A nursing home isn't a place that just looks after old people, it's an extension of our medical system. Many of the things, especially medical things being treated in hospital are often stabilized in hospital and then that person is moved into a nursing home, but still with that underlying condition that was originally stabilized and will probably, in all certainty, become unstable again and will require treatment through the nursing home, through the nurses and the doctors in the nursing home environment or transfer back to hospital or progress on to palliative.
102 Reference was also made by the Association to the evidence of Ms Heath, who has worked at the RSL Veterans' Retirement Village at Narrabeen as a RN since 1990. She described the changes she has observed since that time:
It has just changed tremendously. Out of sight…In 1990 I would describe the village, the hostels, the low care hostels as more like an old man's rest home. We had residents there who would be out most days going to the races, going on public transport trips around the city…They were very active. There were very few of them on supervised medication. There were very few walking aids for instance, in the lower care hostels.
Phyllis Stewart Hostel was always a frail aged, and you would have the walking frames there, but not in any to the same degree as now. There is - whole care needs of the residents have changed remarkably. I would say that in 1990 there were mostly seventy year olds in the hostels. Now they are all about 80, 90 and in the very high care hostels the average age is 90, where it used to be 70, 75. So as they have got older, their care needs have got more and more complex.
Their diagnoses have got more and more complex. (In) 1990 you would have them come in with maybe one problem, like that have a wound which was not healing, and they were there for wound care…I look at some of the files in…our high care hostel, and you have a list of about ten diagnoses, five of which could be life threatening. So that comes with technology changes.
In 1990 even oxygen concentrators were not in the village. Now we seem to have them in every hostel …
103 The Association relied on the evidence of Professor Pearson to the following effect:
My professional observation, this is aside from the report, this is now speaking as a nurse with experience in the field. The population that we see now in residential aged care facilities closely resembles the population 15 years ago in the acute medical wards [in] acute hospitals…These are people generally very frail who are generally sick with more than one condition and where a large proportion of them have some form of dementia and display challenging behaviour. This is a completely different patient population to how it was even ten years ago…15 years ago there was a rise in the popularity called normalisation where we tried to make nursing homes like homes; had domestic type beds and hid the medication trolleys because that was the kind of population we had. That is no longer even talked about in this industry now. We need adjustable height beds and all the kinds of facilities we used to think belonged in hospitals because of dependency of residents particularly in the high care facilities.
104 Reference was also made to the evidence of Mr Paul Sadler, the Chief Executive Officer of ACSA, who said:
[T]here is no question that more residents in residential aged care are now classified at the higher levels of the classification scales, whichever one you use, and that reflects increasing levels of dependency and need for assistance by many of the aged care residents…if you looked at the standard mix in residential care facilities in the seventies and early eighties, there would have been a lot of people in nursing homes who were at relatively low levels for need of care.
Increased complexity of medical procedures
105 The Association submitted there was an "overwhelming amount of evidence of the ever increasing complexity of nursing procedures required by residents in both high and low care accommodation". The Association contended the procedures that have been introduced overwhelmingly since 1990 (and in most cases since 1995) included:
· IV therapy;
· PEG feeding;
· major wound management;
· tracheostomy care;
· supra-pubic catheters;
· peritoneal dialysis;
· treatment of unstable diabetes;
· use of oxygen concentrators;
· continuous oxygen;
· subcutaneous morphine; and
· the management of complex dressings.
106 The Association referred to RCS statistics to demonstrate the incidence of complex medical procedures has gone up. In this regard it was submitted the number of residents in the highest category ("Extensive Assistance Required") had increased nationally by over 66 per cent between 1999 and 2004. The number of residents requiring no technical or complex medical procedures has decreased significantly during the same period.
107 The Association also relied on the evidence of a number of its witnesses as to increased clinical complexity of nursing. For instance, Ms Read stated:
We do get residents now who are discharged from hospital much earlier that they would have been in the past. So if they have gone in with a fractured hip, they come back to us often within the first 24 hours; we then have to organize rehabilitation and you know look after them as you would in hospital after 24 hours of a surgical procedure. As I stated before we do more peg tubing and catheters, tracheotomies, peritoneal dialysis, all those sorts of things you would not have had ten years ago...
108 Evidence relied upon relating to specific clinical issues included evidence from Ms McKenna concerning supra-pubic catheters:
Supra-pubic catheters have become normal for lots of people with debilitating illnesses, people with illnesses like multiple sclerosis now have supra-pubic catheters and these are managed by nurses, changed by the nurses in the nursing home. They all need to be able to do them, because they need to be replaced within an hour of coming outside, coming out. They fall out or are pulled out accidentally.