On the fifth day of the Sydney hearing, the royal commission heard from a panel of aged care executives who shared their experiences and suggestions for ways to provide high-quality care.
The panel consisted of executives from three of Australia’s most progressive and innovative aged care providers: Group Homes Australia, Brightwater Care Group, and Glenview.
The panel consisted of Tamar Krebs and Jonathan Gavshon, co-chief executive officers from Group Homes Australia, Jennifer Lawrence, CEO Brightwater Care, and Lucy O’Flaherty, CEO of Glenview.
Innovative thinking is “refreshing”, commissioner says
Commissioner Richard Tracey AM FRD QC welcomed the more positive nature of the comments from the panel.
“We’ve heard, over recent weeks, a lot of very challenging stories about things that have been going on in nursing homes. And I must say it has been refreshing to hear how a bit of innovative thinking can produce good outcomes,” he said.
Innovative models of care
The panel heard about each of the operator’s different models of care.
Glenview is a not-for-profit aged care provider for people with a diagnosis of cognitive impairment. Ms O’Flaherty said Glenview has six separate houses within its 100-bed facility, and has an outdoor space for residents to enjoy.
Brightwater is a not-for-profit organisation with a diverse business, it has residential aged care, community care, retirement living, disability services as well as two commercial businesses, a linen business and a catering business.
Group Homes operates traditional homes in traditional suburbs, it has no signage, and blends in with the rest of the street. Group Homes offers care for six to ten residents in each home, and 24 hour support is provided by ‘homemakers’ who get to know the residents well.
Residents are involved in all aspects of running the home, from cooking to baking and gardening. Group Homes is a registered home care provider, but not a registered residential aged care facility.
“We believe that that gives them a very strong sense of purpose and meaning in their lives and has a very, very strong element to delivering the right care,” Mr Gavshon said.
Understanding the dignity of the resident and valuing the team
Mr Gavshon said strong leadership is one of the most important elements of aged care, and leadership that understands the dignity of residents and the team.
“Having a culture that respects and builds trust with an older person is critical to good care,” Ms Lawrence said.
What are the care needs of those with dementia?
The panel provided their insights into how care should be provided for people living with dementia.
Get to know the resident
Ms Lawrence said it was important to get to know the resident.
“I think it’s so important that we get to know the resident, what their care needs are, but also who they are as a person. Because we can’t provide personalised care unless we know their background, who they are, what they like to do,” she said.
Having the right environment
Ms Lawrence said having the right environment is also important when caring for people with dementia.
“It’s really important that the environment that somebody lives in is on a human scale and residents are able to find their way around that home, because they are their homes,” she said.
Having the aged care facility on a “human scale” aids people to move freely from the bedroom to the dining room to the lounge room, and then to be able to go outside, Ms Lawrence said.
Having a clear line of sight around the home is also important, she said and helps people navigate their way around.
Colours and textures should also be carefully considered to help “wayfinding” for someone with cognitive decline, she said.
Consistent staff who get to know each resident
Having consistent staff is also crucial, Ms Lawrence said.
“As much as possible, we try to have the same staff rostered to the same clients and the same house, so that the clients and the staff build a relationship… It’s a family type of atmosphere.”
Strong clinical governance
Strong clinical governance is fundamental, Ms Lawrence said. “The people coming to us have higher levels of acuity than ever before,” she said.
A culture of enablement
Ms Lawrence said Brightwater tries to “enable” people with dementia, “to really understand what that person needs, particularly if they are anxious or agitated, what they need to soothe them. Whether that’s music, whether it’s going outside, whether it’s talking to one of their family members. So really getting intimately to understand the person with dementia is really important,” she said.
Ms Krebs said it was important to encourage people living with dementia in the home to try to maintain a “normal” way of life and maintain their own routines.
“Not being institutionalised and having to conform to rigid routines, tapping into their own routines, if they like to wake up early or like to wake up late. Same thing with bed times, time of eating, but very much personalising the approach and not trying to make a one-size-fits-all approach to them,” she said.
Flexible food menus
Homemakers at Group Homes help residents prepare food, Ms Krebs said, and creating and the “smells and sounds of home” are important.
Mr Gavshon said there are no set menus at Group Homes, so residents can choose what they want to cook and eat, so different tastes and appetites can be catered for. This flexibility is especially helpful for those from culturally diverse communities, he said.
Noticing changes so care can be adjusted when needed
Ms O’Flaherty said it was important to build up relationships with residents so it was possible to pick up changes when they occurred, so care could be adjusted to suit the altered need.
Lighting to assist the sleep / wake cycle
Ms O’Flaherty said Glenview pays close attention to lighting in its homes.
Different lighting levels are sued to “tap into” the sleep/wake cycle.
“So brighter in the morning, so that the brain… and the body knows that it’s time to be active… As the light starts to disappear outside, the internal lights start to change so that it’s a trigger or a cue for individuals who may not be able to see that it’s at the end of the day, that it’s the winding down part of the day,” she said
Imagery and items to help with reminiscence
Ms O’Flaherty said her team works with researchers and clinicians to ensure that the imagery in their homes provides an opportunity to reminisce.
Ms Lawrence agged. “Having objects and paintings and familiar environment is really, really important,” she said.
Gardens with purposeful activites
Ms Lawrence said creating purposeful activities in gardens can be helpful.
“There’s purposeful routes to walk, so that you’re not just going out into a garden and not going anywhere. So the paths lead somewhere. There’s actually something that you can do in the garden, whether it’s plants that are, you know, sensory or whether there’s a shed or a table and chairs that people can sit at, something that’s familiar that people will have in their own homes,” she said.
Consistency of staff
Ms Krebs said the use of agency staff can be very confronting for a person with dementia if they don’t know the person.
“For somebody who already has a cognitive impairment and a disorientation and is woken up to be showered with an agency staff can be very confronting for the person,” she said.
“Recruit for kindness and train for excellence”
Ms O’Flaherty said all staff at Glenview have to be trained in dementia.
“We have an in-house dementia consultant…
“We insist that everyone, from the maintenance man to myself, through to the cook, the carer, that everybody does the dementia training, so we all have a shared understanding of what that looks like,” she said.
Ms O’Flaherty said for every position they advertise, they have around 500 applicants. Ms Krebs said they have about 200 applicants for every position.
Family involvement is “absolutely critical”, Mr Gavshon said.
Group Homes encourages homemakers to phone family weekly with positive news. For example, they might share exactly what has happened during the course of the week in a positive framework, rather than only calling when there’s a problem, he said.
Group Homes also creates WhatsApp groups that allows homemakers to communicate easily and regularly with families, “sending photos, sending updates from the day, don’t necessarily need to be clinical updates, but a social update about what their family member has done,” Mr Gavshon said.
Group Homes also has an IT platform that families can log in to, where they can see some of the information about the resident.
“It creates a complete spirit of transparency and trust if they can log in and see a core element around their family member’s care,” he said.
Ms Lawrence said Brightwater has registered nurses and allied health staff who go into people’s homes, meet the family, meet prospective residents, and assess what needs that resident might have before they move in.
“That first point of call is actually really important,” she said. From there, the service manager that runs the home is responsible for communication with the family, and there are regular meetings with residents and families.
“We invite families to come in and participate as much as they want,” she said, noting that participation is “variable”.
Mr Gavshon said Group Homes has training when staff are onboarded, and then staff are assigned a “buddy” who allows the new recruit to shadow them during an operational day. Group Homes also has an e-learning platform, on which they develop their own content, and team development days.
Recommendations for aged care
Ms Lawrence said she would like to see better connectivity between the various systems that are involved in the care of older, such as between hospitals and aged care facilities.
Ms Krebs said she would like to see voucher systems in aged care, where consumers can choose where they want to get care, whether it be in aged care or home care in the community.
Ms O’Flaherty said she would like to see better connections between academia and practice.
The industry need to better support innovation
Ms Lawrence said the aged care funding model in Australia doesn’t encourage innovation. “I don’t think it incentivises innovation, and I think that that is a problem for providers in terms of being able to afford to do anything that’s innovative is actually quite difficult, and I really believe that we should be incentivised for the outcomes we achieve, for our clients, rather than have to demonstrate disability.”
Ms O”Flaherty agreed. “We are funded for the amount of medications we’re giving, how many times we shower someone, what meals we provide. We’re not funded for how happy a resident is and how we’ve reduced their sleep medication because they’re happier and sleeping better,” she said.
Mr Gavshon said the aged care industry would benefit from greater flexibility around funding and innovation.
“The industry hasn’t been overly supportive of innovative models, and we’ve had a challenge around the innovative nature of our model whether it be the funding that our families can receive, or lack thereof, compared to going into a traditional facility.
“Unless we start to embrace and look at different innovative models and support them, I think we can’t necessarily completely raise the bar in terms of that delivery of care,” he said.