The future of aged care

The only thing certain about the future of aged care is that it will change. The best future scenario would comprehend change processes focused on the aspirations of older people rather than reactive, cost-driven responses. The current health system in Australia delivers excellent acute clinical services to deal with major disease entities in young and middle-aged people. There is, however, an escalating crisis in the acute and chronic care of the ‘older old’, representing persons over 75–80 years of age. Acute illness is unambiguously the major driver of loss of self-care capacities and institutional placement in the elderly.1 A 50-month prospective cohort analysis of the Dubbo Study population showed that among 1261 persons (45%) aged >60 years who remained in the community and did not require hospitalization: (i) 95.8% remained at home, (ii) 34 (2.7%) died, (iii) three (0.2%) entered a hostel and (iv) only one (0.08%) entered a nursing home. In contrast, among the 1544 (55%) who were hospitalized: (i) 84% returned home, (ii) 197 (13%) died, (iii) eight (0.5%) entered a hostel and (iv) 46 (3%) entered a nursing home. Negative outcomes of hospitalization result in the victims of inadequate care systems being overtly ‘blamed’ via the mindset that drives the use of terminology such as ‘bed blockers’. Hospital environments that are ‘friendly’ to older people, sensitive to their needs and competent in the delivery of the required acute care represent an absolute right and an infrastructure need in all jurisdictions if we are to achieve the ageing priority and intergenerational policies recently espoused by the Federal Government. Residential care placement represents loss of personal autonomy and physical independence: a breach of the cardinal values of older Australians.2 The death rate in residential care is unacceptably high, as documented by McCallum et al. in the Dubbo Studies.1 Death rates of 48% and 37% applied to nursing home and hostel placements, respectively. These human issues compound the onerous economic costs associated with the capitalization of the housing and the delivery of services within the residential care system. Fundamental system change is also mandated by simple linear extrapolation of the costs of acute and chronic care systems according to the rapid numeric escalation of the elderly population as part of the demographic change termed population ageing (Fig. 1). The probability of illness rises with age, and the acknowledged resource multipliers for therapy with age compound these resource issues. A quantitative estimate of the resource multiplier with age comes from current Australian Health Care Agreements, which specify a >10-fold increase in care requirements for a >85-year-old person versus a 20–39-year-old adult (respective population weights of 5.864020 vs. 0.455793). Allocation of resources to Health Departments by State and Territory administrations through diagnosis-related group (DRG) weightings do not reflect these resource multipliers. Major increases in the efficiency and effectiveness of hospital-based care of the elderly are possible, as documented in Australia and elsewhere.2,3 The summary of the outcomes of re-engineering acute care of the elderly in Canberra at The Canberra Hospital is shown in Fig. 2. A 230% increase in ‘completed episodes’ of care (defined as single events of service from admission to discharge with nil DRG fractionation or ‘gaming’, or use of subacute care facilities) of care to frail individuals aged >75 years with multiple comorbidities was achieved, with >20% reduction in bed-days used. ‘Effectiveness of care’ (defined as return to the preadmission place regarded as ‘home’) was increased in parallel with these changes.