Journal of the New Zealand Medical Association, 16-February-2007, Vol 120 No 1249
Through the looking glass: toward a brighter future for long-term care in a greying New Zealand
Mark Booth, Edward Alan Miller, Vincent Mor
Financing and improving the quality of long-term care for increasing numbers of elderly citizens is an international concern. In the USA, a recent Brown University report, Out of the Shadows: Envisioning a Brighter Future for Long-Term Care in America (available at http://www.chcr.brown.edu/), has been produced to inform the work of the National Commission for Quality Long-Term Care co-chaired by former Senator Bob Kerrey and former Speaker of the House Newt Gingrich.
The purpose of the Commission is to gather evidence and make recommendations on how to improve the quality of long-term care nationally. Given a rapidly ageing population, the present report should be of interest, not only to US observers but to policymakers, providers, and users of long-term care within New Zealand.
The Brown report examines six areas of concern that must be addressed by policy makers and providers to establish a higher quality, more efficient long-term care system: developing adequate sources of financing and insurance; supporting individuals and family caregivers; promoting physical and organisational change; recruiting and retaining a qualified workforce; designing a more effective regulatory control system; and leveraging health information technology.
These concerns are just as applicable to New Zealand as to the US. Indeed, solutions in each of these areas are necessary, not only if New Zealand is to overcome impediments to providing high quality long-term care to its most vulnerable citizens but also if it is to meet the increased demand for services and high expectations posed by the ageing baby boom generation.
The percentage of the New Zealand population aged 65 years or over is expected to rise from 13.0% today to 25.0% by 2050 and, of those, 25.0% will be over 85 years. Furthermore, together with ongoing improvements in life expectancy, we can expect further growth in Alzheimer’s disease and in functional disability going hand-in-hand with the ageing of New Zealand.
Despite differences in financing and organisation, both the US and New Zealand face similar challenges, including an over-reliance on institutional services and difficulties in recruiting and retaining direct care staff. A recent OECD study found that in 2000, home care spending as a proportion of total long-term care expenditure was 17.7% in New Zealand and 25.0% in the USA—both well short of the OECD average of 30.4%.1 This indicates that efforts in the USA, and especially in New Zealand, to ‘rebalance’ long-term care away from nursing homes and towards home- and community-based services, lags behind other countries.
Both countries also face a growing shortage of workers at all levels, including nurses, nurse aides, therapists, and geriatricians. The US government estimates that an additional 1.9 million direct care workers will be needed in long-term care settings by 2010.2 Given that New Zealand’s population is ageing even faster than that of the US, and there has been increased demand for health care workers more generally,3 workforce shortages for long-term care are also likely to become especially acute in New Zealand.
To improve the current system and to better meet the challenges ahead, Out of the Shadows highlights areas for change and action. Those of particular relevance to New Zealand are discussed below.
It is well documented that nursing homes and other long-term care providers have difficulty recruiting and retaining direct care staff.4 This is especially true of lower skilled workers for whom the combination of low wages, insufficient benefits, heavy caseloads, inadequate training, and limited prospects for career advancement make recruitment and retention a particular challenge.
Research has consistently demonstrated a relationship between staffing and quality of care in nursing homes,5 and shown that nursing homes with greater staff turnover have higher costs associated with vacancy, recruitment, and replacement (e.g., overtime pay, temporary staffing), as well as costs associated with lost productivity, low employee morale, and lower service quality.6
New Zealand must continue efforts to improve recruitment and retention. Responsibility for this lies at both the provider and funder level and includes competitive wages, more comprehensive benefits, more extensive training and career programmes. One issue within New Zealand has been ensuring that long-term care providers pass on increased public subsidies to direct care staff in the form of increased employee compensation. Twenty-six states in the USA have addressed this issue through the adoption of ‘wage pass-through programmes’ which mandate use of increased funding for improved salaries and benefits for direct care workers, although the jury is still out as to which approach is most viable for achieving this objective.
The “culture change” movement consists of those who would like to change the context within which frail and disabled individuals live and are treated.7 Rather than treating clients as clinical entities, downplaying their psychosocial and spiritual needs, advocates for culture change believe that systems of care should be adopted that accommodate individuals’ choices rather than forcing them to adhere to the routines of the provider. Patient participation, client autonomy, and shared decision-making are emphasised.8
Though the physical environment is important, deep and long-lasting transformation requires changes in how the caregiving process is organised. This includes de-emphasising top-down authority by placing as much decision making responsibility as possible into the hands of patients and their caregivers.
Especially salient is replacing the practice of rotating staff with ‘primary assignments,’ in which staff work consistently with the same clients, a practice associated with many documented benefits.9 While providers in the US are beginning to transform long-term care in ways commensurate with the culture change perspective,7 there remain significant barriers (regulatory and otherwise) to adopting the changes necessary to make this vision a reality.
Building on lessons from the US, the New Zealand Government should examine how regulation might better enable both physical and organisational innovation to take place. Providers should commit to adopting “home-like” living environments that respect individuals’ privacy and autonomy, honour clients’ preferences about activities and lifestyle choices, and empower direct care workers through primary assignments, self-managed work teams, and other organisational adjustments.
Most individuals entering nursing homes or paid home care in the US are referred for care following hospitalisation. Consequently, the transmission of clinical information to enable medical and nursing care to proceed uninterrupted is critical. Unfortunately, it is rare for such transitions to occur smoothly. Research in the US reveals high rates of inaccurate or missing information, ranging from diagnoses to a complete listing of a patient’s current medications.10
As a result, many patients are re-hospitalised a short time later.11 It is difficult to find comparative details for New Zealand but it is likely that such issues occur here as well. This is because despite New Zealand having a strong HIT tradition within the primary and acute care sectors, use of integrated HIT in the long-term care sector lags behind. Although HIT has yet to penetrate far into US long-term care, nursing homes and home health agencies have well-established common clinical assessment and outcome measurement instruments.
This uniformity should constitute a major advantage since, like hospital diagnoses, the same information can be applied to payment, outcome measurement, and clinical care planning. However, the absence of the requisite electronic information sharing bridges, in addition to a common clinical nomenclature for describing patient functioning, means that interoperability between the acute and long-term care sectors continues to be lacking.
New Zealand is currently examining use of a possible data collection tool to enable the collection of uniform patient-level data that could be compared nationally, or even internationally. Such a system is crucial if information to improve quality in long-term care is to be provided and if interoperable electronic information sharing is to occur.
One step the government could take is to incorporate the needs of long-term care patients into electronic health record designs. Provider investment in HIT, and partnering with hospitals to develop and implement electronic information sharing that promotes smoother patient transitions from one care setting to another should be encouraged.
It is imperative that all relevant groups re-evaluate how long-term care is provided in New Zealand. Information technology systems need to be adopted to better enable improvements in quality and efficiency; increased attention needs to be given to recruiting and retaining a well-trained, stable workforce; and continued development of home- and community-based alternatives to residential care must be pursued. The quickly developing culture change movement, which aims to improve the way chronically frail and disabled people live and are treated, must also be encouraged and supported.
New Zealand has many advantages over the USA in its policy context for long-term care. It has a unitary system of government that is not subject to the boundary issues, competitive stresses, and gridlock that a federal/state system suffers. It also has a strongly articulated plan for meeting the healthcare needs of older people.12 It is critical that New Zealand build upon these advantages in the short term to ensure that the longer term implications of the ageing population can be met.
Conflict of interest statement: There are no conflicts of interest.
Disclaimer: The views expressed here are those of the authors and not necessarily those of the National Commission for Quality Long-Term Care, nor the Commonwealth Fund, its directors, officers, or staff.
Author information: Mark Booth, Harkness Fellow; Edward Alan Miller, Assistant Professor of Public Policy, Political Science, and Community Health, and Faculty, Center for Gerontology and Health Care Research; Vincent Mor, Professor and Chair, Department of Community Health, and Faculty, Center for Gerontology and Health Care Research; Brown University, Providence, Rhode Island, USA
Acknowledgements: The report on which this essay is based was written while Edward Miller and Vincent Mor were supported by the National Commission for Quality Long-Term Care, whereas Mark Booth is currently a Harkness Fellow from New Zealand and visiting fellow at the Brown University Center for Gerontology and Health Care Research. The Harkness Fellowship is supported by the Commonwealth Fund, a private independent foundation based in New York City. In addition to acknowledging the invaluable support from the Commonwealth Fund and National Commission, the authors also thank Beth Sundstrom, Laura Smith, Zhanlian Feng, Brenna Sullivan, and Nicole Palin for their assistance.
Correspondence: Mark Booth, Harkness Fellow, The Center for Gerontology and Health Care Research, Brown University, 2 Stimson Avenue, Box G, Providence, Rhode Island 02912, USA. Phone: (401) 863 9957. Fax: (401) 863-3489; email: Mark_booth@brown.edu
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads)
Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals