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| Journal of the New Zealand Medical Association,
16-February-2007, Vol 120 No 1249
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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.
Enhancing the long-term care workforceIt 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.
Transforming the culture of long-term careThe “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.
Leveraging health information technology (HIT)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.
ConclusionIt 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
References:
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