We have found that the aged care system fails to meet the needs of our older, often very vulnerable, citizens. It does not deliver uniformly safe and quality care for older people. It is unkind and uncaring towards them. In too many instances, it simply neglects them.
Royal Commission into Aged Care Quality and Safety Interim Report
Throughout this inquiry we have heard from many people about substandard care—from those who experienced it and from those who witnessed it … the extent of substandard care in the current aged care system is unacceptable, deeply concerning, and has been known for many years.
The Hon GT Pagone QC, Royal Commission into Aged Care Quality and Safety Final Report
Neglect.
Substandard care.
That’s how the Royal Commission into Aged Care Quality and Safety views Australian aged care.
It’s painting the whole industry with a tarred brush, but with the abundance of witnesses coming forward, these statements aren’t hard to believe.
As a longstanding partner to the aged care industry, we know that aged care executives like you exist. CEOs that care about the lives of their residents and are keen to improve customer experience…
But most Australians don’t.
Most people look at graphic reports like the ABC story on the Oakden nursing home and see every residential aged care service as an extension of that horrifying picture.
Over 2000 public submissions to the Royal Commission were concerns about clinical direct care.
That’s why the Royal Commission’s Final Report focuses so intensely on the levels of substandard care in the current system.
Commissioner Lynelle Briggs said:
The combined impact of the available data leads me to the devastating conclusion that substandard care is widespread in Australia’s aged care system. I conclude that substandard care has affected over 30% of older people accessing aged care. It is shocking to think that at least 1 in every 3 older people using aged care has experienced substandard care. It is dispiriting to understand the range and extent of that failure.
Within their final submissions, the counsel assisting the Royal Commission proposed a way to decrease substandard care. That proposal was to increase required levels of direct care time, shown in Recommendation 47: Minimum staff time standard for residential care.
The Royal Commissioners included this advice in their final report, as Recommendation 86: Minimum staff time standard for residential care.
The questions you’re asking are valid:
- How does the Royal Commission define direct care time?
- What are their recommendations?
- How will it solve the substandard care issue?
- What does it mean for me and the facility I manage?
Direct Care Time Isn’t Your Only Priority
Let’s face it.
With what’s going on all around you right now, you’d be justified to say you’re overwhelmed.
- The financial, mental, and physical chaos from the pandemic
- The systemic view of aged care as a ‘burden on society’
- The understaffed, underpaid state of your industry…
they all combine to make your job more difficult.
As a CEO, you’re accountable for the overall picture of your facility, from profitability to staff retention, from customer feedback to infection control.
Your main concern right now? Keeping your facility afloat, and viable for the future.
A hard-to-pin-down goal like ‘increasing direct care time’ isn’t easy to tackle.
But your board doesn’t have an overload of urgent tasks, and they’re demanding more from you and your staff. They want more direct care time, because they think it’s a quick fix to solve all the problems.
Here’s the thing: direct care time is not a silver bullet.
What is it, then?
What is Direct Care Time?
First, what is the official definition of direct care time in aged care?
No specific, widely publicized definition is easily accessible from any of the authorities in the Australian aged care industry.
In a 2019 research study for the Royal Commission into Aged Care Quality and Safety, the University of Wollongong counted the following roles as ‘direct care employees’:
- Nurse practitioner
- Registered nurse
- Enrolled nurse
- Personal care attendant
- Allied health professional, and
- Allied health assistant.
However, a direct care employee doesn’t necessarily spend all of their time in direct care. Therefore, we need to focus on the tasks that comprise direct care.
The 2001 study for the US Centers for Medicare and Medicaid Services (CMS), Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II, defines five key care processes:
1) dressing/grooming independence enhancement,
2) exercise,
3) feeding assistance,
4) changing wet clothes and repositioning residents,
5) providing toileting assistance and repositioning residents.
These key processes are useful but limited in scope. Further research by BMC Health Services in 2012 classified the following activities as direct care:
| Physical Assessment. |
| Routine hygiene (e.g. daily shower or wash). |
| Continence related hygiene (e.g. shower or wash following pad change). |
| Oral Care. |
| Shave or grooming. |
| Toileting – prompted by a resident. |
| Toileting – prompted by a personal care worker. |
| Pad check. |
| Pad change. |
| Scheduled toileting. |
| Dressing a resident. |
| Resident mobility; passive & active exercises; turning a resident in bed. |
| Medication administration. |
| Specimen collection; urine collection. |
| Assisting a resident with eating and drinking (include feeding systems). |
| Assisting a resident with food (e.g. cutting up food, uncovering food or delivery of food). |
| Care of the deceased; laying out. |
| Assisting a resident with hand washing following the use of toilet. |
| Assisting a resident with transfer to and from a bed, a chair, etc. |
| Transferring a resident to or from dining room or board room. |
| Weighing a resident. |
| Assisting a resident to receive a phone call. |
| Attending to a resident call for assistance. |
In summary, direct care means:
Tasks where a nurse, personal care worker or allied health worker is physically interacting with a resident to provide care.
So, how much of this physical interaction do your direct care employees need to deliver?
What Are the Recommendations for Direct Care Time?
Recommendation 86 of the Royal Commission’s Final Report outlines minimum staff times (read: direct care time) for residential care.
There are two minimums, a first baseline for implementing by 1 July 2022, and an increased minimum for 1 July 2024.
The requirements for 1 July 2022 are:
- 200 minutes of direct care for each resident per day (on average)
- 40 minutes of that time must be provided by a registered nurse
- At least one registered nurse must be available at each residential aged care facility for 16 hours a day.
The second recommendation, for implementing by 1 July 2024:
- Increases the 200 direct care minutes to 215
- Increases the 40 registered nurse minutes to 44
- Increases the 16 hours per day registered nurse availability to 24 hours per day.
These recommendations are based on the CMS star rating system for nursing homes in the United States of America, Nursing Home Compare.
The intent of our recommendation is to bring the entire sector up to a minimum level of staffing that exceeds three star staffing under the Centers for Medicare and Medicaid Services Nursing Home Compare system by 1 July 2022. … The second phase of our recommendation, to be implemented by 1 July 2024, is intended to bring the entire sector up to a minimum level of staffing that equates to four star staffing under the Centers for Medicare and Medicaid Services Nursing Home Compare system.
Royal Commission into Aged Care Quality and Safety Final Report
The CMS star rating system is based on 28 quality measures, 12 for short-stay residents and 16 for long-stay. These quality measures are based on the numbers of residents that have experienced substandard care in their stay, resulting in deteriorating health or hospitalisation.
Several studies have found a link between direct care time from experienced staff and quality of care, including 2018 BMC research article The associations between staffing hours and quality of care indicators in long-term care.
This study found:
“associations between [long-term care] staffing characteristics and overall quality of care … for [nursing assistant] care hours and [nursing assistant] years of experience in the current [long-term care] home.”
The Royal Commission recommended the ‘continuous nursing presence’ for every residential aged care facility, so the registered nurse can direct or provide clinical care.
This is based on United States requirements in the Nursing Home Reform Act 1987, and a 2016 review of 150 studies that ‘found a strong relationship between registered nurse staffing and quality.’
The conclusions drawn:
- Direct care time has a significant effect on quality of care, and
- The Royal Commission regards registered nurse hours as important.
What Does Direct Care Time Mean for Your Facility?
During 2018-19, 103 residential aged care audits identified the issue of ‘clinical care’ in a facility.
That’s almost one clinical care issue in every ten facilities audited.
The Royal Commission’s final report focuses on the need to bring levels up to what the Commissioners call ‘high-quality care’.
Their definition of high-quality care includes ‘receiving appropriate personal and clinical care for their health and wellbeing’.
This definition, with Recommendation 86, clearly indicates that increasing direct care time is likely to improve quality of care in residential aged care facilities.
In their final report, the Commissioners also referenced Professor Charlene Harrington of the University of California, San Francisco, as pointing out other issues with low direct care staffing levels:
Professor Harrington emphasised that inadequate staffing levels and inadequate time to provide care create a vicious cycle of poor outcomes for staff and residents. She explained that missed care can lead to staff ‘burnout’, low job satisfaction and a high turnover of staff. Quality of care, in turn, continues to suffer.
So, increasing direct care time will:
- Boost quality of care and customer satisfaction
- Cut down on staff burnout
- Increase job satisfaction for direct care staff, and
- Improve staff retention.
It seems a win-win situation.
How Can You Increase Direct Care?
Of course, the sticking points are –
- Where are the staff going to come from in your understaffed industry, and
- Where is the money going to come from to pay their wages?
You have a fixed income coming from the government and your residents. Your staff are already stretched by the current workload.
How can you increase your direct care time by over one-third by 2024? Are there ways other than simply increasing your staff count?
Can you free up existing staff time by cutting waste in your care model? We have some ideas – keep an eye out for our next blog on direct care time by subscribing to our newsletter.
* References
- Briggs, L., Tracey, R. (2019) Royal Commission into Aged Care Quality and Safety Interim Report: Neglect, Australian Government, 2019. Page 1. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2020-02/interim-report-volume-1.pdf
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Australian Government, 2021. Page 7. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1_0.pdf
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 1, Australian Government, 2021. Page 29. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1_0.pdf
- citation: Eagar K, Westera A, Snoek M, Kobel C, Loggie C and Gordon R (2019) How Australian residential aged care staffing levels compare with international and national benchmarks. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong.
- Feuerberg, M 2001, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Report To Congress: Phase II Final, December 2001, Centers for Medicare and Medicaid Services (CMS). USA.
- Qian, SY., Yu, P., Zhang, ZY. et al. The work pattern of personal care workers in two Australian nursing homes: a time-motion study. BMC Health Serv Res 12, 305 (2012). https://doi.org/10.1186/1472-6963-12-305
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 3, Australian Government, 2021. Page 423. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-3a_0.pdf
- Boscart, V. M., Sidani, S., Poss, J., Davey, M., d’Avernas, J., Brown, P., Heckman, G., Ploeg, J., & Costa, A. P. (2018). The associations between staffing hours and quality of care indicators in long-term care. BMC health services research, 18(1), 750. https://doi.org/10.1186/s12913-018-3552-5
- Exhibit 15-1, Adelaide Hearing 3, Annexure to Statement of Charlene Harrington, RCD.0011.0042.0003 at 0004; C Harrington et al., ‘The Need for Higher Minimum Staffng Standards in U.S. Nursing Homes’, Health Services Insights, 2016, Vol 9, p 14.
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 3, Australian Government, 2021. Page 422. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-3a_0.pdf
- Aged Care Quality and Safety Commission, Sector Performance Report July – December 2018, 2018, p 2 (Exhibit 8-27, Brisbane Hearing, general tender bundle, tab 34, CTH.0001.4000.8890); Aged Care Quality and Safety Commission, Sector Performance Report January – March 2019, 2019, p 2 (Exhibit 8-27, Brisbane Hearing, general tender bundle, tab 35, CTH.0001.4000.8900); Aged Care Quality and Safety Commission, Sector Performance Report April – June 2019, 2019, p 2 (Exhibit 20-1, Sydney Hearing 4, general tender bundle, tab 55, RCD.9999.0473.0051).
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 1, Australian Government, 2021. Page 28. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1_0.pdf
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 3, Australian Government, 2021. Page 420. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-3a_0.pdf
- Briggs, L., Pagone, G. (2021) Royal Commission into Aged Care Quality and Safety Final Report: Care, Dignity and Respect, Vol. 3, Australian Government, 2021. Page 423. Found at: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-3a_0.pdf
