The changes to the ACFI have meant that we will need to think laterally if we are to ensure that the elderly people we care for do not suffer in silence.
I have looked for inspiration across the world to think about how we can provide the very best care with the lower level of funding. It’s fair to say that when I have spoken to physiotherapy colleagues working overseas, no system is perfect. Everyone seems to be somewhat dissatisfied with funding levels and organizational restrictions. So, we may need to cherry pick to ensure elderly Australians can continue to live in comfort and dignity.
I was intrigued by the government funding model in the UK. Elderly people are assessed according to their needs. If an individual’s level of health and function make them eligible for care they are means tested and a personal budget is calculated to cover the cost of their needs, allowing for their own financial contribution. This money can be used to buy care according to their own wishes and requirements. It really puts the consumer in charge of their own health and wellbeing.
In Britain, financial constraints together with the challenges of an aging population mean that the funding level is often considered to be too low. However, it is an interesting basic model, which could be adapted to our own demands, with integration of home and residential services. It would build on the CDC approach, which is already the benchmark for homecare in Australia. It could enable individuals to choose reablement programs that help them maintain function and live safely at home for longer, to commission regular in-home care and pain relief or choose a day-centre or residential care when the time is right.
In the US, they have developed the Program of All-Inclusive Care for the Elderly (PACE.) It’s a managed long-term care system in the community, as an alternative or a precursor the residential care. It’s funded by Medicare (a program providing health coverage for those over 65 or older or with a severe disability irrespective of income) and Medicaid (a program that provides health coverage for those on a low income) often in conjunction with a financial contribution from the individual.
PACE provides for all aspects of health care, tailoring its services to the needs of each individual.
It focuses around a day centre, with opportunities for recreation, rehabilitation, health and personal care as well as meals. Pain management and reablement programs can also carried out at the centre. PACE can provide a continuum of long-term care services, including hospital and residential care. The centralisation of the service can provide cost savings, however the set-up of programs involves substantial initial investment, time and organization and could be cumbersome and difficult in remote or rural areas.
The physical touch is a vital part of physiotherapy and could never be replaced. However, there may be ways of using technology to improve communication, increase patient led care and ensure treatment compliance. It wouldn’t replace our therapy but it could augment it, so that our contact time and consequently our treatment costs are decreased.
Something as simple as the telephone could be a useful tool in treating and managing chronic pain in the elderly. Research has reported that an initial telephone triage and advice service, followed by face-to-face treatment or referral as necessary, could be a valid alternative to traditional consultations. The service was shown to be as safe and clinically effective as usual care. However, there was slightly decreased patient satisfaction because of the lack of contact with the physiotherapist.
Another trial took a different approach, with an initial assessment from a physio together with personalized advice, a devised treatment program and an information leaflet. Follow up care was by telephone. This method resulted in short term improvements in health outcomes, decreased use of painkillers, improved function and a high level of patient satisfaction. The physiotherapy-led pain management programs seemed to also make individuals less likely to seek help from their doctor. This approach, together with face-to-face follow-up, as needed, could provide a way forward.
As technology develops, so could our way of working and communicating. A very early groundbreaking trial in England caught my eye. A busy, National Health Service hospital physiotherapy department assessed patients and gave them an individual exercise and mobility program. Instead of leaflets, this was followed up by e-mails with short film ‘prescriptions’ demonstrating the exercises in the home environment and reminding them to sign in and take part. Patients who watched films demonstrating the exercises and who provided online feedback about their pain and activity levels, needed fewer appointments than the control group and were much more engaged with their recovery. The physios saw significantly more patients and the department saved time and money. Could this be a way for the future?
None of us have all the answers but it is only by thinking beyond our current horizons that we will be able to overcome the current challenges, cope with the shortfall in funding and provide a service that reaches the high standards of care that we have set.