International Policies – Designing for Aged Care

Why some nursing homes are better than others at protecting residents and staff from COVID-19

Posted on June 12, 2020June 12, 2020 by Joanna Sun

Life Care Center in Washington state was at the center of the U.S. outbreak back in early March.Photo/Ted S. Warren, CC BY

Anna Amirkhanyan, American University School of Public Affairs; Austin McCrea, American University, and Kenneth J Meier, American University

The coronavirus pandemic has posed a serious threat to the U.S. long-term care industry. A third of all deaths have been nursing home residents or workers – in some states it’s more than half.

Yet some long-term care facilities have managed to keep the virus at bay. For example, veterans’ homes in California have seen only a handful of cases among roughly 2,100 residents. And preliminary results of our research on COVID-19 cases and deaths in nursing homes also support the idea that some homes are doing better than others at protecting clients and staff from COVID-19.

Why might this be?

As scholars of public management, we have found that three factors likely play the biggest role in determining how well a nursing home responds to a disease outbreak: whether it operates for profit, the degree of government regulation and the quality of management.

Profit versus quality care

More than 15,000 nursing homes currently operate in the U.S. Most of them are for-profit facilities backed by private investors, but a small share are operated by nonprofits or government.

For-profit companies selling the same product or service typically perform optimally in what’s known as a perfect market in which there’s plenty of competition and consumers have comprehensive information. More importantly, consumers are able to act on the information.

The nursing home industry, however, is far from a perfect market. Residents – who require constant assistance due to serious physical and cognitive limitations – are often unable to differentiate between good and bad care, advocate for themselves or choose a better facility. Their care is often arranged and paid by others.

As a result, for-profit homes, which are motivated to keep costs low and profits high, tend to be understaffed and, on average, provide lower-quality care compared with public and nonprofit homes.

In contrast, nonprofit and public homes tend to put higher emphasis on patient-centered care and reinvest their profits into better physical spaces, equipment and responsiveness to clients’ needs.

The numbers back this up. Our ongoing research shows that government inspection of for-profit homes found nine violations in an average regulatory inspection cycle, compared with 6.4 at nonprofit homes and 6.8 at government homes. These trends have largely remained constant during the past two decades.

As we examine the data on COVID-19 cases in nursing homes reported by states in real time and link them to the federal data on regulatory violations, we are observing more COVID-19 cases per capita in for-profit than nonprofit or public homes. So far, we’ve looked at homes in Illinois, Nevada, Colorado, South Carolina, Oklahoma and Oregon.

While it is too early to draw firm conclusions, it appears likely that fewer regulatory violations will correlate with success in managing the outbreak.

Government regulation is critical

Federal and state government regulation aimed at protecting residents is another critical factor that influences nursing homes’ ability to combat infection.

All nursing homes that accept Medicare or Medicaid must comply with federal regulations, while states are able to set their own rules for all facilities in addition to the federal minimums. A closer look at the variation among states offers strong evidence that more stringent regulation leads to better care quality.

That is a key finding of our recent study on a voluntary federal program that provides biometric criminal background checks of front-line care workers such as nurses and health care aides. About half of U.S. states have signed on to the National Background Check Program. Nursing homes in those states have fewer deficiencies and higher 5-star ratings.

Staffing requirements in nursing homes are regulated too. We looked at the impact of having more high-skilled nurses on the quality of care in counties hit hard by Hurricane Katrina in 2005. Facilities with a higher share of registered nurses on staff experienced little to no impact on residents’ health outcomes, such as mobility or personal hygiene, as well as on the number of regulatory violations, while most that witnessed significant evacuations saw a large increase in violations and deteriorating health.

The federal government sets a minimum requirement of one registered nurse on staff at least eight hours a day. States are allowed to set their own higher standards – yet even these are considered insufficient by experts.

One key problem is that many state regulations emphasize staffing levels, rather than staffing mix, which means there is little incentive for homes to hire more skilled and expensive personnel. While federal rules issued in 2016 would have strengthened staffing requirements, including one that required homes to have an infection specialist on staff, they have yet to take effect, and the Trump administration has taken steps to weaken them.

Better management

Our research also suggests that management plays a critical role in determining the level of care quality – and ultimately a facility’s ability to withstand COVID-19. Specifically, we have identified several key factors that make a meaningful difference and are certainly worth considering by those looking for a home for their loved one.

For example, nursing home administrators who are more innovative and constantly looking for new ideas tend to run better homes, keep costs lower and address organizational flaws. In addition, homes with managers who have been around for longer periods of time usually deliver better quality of care because this makes it easier to buffer external threats – such as a disease outbreak.

We’ve also found that homes that engage residents and their families and apply their feedback in decision-making boast higher ratings and fewer health violations.

Understanding the pitfalls

Billionaire investor and philanthropist Warren Buffet is credited with saying that it is only when the tide goes out that you discover who has been swimming naked.

COVID-19 seems to be having this kind of effect on nursing homes, exposing which ones were in a better position to handle a pandemic. And that’s why it’s essential for more states that are not publicly sharing their COVID-19 cases or deaths in nursing homes – such as Alaska, Hawaii and Idaho – to begin doing so.

This will allow more research to be done and ensure that the U.S. nursing home industry is adequately prepared for the next pandemic when it inevitably comes.

[Get facts about coronavirus and the latest research. Sign up for The Conversation’s newsletter.]

Anna Amirkhanyan, Associate Professor of Public Administration and Policy, American University School of Public Affairs; Austin McCrea, Ph.D. Student, American University, and Kenneth J Meier, Distinguished Scholar in Residence Department of Public Administration and Policy, American University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Caregiving, International Campaigns, Research & Best Practice, The Built Environment

Nursing homes for all: why aged care needs to reflect multicultural Australia

Posted on October 10, 2019October 10, 2019 by Joanna Sun

Do nursing home staff know and respect your cultural background or language? Here’s why that’s important.
from www.shutterstock.com

Helen Rawson, Deakin University

This week, the aged care royal commission looks at diversity in aged care, an issue becoming increasingly relevant to both residents and the staff who care for them.

Diversity includes gender, sexual orientation, religion and social background. The issue is important because if we aim to offer older people and families choice and control in aged care, we must meet the diverse needs of all older people.

Australia’s rich diversity is reflected in its older population. In 2016, more than one-third (37%) of Australians aged 65 and over were born overseas and one-fifth (20%) were born in a non-English speaking country.

These figures have increased continually since 1981, when one-quarter (25%) of older people were born overseas.

Diversity within diversity: culture and language

Culture is important for every person. It indicates a way of life based on customs, beliefs, language and experiences shared with family and a wider community or group.

According to the Federation of Ethnic Communities’ Councils of Australia, many people from culturally and linguistically diverse backgrounds don’t want to move to a nursing home. This is for a number of reasons.

They may not want to be away from family and community, they might speak a different language to staff and other residents, and homes may not understand or meet their individual cultural needs.

Our previous research showed living in an aged care facility could make some older people feel disempowered. Language and cultural diversity can further add to that disempowerment. For the older people we studied, communication, companionship, and staff knowing them as individuals was very important.

Language is particularly important for older people’s physical health and well-being. Many culturally and linguistically diverse older people say they speak English well. However, with age and cognitive decline, they may lose the ability to communicate in English and revert to their first language.

And as more than half of nursing home residents have dementia, with the associated deterioration in language and cognition, communication can be more difficult still.

Appreciating someone’s cultural background can help residents make friends.
from www.shutterstock.com

Being aware of their peer’s culture and language can help residents build relationships with each other, family and staff.

Different cultural expectations and language barriers can create misunderstanding and resident and family dissatisfaction. This can affect residents’ care and quality of life.

How can we support appropriate care?

Aged care needs to be responsive, inclusive and sensitive to a person’s culture, language and spiritual needs. So it is important for nursing homes to understand those needs.

For those who are culturally diverse, government-funded support and culturally specific nursing homes can help. These include services for Greek, Italian, Dutch, Jewish and Chinese older people, reflecting post-war migration.

However, organisations like these cannot meet everyone’s needs. So all residents need care that respects cultural and social differences, works with older people and family, and supports choice.

What might appropriate care look like?

Staff need ongoing cultural competence training to deliver appropriate and supportive care.

Staff cannot know everything about the many cultural and language groups in Australia. They can, however, practise in way that is culturally appropriate, by:

never making assumptions about someone’s culture, heritage, language or individual needs. No two people are the same, even if they are from the same culture and language background
talking to the resident with an interpreter, if needed
learning what is important to the resident. For example, staff could ask family members or close friends to bring in photos or mementos important to the older person
talking with family of residents who are unable to communicate in English to make a list of key words or phrases for staff. This could include how to say “hello”, or how to ask “are you comfortable?”, or “are you in pain?”
making sure the older person isn’t isolated in the nursing home. This could involve working with the local community of the person’s culture, and asking for volunteers who could come and visit the older person.

Family members can be a huge help to staff in understanding the resident’s language, culture and preferences.
Nadya Chetah/Shutterstock

Appropriate and respectful aged care is a human right

Culture and language diversity in aged care is a fundamental human right. Embedding diversity in all aspects of aged care is also recognised by government, and in how the quality of aged care is assessed.

New aged care quality standards, which came into effect this July, include being treated with dignity and respect, with identity, culture and diversity valued, and all residents able to make informed choices about the care and services they receive.

If the outcomes of this royal commission are to benefit Australians now and especially in the future, older people from culturally and linguistically diverse backgrounds must not be an afterthought in the aged care discussion. They must be part of the planning.

Helen Rawson, Senior Research Fellow, Deakin University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Ageing & Culture, Caregiving, International Campaigns, International Policies, Research & Best Practice

World’s largest dementia study reveals 2/3 of people think dementia is a normal part of ageing

Posted on September 27, 2019November 1, 2019 by Joanna Sun

News Release
September 2019| Alzheimer’s Disease International (ADI): World’s largest dementia study reveals two thirds of people think dementia is a normal part of ageing, rather than a medical condition

95 per cent of participants think they could develop dementia in their lifetime – a survey of 70,000 people across 155 countries reveals

2 in 3 people still think that dementia is a normal part of ageing
62 per cent of healthcare practitioners still think it is a normal part of ageing
Over 50% of healthcare practitioners agree that their own colleagues ignore people living with dementia and 33% of people thought that if they had dementia, they would not be listened to by health professionals
1 in 5 people attribute dementia to bad luck, almost 10 per cent to God’s will and 2 per cent to witchcraft
Every 3 seconds someone in the world develops dementia
London, Friday 20 September – Results from the world’s largest survey on attitudes to dementia reveals a startling lack of global knowledge around dementia, with two thirds of people still thinking the disease is a normal part of ageing rather than a neurodegenerative disorder.

Alzheimer’s Disease International (ADI), the international federation of 100 Alzheimer associations and federations around the world, ahead of World Alzheimer’s Day tomorrow (21 September) with the release of the World Alzheimer Report 2019: Attitudes to dementia. The report reveals the results of the largest attitudes to dementia survey ever undertaken, with responses from almost 70,000 people across 155 countries and territories. Analysis of the study was carried out by the London School of Economics and Political Science (LSE).

The report reveals that stigma around dementia is preventing people from seeking the information, advice, support and medical help that could dramatically improve their length and quality of life for what is one of the world’s fastest growing causes of death globally. The number of people living with dementia is forecast to more than triple, from over 50 million currently, to 152 million by 2050.

“Stigma is the single biggest barrier limiting people around the world from dramatically improving how they live with dementia,” says ADI’s Chief Executive Paola Barbarino. “The consequences of stigma are therefore incredibly important to understand. At the individual level, stigma can undermine life goals and reduce participation in meaningful life activities as well as lower levels of well-being and quality of life. At the societal level, structural stigma and discrimination can influence levels of funding allocated to care and support.”

The report reveals astonishing attitudes towards dementia. Survey respondents included people living with dementia, carers, healthcare practitioners and the general public. A major cause for concern from the report, is the number of people across the world who think that dementia is a natural part of the ageing process.

Forty-eight per cent of respondents believe a person with dementia’s memory will never improve, even with medical support, while one in four people think there is nothing we can do to prevent dementia. These are major barriers to people accessing help, advice and support.

The report reveals that dementia stigma is similar to stigma often associated with mental health, focussed on age and is accentuated by a lack of available medical treatments. In reality, many forms of support exist around the world. Talking and planning can help people to live well with dementia for as long as possible.

“Currently, there is very little information about how stigma manifests in relation to people with dementia and how this may vary around the world,” Barbarino continues. “This detailed survey and report now give us a baseline of information for dementia-related stigma at a global, regional and national level. We’re hopeful these findings can kick start positive reform and change globally.”

The report finds that over 50% of healthcare practitioners agree that their own colleagues ignore people living with dementia and 33% of people thought that if they had dementia, they would not be listened to by health professionals.

Interestingly, 95 per cent of participants think they could develop dementia in their lifetime and over two thirds of people (69.3 per cent) would take a genetic profiling test to learn whether they are at risk of dementia (even though there is currently no disease-modifying treatment). However, two thirds of people still think dementia is a natural part of ageing. The fear of developing dementia is high globally, but the true understanding of the disease is low. This is worrying, as Alzheimer’s disease and other dementias are the 5th leading cause of death globally.

Sara Evans-Lacko, Associate Professorial Research Fellow at the Care Policy and Evaluation Centre, LSE, said: “Whereas most stigma studies look at public knowledge and or attitudes, this is the first study to look at the behavioural element – the data collected highlight actual experiences of people. For LSE it has been enriching to be part of the first attempt to create a baseline on dementia attitudes. We are delighted to have been able to bring our rigour and analytical expertise to the table and are conscious of the tremendous importance of this exercise at a global level.”

ADI launched its global campaign ‘Let’s Talk About Dementia’, on 1 September 2019 to mark the beginning of the month of awareness. The campaign is based on the understanding that talking about dementia helps tackle the stigma, normalises language and encourages people to find out more, seek help, advice and support.

Dementia blogger and journalist Pippa Kelly says it is vitally important that as a society we have more conversations about dementia to create better understanding. “Stigma stems from fear. Fear breeds silence, which in turn perpetuates ignorance and misunderstanding,” Kelly says.

Every 3 seconds someone in the world develops dementia but most people with dementia do not receive a diagnosis or support. The annual cost of dementia is over US$ 1 trillion – a figure set to double by 2030. Deaths due to dementias more than doubled between 2000 and 2016, making it the 5th leading cause of global deaths in 2016 compared to 14th in 2000.

The “Let’s Talk About Dementia” campaign simply aims to stimulate a conversation about dementia, the warning signs, risk reduction, who to speak to and where to go for advice. Lack of knowledge about dementia leads to inaccurate assumptions about its effects on the person and their family, as well as negative stereotypes about how a person with dementia will behave, Barbarino says. “Evidence suggests that when people living with dementia and their families are well prepared and supported, initial feelings of shock, anger and grief are balanced by a sense of reassurance and empowerment, so the campaign’s focus is on increasing conversations around dementia globally.”

The full World Alzheimer’s Report 2019: Attitudes to dementia, is available to read here.

For story ideas, interview requests and more information, please contact:

Alzheimer’s Disease International

Annabelle Dick
Mana Communications
T: +64 (0)27 819 7011
E: ad@manacommunications.com

Annie Bliss
Alzheimer’s Disease International
T: +44 20 7981 0886
E: a.bliss@alz.co.uk

About World Alzheimer’s Month

World Alzheimer’s Month is the international campaign every September to raise awareness and challenge the stigma that surrounds dementia. September 2019 will mark the 8th World Alzheimer’s Month. The campaign was launched in 2012: World Alzheimer’s Day is on 21 September each year. For more information, please visit: https://www.alz.co.uk/world-alzheimers-month

About Alzheimer’s Disease International (ADI)

ADI is the international federation of 100 Alzheimer associations and federations around the world, in official relations with the World Health Organization. ADI’s vision is prevention, care and inclusion today, and cure tomorrow. ADI believes that the key to winning the fight against dementia lies in a unique combination of global solutions and local knowledge. ADI works locally, by empowering Alzheimer associations to promote and offer care and support for persons with dementia and their care partners, while working globally to focus attention on dementia and campaign for policy change. For more information, please visit http://www.alz.co.uk.

Ageing & Culture, Caregiving, International Policies, Research & Best Practice, The Built Environment

Truly smart homes could help dementia patients live independently

Posted on September 26, 2019November 1, 2019 by Joanna Sun

PixOfPop/Shutterstock

Dorothy Monekosso, Leeds Beckett University

You might already have what’s often called a “smart home”, with your lights or music connected to voice-controlled technology such as Alexa or Siri. But when researchers talk about smart homes, we usually mean technologies that use artificial intelligence to learn your habits and automatically adjust your home in response to them. Perhaps the most obvious example of this are thermostats that learn when you are likely to be home and what temperature you prefer, and adjust themselves accordingly without you needing to change the settings.

My colleagues and I are interested in how this kind of true smart home technology could help people with dementia. We hope it could learn to recognise the different domestic activities a dementia sufferer carries out throughout the day and help them with each one. This could even lead up to the introduction of household robots to automatically assist with chores.

The growing number of people with dementia is encouraging care providers to look to technology as a way of supporting human carers and improving patients’ quality of life. In particular, we want to use technology to help people with dementia live more independently for as long as possible.

Dementia affects people’s cognitive abilities (things like perception, learning, memory and problem-solving skills). There are many ways that smart home technology can help with this. It can improve safety by automatically closing doors if they are left open or turning off cookers if they are left unattended. Bed and chair sensors or wearable devices can detect how well someone is sleeping or if they have been inactive for an unusual amount of time.

Lights, TVs and phones can be controlled by voice-activated technology or a pictorial interface for people with memory problems. Appliances such as kettles, fridges and washing machines can be controlled remotely.

People with dementia can also become disoriented, wander and get lost. Sophisticated monitoring systems using radiowaves inside and GPS outside can track people’s movements and raise an alert if they travel outside a certain area.

All of the data from these devices could be fed in to complex artificial intelligence that would automatically learn the typical things people do in the house. This is the classic AI problem of pattern matching (looking for and learning patterns from lots of data). To start with, the computer would build a coarse model of the inhabitants’ daily routines and would then be able to detect when something unusual is happening, such as not getting up or eating at the usual time.

A finer model could then represent the steps in a particular activity such as washing hands or making a cup of tea. Monitoring what the person is doing step by step means that, if they forget halfway through, the system can remind them and help them continue.

The more general model of the daily routine could use innocuous sensors such as those in beds or doors. But for the software to have a more detailed understanding of what is happening in the house you would need cameras and video processing that would be able to detect specific actions such as someone falling over. The downside to these improved models is a loss of privacy.

Future smart homes could include robot carers.
Miriam Doerr Martin Frommherz/Shutterstock

The smart home of the future could also come equipped with a humanoid robot to help with chores. Research in this area is moving at a steady, albeit slow, pace, with Japan taking the lead with nurse robots.

The biggest challenge with robots in the home or care home is that of operating in an unstructured environment. Factory robots can operate with speed and precision because they perform specific, pre-programmed tasks in a purpose-designed space. But the average home is less structured and changes frequently as furniture, objects and people move around. This is a key problem which researchers are investigating using artificial intelligence techniques, such as capturing data from images (computer vision).

Robots don’t just have the potential to help with physical labour either. While most smart home technologies focus on mobility, strength and other physical characteristics, emotional well-being is equally important. A good example is the PARO robot, which looks like a cute toy seal but is designed to provide therapeutic emotional support and comfort.

Understanding interaction

The real smartness in all this technology comes from automatically discovering how the person interacts with their environment in order to provide support at the right moment. If we just built technology to do everything for people then it would actually reduced their independence.

For example, emotion-recognition software could judge someone’s feelings from their expression could adjust the house or suggest activities in response, for example by changing the lighting or encouraging the patient to take some exercise. As the inhabitant’s physical and cognitive decline increases, the smart house would adapt to provide more appropriate support.

There are still many challenges to overcome, from improving the reliability and robustness of sensors, to preventing annoying or disturbing alarms, to making sure the technology is safe from cybercriminals. And for all the technology, there will always be a need for a human in the loop. The technology is intended to complement human carers and must be adapted to individual users. But the potential is there for genuine smart homes to help people with dementia live richer, fuller and hopefully longer lives.

Dorothy Monekosso, Professor of Computer Science, Leeds Beckett University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Caregiving, International Campaigns, International Policies, Research & Best Practice

Dementia more preventable in Asia and Latin America

Posted on April 22, 2019April 18, 2019 by Joanna Sun

News Release
April 2019 | University College London, Gower Street, London – Dementia more preventable in Asia and Latin America

Close to one in two cases of dementia could be preventable in low- to middle-income countries, finds a new UCL study.

Dancing in Peru
The findings, published in The Lancet Global Health, found how improving childhood education and other health outcomes throughout life could reduce the risk of dementia.

“After our previous research finding that one in three cases of dementia could be preventable, we realised that the evidence was skewed towards higher-income countries,” said the study’s lead author, Dr Naaheed Mukadam (UCL Psychiatry).

“We have now found that in low- to middle-income countries in Asia and Latin America, dementia may be even more preventable than it is in more wealthy countries. If life-course risk factors such as low levels of education in early life and hearing loss, obesity and low physical activity in mid-life to old age are addressed, these countries could see large improvements in their dementia rates.”

While the number of people with dementia is increasing globally, particularly in low- to middle-income countries, there have been modest reductions in age-specific dementia rates in many high-income countries over the last two decades.* The researchers say this could be due to improvements in health outcomes throughout life that affect dementia risk.

The research team built on their previous work for the Lancet Commission on dementia prevention, intervention, and care, published in 2017, which found that 35% of dementia is attributable to nine risk factors: low levels of childhood education, hearing loss, smoking, hypertension, obesity, physical inactivity, social isolation, depression, and diabetes.*

To understand whether the commission’s findings would apply equally to global regions that were underrepresented in the report, a team of UCL researchers sought out data from China, India and Latin America. They drew from the research collective 10/66 Dementia Research Group’s data, which used similar methodology to gauge prevalence of the nine risk factors in those countries, with sample sizes of 1,000 to 3,000 in each country.

The researchers found even more potential for preventing dementia across the globe, as the proportion of dementia linked to the nine modifiable risk factors was 40% in China, 41% in India and 56% in Latin America.

A major factor in that difference is the lower levels of educational attainment in low- to middle-income countries, which the researchers say signals hope for the future, as education levels rise.

“People growing up in Asia and Latin America today are more likely to have completed schooling than their parents and grandparents were, meaning they should be less at risk of dementia later in life than people who are already over 65. Continuing to improve access to education could reap great benefits for dementia rates in years to come,” Dr Mukadam said.

On the other hand, social isolation is a major risk factor of dementia in higher income countries, but much less so in China and Latin America. The researchers say that public health officials in countries such as the UK could learn from China and Latin America in efforts to build more connected communities to buffer against the dementia risk tied to social isolation.

Obesity and hearing loss in mid-life, and physical activity in later life, were also strongly linked to dementia risk in the study area, as well as mid-life hypertension in China and Latin America and smoking in later-life in India.

“Reducing the prevalence of all of these risk factors clearly has numerous health benefits, so here we’ve identified an added incentive to support public health interventions that could also reduce dementia rates. The growing global health burden of dementia is an urgent priority, so anything that could reduce dementia risk could have immense social and economic benefit,” Dr Mukadam said.

Senior author Professor Gill Livingston (UCL Psychiatry) added: “A lot of the findings of health and medical research derive primarily from higher income countries such as in Western Europe and North America, so ensuring that research is inclusive is vital to the development of global public health strategies.”

“While we don’t expect these risk factors to be eliminated entirely, even modest improvements could have immense impact on dementia rates. Delaying the onset of dementia by just five years would halve its prevalence*,” she said.

The researchers are supported by the National Institute for Health Research UCLH Biomedical Research Centre, Wellcome, NIHR, Economic and Social Research Council, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames.

Links
Research paper in The Lancet Global Health
Dr Naaheed Mukadam’s academic profile
UCL Psychiatry
* The Lancet Commission on dementia, prevention, intervention and care
Image
People dancing in Peru. Credit: Alex Proimos, Source: Flickr
Media contact
Chris Lane
tel: +44 20 7679 9222

E: chris.lane [at] ucl.ac.uk

Caregiving, International Policies, Research & Best Practice, The Built Environment

Australia’s residential aged care facilities are getting bigger and less home-like

Posted on April 18, 2019November 1, 2019 by Joanna Sun

File 20180921 129847 1di589.jpg?ixlib=rb 1.1

Residential aged care facilities should be more like a home and less like a hospital.
from shutterstock.com

Ralph Hampson, University of Melbourne

Most older people want to stay at home as long as they can. When this is no longer possible, they move into residential aged care facilities, which become their home. But Australia’s care facilities for the aged are growing in size and becoming less home-like.

In 2010–11, 54% of residential aged care facilities in major Australian cities had more than 60 places, and the size of the average facility is growing.

Today, more than 200,000 Australians live or stay in residential aged care on any given day. There are around 2,672 such facilities in Australia. This equates to an average of around 75 beds per facility.

Large institutions for people with disability and mental illness, as well as orphaned children, were once commonplace. But now – influenced by the 1960s deinstitutionalisation movement – these have been closed down and replaced with smaller community-based services. In the case of aged care, Australia has gone the opposite way.

Why is smaller better?

Evidence shows that aged care residents have better well-being when given opportunities for self-determination and independence. Internationally, there has been a move towards smaller living units where the design encourages this. These facilities feel more like a home than a hospital.

The World Health Organisation has indicated that such models of care, where residents are also involved in running the facility, have advantages for older people, families, volunteers and care workers, and improve the quality of care.

In the US, the Green House Project has built more than 185 homes with around 10-12 residents in each. Studies show Green House residents’ enhanced quality of life doesn’t compromise clinical care or running costs.

Older people have a better quality of life if they can be involved in outdoor activities.
from shutterstock.com

Around 50% of residents living in aged care facilities have dementia. And research has shown that a higher quality of life for those with dementia is associated with buildings that help them engage with a variety of activities both inside and outside, are familiar, provide a variety of private and community spaces and the amenities and opportunities to take part in domestic activities.

In June 2018, an Australian study found residents with dementia in aged-care facilities that provided a home-like model of care had far better quality of life and fewer hospitalisations than those in more standard facilities. The home-like facilities had up to 15 residents.

The study also found the cost of caring for older people in the smaller facilities was no higher, and in some cases lower, than in institutionalised facilities.

There are some moves in Australia towards smaller aged care services. For example, aged care provider Wintringham has developed services with smaller facilities for older people who are homeless. Wintringham received the Building and Social Housing Foundation World Habitat Award 1997 for Wintringham Port Melbourne Hostel. Its innovative design actively worked against the institutional model.

Bigger and less home-like

Historically, nursing homes in Australia were small facilities, with around 30 beds each, often run as family businesses or provided by not-for-profit organisations. Between 2002 and 2013 the proportion of facilities with more than 60 beds doubled to 48.6%. Financial viability rather than quality of care drove the increase in size.

Today, around 45% of facilities are operated by the private for-profit sector, 40% by religious and charitable organisations, 13% by community-based organisations, 3% by state and territory governments, and less than 1% by local governments.

In 2016, the Australian Institute of Health and Welfare (AIHW) reported that residential care services run by government organisations were more likely to be in small facilities. One-fifth (22%) of places in these facilities are in services with 20 or fewer places. Almost half (49%) of privately-run residential places are found in services with more than 100 places.

All of this means that more older Australians are living out their last days in an institutional environment.

Once larger facilities become the norm, it will be difficult to undo. Capital infrastructure is built to have an average 40-year life, which will lock in the institutional model of aged care.

The built environment matters. The royal commission provides an opportunity to fundamentally critique the institutional model.

Ralph Hampson, Senior Lecturer, Health and Ageing, University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.