The costs and experiences of caring for sick and disabled geriatric patients-Australian observations

Betty Smith and Sandra O’Malley

James Lawson Geriatric Assessment Team, Central Coast Area Health Service, Gosford

School of Health Services A/lanagement, University of New South Wales

Abstract: The costs and experiences of caring for geriatric patients and the effectiveness of a geriatric assessment team have been reviewed in this study from the New South Wales Central Coast. The findings were: that some clients who are referred for placement in nursing homes and who meet standard criteria for admission can be maintained in the community; the cost to the taxpayer of persons admitted to nursing homes was at least $449 to $776 per week (1991 prices), compared to an average cost of $89 per week to maintain at home those whose original assessment met all the criteria for nursing home placement; assessments of needs of some clients were being conducted by five or more separate agencies which led to increased costs and created distrust ancl confusion for the client; a key factor in the decision to maintain a client in the community was found to be the availability and motivation of carers. A geriatric assessment team has an essential role in mobilising expert assessment and facilitates access to community- based sumort services to obviate or delay admissions to nursing homes. (Aust J Public Health 1993; lj:‘131-4)

omprehensive geriatric services were first developed in the United Kingdom and intro- C duced into various parts of Australia during

the 1950s. These services included a ‘model service’ developed by Gibson and colleagues in Newcastle, New South Wales, and expanded in many parts of Australia during the 1970s.’

A key aim of geriatric assessment teams is to assist clients and families to gain access to the types of ser- vices most appropriate to their needs for care.:! Guidelines for such teams have been promulgated by the Australian Department of Community Services. Although there have been several reviews of selected Australian Geriatric and despite their potential importance, there does not appear to have been an examination of their cost and effectiveness.

Methods The geriatric assessment team which provides ser- vices for the aged people of the New South Wales Central Coast (the city of Gosford and shire of Wyong) was selected for study because this team was well established, the elderly proportion of the popu- lation was high (1 5 per cent over 65 years of age) and members of the team were willing to participate actively. The Central Coast Geriatric Assessment Team was established in June 1987 and consisted of a geriatrician, social worker, occupational therapist, physiotherapist, psychologist (part-time) and place- ment officer. The team initially accepted referrals

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Correspondence to Professor Janies Lawson, School of Health Services Management, University of New South Wales, PO Box 1, Kensington, NSW 2033. Fax (02) 662 7698.

only for clients who were said to be in need of nursing home care. This study is a descriptive record of the events in the management of 100 clients, all of whom were consecutively referred to the Central Coast Geriatric Assessment Team for nursing home place- ment and who were subsequently followed up for 12 months whether or not they were admitted to a nurs- ing home. Information was collected about clients with respect to age, sex, disability and social circumstances.

The commencement date of the study, 10 October 1990, was determined, and from that date all referrals for nursing home placement were recorded until 50 clients were accumulated in two groups. Group 1: The first 50 referrals for placement in a nursing home who were considered by the geriatric assessment team to meet the criteria for nursing home care. Group 2: The first 50 referrals for placement in a nursing home who did not meet the criteria for nurs- ing home care according to the team.

In addition, an assessment was made of the needs and wishes of clients and the estimated costs to the community of care in nursing homes and care in the the community.

The number of participants in the study was based on practicality and expense. The sample size was chosen to have statistical representation when disaggregating each group by their disability charac- teristics. It was possible to follow up 100 per cent of subjects.

The experiences of caring for these patients were anecdotal and could not be generalised; however they do provide insights and information that is of potential value and interest to workers and clients.

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SMITH ET AL

Table 1 : Characteristics and and primary diagnosis of 100 clients assessed by the Geriatric Assessment Team and recommended for nursing home admission (Group

1 ) or for maintenance in the community (Group 2)

Group 1 Group 2

Male 23 20 Femole 27 30 Over 75 years of oge 42 41 Acts of daily living Mobility problems 35 30 Recent falls 21 10 Problems with hygiene, dressing,

eating, toileting 50 47 Incontinent of urine or faeces 30 14 Cognitive dysfunction 37 27 Behoviourol dysfunction 15 7 Primary diagnosis Arthritis, musculoskeletal 4 3 Cerebrovoscular Occident 1 1 6 DementialAlzheimer's disease 15 14 Parkinson's/central nervous system

disorder 5 5 Neoplasms 1 5 Fractures 3 1 Other 8 14 Social Widowed 32 31 living olane 15 16 Carer 'stress' 31 31

Assessment procedures and criteria for admission to a nursing home The assessments were based on information from the individual clients themselves, carers, general medical practitioners, neighbours, friends and service pro- viders. The clients recommended by the geriatric assessment team as being suitable for nursing home care all had high levels of dependence in activities of daily living (bathing, dressing, toileting and eating). Such high dependency was mostly a consequence of poor mobility, cognitive dysfunction, dementia and disturbed behaviour, all complicated by problems of incontinence, recent falls, fractures and strokes. This dependency often required care beyond the capacity of a client living alone or the resources of a carer. Despite the availability of guidelines, clearly there was a strong element of judgment exercised by the team with respect to recommendations for or against admission to a nursing home.

Results The results are shown in Tables 1 , 2 and 3. The characteristics and primary diagnoses of clients were very similar in the two groups: 83 per cent were over

Table 2: Outcomes for 100 clients 12 months after referral to the Geriatric Assessment Team for nursing

home admission: 50 met the criteria for admission (Group 1 ) and 50 were recommended for maintenance

in the community (Group 2)

Group 1 Group 2

Home 6 14 Hostel 3 5 Nursing home 29 16 Died 12 15 Totol 50 50

75 years of age, 60 per cent had mobility problems, 97 per cent had problems with hygiene, dressing, eat- ing, toileting, and 31 per cent had had recent falls. The most common primary diagnoses were cerebrovascular accidents and dementia.

The most important differences between the groups were the much higher incidence of inconti- nence of urine or faeces and cognitive and behavioural dysfunction in the groups recommended for admission to nursing homes. Other differences included the greater severity of disabilities in the group recommended for admission. However, the key determinant of recommended admission was the availability, and willingness or otherwise, of a carer to maintain the client out of a nursing home. Indeed, 62 per cent of all referrals were initiated by 'stressed' carers.

Cost estimntes The time spent by carers caring in the home is very variable and no attempt was made to try to cost this care. There is a qualitative and quantitative differ- ence between a client who needs constant general supervision and a client who needs large blocks of intensive caring time, but there is no doubt that the physical, personal and emotional cost to the carer is priceless.

The cost to the taxpayer associated with admissions to nursing homes (nongovernment) relates to the Commonwealth Government subsidy which depends on the patient's dependency classification. These costs (1991) are:

Category: 1. $110.86 per day 2. $101.89 per day 3. $91.44 per day 4. $74.61 per day 5. $64.27 per day

In addition, there is a client contribution of 87.5 per cent of the full age pension plus rent assistance,

Table 3: Service cost guide

Service Occurrences Cost of service Total cost of service

Meols on wheels Community nurse" Twice a week

Home coreb Once o week

Five times a week

Domiciliory benefits Day core Once a week (5 hours)

$2.40 a meol $1 9.78 a visit

$15.85 an hour $21 .OO a week $4.50 on hour

$1 2.00 $36.56 $1 5.85 $2 1 .oo $22.50

Notes: lo) A community nurse visit wos estimated to be equol to one hour to account for travelling time. lb) Home core visits were more frequently 2 hours o fortnight.

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GERIATRIC CARE

currently a total of $158.90 per week. There is also an ‘administration’ cost of between approximately $50 and $100 per week paid by the Commonwealth to nursing homes.

In order to attempt to standardise the process of costing each community-based service, the hourly rate per service from the Seruice type codes-a guide provided by the Department of wouth and] Com- munity Services, New South Wales, in 1990 has been used. These ‘costs’ therefore relate only to the actual service provided and do not take into account the full administrative costs of service.

For services such as home modification, supply of equipment, visits by an occupational therapist or other less frequent services, a cost was added to the yearly cost of those clients at home for the full year or most of the year and averaged out to a weekly cost. The client may have used Residential Respite Care also, and this was added to the cost of that client’s care, and the ‘in-home’ Home and Community Care services deleted for the period of such residential care.

In all cases, the cost to the support service funded by Home and Community Care (not the amount paid by the client towards the service) is the only cost included. N o attempt has been made to put a price on the care given by a full-time carer (spouse or other relative).

The costs of the geriatric assessment team needs to be added to the cost of the process of keeping these clients at home. The costs for the team ($446 000) over the 1991 calendar year divided by the total num- ber of clients seen in that period (1 81 7) was $245 per client per year or $4.72 per client per week.

The overall average cost to the taxpayer for the clients still at home after one year from assessment was $89.90 per week per client. The weekly cost to the taxpayer for a Category 3 resident in a nursing home (nursing and personal care only) was $640.08 per week plus $50 to $100 per week administrative subsidy. The weekly cost to the taxpayer for a resi- dent receiving personal care in a hostel was $164.85 per week.

Specijk observations In addition to the formal results, a number of obser- vations were made during the period of the study. One of the most important was the crucial fact that many disabled aged persons faced a major change in a lifetime role and had lost their negotiating and interpersonal skills as well as their positive self-image. These changes included: from being an active pro- vider for others to being a dependent person; the change from an active healthy role to that of a sick person with severe disability and restriction of mobility; and a change from being a family member to being a resident in an institution in a relatively anonymous atmosphere.

The clients had, in addition to the diagnoses outlined in the results, multiple problems associated with poor eyesight and hearing and poor short-term memory. Many clients made errors with respect to medication, particularly when three or more drugs were used simultaneously.

Some elderly disabled people in the study were observed to be without a voice when major decisions about them were made about how and where they should be cared for. These decisions were frequently determined by financial, family and professional pressures and the decision making was assumed by others.

There was considerable ignorance about services and their availability and considerable reluctance by some to have to fit in with what a service could pro- vide (such as domiciliary nursing only twice a week). Most of the clients had quite close contacts with the community and families, friends and neighbours, all of whom felt some responsibility towards them. These informal contacts were very important and were often what the elderly people relied on exclus- ively. However, in contrast, some clients were very isolated, had few friends and little contact with neigh- bours and no-one to help but geographically distant relatives. For some of the clients, family and friends provided most of the help, whilst for others, com- munity services were particularly relevant and important.

The carer The problems of caring for anelderly relative will affect many people during their lifetime. For some this is a perfectly natural and happy experience. However, it was observed that even in the most con- tented of households, the stress levels involved in caring for a frail elderly person could become intol- erable. The medical and psychiatric crisis of a parent mayforce families to act as families where in fact they may not have been functioning as such for many years. The common practice of maintaining an ill parent at home by shunting him or her from house to house of each adult child often produced shifting family relationships and destabilised family equilibrium.

The problem for carers is to find a balance between their responsibilities to themselves, their families and their parents. Some adult children were observed to have difficulty dealing with their parents in such a mature way.

General observations Clients were observed to be subjected to multiple assessments to obtain multiple services, for example, ‘Meals on wheels’, home nursing, home care, com- munity transport, home maintenance and respite care services. Clients and carers frequently expressed concern about the number of people that they were expected to relate to, communicate with, and in a short time, learn to trust. They reported that their privacy was lost and the quality of their lives had changed, not always for the better, following the pro- vision of supportive services. Their daily lives had become stressful, involving issues of survival, and because of the potential intrusion, they still refused the services which could have been helpful to them. It was observed that clients living alone would fre- quently refuse to accept multiple providers of ser- vices, fearing the prospect of opening the door ‘to

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many different faces’ and the prospect of additional assessments to qualify for each service.

Clients living in hostels appeared to have their placement in nursing homes delayed considerably. Staff of financially subsidised hostels would ‘hang on’ to the residents longer than staff in nonsubsidised serviced apartments. It was observed that hostel supervisors accepted and retained the more depen- dent residents and the traditional progression to a nursing home was not necessarily regarded as normal.

Social changes such as second marriage or defacto relationships were sometimes observed to complicate a client’s care, either from the second spouse or from the extended family, especially when there were property and assets at stake. It was observed that fam- ilies and spouses could occasionally pursue nursing home placement as a cheap separation in lieu of div- orce and property settlement.

It was observed that families needed to be re-educated into realising that nursing home place- ment was not necessarily the end of the road; clients could be and were retrieved from nursing home care, especially where nursing homes were oriented and committed to the successful rehabilitation of resi- dents. For example, four clients in this study were able to return to independent or semi-independent living following placement in a nursing home.

Discussion The Australian population is gradually aging.g In 1991, the estimated proportion of the population 65 to 80 years of age and over 80 was approximately 11 and 2 per cent respectively. However, these pro- portions are expected to rise by the year 2025 to 13 and 3.5 per cent, with the proportion of the ‘aged aged’ (persons 80 years and over) growing the fastest of all age groups. As advancing age is directly related to the prevalence of disability,’O the need for geriatric services, that is, care for disabled aged persons, is increasing.

The range of required geriatric services includes: an assessment service; rehabilitation service; general and specialist medical and dental service; community-based nursing; home help; home modifi- cation and ‘Meals on wheels’ services; and hostels, nursing homes and acute hospital services. In addition, there is a need for specifically designed housing for the aged. This range of services is per- haps best provided in an organised framework, as dis- tinct from independently functioning services.”

The main findings of this study are: Some clients who were referred for placement in nursing homes and who met standard criteria for admission, after assessment and organisation of support services, could be maintained in the community. The cost to the taxpayer (there are additional costs to clients and families) of persons admitted to nurs- ing homes was from $449.89 to $776.02 per week (1991 prices). In addition, there were variable

administrative costs paid to nursing homes by the Commonwealth Government. These costs were far in excess of the average cost to the taxpayer of $89.90 per week to maintain clients whose original assessment met all the criteria for nursing home placement at home. Additional assessments of the needs of some clients was being conducted by five or more separate ser- vice providers. Clearly, there is a need to coordi- nate and rationalise the costs and time in this process and to reduce the distrust and confusion it creates for the client and the service provider. A key factor in the decision to maintain a client in the community was found to be the availability and motivation of carers. Prior to the establishment of geriatric assessment

teams, many aged people were prematurely or inappropriately placed in nursing homes.” We believe that all 100 clients in this study would have been placed in nursing homes had they not been per- sdnally assessed, as all 100 referrals appeared to fit the criteria for nursing home admission.

Area-based geriatric assessment services are essen- tial in order to provide expert assessment, to help mobilise and coordinate community-based support services, and to avoid unnecessary admissions to nursing homes, all of which substantially reduce costs to the taxpayer when community-based care replaces institutional care.

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