HEALTH AGEING AND HUMAN SERVICES

Ministerial Dementia Forum–

Options Paper

Final

October 2014

MANAGEMENT CONSULTING

Disclaimer

Inherent Limitations

This report has been prepared as outlined in KPMG’s Order for Services executed 29 August 2014. The services provided in connection with this engagement comprise an advisory engagement, which is not subject to assurance or other standards issued by the Australian Auditing and Assurance Standards Board and, consequently no opinions or conclusions intended to convey assurance have been expressed.

The findings in this report are based on a qualitative study and the reported results reflect a perception of participants who attended the Ministerial Dementia Forum on 11 September 2014 but only to the extent of the sample surveyed, being the Department of Social Services’ approved representative sample of service providers, clinicians, carers, people with dementia and the Australian Government. Any projection to wider personnel and/or stakeholders is subject to the level of bias in the method of sample selection.

No warranty of completeness, accuracy or reliability is given in relation to the statements and representations made by, and the information and documentation provided by, service providers, clinicians, carers, people with dementia and Australian Government stakeholders consulted as part of the process.

KPMG have indicated within this report the sources of the information provided. We have not sought to independently verify those sources unless otherwise noted within the report.

The report is dated 31 October2014 and KPMG accepts no liability for, and has not undertaken work in respect of, an even subsequent to that date which may affect the report. KPMG is under no obligation in any circumstance to update this report, in either oral or written form, for events occurring after the report has been issued in final form.

The findings in this report have been formed on the above basis.

Third Party Reliance

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This report has been prepared at the request of the Department of Social Services in accordance with the terms of KPMG’s Order for Services executed 29 August 2014. Other than our responsibility to the Department of Social Services, neither KPMG nor any member or employee of KPMG undertakes responsibility arising in any way from reliance placed by a third party on this report in whole or in part, in any format. Any reliance placed is that party’s sole responsibility.

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Executive summary

Dementia is the gradual, progressive and irreversible decline in brain function.It is a syndrome, meaning it is characterised by multiple symptoms which may include difficulties with language, memory, perception, changes in personality and reduced cognitive skills. It can result from one, or a combination of over 100 identified causes, the most common of which are Alzheimer’s disease and vascular disease. With age as the major non-modifiable risk factor, the prevalence of dementia approximately doubles every five years beyond the age of 65 and for those aged 85 and over, the prevalence is approximately one in every four persons.

With Australia’s ageing population, it is important that the Australian Government provides appropriate levels of support for people with dementia; their carers and family; and aged care service providers to ensure that people with dementia receive high quality care.

Following the Australian Government’s decision to cease the Dementia and Severe Behaviours Supplement in June 2014, the Assistant Minister for Social Services Senator the Hon Mitch Fifield and the Minister for Health the Hon Peter Dutton MP held the Ministerial Dementia Forum, ‘Dementia Care – Core Business for Aged Care’, on 11September 2014 in Melbourne. Seventyparticipants from across Australia representing service providers, clinicians, carers,people with dementia and the government attended the forum. The purpose of the forum was to identify what is currently working well, areas for improvement, potential policy options to address the care needs of people with dementia and experiencing severe Behavioural and Psychological Symptoms of Dementia (BPSD).

This paper captures the feedback provided on the day by the forum’s participants, as well as submissions provided by participants subsequently. The future reform options cover a wide range of topics including consumer engagement; education and training; unmet needs; specialised support; quality of life indicators; and funding. Each option that was presented has been developed further, with an assessment of the benefits, risks and feasibility.

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© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity.
All rights reserved.

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Liability limited by a scheme approved under Professional Standards Legislation

Contents

Executive summary

1.Background

1.1Dementia supports in place

1.2Additional supports

1.3Accreditation and funding of aged care organisations

1.4Addressing behavioural and psychological symptoms of dementia

2.Our approach

3.Current state of dementia care

3.1What is working well

3.2Key challenges

4.Options

5.Next steps

Appendix 1 : List of Ministerial Dementia Forum participant organisations

Appendix 2 : Ministerial Dementia Forum – 11 September 2014 Agenda

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© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity.
All rights reserved.

KPMG and the KPMG logo are registered trademarks of KPMG International.

Liability limited by a scheme approved under Professional Standards Legislation

1.Background

Dementia is the gradual, progressive and irreversible decline in brain function. It is a syndrome, meaning it is characterised by multiple symptoms which may include difficulties with language, memory, perception, changes in personality and reduced cognitive skills.[1] Dementia can result from one, or a combination of, over 100 identified causes, the most common of which are Alzheimer’s disease and vascular causes.[2] Its progression can be categorised into four phases:

  • early difficulties (the pre-diagnostic phase)
  • the emergence of significant difficulties in daily living
  • a reduced capacity for independence
  • incapacity and a high dependence on care.[3]

With age as the major non-modifiable risk factor, the prevalence of dementia approximately doubles every five years beyond the age of 65.[4] Amongst those aged 85 and over, the prevalence of dementia is approximately one in every four persons.[5] As a result of the ageing population, the prevalence of dementia is expected to grow from 332,000 in Australia in 2014 to 550,200 people by 2030, and 891,400 people by 2050.[6]

According to the Australian Institute of Health and Welfare, over 50 per cent of permanent residents within Australian Government-funded aged care facilities have a diagnosis of dementia.[7] In 2009-10, two billion dollars of expenditure was attributable to dementia, of which over half was represented by residents within residential aged care facilities.[8] People with dementia are more likely to have longer lengths of stay due to having to enter residential care earlier in their lifespan, as well as being more likely to have higher level complex care needs, including BPSD.

BPSD can be mild or severe, with symptoms including ‘disturbed perception, thought content, mood or behaviour including aggression, apathy, anxiety, agitation, psychotic symptoms, depression, disinhibited behaviours, wandering, nocturnal disruption and vocally disruptive behaviours’.[9]People with severe BPSD present significant challenges for residential care providers but symptoms can be episodic relating to specific physical, social or environmental unmet needs. If these needs are met then symptoms may subside.

Treatment and severity of BPSD is usually assessed in Australia via the Brodaty Triangle, a seven tiered model of service delivery for BPSD which provides an evidence-based practice model of management. People at the bottom end of the spectrum, with less developed signs and symptoms, receive the least intervention, while people at the top end of the spectrum, with further developed symptoms, receive the most.[10]

1.1Dementia supports in place

Currently the Australian Government has the following programs and services in place to meet the objective of better practice in dementia care:

Dementia Behaviour Management Advisory Services

The Dementia Behaviour Management Advisory Services (DBMAS) provide advice and support to those caring for people with dementia. Services may include clinical advice over the phone, assessment, care plan development, mentoring and education and training. DBMAS staff are accessible over the phone via a 24 hour helpline and cater for aged care workers as well as family carers.[11]

National Dementia Support Program

The National Dementia Support Program (NDSP) is anAustralian Government funded initiative delivered by Alzheimer’s Australia and was formed as a consolidation of previously run programs aimed at dementia support. NDSP delivers a helpline and referral service, dementia and memory community centres, early intervention support, non-clinical advice, counselling and professional support, education and training, special needs support, as well as serving an awareness function.[12]

Dementia Training Study Centres

Dementia Training Study Centres (DTSCs) provide courses, workshops and seminars for continuing professional education for dementia health care professionals and students as well as assisting universities with curriculum development.[13]

Service Access Liaison Officer

Additional funding was allocated to Alzheimer’s Australia via the NDSP to provide Service Access Liaison Officers (SALOs) in each state and territory throughout Australia to address barriers to access for specific needs groups. SALOs aim to provide access to dementia services to Aboriginal and Torres Strait Islander people; people from Culturally and Linguistically Diverse backgrounds; Gay, Lesbian, Bi-Sexual, Transgender and Intersex people; people with Younger Onset Dementia; and people in rural and remote locations. SALOs’ projects have been focused on raising awareness and reducing stigma, as well as enhancing services’ ability to meet the needs of these groups.

DementiaEducationandTraining forCarers

The Dementia Education and Training for Carers (DETC) programme is Australian Government funded and delivered via the Commonwealth Respite and Carelink Centres. DETCs provide carers with early intervention support, including in-home and group education as well as providing help in linking carers to other available resources depending on their individual needs. DETCs aim to improve care services for people with dementia by increasing the competence and confidence of carers and providing more support for timely diagnosis.[14]

Younger Onset Dementia Key Worker Programme

The Younger Onset Dementia Key Worker Programme provides individualised information and support to improve the quality of life for people with younger onset dementia. The key worker acts as a primary point of contact for people with younger onset dementia, their families and carers. The key worker provides information, support, counselling, advice and helps consumers effectively engage with services appropriate to their individual needs.[15]

The Dementia and Cognition Supplement in Home Care

The Dementia and Cognition Supplement in Home Care is available to home care recipients who are assessed as having moderate to severe cognitive impairment. The supplement is paid at the rate of 10 per cent of the basic subsidy payable for each of the four levels of Home Care Package and is indexed annually.[16]

1.2Additional supports

The Commonwealth funds a range of other support for older people accessing aged care. These are also available for people with dementia.

Aged care assessment teams

Aged care assessment teams or services(ACATs/ACAS) assess a consumer’s eligibility for government subsidised residential and home care aged care services. This assessment can help people with dementia to identify the type of care services that will help them stay at home, receive certain respite services or to enter into an aged care facility.

National Aged Care Advocacy Program

Operating in each of the states and territories, the National Aged Care Advocacy Program (NACAP) provides advice and help to people with dementia and carers to understand and exercise their rights. NACAP also acts on behalf of people with dementia and carers in discussions within the aged care industry in policy formation.[17]

Community Visitors Scheme

Referred by family, friends or service provider managers,[18] the Community Visitors Scheme (CVS) matches volunteers to socially isolated people in residential aged care facilities for companionship and social engagement.[19]

1.3Accreditation and funding of aged care organisations

Aged care accreditation

There are 44 expected outcomes across four standards in residential aged care, and 18 expected outcomes across three standards for home care providers. These are based on the QualityofCarePrinciples2014, issued by the Assistant Minister as permitted by sections 96-1 the AgedCareAct1997,[20] and the expected outcomes are required for accreditation and quality review of residential aged care facilities, and home care providers respectively.

Residential facilities are reviewed periodically using standard audit methodology which systematically reviews all 44 expected outcomes. Failure to meet the outcomes will result in the submission of a timeline of improvement, after which further noncompliance can result in accreditation being revoked or other sanctions.[21]

Aged Care Funding Instrument

The Aged Care Funding Instrument (ACFI) is a tool designed to align allocation of funding with needs. It assesses people’s care needs on the basis of their diagnoses, and assessed level of assistance required or level of impairment across the domains of activities of daily living; behaviour; and complex care needs. People are assessed using approved validated instruments to determine a low, medium or high level.[22]

1.4Addressing behavioural and psychological symptoms of dementia

In order to assist residential aged care providers in addressing the needs of residents with severe BPSD, the Australian Government introduced the DSBS of $16.15 per day per eligible resident in August 2013.

It was estimated that 2,000 aged care residents would be eligible for the DSBS in 201314 with a budgeted expenditure of $11.7 million. As of April 2014, 29,927 people were receiving the DSBS with an estimated actual cost of approximately $110 million in 2013-14. As a result of far higher than expected claiming, the Australian Government ceased the DSBSon 31July2014.

2.Our approach

The Assistant Minister for Social Services Senator the Hon Mitch Fifield and the Minister for Health the Hon Peter Dutton MP committed to a forum to look at dementia as ‘core business’ across aged care and, as part of that, to consider alternatives to the Supplement. The Department of Social Services (DSS) Ageing and Service Improvement Branch engaged consultants to conduct and report on theMinisterial Dementia Forum aimed at undertaking broad stakeholder consultation on possible future directions in improving dementia care. The Ministerial Dementia Forum, ‘Dementia Care – Core Business for Aged Care’, was held on 11 September 2014 with 69participants from across Australia representing service providers, clinicians, carers and people with dementia and the Australian Government (See Appendix 1 for a list of the participant organisations). The forum was CoChaired by AssociateProfessorSusanKoch and Ms SuePieters-Hawke.

The overarching aim of the day was to establish what is needed to improve the provision of dementia care both in residential aged care and home care, whilst remaining within the current funding envelope. The discussions were built on the following four objectives:

  • Objective one: improve and promote the wider adoption of better practice care and support of people with dementia within the aged care system both in residential care and care and support in the home.
  • Objective two:consider effective models of care and support for people with severe BPSD and dementia within the aged care system, both in residential care and care and support in the home, and examine ways to promote them.
  • Objective three:explore strategies that facilitate and consolidate dementia care as ‘core business’ for all aged care services.
  • Objective four:explore models of care that provide timely and cost effective specialised support for care of people with dementia with complex needs or severe BPSD, including for particular populations with special needs.

Senator the Hon Mitch Fifield, Professor Henry Brodaty, Ms Kate Swaffer, and Dr Stephen Judd gave short addresses in order to identify the Government, clinician, consumer and service provider perspectives, on dementia, respectively. This was followed by three workshop sessions, involving round table discussions amongst the table groups, with the key findings presented to the broader group. The three workshop sessions answered the following questions:

1)When it comes to supporting people with dementia, what is working in the current system? Where is there opportunity for improvement? What is needed in the short, medium and longer term?

2)Within the current funding envelope, how would you address the need to assist residential aged care consumers with dementia and severe BPSD? Consider opportunities in the short, medium and longer term.

3)What needs to be done specifically for people with severe BPSD within the available budget envelope? What is needed in the short, medium and longer term?

Each table had a scribe to capture the key ideas within the discussions. Following the day, scribes reports were sent to table captains for verification, after which theme analysis was undertaken to inform this report and the options within it. A summary of the workshop sessions is outlined in Sections 3 and 4, with potential next steps identified in Section 5.