Department of Health
Key Themes Identified in Rural and Remote Aged Care Consultations
December 2015

KPMG

Key Themes Identified in Rural and Remote Aged Care Consultations

Department of Health

December 2015

ADVISORY

Contents

Executive summary

1.Introduction

1.1Objective of Study

1.2Approach

2.Residential Care and Home Care Providers

2.1Introduction

2.2Key Themes

3.Multi-Purpose Service Aged Care Providers

3.1Introduction

3.2Key Themes

4.National Aboriginal and Torres Strait Islander Flexible Aged Care Programme Providers

4.1Introduction

4.2Key Themes

Appendix A – Consultation Guide

1

Department of Health
Key Themes Identified in Rural and Remote Aged Care Consultations
December 2015

Executive summary

Introduction and Approach

KPMG conducted a number of one-on-one consultations with rural and remote aged care providers, in order to gather direct feedback and identify the key factors that influence the financial performance of rural and remote aged care providers. This information will inform the Aged Care Financing Authority (ACFA) and Department of Health’s (Health) study on issues that affect the financial and operational performance of rural and remote aged care providers throughout Australia.

KPMG held consultations with 30 aged care providers across Australia, including residential and home care packages providers, multi-purpose service (MPS) providers and National Aboriginal and Torres Strait Islander Flexible Aged Care Programme (NATSIFACP) providers.

In these consultations, providers were asked questions regarding: service provider management; occupancy; clientele demographics; workforce; and financial performance. Providers were also invited to discuss any other key issues that were impacting on their financial performance.

Key Themes Identified for Residential and Home Care Aged Care Providers

KPMG consulted with ten providers across New South Wales, Queensland, South Australia, Victoria and Western Australia. Providers were contacted in the Northern Territory and Tasmania, but declined to participate as they had submitted a detailed submission to Health or attended a communication forum.

Key themes identified through these consultations were:

  • The change in community need has impacted on providers in terms of residents entering residential care with much higher care needs as a result of staying in their homes longer;
  • Issues are experienced with attracting qualified and experienced staff in remote areas. As such, providers often invest significantly in training to ensure their workforce have the right skills;
  • Retention of staff varies across providers. For staff that had a low turnover, they expect issues in the future due to the ageing of their current workforce (i.e. 65 years and older);
  • It is costly to access training off-site due to travel and accommodation costs and can sometimes be difficult to get staff engagement. Some providers worked with other providersin their region to bring trainers in to deliver a course to reduce costs;
  • Boards are often averse to borrow for capital developments or improvements, leading to providers relying on capital grants or cash reserves for these activities;
  • Having a good relationship with the community was highlighted as key for many providers, in terms of referrals, volunteering, and quality of Board membership;
  • Establishing relationships with other organisations both in the region and in the community (such as Regional Development Australia, TAFEs etc.) can benefit the provider from a grant funding, staff retention and reputational perspective;
  • There are a number of additional costs of operating in a remote area, such as: freight costs; labour transport costs; general higher cost of operating in a smaller region; and costs of bringing specialists to service their residents;
  • The low value and poor real estate market in rural and remote areas affects the ability to levy a RAD/DAP that was reflective of their accommodation costs; and
  • A variety of approaches are taken by providers in regards to the RAD, with some willing to negotiate the price with residents, and others who will not alter their advertised price depending on individual circumstances.

Key Themes Identified for MPS Aged Care Providers

KPMG consulted with sevengovernment providers across New South Wales, Queensland, Tasmania, Victoria and Western Australia, and one peak body in Victoria. The State governments were contacted in the Northern Territory and South Australia, but they did not respond to requests for a consultation.

Key themes identified through these consultations were:

  • Broader Hospital and Health Service (HHS) management sometimes limits the ability of individual MPS’s to control their budget, which can lead to a limited incentive for the MPS to improve their performance as any savings are not retained by the MPS;
  • Access to specialist services can be challenging;
  • There is difficulty in attracting experienced staff, due to the nature of rural locations and the associated lifestyle challenges, including the small rental market, which makes sourcing accommodation for relocation significantly challenging;
  • The blended service offered by the MPS sites can help retain staff due to the variety of work on offer. It alsoallows more registered nurses to be used in the aged care facility, as they can be used across the different types of services offered by the broader MPS.
  • MPS’s in rural and remote locations have a higher staff cost per resident. This is due to the need to have a certain number of qualified staff and a director of nursing employed, but having a smaller number of residents than in a metropolitan provider;
  • Training for staff can be difficult due to both cost and resource constraints. E-learning was embraced by a number of providers to address this limitation;
  • Fluctuating occupancy levels in some providers can have a large impact on financial performance, as staffing levels need to be maintained even if the current occupancy level is low;
  • Key cost drivers identified for rural and remote MPS providers were: the cost of travel and accommodation for specialised health services (and equally, the lack of availability of these services locally); higher staffing costs and the need to provide rural incentives; the higher cost of transport of goods and services; and the lack of availability of multiple local suppliers; and
  • In the more remote areas, it was identified by a number of MPS providers that there was a ‘market failure’ with no non-Government aged care providers in the region, leaving the State Government MPS as the only option for aged care. This led them to feel that they had no choice but to operate.

Key Themes Identified for NATSIFACP Aged Care Providers

KPMG consulted with 12 NATSIFACP providers across New South Wales, the Northern Territory, Queensland, South Australia, Tasmania, Victoria and Western Australia.

Key themes identified through these consultations were:

  • Multiple benefits were identified where NATSIFACP provider belonged to a larger organisation, including: centralisation of key staff management functions at a broader organisation level; ability to access training; broader organisation budgeting, quality and risk processes were able to be used by individual providers; and in some providers, staff were able to shift between remote locations easily (“roving staff”);
  • Higher staff numbers are often needed to accommodate Indigenous cultural sensitivities, where staff may need to be absent for long periods of time;
  • Providers experience difficulty in attracting staff, which in some cases led to providers having beds empty due to workforce capacity. Some providers offered additional incentives, such as additional leave, whereas others operated a ‘fly-in, fly-out’ staff model to keep staff motivated;
  • A large number of providers noted that job applicants often lack the required skills for the job, but due to difficulty in attracting qualified staff, providers would hire staffand up-skill/train them while they were employed;
  • Staff absenteeism was noted as an issue, leading to large wage expenses due to penalty rates being paid to staff to work additionalshifts to cover periods of absenteeism;
  • Providers noted additional costs of operating in a remote area, such as: travel costs to take clients to specialists; travel costs for training of staff; freight costs; and the additional travel costs for tradespeople from largerregional centres to conduct repairs.
  • Providers also noted additional specific costs due to the Indigenous culture of the provider and its residents, such as additional cultural competency training for staff;
  • Providers valued the model of flexible care packages as they enabled flexibility for customer focused service provision; and
  • Providers felt that an Annual Forum would be beneficial so that they can learn from other NATSIFACP providers.

1.Introduction

1.1Objective of Study

In the Aged Care Financial Authority’s (ACFA) report to Government entitled Factors Influencing the Financial Performance of Residential Aged Care Providers it was recommended that a more detailed study be undertaken of issues affecting the financial performance of rural and remote aged care providers. As a response to this,ACFA and the Department of Health (Health) organised a number of consultations with rural and remote aged care providers, through communication forums and one-on-one consultations. KPMG were engaged to assist Health in facilitating these consultations. These consultations were undertaken with the following types of providers:

  • Residential care providers;
  • Providers offering Home Care Packages of tailored services to assist individuals who wish to remain in their own home as long as possible;
  • Multi-Purpose Services (MPS) which provide integrated health and aged care services; and
  • National Aboriginal and Torres Strait Islander Flexible Aged Care Programme (NATSIFACP) providers.

In undertaking these consultations with rural and remote aged care providers across Australia, Healthand ACFA intended to gather direct feedback on key factors that influence the financial performance of rural and remote aged care providers.

This report summarises the key issues and common themes identified throughout the one-on-one consultations attended and facilitated by KPMG with 30 aged care providers across Australia.

1.2Approach

KPMG developed a number of key questions to ask each aged care provider in the one-on-one consultations. These questions broadly focused on five key areas, namely:

  • Service provider management;
  • Occupancy;
  • Clientele Demographics;
  • Workforce; and
  • Financial Performance.

Aged care providers were also invited to discussany other key issues from their perspective that impacted on their financial performance.The consultation guide is included at Appendix A.

A list of aged care providers was provided to KPMG by Health. In our consultations, we met with a variety of key personnel, ranging from Chief Executive Officers, to the Director of Nursing, to finance managers. A number of aged careproviders did not respond to consultation requests, or declined to participate.

2.Residential Care and Home Care Providers

2.1Introduction

Residential aged care providers deliver a range of care options and accommodation for older people who are unable to continue living independently in their own homes. The type of care provided ranges from personal care, to assistance with activities of daily living, through to nursing care on a 24-hour basis. Residential aged care services are delivered by a range of providers including not-for-profit, private and public sector organisations. Funding for residential aged care is provided by the Australian Government under the Aged Care Act 1997.The resident also contributes to residential care depending on their means.

The Home Care Packages Programme aims to provide a tailored, coordinated package of services that meet an individual’s specific care needs, thus assisting care recipients to stay living in their own home and providing them with choice and flexibility in the way the care and support is delivered. A Home Care Package is coordinated by an approved home care provider with funding provided by the Australian Government under the Aged Care Act 1997. This provider can be a stand-alone provider, but can also be a residential care provider. Commonwealth subsidies under the package are paid to the provider at a fixed amount by care level. The services that can be provided in a Home Care Package include, but are not limited to:

  • Support services – such as help with washing and ironing, house cleaning, gardening, basic home maintenance, home modifications related to care needs, and transport to help with shopping, doctor visits or attend social activities;
  • Personal care – such as help with showering or bathing, dressing and mobility;
  • Nursing, allied health and other clinical services;
  • Hearing services and vision services; and
  • Care coordination and case management.

2.2Key Themes

Consultations were held with the following aged care providers:

State / Aged Care Provider / Type of Care
NSW / Berrigan & District Aged Care Association, Berrigan / Residential
QLD / Lower Burdekin Home for the Aged - Home Hill Hostel, Burdekin / Residential
Sarina Aged Residential Home, Sarina / Residential
Proserpine Nursing Home, Proserpine / Residential
SA / Keith & District Hospital Inc, Tatiara / Residential
Riverview Lutheran Rest Home, Loxton / Residential
Mt View Homes, Booleroo / Residential
VIC / Edgarley Home Incorporated, Casterton / Residential
Dimboola District Hospital Nursing Home Unit, Nihill Region / Residential
Home Care
WA / Esperance Aged Care Facility, Esperance / Residential

* Note:ten providers contacted did not respond to requests for a consultation; and three providers declined to have a one-on-one consultation as they had submitted a detailed submission to Healthand / or attended a communication forum.

The key themes identified from consultations with residential and home care providers are included in the table below:

Key Theme / Summary
Change in community need has impacted on providers / Multiple providers noted that there has been a noticeable change in community need due to the increase in home care packages. This has led clientsto stay in their homes longer, but results in very high care needs when they eventuallyenter residential care.This has impacted on turnover of residents (in terms of shorter length of stay in care due to a higher number of deaths).
It was also noted that the facilities that were originally built for low care have to be altered to accommodate the greater number of clients requiring high care needs. If they are unable to do this due to lack of capital, beds remain vacant. In order to offset the loss in revenue, some providers offer beds for respite in between permanent residents to ensure beds are not empty. It was noted that providers need to be able to diversify to better use their facilities.
On the other hand, facilities that cater mostly for high care residents are almost at full occupancy.
Quality of Staff / While it was noted by providers that there is often no issue with attracting staff, it can be difficult to attract quality staff (in terms of qualifications, experience, attitude and competence). Providers tended to hire inexperienced staffdue to need, but then had to invest in significant training for all staff, from the cooks to the personal care workers and enrolled nurse positions to ensure they are satisfactorily skilled.
Additionally, in more remote regions, providers often experience limited access to Registered Nurses. A number of providers noted that they are reluctant to use agency nurses and staff as there is a perception that the care is not personalised due to lack of rapport with the residents. It is also very costly for the provider to employ agency staff.
Retention of Staff / Some areas had issues retaining staff, whereas others did not.
For providers that had a low turnover of staff, they noted that as part of their recruitment process, they targeted (where possible) staffthat wanted to stay in the town. It was noted by providers with a higher turnover of staff that declining economic conditions of other industries within the region, for example mining, had a large impact on their staff turnover as families were forced to leave to find work in other areas.
Some providers noted that staff turnover being low is a concern as they have a rapidly ageing workforce servicing a high needs client base. One provider identified that from 2017/18, the ageing workforce (65 years old plus) issue is likely to become critical for service delivery.
One provider used a “bonded” system to retain staff, and noted that it worked very well. This involved the provider paying for workers to undertake an enrolled nurse course and, in exchange, that person had to work at the provider for an additional two years.
Costly to access training off-site and difficult to get staff buy-in / Providers noted that training for staff is seen as important by management, but they sometimes have difficulty in attracting staff to undertake the training. Some providers encouraged training as an incentive mechanism, and one provider specifically looked at training undertaken during the year as a performance measure in staff annual performance reviews. It was also noted that training can be quite time-consuming to undertake, and due to lower staffing numbers, staff do not have sufficient time to undertake the training.