VCOSS Submission to the Royal Commission into Aged Care Quality and Safety

A strong aged care system is important to Australia’s future. Over 1.3 million people used some form of aged care services in 2017-18. By 2057, it is projected there will be 8.8 million older people in Australia (22 per cent of the population). The characteristics of these future 65+ generations will be different to those of earlier generations, including values, attitudes, expectations, geography and ethnicity.

Much of the conversation and early focus of the Royal Commission has been on residential care. But focusing solely on residential aged care facilities is misplaced.[1] While we recognise the vital importance of a safe, high-quality, person-centred residential care system, only 5 per cent of older people live in residential care homes.

Australia needs to shift the conversation from aged care facilities, to talking about quality of life in all settings. Residential aged care service provision should be considered just one pillar of a comprehensive national approach to ageing.

This Royal Commission is an opportunity to develop a vision for the needs of Australia’s ageing population. Australia need a long term strategy plan for how housing, health and community-based aged care services will meet the changing needs of our ageing population.

Service infrastructure must be put in place now to ensure that services for older people are delivered in accordance with people’s needs, at the right time, and in the right place.

This submission draws on VCOSS members’ first-hand experiences assisting and supporting older people, their families and carers.

VCOSS advocates for a safe and high-quality aged care system that:

• Puts older people at the centre of the system – the system should be guided by the needs of older Australians, and their experiences of aged care should be central to our understanding of system success.
• Focuses on healthy ageing and addressing the challenges that can reduce people’s wellbeing (including poverty and homelessness)
• Offers a continuum of care and support, including access to community-based supports that enable people to age in place (if that is their preference)
• Empowers consumers and maximises their agency (autonomy, choice and control)
• Provides timely and equitable access to care and support
• Is simple to navigate for consumers, carers and advocates
• Can flex in response to changing needs – both at a population level and an individual level (i.e. an older person’s changing needs over the life course
• Has a strong regulatory framework and safeguards against abuse and neglect.

 

Recommendations

Take a comprehensive national approach to ageing

• Focus on quality of life in all settings
• Design an overarching national ageing strategy
• Expand Australia’s Long Term National Health Plan and National Preventive Health Strategy to address the risk and protective factors for healthy ageing
• Include an expert on ageing in the National Preventive Health Strategy Expert Steering Committee
• Take a lifecourse approach to ageing, removing arbitrary age restrictions on service delivery

Address poverty among older people

• Establish an independent mechanism to set the rates of social security payments
• Expand provision of accessible and free dental care

Expand affordable housing options

• Develop a National Housing Strategy that includes the delivery of 500,000 new social and affordable houses
• Expand the Assistance with Care and Housing (ACH) Program for older people at risk of homelessness
• Increase Commonwealth Rent Assistance

Give people choice and access to services

• Increase the number of home care packages available
• Support people to age in place
• Retain a mixed model of funding for aged care, that continues to provide block funding to certain types of services, as well as individualized funding packages
• Provide market stewardship to intervene in thin markets
• Fund advocates and system navigators so people can access services that meet their needs
• Upskill the mental health competencies of My Aged Care staff
• Ensure screening processes are person-focused and meet the needs of diverse communities
• Investigate the barriers to MBS and specialist health services for people living in residential aged care
• Change the national construction code to allow people to age ‘in place’
• Get young people trapped in aged care facilities into housing in the community
• Support aged care organisations to engage in emergency planning and preparedness

Support people caring for older Australians

• Provide more support for carers, including access to short- and long-term respite support

Deliver safe, high quality, person-centred residential aged care

• Strengthen the regulatory framework to keep people safe
• Require facilities to roster appropriately skilled staff at all times
• Eliminate restrictive practices in aged care facilities
• Implement an official visitor scheme
• Support wellness and ‘reablement’ of people in aged care
• Streamline the interface between aged care and hospitals
• Deliver a proper complaints system for people in aged care
• Incentivise aged care facilities to engage with broader communities
• Investigate models of best practice, evidence-based consumer directed care in aged care facilities.

Build a quality, skilled aged care workforce

• Pay the aged care workforce appropriately
• Grow the workforce sustainably, in partnership with broader community services industry workforce development
• Consider a mandatory registration scheme for personal care workers
• Invest in skilling the aged care workforce

 

Take a comprehensive approach to healthy ageing

Recommendations

• Focus on quality of life in all settings
• Design an overarching national ageing strategy
• Expand Australia’s Long Term National Health Plan and National Preventive Health Strategy to address the risk and protective factors for healthy ageing
• Include an expert on ageing in the National Preventive Health Strategy Expert Steering Committee
• Take a lifecourse approach to ageing, removing arbitrary age restrictions on service delivery

This Royal Commission presents an opportunity to consider aged care services as part of the bigger picture. It must consider what ‘good ageing’ looks like, amid changing demographics and supporting people outside of aged care facilities.

This requires a reframing of Australia’s policy settings, so that ageing is viewed as a life-long process, rather than an end point.

Design a national ageing strategy

Australia does not have an overarching Commonwealth ageing strategy.[2] A comprehensive national approach could set the direction for key areas that contribute to positive ageing, such as housing, location, health, employment, digital literacy, loneliness, health and aged care infrastructure and ageism.

An overarching strategy allows us to consider how all parts of society contribute to people ‘ageing well’. Only 5 per cent of older people are in ‘cared’ homes, meaning that a focus solely on aged care services is misplaced.[3] There should be a shift in conversation from care in aged care facilities, to talking about quality of life in all settings. Aged care service provision should be considered one pillar of a comprehensive national approach to ageing.

Older people do not exist in siloes. They use a multitude of services that are funded by all levels of government. Local government, for example, provides much-valued services for older people. This includes libraries, community hubs and swimming pools.

Policy makers must consider the demographics of Australia’s changing ageing population. For example between 2017 and 2047, it is projected that the number of people aged 65-74 will have decreased from 57 per cent to 45 per cent, whilst the number of people aged 75-84 will increase from 30 per cent to 35 per cent. Those aged 85 and over will increase from 13 per cent to 20 per cent.[4] Within the cohort of over 65s, there are significant generational differences between the younger and older age groups.

The characteristics of these future 65+ generations will be different to those of earlier generations, such as values, attitudes, expectations, geography and ethnicity.

A long term strategy would ensure that Australia has a vision for how housing, health and aged care services and productivity will need to change in accordance with these demographic changes. Service infrastructure can be put in place to ensure that services for older people are delivered in accordance with people’s needs, at the right time, and in the right place.

A National Ageing Strategy could use an intersectional approach to ageing, examining the relationship between ageing and gender, sexuality, cultural background, disability, the lifecourse, geographic location and socio-economic status. All of these factors influence a person’s wellbeing, how they age and what services they need. A comprehensive strategy would build on existing work, such as:

• The National Lesbian, Gay, Bisexual, Transgender and Intersex Ageing and Aged Care Strategy
• National Ageing and Aged Care Strategy for People from Culturally and Linguistically Diverse Background

Address physical and mental health

Good physical and mental health is key to an older person remaining independent.

A robust examination of the wellbeing of older people must consider the factors that affect their health. Health is crucial to how we experience older age. It is affected by how and where we live, work, play and age.

Governments have an important role to play in giving people a fair chance at having good health. They can put safety nets in place to ensure that people have enough to eat. Through good strategic planning they can ensure that people have good access to fresh food, regardless of where they live. They can ensure that services are easily accessible for people in rural areas. Ensuring good health is about more than funding medical services and medication. It is about putting the right policies and funding in place to ensure that everyone has a good chance at living a healthy life.

The Australian Government is in the process of developing two significant health planning documents: Australia’s Long Term National Health Plan and National Preventive Health Strategy. These centrepiece documents must consider ageing and the factors that contribute to people ageing well. To do this, ageing could be viewed through an intersectional lens, considering how individual and environmental factors affect ageing and health.

An ageing expert would be a valuable addition to the membership the National Preventive Health Strategy Expert Steering Committee and would align with a reformed approach to planning for aged care services.

Remove system siloes and age limitations

Age is not a good indicator of the health of a person. Some older people may have aged with no significant change to their physical ability. Similarly, some people age prematurely.

Systems must have the capacity to respond to people’s needs, regardless of their birth date. It is important that policy settings support people to live at whatever level is required. [5]

The current system for responding to the needs of older people is not working. The response to their health and wellbeing needs is characterised by siloed care according to an arbitrary, chronological age. At present, people receive care through siloed systems based on age, disability and illness.

This siloed service system does not work for older people who have a combination of complex conditions, such as mental illness and housing insecurity.

More people can get the right care, when they need it, if arbitrary age limits that determine eligibility are removed.

A lifespan approach would work particularly well for people who age prematurely. People could benefit from receiving low-cost support services early, before problems escalate to the point where crisis responses are the only option.

Crisis responses, such as emergency respite, ambulances, medication and hospitalisation, are costly. When services intervene early, a person can stay well.

Older people with disabilities can also suffer from the disadvantages of siloed systems. If they have developed a disability after the age of 65 (the cut-off for the NDIS), they are ineligible for the extensive range of supports that the NDIS supplies, but they may also not be covered by aged care packages (eg. assistive technologies).

 

Address poverty among older people

Recommendations

• Establish an independent mechanism to set the rates of social security payments
• Expand provision of accessible and free dental care

Rising housing, food, energy and fuel costs impact older people, as do out-of-pocket costs for healthcare and services. About one in 8 older Australians live in poverty, a rate slightly lower than for the general population, at 12 per cent.[6]

However, the critical factor that determines whether older people are poor is their housing status: 43 per cent of tenants aged 65 years and over are in poverty, compared with 12 per cent of all older people.[7]

Clearly, the older people most at risk of poverty are those renting their homes.

Older women are at particular risk of poverty. This has been linked to a number of factors including that older women did not benefit from compulsory superannuation at the beginning of their working lives, they were more likely to have been paid at a lower rate than their male counterparts and were likely to have taken time out of the paid workforce to have children and fulfil caring roles. Given their age, they usually do not have capacity to earn additional income and have less superannuation, savings to draw on or assets.

Poverty impacts people’s health and wellbeing. It can force people into environments that make them sick, like poor quality housing, and make them choose between paying for a medical appointment and turning on the heating in winter. It can also cause or exacerbate loneliness, by making it more difficult for people to meet with friends or participate in activities they enjoy.

Reducing poverty among older Australians can keep people healthier for longer, potentially reducing the need for some types of aged care and support.

Social security policies have an impact on poverty, for better or for worse. The poverty rate for older Australians has shifted significantly in the last 20 years. For example, before-housing poverty rates for older single women rose from 49 per cent in 2005 to 58 per cent in 2007, then fell to 39 per cent in 2009. This is primarily due to changes in social security, including the $32 per week increase to the single aged pension rate in 2009.

The volatility of the poverty rate for single older people is due in part to the close proximity between the single pension rate and the 50 per cent of median income poverty line before housing costs are taken into account. This means that short-term changes in pension rates relative to median incomes can shift large numbers of pension recipients from one side of the poverty line to the other.

Establishing a mechanism to independently set the aged pension would help make sure older people’s income keeps pace with the cost of living. The setting of social security payment rates has largely been a political process. An independent body to advise the parliament on the setting of payment rates and payment settings would enable a fairer approach to social security design.

For many people on the age pension experiencing poverty, private health insurance is one of the ‘essentials’ that must be dropped because they cannot afford the cost of living. As a result, dental care is a major area of avoidance.

 

 

Expand affordable housing options

Recommendations:

• Develop a National Housing Strategy that includes the delivery of 500,000 new social and affordable houses
• Expand the Assistance with Care and Housing (ACH) Program for older people at risk of homelessness
• Increase Commonwealth Rent Assistance

Older Australians experience homelessness. Seventeen per cent of homeless Australians are aged over 55 – that’s almost 18,000 people.[8] People in this age group are also over represented among those living in temporary and insecure housing and at risk of homelessness.

But older people’s homelessness is often hidden. They may be less likely to sleep rough, but more likely to be in rooming houses, caravan parks, staying temporarily with friends and family with no security of tenure.

Many older people experiencing homelessness are capable of living independently if a safe and secure house, with appropriate supports in place, is available to them. Residential aged care is not a suitable or necessary option for this group.

However, upward pressure on rent prices and a chronic shortage of affordable houses means more people are at risk of homelessness. 82,000 Victorians are waiting for public and community housing. The Everybody’s Home Campaign estimates 500,000 new social and affordable homes are required to meet the needs of Australians at risk of homelessness.[9] The Federal Government can develop a coherent National Housing Strategy that includes new capital investment to generate 300,000 new social and Aboriginal housing properties and a new tax incentive or direct subsidy to leverage super fund and other private sector investment in 200,000 low cost rental properties for low and middle-income earners

Older single women have emerged as the fastest growing cohort of people experiencing housing stress and homelessness. The estimate of older women experiencing homelessness on the night of the 2016 census was 6,866. This was a 31 per cent increase from the 2011 figures.[10]

The number of older women renting has also increased significantly, nearly doubling in the decade to 2016. However there are very few affordable rental properties for older people on low-incomes. Less than one percent of rental properties across the country are suitable and affordable for a single person on the age pension.[11] Rent assistance has simply not kept up with the costs of rent in Victoria and across the country. The Government can help more people maintain their tenancies and avoid homelessness and financial hardship by increasing the maximum rates of rent assistance by 30 per cent and indexing payment to median rent movements

There are very few homelessness services specifically funded to help older people. The one program that is specifically funded to help this group, the Assistance with Care and Housing (ACH) Program funded by the Commonwealth Department of Health is poorly resourced and has a low profile.

Aged care services are also in an excellent position to assist high risk older people but assessments do not identify housing problems and they are generally not well connected to housing services.

Make sure infrastructure supports ‘ageing in place’

Recommendation

• Change the national construction code to mandate minimum accessibility requirements

Minimum accessibility standards must be regulated to deliver appropriate homes for Australia’s ageing population. The National Construction Code (NCC) should be changed to mandate minimum accessibility requirements for homes at the time of construction. Failing to change the NCC now will affect millions of Australians for many years. In-home care delivers lower aged care and healthcare costs and reduces the costs of moving to other accommodation. People remain included within their community and connected to family and friends.

People’s homes have always been places for the provision and care of children, and will increasingly become places for the provision of care for adults.[12] By 2050, over 3.5 million Australians will access aged care each year, with around eighty per cent of services delivered in the community, including in people’s homes.[13]

VCOSS believes minimum accessibility for newly built homes must become the ‘new normal.’ New homes are being built that a growing proportion of people can’t access. Like new cars having seatbelts, or swimming pools having fencing, regulation sets a basic minimum for the benefit of the whole community.

Making more homes universally accessible will allow people to stay in their homes for longer as they age. It will make homes easier to modify and cater for the changing mobility needs acquired by people later in life.

 

Give people choice and access to services

Recommendations

• Increase the number of home care packages available
• Support people to age in place
• Retain a mixed model of funding that continues to provide block funding to certain types of services, as well as individualised funding packages
• Provide market stewardship, to intervene in thin markets
• Fund advocates and system navigators so people can access services that meet their needs
• Upskill the mental health competencies of My Aged Care staff
• Ensure screening processes are person-focussed and meet the needs of diverse communities
• Investigate the barriers to MBS and specialist health services for people living in residential aged care
• Get young people trapped in aged care facilities into a home in the community
• Support aged care organisations to engage in emergency planning and preparedness

Provide market stewardship

High quality aged care cannot be delivered without adequate funding to meet the demands and needs of Australia’s ageing population. Government must increase the quantum of funding dedicated to delivering aged care services in Australia. Along with increasing the quantum of funding available, the aged care funding model should also be flexible enough to let people choose the care that they want, and support service delivery organisations to have stability and consistency in the care they deliver.

The current aged care funding model is not fit-for-purpose in allowing older people in Australia to access the type and quality of care they want and need.  The funding model must be revised to meet actual demand, and the level of funding should be based on principles of equity, supporting consumer choice and maximising wellness.

Many older Australians report a desire to age in place, remaining part of their community and connected to family and friends.[14] Government should ensure that people are able to access services and supports that allow them to age in their own homes if they choose to, consistent with broader policy goals that successive Australian governments have had around consumer choice and control in human services markets.

VCOSS notes with concern that in the most recent Productivity Commission Report on Government Services, almost a third of older people living at home and in need of assistance reported that their need was not fully met. Unmet need was especially pronounced for people with a profound or severe disability, with almost 40 per cent reporting that their need was not fully met.[15]

Increasing the system’s capacity to provide in-home support will also deliver significant community benefit in terms of lower aged care and healthcare costs.

While there are many benefits to individualised funding, including improved choice for people who are able to choose, market mechanisms struggle to deliver the same improvements for people who are highly vulnerable.

The Parliamentary Committee report on the Inquiry into Quality of Care in Residential Aged Care Facilities in Australia found that there has been a loss of competition in the market due to a high level of demand for services. It found that consumers are not able to exercise full choice of aged care facility due to the urgent need to enter residential aged care, geographic or economic constraints, and complexity of care required.[16]

Thin markets in the aged care sector – where available services do not meet the needs of participants – are also of significant concern to VCOSS. VCOSS supports older people having access to services, and choice over which services they engage, but thin markets mean this is not realised for many people. People should have access to the services they need and choose regardless of where they live or the complexity of their needs, and providers should be able to deliver high quality services without operating at a loss.

VCOSS members voiced concerns about a lack of choice in providers, if smaller providers are pushed out of the market or choose to exit aged care for sustainability reasons (for example, in rural areas). There is an invariable need to deliver some block funded services to provide for a sustainable aged care sector and to support the specific needs of population groups, including rural and regional communities, Aboriginal and Torres Strait Islander people and people with culturally and linguistically diverse backgrounds.

Market stewardship involves “oversight actions of government that fully support the functioning of public service markets,” in contrast to market regulation, which involves a “‘light’ touch approach”.[17] Government should take a proactive role and put in place strategies and intervention mechanisms to address the significant risk of market failure in some areas and for some groups.

VCOSS recommends retaining a mixed model of funding that continues to provide block funding to certain types of services that support vulnerable people to engage in the system and access appropriate supports but also allows person-centred control of funding allocations.

VCOSS and its members strongly reinforce the need for greater intervention in, and stewardship of, aged care markets where people may not be able to access appropriate services such as regional and remote locations, and for specific groups such as Indigenous people and people from culturally and linguistically diverse backgrounds.

Increase services to meet demand

People enter the aged care system at different times, for some people it may mean recognition that they need a little more help around their home, for others it may be less of a transitional process, and there may be an immediate need to enter a residential aged care facility.

Older people are stuck waiting too long to access in-home care services and to find suitable placements in residential aged care. The average delay between approvals for high needs in-home support package and receiving help is almost two years.[18] In 2017-18, over 16,000 people died while waiting for aged-care support in their own home and others have been forced into residential aged care.[19] Evidence presented at the Royal Commission hearings suggest that people must wait until other people die before they can access the level of care that they have been assessed as requiring.

It is taking longer for people to move into residential aged care after getting approval for a package. In 2017-18, 44.7 per cent of older people entered residential aged care within 3 months of their package approval. The median elapsed time between approval and moving into care was 121 days, an increase from 105 days in 2016-17 and 84 days in 2015-16.[20]

Changes must be made to enable older people to access the care that they need, and are entitled to receive. Investment in more infrastructure and a stronger workforce will give older people with high care needs timely access to the services they need to maintain independence and live dignified, safe lives. Giving people the support that they need to stay in their own homes as quickly as possible will reduce the need for people to transition into residential aged care.

Make the system easier to navigate

Getting access to and help in the aged care system is often complex, difficult and time-consuming. It is required when people are also dealing with significant changes in the lives, like the death of a spouse, an accident or a period of declining health.

VCOSS members identified a need for older people to be able to talk about supports and care services that are available and to understand how they can access them before it’s too late. Members suggested that there is a reliance on GPs to have conversations with older people about their ongoing health and care needs but that there is a lack of information after a GP referral. Post-diagnosis support would assist people to enter and navigate access to aged care support.

Part of the issue is the funneling of older people to a single point: the MyAgedCare.gov.au website. Older people experience the “digital divide” more than any other social group. People aged 65 and over are among the least digitally included groups in Australia, particularly if they are women, on lower incomes or not living in a major city.[21] People experiencing a cognitive decline or early symptoms of dementia may also struggle to use an interface like the MyAgedCare.gov.au website.

While many consumers benefit from the choice and control that individual packages can provide, vulnerable older people are most likely to find the process difficult or be disadvantaged. Some of the risks identified by the community sector for vulnerable consumers, include:

• Providers may avoid vulnerable consumers, or people with highly complex needs, because they will be more costly or difficult to support.
• Consumers are required to make informed choices about their care; this assumes a level of literacy and financial literacy that not all older people have. It can also be difficult for people with cognitive disabilities or mental illness, or people with limited family or other natural support.
• People who need intensive case management are struggling to stretch their package to meet their full support needs. This is often people with no carer, and who do not have capacity to self-manage their plan and care.
• Packages can be depleted prior to the end of the funding period, leaving people unable to afford services that help them maintain their safety, independence and quality of life.

Additional funding is needed for existing advocacy services, and to ensure people are able to access and make informed choices about aged care support that they may be entitled to. People from different backgrounds, including Aboriginal and Torres Strait Islander older people, people from culturally and linguistically diverse backgrounds, and people with diverse gender and sexual identities may also need additional support navigating and accessing the aged care system.

People are often unaware of the aged care support options that they may be able to access. Advocates and system navigators have an important role to play in educating people about staying at home and what they need to do so they can get the support they need.

There is a reliance on family to navigate the system, for people who may not have family or friends who they can rely on to assist, there is a role for support coordinators and advocates to play in helping people navigate a complex bureaucratic system. VCOSS member organisations also report that families often feel guilty about placing an elderly member of their family in a home. Advocates and system navigators may help assuage some of these feelings by providing better information about the options available and enabling older people and their families to make an informed choice about care options.

As demand for aged care services grows, more advocates and system navigators are needed to help people understand and access the aged care system.

Streamline the interface between aged care and health services

Just like the rest of the population, older people have a range of health, care and personal needs.  Yet the response to their health and wellbeing needs is characterised by siloed care. Once they tick over to 65, they are no longer eligible for the NDIS, and are excluded from adult mental health services. On the flip side, vulnerable groups who prematurely age (such as people experiencing homelessness and poverty) are not eligible for aged care services.

People who receive care often require a range of different types of health and care services including primary, acute and dental care. Different types of care are provided by a range of different professional and non-professional workers. VCOSS members report that there is a lack of service coordination  between the care and health services that older people are provided because different parts of the aged care system are not “talking to one another”. The most commonly reported problem was the lack of coordination between residential aged care providers and primary and acute care settings, such as hospitals, GPs and allied health professionals.

People in aged care facilities who require long-term care are not necessarily sick and most of the time they don’t need intensive medical treatment. However, they tend to see a doctor more regularly and are high level acute care service users. The frequency of older people’s interaction with the acute care system means that coordination and communication between aged care providers and acute care services is vital to ensuring that ongoing care is delivered that is informed by the health of individuals.

Accurate medical information must be shared between health providers and aged care providers in a timely and reliable way when people transfer between locations of care. One study found alarming failures in the provision of critical clinical information—clinically important documentation was frequently absent, including the reason for transfer to the emergency department (in 48.2 per cent of transfers), baseline cognitive function (in 59.7 per cent of transfers), and vital signs at the time of complaint (in 69.9 per cent of transfers).[22]

Failure to provide clinical information with residents transferring to and from hospital may have adverse impacts on the health outcomes of older people. It may result in service duplication, the provision of medical services that are not required or incorrect care being provided. Standards for the transfer of information with the patient should be adopted for the transfer of aged care residents when they enter or exit other health service locations from and to residential aged care.

Older people in aged care deserve appropriate care to be provided at all times. The onus of responsibility should not fall on people who are receiving care. The interface between aged care and primary and acute health services must be improved to ensure consistent high quality care is delivered to people in residential aged care.

Get people mental health care when they need it

Mental illness is the single largest contributor to years lived in ill health and is the third largest contributor (after cancer and cardiovascular conditions) to a reduction in the total years of healthy life for Australians so it is of critical importance to aged care

Between ten and 15 per cent of older Australians have symptoms of depression. The rate of depression increases to 45 per cent for those entering residential aged care facilities and more than 50 per cent for those residing therein.

Dementia is also having an increasing impact on the mental health of older Australians. Though strictly a neurological condition, the majority of people living with dementia will experience distressing associated behavioural / psychological symptoms. This may drive or exacerbate mental health symptoms and illnesses.

Older people access mental health services at much lower rates than the general population and many only do so in a crisis. Barriers to accessing quality services relate to geography, government policy, and the inability of the various parts of the system to work together to provide integrated care.

More than 30 per cent of people aged over 70 receive subsidised medications but less than 5 per cent access subsidised mental health-related services.

While access to mental health services is low for older Australians, medication rates are high. Medication is often an appropriate response to mental health issues such as dementia but there is concern that prescriptions occur at such high rates and are not routinely provided with other treatments, like counselling or cognitive behavioural therapy.

Like their counterparts living in the community, aged care residents should have unrestricted access to the MBS and more specialist service visits to provide the appropriate diagnosis, treatment and ongoing care.

For older people living in the community, screening, assessment and referral takes place through the My Aged Care system. However, VCOSS members report people experience numerous problems with this system, including

• inconsistencies in the quality of assessment processes including in relation to mental health competencies of assessment teams
• ageist attitudes that mean symptoms of mental distress in older people are wrongly dismissed as natural outcomes of the ageing process
• inefficiencies and duplications in screening and assessment processes
• ineffective needs assessments across diverse population groups due to inflexible use of standardised assessment tools .

Get young people trapped in aged care facilities into a home in the community

There are over 5,900 people aged under 65 years of age living in residential aged care facilities across Australia because they have no alternative housing option available to them. Residential aged care facilities are not designed with the needs of younger people in mind.

Young people experience extreme social isolation and under half don’t receive a visit from family or friends in any given year. A third of young people almost never participate in community activities within the aged care facility.  Young people may have different expectations in relation to social or leisure activities than older people in residential aged care. The activities and social opportunities may not be appropriate for young people with complex needs who are stuck in residential aged care.

Young people with disability should have the opportunity to choose where they live and to create a home that meets their needs. They should be able to actively participate in their community, and to develop and enjoy relationships with family and friends.

VCOSS supports the action plan announced by the Morrison Government on 22 March 2019 that included the following goals:

• support those already living in aged care aged under 45 to find alternative, age-appropriate housing and supports by 2022, if this is their goal
• support those already living in aged care aged under 65 to find alternative, age appropriate housing and supports by 2025, if this is their goal; and
• halve the number of younger people aged under 65 years of age entering aged care by 2025.

Ensure older people are protected against climate change, emergencies and disasters

Extreme weather, emergencies and disasters occur frequently in Australia and will become more unpredictable and severe due to climate change.

Extreme heat causes more deaths in Australia each year than all other natural disasters combined, and has a greater negative impact on population health than any other natural hazard. In 2009, 374 Victorians died as a result of the heatwave that impacted south-eastern Australia. The greatest number of those who died were people aged 75 years or older.[23]

Older people have a reduced ability to physiologically deal with heat and are at increased risk of heat related illness, especially if they live alone, have medical conditions or take certain medicines. Moreover, older people may have a pre-existing medical condition that may be exacerbated by heat or take certain medications that may be less effective or more toxic in the heat. Despite this, aged care providers objected to proposed regulations that could have made air conditioning mandatory in nursing homes.[24]

Older people bring with them a lifetime of experience, skills and practical knowledge, and these attributes can make them resilient to emergencies and disasters. However older people are also at disproportionate risk of being affected these events. It is not age alone that makes older people vulnerable – it is the factors associated with advancing age such as impaired physical mobility, diminished sensory awareness, pre-existing health conditions, as well as social and economic constraints, that contribute to their vulnerability.^[25]

Many older people in Australia receive care in their own homes. Emergencies and disasters can present a challenge in ensuring continuity of this care. Ageing in remote or disaster prone areas poses significant emergency management issues, particularly in the face of policies that encourage older people to remain in their own homes.[26]

Older people residing in high density areas, such as social housing or retirement villages, can be cut off from help. If there is no strong sense of community, homebound older people may be invisible to neighbours, rendering them extremely vulnerable in a disaster. A building with no elevator – or an elevator that breaks down in a disaster – may further isolate older adults. If connections to family or friends are fragmented, older adults can be further left to fend for themselves. The risks to older people were highlighted during the September 2019 Sunshine Coast bushfires when firefighters were forced to form a shield around an aged care facility while residents were trapped inside.

Legislation and standards regarding the health and safety of older people as it relates to climate change, emergencies and disasters is not consistent across Australia. NSW, for example, requires retirement villages to have an emergency plan in place,^[27] while Victoria does not.

Emergency planning and preparedness must be a key priority for all organisations that play a role in caring for older Australians, whether they live in their own homes, retirement villages, aged care facilities or any other setting.

 

Support people caring for older Australians

Recommendation

• Provide more support for carers, including access to short- and long-term respite support

Caregiving is highly demanding and stressful. Respite care provides breaks for caregivers that can relieve their stress, renew their energy and restore a sense of balance to their lives. It is vital for carers to be able to have some time to themselves to relax and focus on themselves without managing care concerns. The physical, emotional and economic burdens on caregivers today can become overwhelming without some form of respite. Carer burnout may result in poorer care outcomes being delivered in the long-term.

Unpaid carers include parents or siblings who care for people with disability, and people supporting their ageing parents. In 2015, more than one in eight Australians (2.86 million people) provided some informal care and 825,000 informal carers were primary carers, providing the majority of the recipient’s care.[28] Some 91.5 per cent of primary carers were providing assistance to a partner, child or parent and 31 per cent of carers report living with a disability themselves.[29]

The majority of carers of older people are women of working age and more than half of all primary carers are in the workforce.[30] Recent estimates indicate almost two billion hours of care were provided in 2015 nationally, and that it would cost more than $60 billion per year to replace this with paid services and supports.^[31]

VCOSS members raise concerns at inadequate support for carers. In particular, our members report significant shortfalls in the availability of respite care. All carers must have access to appropriate levels of carer specific support and services to address and identify their own needs. This includes access to general carer support, carer advocacy, counselling, and carer respite services.

Providers report that many vulnerable older people are not accessing respite services because they cannot afford to. People must pay a daily fee for residential respite care, up to a maximum of 85 per cent of the single aged care pension. Their home care package is also reduced if the respite stay exceeds 28 days. This rate leaves someone with no income other than the pension with very little to pay their rent and bills. They risk coming back home from respite to rental arrears or disconnected utilities. Vulnerable consumers could be excluded from the reduction in their home care package while they are in respite.

Greater access to respite services is needed to improve the health and quality of life for carers and the people that they care for.

Improved recognition and inclusion of carers by residential aged care facilities would also promote improved safety and quality of care for consumers. Consideration should be given to establishing a charter of rights for carers, relatives and friends to more clearly define the responsibilities of residential aged care facilities in relation to the involvement of carers.

 

Deliver safe, high quality, person-centred residential aged care

Recommendations

• Strengthen the regulatory framework to keep people safe
• Require facilities to roster appropriately skilled staff at all times
• Eliminate restrictive practices in aged care facilities
• Eliminate elder abuse in aged care services
• Implement an official visitor scheme
• Investigate models of best practice, evidence-based consumer directed care in aged care facilities.
• Support wellness and ‘reablement’ of people in aged care
• Deliver a proper complaints system for people in aged care
• Incentivise aged care facilities to engage with broader communities

Strengthen the regulatory framework to keep people safe

A strong regulatory framework should promote high quality, person-centred services and monitor outcomes for residents. It should not focus solely on compliance or ‘tick-box’-type approaches.

The existing regulatory framework is not working as well as it could. For example, in 2017, the South Australian Government conducted a review into the Oakden Older Persons Mental Health Service, a Commonwealth regulated residential aged care facility. The review found serious and long-standing failings in the quality of care delivered and the service was closed.[32] However, the facility had met all expected outcomes of the aged care quality standards as recently as 2016.

Some VCOSS members suggested the focus of regulatory frameworks is complying with policies and meeting clinical targets (such as number of falls or infection control) instead of the quality of care of residents. Accreditation reports reflect the existence of policies and maintenance of processes, not actual outcomes.

VCOSS members warn against repeating mistakes of other sectors. For example, a Victorian review of the Vocational Education and Training sector identified a key issue was quality assurance audits focused too heavily on compliance with contractual requirements and paper-based performance measures such as financial sustainability and record-keeping, and not enough on the quality of services provided.[33]

There is no comprehensive data available on the prevalence of abuse of people receiving aged care. However, the Royal Commission has already heard from a large number of people who have experienced elder abuse or a lack of care in residential aged care facilities and there are clear systemic safeguarding issues with the current delivery of care in residential settings. The introduction of new Aged Care Quality Standards on 1 July 2019 is likely to improve the standard of care delivered in residential aged care facilities but it may not go far enough.

A reportable incidents scheme that covers in-home and residential care environments should be implement. It should require approved providers to proactively notify the Aged Care Quality and Safety Commission of incidents. The Commission must oversee and publicly report on the approved provider’s response to incidents.

Broaden the scope of incidents that must be reported, investigated and responded to. VCOSS supports the proposal from the Australian Law Reform Commission 2017 review into elder abuse that the term ‘reportable assault’ in the Aged Care Act 1997 (Cth) should be replaced with ‘reportable incident’.[34]

Legislative exemptions regarding the reporting of alleged or suspected incidents committed by a care recipient with a pre-diagnosed cognitive impairment on another care recipient i.e. s 53 of the Accountability Principles 2014 (Cth) should also be removed.

Require facilities to roster appropriately skilled staff at all times

The Australian Nursing and Midwifery Federation reports that about 80 per cent of residential care workers surveyed considered staffing levels were insufficient to provide an adequate level of care to residents.[35]

Legislation requires providers to “maintain an adequate number of appropriately skilled staff to ensure that the care needs of recipients are met.”[36] Unlike in other settings, including schools and hospitals, there is no further requirement for providers to meet any worker to resident ratios.

The number of registered and enrolled nurses who provide care in nursing homes has decreased since 2003[37], despite the aged care system experiencing a significant increase in demand from an ageing population. The number of allied health workers has also decreased.[38]

VCOSS members feel that the staffing levels in residential aged care facilities must be aligned to the needs of the people who are living in the facility. There should be an alignment between the number and the skills mix of staff with the support needs required by people under their care.

In 2015, the Victorian Government introduced nurse-to-patient ratios in public high-care residential facilities and wards (operated by hospitals and excluding private and not-for-profit facilities), requiring:

• one nurse to every 7 residents in the morning shift
• one nurse to every 8 residents in the afternoon shift
• one nurse to every 15 residents on the night shift.[39]

Round-the-clock registered nurse coverage is essential for appropriate nursing care to be delivered and monitored for residents in aged care facilities. An on-call nurse function is not good enough. People in aged care facilities have a right to expect that they will be provided with appropriate care at any point in the day or night, including access to medication and expertise that only a registered nurse can provide.

Early childhood education and care services (ECEC) provide another example of staff ratios in practice. To support high quality care for children, the National Quality Framework sets out minimum ratios for educators to children in ECEC services.

The Commonwealth Government should follow the example set by Victoria, and introduce nurse to resident ratios to improve the quality of care provided to older people. Registered nurse coverage must be available on-site at all times.

Eliminate restrictive practices in aged care facilities

A restrictive intervention includes any intervention used to restrict the rights and freedom of movement of a person and can include the use of chemical, physical or mechanical restraint or seclusion. Restrictive practices impinge on people’s human rights, and if used inappropriately are a form of abuse.

VCOSS believes that restrictive practices should only ever be used as an absolute last resort, when a person’s safety is at immediate and serious risk, and when all other strategies have been considered. Appropriate facility design, adequate and skilled staffing and flexible and responsive practices can eliminate the need for restrictive practices by addressing the reasons for problematic behaviour.

Current laws and regulation of restrictive practices are ill-suited and incomplete (for example, relevant laws include the Victorian Charter of Human Rights and Responsibilities, the Aged Care Act, the tort of false imprisonment and the writ of habeas corpus) and fail to provide a comprehensive framework for the use and oversight of restrictive practices.

VCOSS supports the Australian Law Reform Commission’s recommendation that:

Aged care legislation should regulate the use of restrictive practices in residential aged care. Restrictive practices should be the least restrictive and used only:

• As a last resort after alternative strategies have been considered
• To the extent necessary and proportionate to the risk of harm
• With the approval of a person authorised by statue to make the decision
• As prescribed by a person’ behaviour support plan
• When subject to regular review.[40]

In Victoria, a Senior Practitioner has a legislative role in monitoring and evaluating the use of restrictive interventions in disability support and care services. The role of the Senior Practitioner is to:[41]

• Evaluate and monitor the use of restrictive interventions in disability services
• Develop guidelines and standards
• Provide education and information to disability service providers
• Develop links to professionals and academic institutions to facilitate knowledge and training in clinical practice
• Research restrictive interventions and compulsory treatment.

The Senior Practitioner can:

• Visit, talk to and inspect any disability service.
• See any person who is subject to any restrictive intervention or compulsory treatment.
• Investigate, audit and monitor the use of any restrictive interventions or compulsory treatment.
• Direct a disability service provider to discontinue a restrictive practice.

Appointing a similar role to monitor the aged care system would help provide leadership, expertise and accountability in reducing the use of restrictive practices in residential aged care.

Residents must be the driving force behind tailored service delivery

A successful aged care service must be tailored to the needs of the person. Residential aged care facilities are moving towards a Consumer-Directed-Care model, which in theory should mean that the person has control over the types of care and services they can access.

An NHMRC trial is currently being run by Swinburne University, evaluating consumer-directed care in an aged care facility.  The Resident at the Centre of Care staff training program trains senior and floor staff to implement a model of care that is focused on resident needs and wants. Care is designed to wrap the activities of the facility around the resident’s needs, rather than it being driven by tasks that need to be completed. The resident is driving the care provided, not the organisation.

Care then becomes a two way process that is negotiated between residents and staff. The care that is provided is determined by the residents’ needs and the capacity of staff. As stated by one resident:

“I would like to set the table. Make a cup of tea. I like to have a purpose in life, rather than getting bedsores.”

Residents are not asking for complex, costly activities. Initiatives that are responsive to the needs of the resident can be relatively easy to achieve. However, this model does require a commitment from the organization and staff to be person-centred. On-floor staff need to be empowered to find out what the resident wants. This is one model that can be examined when looking at evidence-based models for consumer-directed-care. It is important to put the person first and the system second.

Support wellness and ‘reablement’ of people in aged care

Residential aged care is often the option of last resort for people who would prefer to remain in their homes. VCOSS members report residents often only enter aged care because they fear becoming a burden to family or carers. At the same time, they fear losing their identity and autonomy.

VCOSS members report the existing model of care is flawed, realising many of the fears expressed by older people. It often fails to provide older people with choice and does little to encourage them to live as full a life as possible.

Residential aged care providers should be incentivised to implement care models that support older people’s autonomy and capacity and that allow for reablement opportunities and ways for older people to improve their quality of life.

For example, to address the lack of choice residents can experience in the ‘traditional’ aged care system, some providers are moving to ‘household models,’ where smaller groups of 15-20 residents share their own kitchen and living areas. Residents are in control of their own routines, can help themselves to food at any time rather than waiting for set mealtimes, and work with staff to fill social and leisure time, rather than waiting for pre-planned activities.[42]

A range of other more innovative models are also being explored in Australia and overseas. For example, the Homeshare program based in Melbourne matches older people living in their own home with people willing to provide some care and household maintenance in return for accommodation. A program in the Netherlands has gone further, trialing intergenerational living by offering free accommodation to students within an aged care facility, in return for 30 hours of socialising with the older residents each month.

Other countries are also trialing intergenerational learning, which includes placement of childcare centres within aged care centres.[43] Closer to home, Playgroups Victoria has run playgroups at aged care facilities. Workers report people with dementia become more engaged chatting with toddlers, and children can learn a lot from engaging with older people. Intergenerational activities show older people that they are valued as individuals that still possess lifelong skills, rather than just being passive recipients of care.

Deliver a proper complaints system for people in aged care

Resident voices and perspectives are an important part of assessing quality of care and identifying where a service is failing to meet expected standards. The accreditation process can be improved by strengthening the role of consumers and better valuing their contribution.

Residents and their representatives, including family and friends, must be interviewed as part of the accreditation process. VCOSS members reported that residents and families are often not made aware that accreditation processes are taking place, or provided opportunity to participate. Consultations may need to be held outside business hours, or remotely, to allow participation of family members and carers who are working.

VCOSS members also highlighted the challenges of seeking feedback from residents, especially people with dementia or who are non-verbal. Some providers are exploring alternative models for seeking input from residents, for example through visual cues and depictions.

VCOSS members believe that independent advocacy is a crucial safeguard for older people in residential aged care. Advocacy organisations can help identify violence, abuse or neglect, build people’s capacity to understand their rights and help people make complaints. Advocates can also help address the power imbalance between residents and staff. There are few advocacy services specifically funded to support older people, especially people entering into residential aged care.

While some resident and family feedback is taken into account as part of the accreditation process, the aged care sector requires a more accessible complaints process to be established. This complaints process should be operated by an independent organisation that proactively seeks the views of people in aged care and has power to investigate areas of concern.

People who used aged care services must be listened to. They must be able to access appropriate complaints processes when they are not receiving services that they are paying for or face circumstances that increase their risk of harm.

Providers of aged care services must be held to account when they fail to deliver a safe or adequate level of care. The imposition of criminal and financial penalties on providers who fail their duty of care to residents should be considered.

Incentivise aged care facilities to engage with communities that they are a part of

Family and friends can play an important role in the care and support of older people in residential aged care. Family and friend involvement has been linked to improved physical and emotional wellbeing among aged care residents.[44] Frequent visitors to facilities can also act as a protective factor against abuse and mistreatment.

VCOSS members reported that isolation and loneliness of older people in residential aged care was a key concern. The lack of involvement or sense of belonging was raised as an issue to be overcome, with residents of aged care facilities unable to actively participate in the community that they are a part of.

VCOSS members report that some providers are less encouraging of family and friend involvement than others. Simple strategies that should be encouraged in all services include:

• Establish friends and families groups to connect people with an interest in a high quality service
• Expand and support initiatives such as the Community Visitors Scheme, where volunteers make regular visits to people who are at risk of loneliness or social isolation.
• Encourage people from the general community to visit aged care facilities with appropriate safeguards (for example, by establishing a playgroup that meets regularly at the service).

Residential Aged Care facilities should be incentivised to engage with the communities that they are a part of by fostering relationships with local organisations. These partnerships would allow for greater opportunities for visits, trips for residents away from the facility and will help to change social views on the value of older people in aged care.

 

Build a quality, skilled aged care workforce

Recommendations

• Pay the aged care workforce appropriately
• Grow the workforce sustainably
• Consider a registration scheme for personal care workers
• Invest in skilling the aged care workforce

Pay the aged care workforce appropriately

The community service workforce is highly feminised; remains lower paid than other occupations with similar skills sets; is characterised by high levels of casual and part-time work, and often short-term contracts with uncertainty of renewal; has a high staff turnover and often requires people to change employers in order to build a long-term career path. The workforce is also ageing, with the average age of people employed in the disability and aged care sector 47 years.[45]

Working with vulnerable people is demanding and can be stressful and emotionally draining. Community service organisations report workers, particularly new entrants to the industry, often ‘burn-out’ and do not stay in the industry. Workers also complain that their work requires unpaid overtime on reporting and form filling, directing attention away from providing key services.

Attracting people from outside the industry is also difficult because little is known about the industry amongst the general public. In particular, attracting school leavers is challenging because few parents, teachers and school career advisors know much about the work of the industry, its growth and opportunities. For rural localities, attracting experienced, qualified workers is particularly difficult. Services located in these areas often recruit less experienced and qualified employees, which can lower the quality of service in some cases.

The Tune Review observed that aged care nurse wages are appreciably lower than their counterparts in the acute sector, which is the major competing employment sector. On average, personal carers are paid an average 15 per cent less than their peers in the broader health system and nurses are paid about 10 per cent less.[46]

Low wages, insecure work, poor conditions and lack of support for workers should be addressed through the introduction of minimum training standards and improved pay and work conditions for employees in the aged care sector.

Government should raise the wages of aged care system workers to be equivalent to the broader health system.

Grow the workforce sustainably

The aged care workforce needs to grow to over 800,000 people by 2050 to meet the demands of the ageing Australian population.[47] However, it is unclear how the positions needed to deliver aged care in the future will be adequately filled.

The aged care workforce will face growth pressures that have been experienced concurrently in disability, family violence and mental health sectors. The pressure on the community sector workforce is becoming even more acute in the wake of landmark policy and funding reforms in these areas. Consequently, VCOSS members in these sectors end up competing for the same workforce to fill vacancies.

The current service system can be fragmented with ‘siloed’ workforces, which prevents Victorians from being able to seamlessly access the full spectrum of services they require. Funding silos contribute to service fragmentation.

Work in the community services sector is often casual or fixed term, which is a disincentive for the sector to invest in training and provides little long-term certainty for workers. The short-term nature of many funding contracts contributes to this, as does other uncertainty relating to individualised funding and competition for clients.

The 2017 Senate Community Affairs Reference Committee inquiry report on the Future of Australia’s aged care sector workforce raised a number of pertinent points in relation to competition between multiple community service sectors. The Committee considered that “The committee considers that there is potential for the aged care and disability sector to invest in new innovations to share workers across these sectors, such as creating a combined workforce pool and establishing collaborative care arrangements.”

Government should invest in a comprehensive strategy to attract, develop and maintain enough skilled workers to meet the care needs of the ageing population in Australia into the future.

Consider a mandatory registration scheme for personal care workers

The staffing profile of the residential aged care sector is changing. The proportion of enrolled and registered nurses has decreased in recent years, and the proportion of personal care attendants has increased.

People with disability and older people have the right to be safe and receive high quality services. Currently there are no minimum qualifications or ongoing professional development requirements to work in the aged and disability care sectors. This is despite the Federal Government recognising aged and disability workers as skill level 4 occupations, generally requiring a Certificate II, III or equivalent. Risks are created for both workers and consumers if they are matched through an online provider platform without any safeguards. These include workers not having minimum qualifications, access to ongoing professional development and training, or the requisite skills, experience or qualifications to be able to provide high quality services.

Personal care attendants have less training than nurses; approximately two-thirds of personal care attendants have a Certificate III in Aged Care compared to a Diploma of Nursing for enrolled nurses and a bachelor degree for registered nurses. Inquiries show that many training providers are offering minimalist ‘fast-track’ Cert III courses that are failing to meet quality benchmarks, and are of less than 15 weeks duration.^[48] As a result, personal care attendants are not always well equipped when they enter the aged care workforce.

Vocational and Educational Training providers should work with the community sector, aged care providers and consumers to ensure the training they offer remains fit-for-purpose. In addition, VCOSS members recommended development of additional training for personal care attendants in areas including diversity, identifying elder abuse and dignity of risk.

Most personal care attendants, unlike nurses, are not members of a registered profession. Victoria is currently implementing a scheme for registration of disability workers. The scheme will likely incorporate a criminal history, working with children and reference check, providing a basic level of screening to prevent workers who have committed violence, abuse or neglect from continuing to work in disability services. Registered workers will also be able to use various protected titles, including ‘Registered Disability Worker.’ The requirement to abide by ethical standard of practice and the threat of being deregistered for professional misconduct should deter workers from committing violence, abuse and neglect and should promote the delivery of high quality services.

A qualified workforce has significant benefits. Appropriate, professional training helps maintain high quality, personalised services. Gradually introducing minimum qualifications for registered aged care support workers will help lift service quality across the sector, and provide greater protection for both older people and workers. A professionalised workforce also helps address supply challenges through providing occupational progression, including training entitlements and pay progression.

Government should implement a mandatory scheme of registration for personal care workers and gradually introduce a minimum qualification requirement for registered support workers.

Invest in up-skilling the aged care workforce

Currently there is no coordinated approach to professional development and in-service training across the aged-care sector. Many organisations are training staff on-the-job and in isolation from one another. As a result, inconsistent standards of training are delivered. There is no clear benchmark for the quality or standard of training that employees require.

Government should engage the aged care sector, the vocational education and training, and tertiary education sectors to ensure education and training is responsive to the sector’s needs. A comprehensive aged care workforce strategy requires:

• identifying the scope of training required for on the-job training, continuing professional development, and specialised training
• exploring a range of options to deliver what is required, e.g. partnerships, cooperative models or arrangements with existing non-aged-care training providers
• promoting and encouraging ageing and aged care as a specialisation in nursing education

Building a skilled aged care workforce must focus on the areas of pay, education and training, retention, recruitment and workforce growth. Government must support the aged care sector to build the skills required to meet the future demand in the sector over the coming decades.

 

 

[1] [1] https://www.aihw.gov.au/reports/australias-welfare/australias-welfare-2017-in-brief/contents/ageing-and-aged-care

[2] Natinoal Ageing Research Institute Ltd, What makes a good old age? Aged Care Roundtable Discussion Paper, May 2018.

[3] [3] https://www.aihw.gov.au/reports/australias-welfare/australias-welfare-2017-in-brief/contents/ageing-and-aged-care

[4] AIHW Older Australians at a glance 10 September 2018

[5]  World Health Organization, What is Healthy Ageing?  https://www.who.int/ageing/healthy-ageing/en/

[6] Davidson, P., Saunders, P., Bradbury, B. and Wong, M, Poverty in Australia, 2018. ACOSS/UNSW Poverty and Inequality Partnership Report No. 2.

[7] Ibid.

[8] AIHW, Older Australia at a glance, September 2018.

[9] Everybody’s Home campaign, https://everybodyshome.com.au/our-campaign/more-social-and-affordable-homes/

[10] ABS, Census of Population and Housing: Estimating Homelessness 2016, Cat No. 2049.0, 2018.

[11] Anglicare Australia, Rental affordability snapshot: National Report 2019, April 2019.

[12] Beer, Faulkner, 21^st century housing careers and Australia’s housing future, 2009, p. 207

[13] Department of Health and Ageing, Living Longer. Living Better, 2012, p. 3

[14] Australian Institute of Health and Welfare, The desire to age in place among older Australians, 2013, p. 1

[15] Productivity Commission, Report on Government Services – Aged Care Services, 2019, p. 14.16

[16] House of Representatives Standing Committee on Health, Aged Care and Sport, Report on the Inquiry into Quality of Care and Residential Aged Care Facilities in Australia, 2018, p. 122.

[17] G Carey, H Dickinson, E Malbon and D Reeders, ‘The Vexed Question of Market Stewardship in the Public Sector: Examining Equity and the Social Contract through the Australian National Disability Insurance Scheme’, Social Policy & Administration, January 2018, vol.52, no.1.

[18] Aged Care Royal Commission, Transcript 22 March 2019, p. 1097

[19] Aged Care Royal Commission, Transcript 22 March 2019, p. 1098

[20] Productivity Commission, Report on Government Services – Aged Care Services, 2019, p. 14.8

[21] Australian Digital Inclusion Index, Measuring Australia’s Digital Divide, 2017, p.14

[22] Morphett, J., et al., 2014, ‘Shortfalls in residents’ transfer documentation: challenges for emergency department staff’, Australasian Emergency Nursing Journal, Vol. 17, pp. 98-–105.

[23] Victorian Government Department of Health and Human Services, January 2009 Heatwave in Victoria: as assessment of health impacts, 2009.

[24] ABC News, No mandatory air conditioning for aged care residents after pressure from lobby group, https://www.abc.net.au/news/2019-02-18/air-conditioning-unlikely-in-final-aged-care-regulations/10820210 accessed August 2019.

[25] VJ Cornell, L Cusack, P Arbon, Older people and disaster preparedness: a literature review, Australian Journal of Emergency Management, Vol. 27 No. 3, July 2012.

[26] Astill, S, Ageing in remote and cyclone prone communities, Geographical Research, 1.13, 2017

[27] NSW Fair Trading, Safety, emergency plans and evacuation exercises, https://www.fairtrading.nsw.gov.au/housing-and-property/retirement-villages/living-in-a-retirement-village/safety,-emergency-plans-and-evacuation-exercises, accessed August 2109

[28] Deloitte Access Economics and Carers Australia, The economic value of informal care in 2015. Canberra: Carers Australia, 2015.

[29] ABS, Disability, Ageing and Carers, Australia: Victoria, 2015, Catalogue #4430.0.

[30] Royal Commission into Aged Care Quality and Safety, The Changing Demographics and Dynamics of Aged Care, 2019, p.9

[31] Deloitte Access Economics, The economic value of informal care in Australia in 2015, commissioned by Carers Australia, 2015, p.iii.

[32] A Groves, D Thomson, D McKellar and N Proctor, The Oakden Report, for the Department for Health and Ageing (SA), 2017.

[33] Deloitte Touche Tohmatsu, Department of Education and Training Review of Quality Assurance in Victoria’s VET system, 2015, pp 6.

[34] Australian Law Reform Commission, Elder Abuse, 2017, p.200

[35] Australian Nursing and Midwifery Federation, ANMF National Aged Care Survey Final Report, 2016.

[36] Aged Care Act 1997.

[37] Aged Care Financing Authority, Sixth report on the funding and financing of the Aged Care Sector, June 2018, p. 18

[38] Aged Care Financing Authority, Sixth report on the funding and financing of the Aged Care Sector, June 2018, p. 18

[39] Victorian Department of Health and Human Services, Safe Patient Care (Nurse to patient and midwife to patient ratios) Act 2015; Implementation Guide. 2015.

[40] ALRC, Elder Abuse – A National Legal Response, pp 142.

[41] Victorian Department of Health and Human Services, About the Senior Practitioner in Victoria, 2014.

[42] Residents feel ‘at home’ with new care approach, https://www.agedcareguide.com.au/talking-aged-care/residents-feel-at-home-with-new-care-approach,

[43] The Conversation, ‘Combining daycare for children and elderly people benefits all generations,’ January 5 2017 https://theconversation.com/combining-daycare-for-children-and-elderly-people-benefits-all-generations-70724

[44] Australian Centre for Evidence Based Aged Care, Constructive staff/family relationships in residential aged care, La Trobe University, 2009.

[45] Productivity Commission 2017, National Disability Insurance Scheme (NDIS) Costs, Study Report, page 320, https://www.pc.gov.au/inquiries/completed/ndis-costs/report/ndis-costs.pdf.

[46] Aged Care Workforce Strategy Taskforce, A matter of care, 2018 p.92

[47] Productivity Commission, Caring for Older Australians, 2011, p. XLV

[48] Australian Skills Quality Authority, Report; Training for aged and community care in Australia, 2013.