acfi survey 2014 - physiotherapy · pdf fileaustralian physiotherapy association acfi survey...

ACFI Survey 2014

Australian Physiotherapy Association ACFI Survey 2014 2

ForewordThe Australian Physiotherapy Association (APA) advocates for equitable access to quality physiotherapy and optimal health care for all Australians, and is committed to ensuring that government policy decisions do not adversely affect the delivery of physiotherapy within our communities.

The introduction of the Aged Care Funding Instrument (ACFI) by the Federal Government has been of great concern since its proposal in 2005 and introduction in 2008. In response to these concerns the APA undertook a series of surveys to gauge the level of physiotherapy provided to clients in residential aged care facilities (RACFs).

The first survey in 2007 established the level of physiotherapy service delivery before the introduction of the ACFI. In 2009 APA surveyed the effect of the introduction of the ACFI.

The 2014 survey monitors the effect of the ACFI and members’ experiences and perceptions of its implementation.


Executive summary• Optimal pain management has been compromised since the introduction of the Aged Care Funding Instrument (ACFI)

• The current funding model is prescriptive, rigid and not based on clinical assessment, need, or best practice.

• TheACFIcreatesfinancialincentivestotreatresidents,whichencouragerortsandover-servicing.Italso channelsfundingtopassivetreatmentstomanagepainratherthanevidence-based,activetreatments and causes resident dependence, rather than developing independence and function and the quality of residents’ life.

• An interdisciplinary team, including nurses and key allied health practitioners such as physiotherapists, podiatrists, dieticians and psychologists, should help revise 4a and 4b.

• Pain management in Residential Aged Care Facilitates (RACFs) should instead be part of multimodal physiotherapyservices.Suchservicesshouldbepatient-oriented,flexible,outcomes-focusedandbased onevidence-basedclinicalassessmentandneed.

• Themodelshouldsupportresidentindependenceandallowforpreventativeinterventions,exercise, falls prevention and an emphasis on mobility and function.

• Respondentshaveraisedconcernsaboutpay,staffing,andprofessionalstanding;technology,equipment andfacilities;training;treatmentsandinterventions;andtheadministrationoftheACFIandRACFs


BackgroundThe Aged Care Funding Instrument

The Aged Care Funding Instrument (ACFI) is a resource allocation instrument for determining care payments for residents of aged care homes. The ACFI assesses care needs as a basis for calculating and allocating funds to the aged care facility.

TheACFIframeworkappliestwelveACFIquestionsthatfallwithinthefollowingthreeDomains:

• ActivitiesofDailyLiving(Questions1-5onNutrition,Mobility,PersonalHygiene,ToiletingandContinence)

• BehaviourSupplement(Questions6-10:CognitiveSkills,Behaviour,andDepression)

• ComplexHealthCareSupplement(Questions11-12onMedicationandComplexHealthCare).

ThissurveyconcernstheComplexHealthCareSupplement,question12aand12b

Items 12 4a and 4b

Facilities may seek funding for providing services under either 4a or 4b. Items 4a and 4b relate to therapeutic massageand/orpainmanagementinvolvingtechnicalequipmentspecificallydesignedforpainmanagement.Equipmentincludeselectro-therapeuticequipmentsuchasTranscutaneousElectricNerveStimulation(TENS),interferentialtherapy,ultrasonictherapy,lasertherapy,andwaxbaths.TheDepartmentofHealthandAgeingdoesnotmaintainanexhaustivelistofequipmentthatcanbeincludedasthisissubjecttochangeovertime.

4a:Complexpainmanagementprovidedbyanalliedhealthprofessionalorregisterednurseinvolvingtherapeuticmassageand/orpainmanagementusingtechnicalequipmentspecificallydesignedforpainmanagement, performedatleastweeklyandinvolving20minutesofstafftime.

4b:Complexpainmanagementprovidedbyalistedalliedhealthprofessionalandthedirectivegivenbyamedicalpractitionerorlistedalliedhealthprofessional.Thiswillinvolvetherapeuticmassageand/orpainmanagementinvolvingtechnicalequipmentspecificallydesignedforpainmanagementandongoingtreatmentasrequiredby theresident,atleast4daysperweek.

2014 Survey

Thissurveywasconductedonlinefrom21February2014to30April2014.AllmembersoftheAPA’sGerontologyPhysiotherapyAustralia(GPA)andPhysiotherapyBusinessAustralia(PBA)wereinvitedparticipateinthesurveyandencouragedtoforwardthesurveytoanyphysiotherapistworkinginanRACF.

Thisyear,370respondentsansweredquestions.Thenumberofresponsesvariesconsiderablybecauseitwasnotcompulsorytorespondtoallquestions.In2009,APAreceived206responsesand157in2007.


ResultsQuestion 1: asked for an email. Totalrespondents:229;skippedthisquestion:141.

Question 2: asked for the name of the RACF. Totalrespondents:228;skippedthisquestion:142.

Question 3: State/Territory of RACF. Totalrespondents:219;skippedthisquestion:136.

Thenumberofresponsesreceivedfromeachstateorterritorybroadlyreflectedthepopulationofthosestatesorterritories exceptforNSWwhichwasoverrepresented(approx.%ofnationalpopulation:32%),andVictoria(approx.%of nationalpopulation:25%)andQueensland(approx.%ofnationalpopulation:20%)whichwereunderrepresented.

4. What type of employment do you have at this RACF? Totalrespondents:170;skippedthisquestion:185

•Comparisonwiththe2009resultsindicatesadecreaseinthepercentageofrespondentswhoarein permanent ongoing employment.

Type of employment 2014 2009

Ongoing, permanent 32% 40%

Contract employment 63% 55%

Other* 5% 6%

* consultant or contractor agreement.

Responses by State/Territory

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

49%

0%

12%6%

4%

18%

8%

3%

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

49%

0%

12%6%

4%

18%

8%

3%


5. How many beds are there at this RACF? Totalrespondents:167;skippedthisquestion:188.

The percentage of high care beds has increased.

Number of beds Beds per facility

2014 2009 2014 2009

TotalNumber 14388 21,775 86 106

High-Care 9333 12,406 65% 57%

Low-Care 5050 6,761 35% 31%

6. In a normal week, what are the total hours of employment at this RACF? Totalrespondents:167;skippedthisquestion:188

Total hours per facility

2014 2009 2014 2009

TotalNumber 3172 2,495 19hrs/week 12.1hr/week

Paid 2945.4 2,275.5 92% 91%

Unpaid 225.6 219.5 7% 9%

7. In a normal week, how many hours do you spend with clients in a clinical setting at this RACF? Totalrespondents:167;skippedthisquestion:188.

•7.11%ofallhoursworkedareunpaid;4.49%ofclinicalhoursareunpaid •66.33%ofallhoursworkedareconsideredclinical;68.19%ofpaidhoursworkedareconsideredclinical

Total hours Total hours Unpaid

2104 2009.4

94.6

Hours spent with clients


8. In a normal week, how many hours do you spend with clients on pain management?

Totalrespondents:167;skippedthisquestion:188.

•46%ofphysiotherapisttimeisspentonpainmanagement

9. In a normal week, how many hours are spent with clients providing non-pain management treatment?

Totalrespondents:167;skippedthisquestion:188

•25%ofphysiotherapisttimeisspentonnon-painmanagementtreatments.


1456.5 1429

27.5

Time spent with clients on pain management


798.25 762.75

35.5

Hours spent providing clients non-pain management treatment


10. In a normal week how many hours do you spend on documentation/paperwork at this RACF?


•27%ofphysiotherapisttimeisspentonadministrationandpaperwork

11. Every client in this RACF receives the physiotherapy treatment they require from a qualified physiotherapist.


•55%ofrespondentsbelieveRACFclientsdoNOTreceivethephysiotherapytreatmenttheyneed.

Percentage

2014 2009

Strongly agree 9 9

Agree 22 21

Neutral 14 15

Disagree 42 40

Strongly disagree 13 16


865.05 777.95

87.1

Hours spent on paperwork


12. In the RACF, what proportion (%) of services that should be undertaken by a physiotherapist is carried out by non-physiotherapist staff?


• Respondents report a decreasing proportion of physiotherapist services are being carried out by non-physiotherapistssince2009.

Additionalcomments: …therapy assistant does excellent work appropriate to her training. …we are greatly under resourced. Registered nurses conduct massage as per the ACFI guidelines. There is no longer a physio employed at the facility at all.

13. Clinical consultation time is adequate for clients in this RACF. Totalrespondents:161;skippedthisquestion:194

•60%ofrespondentsdonotbelieveclinicalconsultationtimeisadequate

Percentage

2014 2009

Strongly agree 5 9

Agree 20 27

Neutral 15 13

Disagree 44 39

Strongly disagree 16 11

Proportion (%) of physiotherapist services undertaken by non-physiotherapist

2009

2014

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

35

30

25

20

15

10

5

0

2009

2014

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

35

30

25

20

15

10

5

0


14. In the last 2 years, my hours at the RACF have: Totalrespondents:149;skippedthisquestion:214

•40%ofrespondentsreportanincreaseinhoursworkedattheRACF

15. Do you think that Pain Management 4b should have a minimal time frame on the duration of treatment?

Totalrespondents:130;skippedthisquestion225

16. If you answered yes to the questions above, what time frame should be applied to Pain Management 4b?


Mostrespondentsconsideredthat10-20minutesperpersonpertreatment1-3timesperweekwas commonlysufficienttorespondtopainmanagementinterventionsunder4b.

Fewbelievedthatfourtreatmentsperweekwerenecessary,andthatsettingthenumberoftreatmentsat eitheroneorfourperweekwasarbitrary.Mostproposedamoreflexibleapproachbasedonclinicalneed. Thiswasoftenconsideredtobeonetothreetreatmentsperweekorasrequiredandcontinuednolonger thanclinicallynecessaryandtreatmentshouldbesubjecttoassessment,referralandrecommencement as necessary.

Arepeatedresponsewasthatthecurrentmodelisprescriptive,rigidandnotbasedonclinicalassessment, need,orbestpractice.Amodelbasedonclinicalneed,evidencebasedpractice,patientneedanddrawing onavarietyofmodalitiesandinterdisciplinaryteamswouldbeinthebestinterestsofconsumers.

Ceased: 1Decreasedslightly: 5

Increasedsubstantially: 21

Decreasedsubstantially: 0

Increasedslightly: 35

Remainedunchanged: 79

40%

60%

Yes

No

Should Pain Management 4b have a minimal time frame on the duration of treatment


17. How could pain management funding change to better meet the needs of your clients?


Problems with the ACFI 12 4a and 4b

This survey highlighted a lack of support for 4a and 4b of the ACFI. In practice, 4a and 4b create incentives to treat residents not based on clinical need but to receive related funding. One respondent called the ACFI 124aand4ba‘racketthatneedstobecleanedup.’

TheACFIcreatesfinancialincentivestotreatresidents,whichencouragerortsandover-servicing.Italso channels fundingtopassivetreatmentstomanagepainratherthanevidence-based,activetreatments and causes resident dependence, rather than developing independence and function and the quality of residents’ life.

RespondentsnotedthattheACFIisprescriptive,inflexibleandallowsonlylimitedinterventionsthatare passive and not supportedbyevidence-basedpractice.Thisdoesnotmakebestuseofphysiotherapist skills;itremovesprofessionaljudgementtoassessandreviewasclinicallyappropriate,andtomanagepain and effect reablement.

TheACFIpromotesinequitableservicedelivery.Forexample,residentsofsmallfacilities,morelikely in remote or rural locations, miss out on any physiotherapist treatment if these facilities cannot employ aphysiotherapisttowork4daysaweektocomplywith4b;andthepresentsystemisusedbysomefacilities tocoverthecostofnon-fundedphysiotherapy.

Recommendation

An interdisciplinary team, including nurses and key allied health practitioners such as physiotherapists, podiatrists, dieticians and psychologists, should help revise 4a and 4b.

Pain management in RACFs should instead be part of multimodal physiotherapy services. Such services should be patient-oriented,flexible,outcomes-focusedandbasedonevidence-basedclinicalassessment andneed.Themodelshouldsupportresidentindependenceandallowforpreventativeinterventions, exercise,fallspreventionandanemphasisonmobilityandfunction.

18. As a physiotherapist, what changes would you like to see happen over the next 2 years in this RACF?


Thefollowingareextractsoftheresponsestothisquestion:

Workforce

•Physiotherapistsshouldcarryoutaninitialassessmentafterwhichaphysiotherapistassistantshould beallowedtoperformpainmanagementtreatment.

• Increase hours of physiotherapy treatment and increase the availability of physiotherapists and physiotherapyassistantssomoreclientsreceive1:1andgrouptreatment.

• Allowmoreautonomyforthephysiotherapisttodevelopandapplythemosteffectivetreatment.

• Employapermanentphysiotherapisttomaintainorimproveresidents’function,fitness,balance, reducefallsriskaswellasimplementabetterpainmanagementprogram.

• EmployaRegisteredNurseonduty24/7


Technology, equipment and facilities

• Invest in manual handling, gait aids and other equipment and appliances for clients.

• Investinagymoraproperlyequippedtreatmentroomwhereresidentscanbeseenby a Physiotherapist.

• Upgrade facilities – such as bathrooms – to suit the abilities of all residents and improve safety.

• Use an iCare electronic medication management system

Training

• Increase training of staff about manual handling, postural seating and matters relating to physiotherapy

• Improveeducationandshareinformationaboutresidents’medicalconditionsandspecificneeds

• Promote the role of the physiotherapist in providing services beyond pain management

Treatments and interventions

• Promoteevidence-basedmeasuresforreablementandtoimprovefunctionandqualityoflife.

• Promotepreventativephysiotherapy–suchasfallsprevention–andthemaintenanceoffitnessfor residents’ independence and safety

• Allowadditionalclinicaltimetodeliverprogramsandindividualisedtreatmentplansdeveloped by physiotherapists

• Incorporatehydrotherapyasanoutingandfocusonexerciseandmovementtodecreasepainas supported by the literature.

• Haveseatingassessmentscarriedoutbytrainedseatingspecialists.

• Improve treatment for incontinence rather than using pads

• Increasethefocusonrehabilitationandfundrehabilitationfollowingspecificincidents,suchasfalls, fractures or strokes.

Administration

• Rationalise the documentation required by the facility, managing entity or for ACFI


19. What do you see as the biggest problem/issue regarding physiotherapy and RACFs?



ACFI

• As described above, the ACFI model is considered the cause of problems for physiotherapy in RACFs.

Workforce

• A lack of physiotherapists diverts physiotherapist resources from preventative interventions, assessments and treatment.

• Alackoftrainedstaffpreventsresidentsreceivingnecessaryhelpwithprescribedexercisesandothertreatments.

• As frontline providers of care, a lack of hours for carers, including 24/7 care, impacts residents’ overall quality of life.


• Thebenefitsofcommunitycareareimportant.However,ifpeoplecomeintoresidentialcarethey increasinglypresentwithmorecomplexproblems.RACF’sarelesswellequippedtomeettheneeds oftheseresidentsinsufficient–HighCarenowreallymeans‘ExtraHighCare,’andHighCareresidents areinLowCarefacilities.

• Theprovisionof,anddependenceonunsuitableequipment,suchaswalkingframes,leadstoother conditions (e.g. respiratory, digestive inter alia)

• Difficultyinfundingequipmentformobilityandmanualhandlingequipmentunderminessafetyand residents‘qualityoflife’.

Iampassionateaboutimprovingtheindependenceofourresidents,butfinditsodifficultastheredoes not seem to be funding for this at any level; and in fact the current instrument works to promote and reward dependenceanddifficultandchallengingbehaviours.

Training

• Thereisinsufficienttrainingofphysiotherapyassistantsandcarestaff.Untrainedstaffareaskedtotreat residents, in an effort to reduce costs.

• ManagementrefusestoreleasethePhysiotherapyAssistant(PTA)forAustralianPhysiotherapy Association (APA) education as they have carer duties on other days.

Treatments and interventions

• Physiotherapistsshouldalsobefundedfortimespenthelpingresidentsremainmobile,exerciseto preventfalls,maintainfunctionalabilitytoallowforimprovedqualityoflife.

Administration

• Administration of the ACFI and other documentation related to the management of the RACF isaconsiderableburdenwhichdivertsresourcesfromresidentcare.

• Communicationbetweenthestaffandotherhealthcareprovidersdoesnotsupportbestpractice: poorcommunicationoffallsandhospitalisations,forexample,meansresidents‘slipthroughthecracks’ and health issues are not adequately addressed.


20. Are there any other concerns you have regarding this RACF?



ACFI

• The future of quality physiotherapy in aged care is being compromised.

• StaffareallanxiousandconfusedaboutACFI.

• Stretchingthetruthoradjustingotherprofessionals’assessmentstomatchorincreaseACFIfundingneeds.

• LotofpressureonACFIstafftomaximisecategoriestogainfundingsohostelcanmakeendsmeet.

Workforce

• Therearenolongermanyfacilitiesemployingphysiosonstaff.Thewagescalefornewemployeesisinsulting.

• Peoplewhomakeclinicaldecisionsarenotclinicianssotheydon’tunderstandtheclinicalneeds (notjustinphysiobutallclinical)toprovideagoodservice…peoplewhoworkinheadofficedon’teven go to the RACFs to understand the impact of their decisions on the RACF.

• Thereisalackofstaffingonthefloore.g.dementiaunitof17residentshas1staffmemberavailable fora2hourperiodeachafternoon.Verypoormanagementandculture,andeducation/training.

• Highturnoverofbothmanagerialstaffandnursingstaff.Thereisnocontinuityfortheresidents.

• Everyoneworkingthereseemedquitestressed-notgoodforstafforresidents.


• Verypoorphysicalenvironment-unsafeforstaffandresidents,admittingresidentswithdisabilities waybeyondlevelofcareavailable-e.g.nospecificsecuredementiaarea;residentswithBPSD in same area as cognitively able residents causes distress to all.

• Lackofbariatricequipmentandbariatricsizedrooms.

Training

• Poor manual handling techniques and poor communication have led to many falls and secondary issues that could have easily been avoided.

• AlsothereislimitedspecifictrainingandongoingeducationeventhroughtheAPAforphysiotherapists in aged care facilities.

Administration

• TheassessorsfromFederalDept.ofHealthandAgeingseemmoreinterestedinwhetherfacilities have perfectpaperworkratherthanstandardofcareandwhetherphysioactuallydoesagoodjob.

• Thatthephysiotherapyspecificquestionnairesarenotstandardisedmakingresultsinvalid, non-transferrable,etc.


ConclusionRespondentshaveidentifiedthecurrentfundingmodelisprescriptive,rigidandnotbasedonclinicalassessment,need, or best practice.

TheACFIcreatesfinancialincentivestotreatresidents,whichencouragerortsandover-servicing.Italsochannels

fundingtopassivetreatmentstomanagepainratherthanevidence-based,activetreatmentsandcausesresident dependence, rather than developing independence and function and the quality of residents’ life.

Thesurveyidentifiesthatthefundingmodelneedsfurtherrefinement.Aninterdisciplinaryteam,includingnurses and key allied health practitioners such as physiotherapists, podiatrists, dieticians and psychologists, should help revise 4a and 4b in particular.

4aand4bshouldpromoteresidentindependenceandallowforpreventativeinterventions,exercise,fallspreventionandanemphasisonmobilityandfunction.ItshouldallowforpainmanagementinRACFsaspartofmultimodal physiotherapyservices.Suchservicesshouldbepatient-oriented,flexible,outcomes-focusedandbasedon evidence-basedclinicalassessmentandneed.

Contact:Australian Physiotherapy Association POBox437,HawthornBC Victoria3122

Phone: +61390920888 Fax: +61390920899 Email: [email protected] Website: www.physiotherapy.asn.au

acfi survey 2014 - physiotherapy · pdf fileaustralian physiotherapy association acfi survey...

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