Ian Powell: Should DHBs Be The Providers Of Rest Home Care?
One of the valuable things about Health & Disability Commission (HDC) decisions (findings) is that interesting experiences are published in a readable manner from which much can be learned. Decisions are specific to their own distinctive circumstances. Each HDC decision involves some form of tragedy. But they can provide insights into how our health system might be further improved or at least raise relevant questions deserving of answers.
Like hospitals (public and private) and general practices, residential aged care facilities (rest homes) come under the coverage of the HDC. Its decisions affecting rest home care are not evidence of a crisis or a need for alarm. But they do raise interesting questions about the role of district health boards (DHBs) in the healthcare provided for residences and the wider issue on who should provide residential aged care.
Health & Disability Commission
The Health & Disability Commission is a creature of statute – the Health and Disability Act 1992 – which arose out of the recommendations of the Cartwright Inquiry into informed consent at Auckland’s National Women’s Hospital. The purpose of the Act is to “promote and protect the right of health consumers and disability consumers” and to facilitate “fair, simple, speedy, and efficient resolution of complaints”.
The Act established the Commission, its head Commissioner, and the Code of Consumer Rights. Most complaints are dealt with in a manner that do not require formal decisions, but those that do are published including any recommendations.
The HDC’s Annual report for the year ended 30 June 2019 reports a record 2,392 complaints dealt with. Unsurprisingly, given their size and the complexity and acute nature of public hospital care, the largest number of complaints involved DHBs (986) followed by general practice (493). Aged care residential facilities were the source of 130 complaints. The number of complaints that led to decisions involving recommendations and/or educational comment was 448. The acceptance rate of its recommendations was 99%.
One of these decisions highlighted in the 2018-19 annual report involved an aged care facility which was held accountable for failing to provide services with reasonable care and skill, including reviewing medication and monitoring diabetes.
Its significance is unclear but a review by Ernst & Young commissioned jointly by the Ministry of Health and DHBs (August 2019) into the funding model for aged residential care observed that for-profit rest homes had lower staffing levels than similar not-for profit rest homes (https://tas.health.nz/assets/Health-of-Older-People/ARC-Funding-Model-Review-Final-Report.pdf).
The review refers to international research showing that in North America outcomes were poor for residents in for-profit providers compared with not-for-profit providers. However, largely due to the absence of a universal public health system in the United States and the consequential greater proportionate influence of the private sector, the situation in New Zealand is more nuanced. But interestingly the review also noted that the market share of aged care residential beds in not-for-profit rest homes in New Zealand had been declining slightly since 2013 down to around 30%. Consistent with this, not-for-profits were more likely to be found in rural rather than urban New Zealand.
HDC rest home findings in 2020
This year the HDC has published the results of five findings to date arising out of investigations into standards of patient care in aged care residential facilities. These findings assess the conduct and performance of the affected rest homes against their obligations under the Code of Consumer Rights.
The first found the rest home and one of its staff in breach of the Code for failures relating to the palliative care provided to a rest home resident who required hospital-level care at the facility. Basic care that should have been provided for a person with significant co-morbidities requiring end-of-life care was neglected. Family complaints about care were not sufficiently considered.
The HDC reported that the case highlighted the need to ensure that palliative care is appropriately planned to meet a person’s end-of-life care needs. Rest home staff identified an environment which was not sufficiently supportive for them to do their jobs. There was also a failure to provide appropriate oversight of the nursing documentation and care planning.
Among the recommendations were that the rest home report back to the HDC on the implementation of an action plan developed in light of this case, audit its compliance with protocols, review its palliative care policies, and improve staff training and learning (https://www.hdc.org.nz/media/5436/18hdc00700.pdf).
The second finding found a rest home and three of its nurses in breach of the Code for failing to adequately manage and assess a resident following two falls. On subsequent admission to a hospital, the resident died following a brain bleed. The finding included incomplete neurological observations and incomplete information provided to the ambulance service (including the need for urgent medical attention).
It was found that the rest home’s policy and documentation for neurological observations did not align with national best practice, and nursing staff lacked understanding about the frequency or length of time for neurological observations after a fall. The HDC’s recommendations included that the rest home review its policies and arrange for further training for its staff (https://www.hdc.org.nz/media/5438/17hdc01545.pdf).
The third finding involved a rest home in breach of the Code for failing to provide appropriate care and services to an elderly woman who began suffering from vulvar pain and symptoms of a urinary tract infection during her stay. The rest home neither initiated a short-term care plan nor forwarded urine test results to her general practitioner. As her condition deteriorated her GP prescribed nebulisers to relieve her coughing, Unfortunately, nursing staff did not administer these as required. Further, the rest home did not prepare an end-of-life care plan and its administration of prescribed palliative medication was delayed. She died a short time later.
Recognising the lack of planning, a delay in starting palliative medications and poor staff documentation, the HDC’s recommendations included that the rest home conducts an audit on a number of its policies and use the report as a basis for staff training (https://www.hdc.org.nz/media/5447/17hdc02135.pdf).
The fourth finding was that a rest home had breached the Code for failing to appropriately manage a woman’s care when her condition rapidly deteriorated. Over a period of four days in the rest home, the woman experienced confusion, constipation, pain and urinary incontinence. She was admitted to hospital after she lost consciousness and died from sepsis and cellulitis.
The HDC found there was an overall lack of response to the woman’s declining condition, despite her medical history suggesting that she was likely to experience a progressive decline in her general function. Further, although she was diabetic, staff did not assess her blood sugar levels and the rest home failed to promptly contact a doctor in response to the woman’s confusion and deterioration. Opportunities to consider concerns raised by her daughter were also missed.
HDC recommendations included scheduling specific education sessions for the rest home’s nursing staff, using an anonymised version of this case as a case study to encourage staff reflection and discussion, and reviewing its policy on clinical emergencies (https://www.hdc.org.nz/media/5482/17hdc01279.pdf).
The final and most recent finding this year (to date) involved a rest home breaching the Code over its management and treatment of a woman’s recurrent urinary tract infections and poor catheter care. She had multiple complex health issues and needed hospital-level care. The management of her health was complex and the staff did put considerable effort in providing some areas of her care. However, the rest home’s poor management and treatment of the woman’s infections included a lack of short term care plans and no consideration of different interventions. Her catheter care was also poorly managed, with staff failing at times to empty the catheter bag or change it.
HDC recommendations included requiring the rest home to develop and present training to its staff on management of urinary tract infections and catheter care, update its infections and catheter care policies, and consider developing a form for recording discussions with families and the resulting decisions about a resident’s care (https://www.hdc.org.nz/media/5494/18hdc01468.pdf).
Role of DHBs
Rest home funding comes from DHBs and residents. As at September 2019 the total annual funding to certified rest homes was $1.95 billion of which $1.2 billion (61.5%) came from DHBs. In order to receive DHB funding they must be certified under the Health and Disability Services (Safety) Act. Currently, there are over 650 certified rest homes.
DHBs already have significant powers and responsibilities involving rest homes which stem from both their legislative responsibility to be responsible for defined populations and the level of funding they provide. This includes the responsibility for assessing the appropriateness of rest home audit processes and to undertake reviews. Although rarely used DHBs can take over a rest home by putting it in statutory management until the problem is resolved or an alternative facility is provided.
Requiring DHBs to ensure and monitor the implementation of its recommendations to rest homes. would not take a quantum leap from the HDC. What stands out in the five HDC cases discussed above is a failure of the rest homes to provide safe appropriate medical care for its elderly residents – not providing hospital-level care for a palliative care resident with co-morbidities, inadequate understanding of neurological observations, not developing a plan (including medications) for a palliative care resident, failing to respond to a resident’s quickly declining condition, and managing urinary tract infections and catheter care.
There is precedent for DHBs assuming responsibility and accountability for patient outcomes in services it funds but does not directly provide. In 2004 the HDC ruled on a complaint from a mother about the care provided to her daughter. This was an unusual case because involved the emergency department based in Tairawhiti DHB’s Gisborne Hospital but run by a private company. Privatised emergency departments have been rare, and fortunately, none exist today. The complaint was against a company employed doctor, the company itself, and Tairawhiti DHB as well as an independent midwife.
The HDC found that the standard of care provided was inappropriate, including the assessment and investigation of the baby’s condition and the advice given to her family before discharging her. Among the HDC’s recommendations was that the DHB should confirm to it a specified date that the provision of emergency department services of an appropriate standard at Gisborne Hospital (https://www.hdc.org.nz/decisions/search-decisions/2005/04hdc04456/).
This HDC finding jolted the DHB. It led to Tairawhiti DHB sensibly bringing the emergency department back in-house. The statutory responsibility of DHBs for their defined population meant that they could not escape responsibility for failures in patient care whether or not they directly provided the service.
If the HDC can require DHBs to take responsibility when privatised services breach the Code of Consumer Rights, then surely where justified they can also require this when breaches occur in the rest homes they are also responsible for. The five cases reported this year would appear to justify HDC recommendations requiring DHB actions.
Given DHBs statute-based responsibility for defined populations regardless of where patient care is provided, their dominant funding role, and the declining number of rest home beds provided by not-for-profit providers, should not we also consider whether DHBs should gradually move to directly providing rest home care for the elderly?