AMA Submission to the Inquiry into the care and management of younger and older Australians living with dementia and behavioural and psychiatric symptoms of dementia
The AMA is pleased that dementia has been designated as the ninth National Health Priority Area. It is hoped that this will provide a focus for more targeted Government activities to ensure that timely diagnoses can be made, and that patients can access timely and appropriate support services.
One of the first barriers to properly caring for and managing patients with dementia, of any age, is the requirement for assessment by an Aged Care Assessment Team (ACAT). AMA members report poor timeliness with ACAT assessments as a tremendous obstacle when coordinating access to services. In different jurisdictions, waiting times for ACAT assessments can be up to three months.
In 2008, the Aged Care Amendment (2008 Measure No. 2) Act 2008 removed the requirements for annual reassessments for residential respite and high-level residential aged care. This measure was expected to reduce the number of ACAT assessments by 15% (30,000) and subsequently free up ACAT resources to reduce the waiting time for those needing initial assessment.
Since the implementation of that measure on 1 July 2009, no public information has been made available on the extent to which waiting times for an initial ACAT assessment have been reduced. The AMA was advised in a letter from the Department of Health and Ageing that the number of assessments had reduced by around 11%. However, AMA members tell us there has been no discernable difference in the waiting times for ACAT assessment.
The assessment process can be improved by including the patient’s usual medical practitioner in the assessment arrangements. Our members tell us ACAT assessment currently makes little use of the information doctors can provide about their patients. Medical practitioners form long-term relationships with their patients. A person’s usual doctor can bring his or her background knowledge of the whole person and their current circumstances to the assessment process. This information would ensure the person’s assessment results in them receiving the care that is most appropriate for them. It would also reduce the assessment time, which would allow people to access services more quickly.
The extent to which the Aged Care Gateway will provide more timely assessments for people with dementia is unknown. From the information the AMA has about the proposed Aged Care Gateway, it does not appear to draw on information provided by the patient’s usual medical practitioner.
Services and support
There is no doubt that there is a range of services and supports available for people with dementia, and various models of care. The AMA will leave it to the organisations who provide the services and supports, and to those who fund them, to describe them to the Committee. This is because the AMA, and more importantly its members, have limited ability to identify, and subsequently organise those services for the patients who need them.
In addition, the extent to which support and services for people with dementia will be able to be co-ordinated and provided in a timely way is unknown.
Most often the need for services for people with dementia arises is a crisis situation. Sometimes the situation for the patient changes dramatically – they may have a serious fall, or a rapid deterioration of their condition. Sometimes it is their carer who has an unexpected health care event. Medical practitioners find it difficult to secure timely services for people with dementia in these circumstances. It is unclear whether delays are caused by a lack of services, or by poor systems of administration.
Approval for respite care requires an ACAT assessment. In a crisis situation and without an ACAT assessment, sometimes the only option a medical practitioner has is to admit the patient to hospital. This causes great distress for patients and their carers.
A streamlined process is required to improve access to respite care for people who have not yet been assessed by an ACAT or by the proposed Aged Care Gateway system. In these circumstances, access to respite care could be streamlined by allowing medical practitioners to approve respite care for people with dementia in need of urgent respite care in much the same way a doctor determines that hospital admission is necessary.
The need for physical or medical restraint is based on the medical practitioner’s assessment of the issues. The medical practitioner has to determine the right balance between:
- A patient’s right to self determination;
- The need to protect the patient from harm; and
- The possibility of harm to others.
The decision to use restraint is not made in isolation. It involves a process of: request; assessment; team involvement; and consent within an ethical and legal framework.
In the environment of an under resourced residential aged care facility, with limited qualified nursing staff and sufficient numbers of carers, the need for restraint is an unfortunate reality.
Medical assessment and management
In the primary care setting the assessment and management of a patient with dementia is challenging. Good quality medical assessment (and early diagnosis) and management takes time, and requires interaction with a number of people. This work is not adequately covered by the current Medicare benefits arrangements. Dementia in the primary care setting could be better supported with Medicare arrangements that specifically cover prolonged medical assessment, general practitioner management and team care arrangements for dementia.
The AMA looks forward to the outcomes of the Committee’s inquiry into the very important issue.