Greta* has called Glenbrook Rest Home in Waiuku “home” for the past six years. She is, to quote manager Peter Mathyssen, a “delightful” resident. She dotes on one of the rest home dogs, Toby. At the moment she is mobile and “still going strong”, but she is becoming increasingly frail and suffers from glaucoma. Despite being nearly blind, she can find her way easily around the rest home because she is familiar with it – after all, Glenbrook is her home.
Greta has expressed a wish to stay at Glenbrook for the rest of her life – a wish shared by her daughter who lives a kilometre down the road.
However, Mathyssen is mindful that should her condition decline, it may not be possible for Greta to remain at Glenbrook. Glenbrook is a 22-bed facility that is contracted to provide rest-home level care.
But in this age of person-centred care and consumer choice, surely there is a way to fulfil Greta’s wish?
Apparently not. Over the course of nine weeks, over 30 emails were exchanged between Mathyssen and Counties Manakau District Health Board (CMDHB) last year, discussing this situation.
Mathyssen wanted to know if he could apply for private hospital-level funding in order to be able to continue to provide care for Greta, should her needs escalate beyond rest home-level care. He thought it should be possible for Glenbrook to apply for this funding through the ‘Dispensation Policy to Provide Hospital Level of Care for One Named Person’.
The gist of the dispensation policy is that if a person is assessed as requiring hospital-level care during the final stages of life and is in a rest home-level only facility, the facility can apply to HealthCert for the dispensation to provide hospital-level care without having hospital-level certification.
A facility can’t apply for dispensation in advance – only when a resident is assessed as needing higher level of care. The intent of the dispensation is so that residents who are actively dying do not need to move, rather than apply to those residents who would be anticipated to require a long period of hospital level care.
Hospital-level care at a rest home-level price
However, even if dispensation was granted and hospital-level care could be provided, Glenbrook would only receive rest home-level funding.
A rest home’s certification to provide a particular level of care is different to its funding arrangements, which relate to the contract the rest home holds with the DHB, its ARRC contract. It seems peculiar that a rest home can temporarily be allowed to provide care beyond its certified level, but for the funding not to follow suit. The DHB’s argument is that the heightened level of care is intended to be for a short period of time.
Essentially this all means that Glenbrook would be providing private hospital-level care – albeit for a short time – with rest home-level funding.
“This doesn’t seem fair to me, especially since CMDHB would be required to fund [Greta] at hospital level anyway if she was transferred to a private hospital,” says Mathyssen.
The DHB informed Mathyssen that if Greta requires more complex care than Glenbrook can offer, Greta and her family will be supported to select the most appropriate facility at the time.
Mathyssen has described this as “nonsense”.
“The most appropriate facility is Glenbrook Rest Home, as expressed by the resident and her family, and there is no support from CMDHB for this,” says Mathyssen.
“CMDHB’s unwillingness and cold-hearted refusal to redirect funding is a slap in the face and a total let-down. They obviously don’t care.”
Care Association New Zealand (CANZ) shares in Mathyssen’s frustration.
“CANZ was happy to support the policy of having a single hospital-level resident in a facility but was blindsided when HealthCERT stipulated that payment could only be at private hospital-level if the facility had a private hospital attached,” says CANZ’s Victoria Brown.
“This means once again that the stand alone facilities, who deliver this care, cannot be suitably remunerated for it.”
Mathyssen also felt aggrieved that he was “barred from corresponding with the elected members of the CMDHB board, who are meant to represent the public” – something that he views as “highly undemocratic”.
CMDHB’s General Manager, Adult Rehabilitation and Health of Older People Dana Ralph-Smith says the DHB has nothing further to add to Mathyssen’s queries on the matter.
“We have requested that he does cease to contact board members simply because we have answered [his questions] many, many times. As explained, we, as a DHB, are constrained within the boundaries of the national funding agreement and we cannot act beyond this,” she told INsite.
Ralph-Smith confirmed that CMDHB processes aligned with the regional and national view.
“The ARRC is a national agreement. Any change to the contract requires to be negotiated nationally through the annual A21 negotiations – DHBs do not have an ability to arbitrarily change the contract, including the pricing structure.”
This may be so, however, Jon Shapleski, Programme Director, Health of Older People for DHB Shared Services also says each DHB should consider the needs of their population.
“With regard to support for stand-alone rest homes, DHBs have responsibility to ensure services required to meet the needs of their population are available. A DHB will make local decisions in regard to any support required to ensure those obligations are met,” he says.
Consequently DHBs find themselves in a difficult position – bound to the parameters of a nationally agreed contract, yet expected to meet the needs of their populations at the same time.
Greta’s case highlights the tension between adhering to the contract and acting in the best interests of the resident.
Greta didn’t get her wish to remain in Glenbrook. Instead she has been transferred to a private hospital. Glenbrook staff recently went to visit her and took Toby, the rest home dog she adores, for a cuddle.
Raising the bar for rest home admission
Greta’s story illustrates the reality for many rest homes in New Zealand.
In days gone by, it was not uncommon for rest homes to have car parks for their residents’ cars. They would live for years in residential aged care. These days, thanks to the emphasis on keeping people in their homes and raising the bar for rest home admission, residents are often barely able to walk when they are admitted. People are now entering residential aged care at such a heightened state of frailty that they require a very high level of care. Yet rest homes are not funded adequately to provide this level of care.
The line between what constitutes rest home level care and hospital level care is becoming increasingly blurred thanks to the trend towards hospital-level care and inconsistencies between DHBs.
“My members tell me that they find themselves providing care that is more aligned with hospital care but funded at the rest home level rate,” says New Zealand Aged Care Association (NZACA) chief executive Simon Wallace.
“Evidence is emerging of inconsistency in the application of interRAI assessments between DHBs which means the threshold for a change in level of care might be quite different from one region to another.”
Is rest home-level care in danger?
If we continue along this path, rest home-level care appears to be in danger of being phased out. There have been (unconfirmed) reports from providers that authorities at Auckland DHB have suggested that there will be no such thing as rest-home level care in two years’ time.
Associate Minister for Health Nicky Wagner was hard to pin down on the subject.
“The current trend of reducing demand for rest home care is expected to continue, however, phasing it out would require new, alternative care arrangements,” she says.
Jon Shapleski says there is no plan to phase out rest home-level care “at this stage”. He describes rest home-level care as “a substantial part of the aged care service delivery framework” absorbing around half a billion dollars of government funding, purchasing around 3.5 million bed days of service per annum.
Shapleski says the current funding model for aged residential care and the agreements between providers and funders both support the continuing demand for rest home-level service.
“Having said that, demand for rest home care has shown a downtrend over recent years offset by an increase in demand for dementia and hospital-level care as our population ages and present to aged care later in life than was the case 10 years ago with more acute and complex conditions.”
NZACA agrees. Simon Wallace says he is not aware of any plan to phase out rest home level care.
“In fact dedicated rest home level care makes up around 31 per cent of total beds in the sector, although this has been slowly declining over time as dementia beds in particular increase.”
Victoria Brown says anecdotal evidence suggests that the number of referrals to rest homes has fallen and this appears to be affecting the stand alone facilities negatively.
“These facilities are also not faring well as DHB staff seem to encourage families to choose a dual facility – that is, a rest home with a private hospital attached. The reason given for this is that when a resident becomes private hospital-level care they ‘don’t have to move’. The fact that they do move out of a facility into another part seems to have escaped everyone’s notice.”
DHBs have been reminded of their obligations to ensure client choice. DHB Lead for Older People’s Health Chris Fleming wrote to the DHBs and NASC portfolio managers in April last year on behalf of the ARRC Joint Steering Committee managers, reminding them of their responsibilities towards prospective clients and that they shouldn’t be suggesting certain facilities over others.
Northland DHB’s Sandie Kirkman, who sits on the Needs Assessment Service Coordination Agencies (NASCA) Executive, says one of NASC’s core roles is to provide all options to the clients and carers so that they are able to make an informed decision.
Of course, when taking into consideration the increasing levels of acuity for eligibility into residential aged care, the DHBs and NASCs can hardly be blamed for pointing out to people who might be requiring hospital-level care very soon that they should probably consider a facility that offers hospital-level care. It must be difficult for assessors to remain completely neutral about all facilities when some are clearly a better long-term fit for people than others.
If the bar for admission to residential aged care continues to be raised, things do not appear to bode well for stand-alone facilities offering only rest home-level care. The situation is further aggravated by low levels of government funding.
The silver lining is that the Age-Related Residential Care (ARRC) Funding Model is about to undergo a review, providing an opportunity to take a good look at a model that has been largely unchanged for more than a decade. The review will look at where opportunities for innovation can be offered to all providers, small, medium or large.
Hopefully the review will offer some solutions that allow funders and providers to see eye-to-eye on how to provide truly resident-centred care at a fair price.