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.
Australian Physiotherapy Association ACFI Survey 2014 3
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
Australian Physiotherapy Association ACFI Survey 2014 4
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.
Australian Physiotherapy Association ACFI Survey 2014 5
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%
Australian Physiotherapy Association ACFI Survey 2014 6
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
Australian Physiotherapy Association ACFI Survey 2014 7
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.
Total hours Total hours Unpaid
1456.5 1429
27.5
Time spent with clients on pain management
Total hours Total hours Unpaid
798.25 762.75
35.5
Hours spent providing clients non-pain management treatment
Australian Physiotherapy Association ACFI Survey 2014 8
10. In a normal week how many hours do you spend on documentation/paperwork at this RACF?
Totalrespondents:167;skippedthisquestion:188
•27%ofphysiotherapisttimeisspentonadministrationandpaperwork
11. Every client in this RACF receives the physiotherapy treatment they require from a qualified physiotherapist.
Totalrespondents:161;skippedthisquestion:194
•55%ofrespondentsbelieveRACFclientsdoNOTreceivethephysiotherapytreatmenttheyneed.
Percentage
2014 2009
Strongly agree 9 9
Agree 22 21
Neutral 14 15
Disagree 42 40
Strongly disagree 13 16
Total hours Total hours Unpaid
865.05 777.95
87.1
Hours spent on paperwork
Australian Physiotherapy Association ACFI Survey 2014 9
12. In the RACF, what proportion (%) of services that should be undertaken by a physiotherapist is carried out by non-physiotherapist staff?
Totalrespondents:168;skippedthisquestion:195
• 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
Australian Physiotherapy Association ACFI Survey 2014 10
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?
Totalrespondents:14;skippedthisquestion:214
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
Australian Physiotherapy Association ACFI Survey 2014 11
17. How could pain management funding change to better meet the needs of your clients?
Totalrespondents:126;skippedthisquestion:229
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?
Totalrespondents:136;skippedthisquestion:219
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
Australian Physiotherapy Association ACFI Survey 2014 12
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
Australian Physiotherapy Association ACFI Survey 2014 13
19. What do you see as the biggest problem/issue regarding physiotherapy and RACFs?
Totalrespondents:140;skippedthisquestion:215
Thefollowingareextractsoftheresponsestothisquestion:
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.
Technology, equipment and facilities
• 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.
Australian Physiotherapy Association ACFI Survey 2014 14
20. Are there any other concerns you have regarding this RACF?
Totalrespondents:101;skippedthisquestion:254
Thefollowingareextractsoftheresponsestothisquestion:
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.
Technology, equipment and facilities
• 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.
Australian Physiotherapy Association ACFI Survey 2014 15
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