MD INK recently organized a seminar in Johannesburg hosting Nicki Liebenberg, (Healthcare consultant from B Cared 4) and Syd Eckley, a widely recognized consultant in the field of Aged Care in SA, to look at the current challenges facing Frail Care. The South African Care Forum was there with organisations representing Cape Town, Johannesburg, Pretoria, Durban and Pietermaritzburg regions: confirming that across the country we in the Aged Care Industry are facing similar experiences and challenges.
There are more older people in South Africa than ever before, (9% ? of our population being over 60 in 2019 and expected to increase to 16 % by 2050) yet Frail Care Facilities are closing across the country and there is an estimated 41% vacancy rate in existing Frail Care facilities.
While many would like to point a finger at Covid, Syd Eckley pointed out that the cracks in the industry were evident long before Covid.
Covid has, none-the-less, had an effect : Internationally Care facilities were perceived as “hothouses of infection” with many experiencing high Covid mortality rates. Sensationalist reporting may have magnified misconceptions and created fear amongst our elders and their family. Determined to protect themselves from this possible threat, some people have taken parents out of facilities or been reluctant to utilize Care Facilities for frail relatives.
However, in South Africa, our Care Industry responded with speed and determination resulting in heightened infection control and severe lockdowns across the industry. Result? Mortality rates were kept to a minimum. In fact many experienced a lower mortality rate for the period May to December than in previous years. Residents and families have expressed a sense of “being kept safe”. However the physical, spiritual, emotional and mental consequences of Lockdown have been severe. All reported significant deterioration in wellbeing and independence amongst their residents with a concomitant increase in institutionalisation. Lack of exercise impacted on physical mobility . Lack of family contact, activities and spiritual gatherings contributed to increased depression and in extreme cases an increase in suicide. While “fear of infection” does not seem to be impacting admission rates locally, loss of independence and fear of not being able to visit and hug loved ones is a real constraint on admission. There is likely to be long term impact on the industry with people reluctant to lose the power to decide for themselves who they see and how often they may visit or how physically close they may be with a family member; particularly in the last phase of life when quality of relationship is all important.
How to balance the need to minimize the possible spread of infection with a “life worth living” was something of a challenge and a burden to most managers of facilities who sincerely grappled with these realities.
Besides the direct financial consequences (supplying PPE, rotating staff, keeping “non earning” sections or rooms aside for isolation purposes), the financial consequences of Covid across the country are also a real threat to the industry as families who supported relatives in Care have lost income and can no longer afford to contribute to the Care of their relative. A number are taking relatives home to care for their relative themselves, especially now that many have lost jobs or are working from home. Altered lifestyles are offering families more flexibility in terms of caring for an elder.
Ms Liebenberg went on to list a number of change agents impacting the future of residential care facilities of which Covid was only one.
- The Economics of Frail Care are without a doubt one of the major driving forces threatening frail care. But Syd Eckley points out that rising cost of frail care is a pre-covid issue merely underscored by the financial consequences of world wide lockdowns. He quotes a study done by De Loittes in 2018 that points out the cost of frail care has doubled in the last 10 years, straining the average family’s ability to afford such care. Factors affecting the economics of the industry are :
- Staffing is a driving factor in the cost of frail care : if we are going to survive we will need to relook at staff structuring, using some of the changes proposed in the Amendments to the Act 13 / 2006 making greater use of upskilled carers and ENAs. The high ratio of staff to residents increases the cost of care and so the increased use of assisted living options where possible will be critical. Ms Liebenberg believes that if we are following a Person Centred Care model , as an industry we need to challenge the staff to patient ration of 1: 6 as set in the act. She is of the opinion that if proper assessments are done on admission with appropriate care plans focusing on quality of life, we will find most of our facilities are overstaffed. We will need to upskill ENAs to include medical management and dispensing of medication.
- The need to meet the regulations and requirements of a myriad pieces of legislation continues to flummox and bewilder many of us necessitating the use of outsourced experts.
- Static Government contributions (subsidies) that do not begin to meet the per capita cost of Frail Care means those with limited economic means can no longer afford the care they may desperately need and facilities, largely PBOs and NPOs can no longer fund the deficit. This is dividing care into that which the wealthy can afford and a very different model for the economically disadvantaged.
- Finally : Do you know the per capita cost of your residents? And what is the ratio of staff – all staff , outsourced included – to residents? To budget and plan appropriately we need to be on top of these figures and look at creative ways of minimizing them.
One of the consequences is that age on admission has increased to late 80’s and 90’s and there is a quick turnover of residents, with the focus on the need for palliative care.
In navigating these waters we are going to have to look to our policies and procedures to ensure that they meet legislative requirements and core documents such as our constitution, admission policy, House rules will all need to talk to each other and
Generational perceptions : Baby Boomers (the new old / emerging older generation) require a very different model of care to that which their parents might have accepted. The need for choice and recognition of individual preferences is going to be critical for the long term survival of our industry. Thus the demand for Person Centred Care such as the Eden Alternative , and “Attentive Care” Approach which focusses on the dignity of the individual and is relationship driven, are critical. Different Models of Care are also impacting on the industry as the traditional medical model of care is perceived as institutionalized and people are looking for alternative options.
For those who must move; they want a “home away from home” and to offer this we are going to have to rethink our attitudes to pets and children in the home, even in frail care. Ageing in Place is the recognition that many people are most comfortable in their own homes and would prefer not to move for care. A growing number of organisations are offering this option to people in their own homes. “Care Homes” are a rising force in the industry: these are small often suburban houses accommodating 5 to 10 older persons with a few carers who are also usually the cooks and cleaners and 1 registered nurse overseeing 4 or 5 homes at a time. With smart phones, Whatsapp, video conferencing, and cameras monitoring carers, the registered nurse does not need to be on site to supervise every action. Smaller homes may also be able to fly under the radar when it comes to adhering to onerous legislation. Both Mr Eckley and Ms Liebenberg challenged the industry to Self Regulate and to set standards and criteria for our industry that will inform Government instead of the other way around. It will be up to the industry to challenge existing norms and standards based on a medical model of care and to find a more appropriate staffing structure based on Person Centered Care, which recognizes that we are homes and not hospitals. Problem is we are fragmented as an industry so to set standards will be a challenge.
Purpose. Care homes must be clear about their primary function: To provide state of the art medical care at the end of life so as to prolong life as long as possible ? Or to provide care that maximizes wellbeing and quality of life that recognizes the need for contentment, purpose and meaningful relationships at the end of life.
Cultural perceptions and the Racial Divide ; in 1990 12.8% , a total of 55 640 of the white older population, were accommodated in Care Homes. Today the number is as low as 25 000; perhaps only 4% of the population over 60 . This contrasts starkly with only 0.5% of older black people who live in care homes. Most cannot afford the care that they may require, and as previously mentioned Government subsidies are limited. But more than that few would choose this type of care; choosing to stay in their communities with family caring for them. If the industry is to survive, Care facilities must find a way of meeting the needs of people of all races. It has been suggested that alternative approaches such as a facility in the rural surrounds of Ladysmith practices will be essential. Residents are involved in the kitchen, some keep chickens and cows and some manage vegetable gardens despite various levels of frailty. Certainly most older persons have a particular bond with their grandchildren and play a critical role in the rearing of children. Any facility wanting to attract people of colour would need to revisit their policies on having children stay in the facility.
The Rise of Technology has already brought about changes in Europe and the States with regard to providing and monitoring care cost effectively and our industry will need to catch up to survive. Carers using tablets for record purposes; linking to greater systems eg : Medimass; linking residents to families using skype and zoom etc. We need to find an alternative to the archaic bell system many of us are stillusing.
We in the industry are going to have to do things differently. There will always be a need for Care but the future of Care may not look like the institutionalized settings we inherited. We will need to focus not just on quality of care but on residents’ quality of life.
Services offered will need to be appropriate to the needs of a changing population ;
astute in navigating the waters of legislative requirements and creative in keeping