Taking matters into their own hands

A GP-led solution for aged-care is achieving a dramatic drop in hospital presentations

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Enterprising GPs are going against the tide by setting up dedicated services for patients in residential aged care.

With financial and time constraints making aged care visits too onerous for many doctors, GPs at a forum earlier this year reported added difficulties in gaining entry to premises, accessing records, finding examination rooms and communicating with staff.

GPs at the forum, held by AMA Victoria, also raised concerns about being sidelined by big corporate aged-care providers who are increasingly installing their own doctors, another sign the traditional care model is cracking.

“There are more and more corporate aged-care facilities being developed, and what we’re finding is that facilitating ease of access [for visiting doctors] is not there in some cases,” said Dr Tony Bartone, the recently appointed AMA vice president.

“As long as patients are not coerced, and have an opportunity to choose their own doctor, and that doctor can provide care to a quality standard he or she is comfortable with, and the facilities are appropriate… that’s the position we’d like to work towards,” Dr Bartone said.

Dr Richard Bills, who operates a large practice at Woodend, northwest of Melbourne, is one of the GPs exploring more opportunity in aged care while others are retreating.

“I discovered the best way to do aged care is to commit to aged care, as opposed to the traditional add-on model of trying to squeeze it in around the edge of what you do,” Dr Bills said.  “It’s an attractive model for GPs to work in, providing a good platform for them to deliver aged care services in a supported way.”

Doctors like the broad spectrum of practice, with some choosing to work exclusively in the more structured visiting service, and demand is strong, he says. The service also offers education for residential care staff and ensures they know how to access patients’ Advance Care Directives and medication plans.

“This style of care is dramatically reducing unnecessary transfers and hospital presentations,” Dr Bills said. “Unfortunately, we don’t have a measuring and sharing arrangement with the government on all the money it is saving, but we do get to have that warm, fuzzy feeling.”

His start-up venture, New Aged Care, launched in 2014, got a kick-start from a small Medicare Local grant to address problems at two residential facilities in outer suburbs of Melbourne.

“The nearby public hospital had identified these facilities as having lots of ‘frequent fliers’ who were turning up during unsociable hours by ambulance, without necessarily being terribly unwell,” he said. “These patients did not have a regular GP, and the staff had nowhere to go. Rather than wait 10 hours for a locum, they would pop the patients in an ambulance.”

The New Aged Care team is led by four specialist nurses who are the first point of contact. Instead of scrambling to manage a small number of patients across several facilities, doctors can achieve economies of scale with regular visits.

Dr Bills says the service has grown rapidly through word of mouth, including approaches by other GPs to take on their patients.  It now reaches 260 patients at five premises and has had talks with another two providers.

Many aged care homes face situations where new residents do not have a local GP and none steps into the breach, and fewer highly skilled nurses are on staff as providers keep a tight lid on wage costs, he says.

But the recent practice of corporate providers hiring their own doctors strikes him as fraught with potential conflict, given the direct relationship between patients’ assessments and commonwealth funding.

“It seems a bizarre loophole in the system that the people who own the facility have the ability to assess the residents and therefore determine the funding they get,” he said.

Dr Jenny Downes-Bryden says building relationships with patients and their families is a key ingredient of the aged-care services she runs from her general practice on the Mornington Peninsula, southeast of the Victorian capital.

“We put so much effort into getting to know them,” she said.

“We’ve got lots of GPs and we’ve been using this as a fantastic training model for GP registrars, getting them to buy into coordinated compassionate care and steering away from 10-minute medicine. They can practise longitudinal medicine over their period of attachment to us and get to know these patients really well.”

GPs from Dr Downes-Bryden’s Peninsula Family General Practice now take care of more than 2000 patients across six premises, ranging from independent living units to high care, a long way from a modest start about 12 years ago.

The idea came to her because there was an abundance of specialists in the area but no “glue” to coordinate the care of aged patients.  She recruited an allied health team and started out with just 10 patients at a couple of large not-for-profits.

“What makes it work is attention to the chronic disease management items in aged care, care plans, health assessments, medication reviews, although sadly these are being eroded.”

Mental health plans, for example, are no longer available to commonwealth-funded patients in an aged-care setting, and medication reviews under Medicare have moved from yearly to once every two years, Dr Downes-Bryden says.

Doctors not only see the gamut of clinical issues and interdisciplinary work with pharmacists and specialists, but also take on the burden of counselling patients with anxiety and depression – said to affect 70% of aged-care patients.

“So much of aged care is about counselling or anxiety reduction, or discussing the end of life. It’s incredibly labour intensive and probably not the best use of my time when a psychologist could be doing it for us.”

Each facility using the service basically has four regular rounds a week, with three doctors spacing out their visits, and Dr Downes-Bryden fields after-hours calls.

“We’ve started sending a doctor on Saturdays as well, when the facilities have a lot of agency staff on who don’t know these patients so well. That has created a huge reduction in costly ED attendances, so these elderly people are not sitting around a hospital on trolleys and it ultimately saves money for the community.”