Mental health of older Australians

Mental health of older Australians

In recent years, the aged care sector has endeavoured to improve the quality and safety of care provided to older Australians, following the recommendations of the Royal Commission into Aged Care Quality and Safety (the Royal Commission) and the Australian Government’s response to this.¹ In the background, the mental health and wellbeing of many older Australians, particularly those who live alone or in residential aged care, have deteriorated due to greater isolation and loneliness.² In June 2019, approximately 87 per cent of aged care residents were experiencing at least one mental health or behavioural condition, and 49 per cent were experiencing depression.³ This was exacerbated by the COVID-19 pandemic, which continues to threaten the safety of older Australians and limits their ability to establish and maintain social connections. Older people have experienced dramatic increases in anxiety, worry and psychological distress as a result of the pandemic.⁴ Despite this, their uptake of government-subsidised mental health services remains lower than the general population’s.⁵ Additionally, there is growing recognition that improving the mental health and wellbeing of older Australians requires prioritising quality of life. We must ‘add life to years’,⁶ going beyond quality of care to quality of life.

To improve quality of life for older Australians, we must consider alternative models of care that engage and stimulate each person, to minimise cognitive decline and help them establish and maintain social connections. Momentum is building on this front, with some institutions leading the change. For example, the University of Wollongong is developing Australia’s first ‘Intergenerational University Community’, where older Australians live on campus and enjoy the benefits of living, learning, working and growing alongside university students and preschoolers.⁸ Similarly, some Australian providers have opened residential aged care homes to students, including Calvary Health Care with its Outside In program which saw occupational therapy students living and volunteering on-site.⁹ In Sydney, Neuroscience Research Australia is testing the feasibility and practicability of structured intergenerational programs that bring together preschool children and older Australians for physical and social activities.¹⁰

Governments also emphasise the importance of improving quality of life, mental health, and wellbeing for older Australians. Recently, the Australian Department of Health and Aged Care added quality-of-life and consumer-experience measures to clinical indicators in the National Aged Care Mandatory Quality Indicator Program (QI Program).¹¹ From April 2023, residential aged care services will report on these each quarter. The measures will amplify the voices of older Australians and shift the focus from quality and safety of care, to quality of life. For example, while services already measure the prevalence of unplanned weight loss among residents, and strive to improve nutrition, the new measures will emphasise residents’ opinions on the taste and variety of food, to help providers align each resident’s nutritional needs with their unique personal preferences. The proposed Support at Home Program, to be implemented from mid-2024, expands the list of service categories for those living at home, to improve their independence and social connections.¹² NSW and the ACT have implemented strategies to improve the mental health of older people,^13,14 offering strategic guidance for government investment in efforts to improve the mental health and wellbeing of older Australians.

Although these actions represent a shift in the right direction, their siloed implementation can lead to inequitable results across the country. 

Such a framework should recognise barriers to accessibility and uptake of mental health services: cognitive impairment and dementia,¹⁶ poor digital literacy and digital exclusion,¹⁷ stigma around mental ill-health,¹⁸ and cultural and linguistic factors.¹⁹ Additionally, demographic factors such as gender and socioeconomic status must be considered. While the framework should clearly state the strategic priorities, it should also permit flexible implementation, encouraging innovative design and delivery of initiatives.

Mental health of the aged care workforce

The roles and responsibilities of the aged care workforce are expanding and evolving. For clinical care staff, providing high-quality clinical care is rarely their sole responsibility. These workers also respond to the social and emotional needs of older people, oversee administrative tasks, and undertake regulatory reporting. The COVID-19 pandemic imposed complex and unrelenting difficulties on these workers as they responded to the new threat to the health and safety of older people. In fact, many of the 8,000 older Australians who have died as a consequence of COVID-19 (to 31 August 2022)³¹ were cared for in their final days by aged care workers, who also supported bereaved family members and friends. Workers carried this burden while also coping with workforce shortages due to staff contracting the virus, and skills gaps due to greater turnover across the sector. Worker shortages have prompted nationwide reviews into pay and conditions.

In parallel, the aged care workforce has been required to prepare for and adapt to continuing reforms to the sector, prompted by the Australian Government’s response to the Royal Commission, including the implementation of:

• a new home care system, including changes to the service list and classification system, and a new payment system

• a new funding model (Australian National Aged Care Classification or AN-ACC), which will change the assessment of aged care residents’ needs for the purposes of funding

• new care-minute standards, which will require an average of 200 minutes of daily care per resident, including at least 40 minutes of registered nurse time, from 1 October 2023.

With these changes come new pressures for providers to diversify, innovate and adapt in order to be financially sustainable while meeting regulatory requirements. This, along with other trends – for example, older Australians choosing to stay at home longer and the pandemic’s effects on skilled migration – is likely to cause another wave of market consolidation across the sector.³² For workers, this can mean new employers, new clients, and new roles and responsibilities.

Protecting the mental health and wellbeing of aged care workers also benefits older Australians, their families and carers. In particular, the following require consideration:

• Strengthening workers’ capability. Delivering services is becoming increasingly difficult due to the pace of reforms, changing preferences, and recipients’ more complex needs. Workers must be challenged and supported in responding to these changes. Firstly, formal and informal training courses and qualifications are needed for improved and more specialised workforce skills. This fosters workforce flexibility and responsiveness, and creates career progression opportunities.

• Support for self and others. There is an opportunity to protect and promote workers’ mental health and wellbeing. Increasing mental health literacy is essential to building a resilient workforce that can respond to difficult events and major changes. Measures can include techniques to manage one’s own mental health and support others in managing theirs, promoting self-care, and raising awareness on how to get support. Research shows that training should go beyond compliance, to giving workers the practical and relational skills to provide high-quality care.

• Designing mentally healthy workplaces. Residential care settings are a workplace for staff, as well as a home for residents, so we should create and sustain a positive working environment (for instance, by creating a dedicated workspace for non-resident interactive tasks, and a safe space where workers can take breaks and connect with each other – away from areas where care is provided).

• Responding well to mental ill-health and providing a good return-to-work experience. Supported by stronger capability, the workforce should be equipped to respond to mental health concerns raised by colleagues in a manner that reinforces psychological safety and reassures individuals that support is available. Return-to-work policies and practices need to be person-centred, and processes to support recovery, rehabilitation and return to work must not come at the expense of the individual’s career development or progression.

• Decisions based on data. In light of expected changes to the aged care workforce, workforce data – particularly metrics for mental health (staff turnover, psychological injury claims, job satisfaction) – will help set a baseline for measuring and monitoring mental health and wellbeing. Consistent collection, retention and analysis of data will enable evidence-based decisions to be made as and when required, to support workers and their evolving needs and preferences, and reveal any emerging trends. Current efforts to embed nationally agreed standards on workforce data (through the QI Program and the government’s Aged Care National Minimum Data Set) will provide useful information here.

• Managing change. The aged care workforce is undergoing significant change. Managers should support workers through these changes by communicating clearly and providing guidance and transparency.

^References

^{1 Royal Commission into Aged Care Quality and Safety, Final report: care, dignity and respect. Volume 1: Summary and recommendations, Commonwealth of Australia, 2021. See recommendations 16, 36, 38, 59, 61, 114.}

^{2 PA Strutt, CJ Johnco, J Chen, C Muir, O Maurice, P Dawes, J Siette, C Botelho Dias, H Hillebrandt and VM Wuthrich, ‘Stress and coping in older Australians during COVID-19: health, service utilization, grandparenting, and technology use’, Clinical Gerontologist, 2022, 45(1):106–19, doi.org/10.1080/07317115.2021.1884158.}

^{3 Australian Institute of Health and Welfare, ‘Mental health’, in Older Australians (web report), Australian Government, 2021, viewed 1 February 2023.}

 ^{4 Ibid.}  

^{5 M Cations, LR Collier, G Caughey, J Bartholomaeus, C Lang, M Crotty, G Harvey, S Wesselingh, M Corlis and MC Inacio, ‘Government-subsidised mental health services are underused in Australian residential aged care facilities’, Australian Health Review, 2022, 46(4):432–41, DOI: 10.1071/AH22049.}

^{6 World Health Organization, Good health adds life to years: global brief for World Health Day 2012, World Health Organization, Geneva, 2012..} 

^{7 Royal Commission into Aged Care Quality and Safety, Final report: care, dignity and respect. Volume 1: Summary and recommendations, Commonwealth of Australia, 2021, pp. 32–33.}  

^{8 University of Wollongong Australia, Innovation campus: health & wellbeing precinct, 2022, viewed 1 February 2023.} 

^{9 Calvary Health Care, Live-in students turning aged care Outside In, 2021, viewed 20 February 2023.}

^{10 Neuroscience Research Australia (NeuRA), Intergenerational integration initiative, 2022, viewed 1 February 2023.} 

^{11 Department of Health and Aged Care,} New residential aged care quality indicators, Australian Government, 2022, viewed 1 February 2023. 

^{12 Department of Health and Aged Care, Support at home: program overview, Australian Government, 2022.} 

^{13 Office for Mental Health and Wellbeing, Towards our vision: re-envisioning older persons mental health and wellbeing in the ACT. Strategy 2022–2026, ACT Health, Canberra, 2022}

^{14 NSW Health, NSW older people’s mental health services: service plan 2017–2027 , NSW Government, Sydney, 2017}

^{15 National Mental Health Commission, Submission to the Productivity Commission 2019 draft report on mental health (submission no. 949), Australian Government, 2020.}

^{16 Mental Health Australia, Submission to the Royal Commission into Aged Care Quality and Safety, 2019.}

^{17 J Thomas, J Barraket, S Parkinson, C Wilson, I Holcombe-James, J Kennedy, K Mannell and A Brydon, Measuring Australia’s digital divide: the Australian Digital Inclusion Index 2021, RMIT University, Swinburne University of Technology, Telstra, Melbourne, 2021}

 ^{18 G Batten, Normalising mental illness in older adults is a barrier to care, Australian Institute of Family Studies, 2019, viewed 1 February 2023.} 

^{19 E Solway, CL Estes, S Goldberg and J Berry, ‘Access barriers to mental health services for older adults from diverse populations: perspectives of leaders in mental health and aging’, Journal of Aging and Social Policy, 2010, 22(4):360–78, https://doi.org/10.1080/08959420.2010.507650.}

 ^{20 V Camões-Costa, J Loganathan, C Barton, S Chakraborty, A Hewitt, X Lin and B Brijnath, ‘Factors contributing to the mental health outcomes of carers during the transition of their family member to residential aged care: a systematic search and narrative review’, BMC Geriatrics, 2022, 22(1):1–3, https://doi.org/10.1186/s12877-022-03105-4.} 

^{21 Ibid.}

^{22 Ibid.} 

^{23 P Hill and TR Broady, Understanding the social and emotional needs of carers: final report (SPRC Report 2/19), Social Policy Research Centre, UNSW Sydney, for NSW Carers Advisory Council, 2019, http://doi.org/10.26190/5c59202697201.}

^{24 Ibid.} 

^{25 Ibid.} 

^{26. R Gordon, P Grootemaat, M Rahman, C Loggie and P O’Shea, Evaluation of the NSW Family and Carer Mental Health Program: interim report, Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, 2021} 

^{27. Department of Health and Aged Care, National Aboriginal and Torres Strait Islander Flexible Aged Care Program, Australian Government, viewed 1 February 2023.} 

^{28. Carers Australia, Culturally & linguistically diverse carers, viewed 1 February 2023.}

^{29. C Francesca, LN Ana, M Jérôme and T Frits, Help wanted? Providing and paying for long-term care, OECD Health Policy Studies, Organisation for Economic Co-operation and Development, Paris, 2011.} 

^{30. Ibid.}  

^{31. Australian Bureau of Statistics, COVID-19 mortality in Australia: deaths registered until 31 August 2022, Australian Government, 30 September 2022, viewed 1 February 2023.} 

^{32. C Ansell, The third wave of consolidation: a new investment cycle begins in the aged care sector, Ansell Strategic, 2021.} 

^{33. National Mental Health Commission, Response to the Royal Commission into Aged Care Quality and Safety, Australian Government, 2020.} 

^{34. L Naccarella, C Newton, A Pert, K Seemann, R Williams, K Sellick and B Dow, ‘Workplace design for the Australian residential aged care workforce’, Australasian Journal on Ageing, 2018, 37(3):194–201, doi: 10.1111/ajag.12493.} 

^{35. Senate Community Affairs References Committee, ‘Chapter 2: Changing pressures on the aged care workforce’, in Future of Australia’s aged care sector workforce, Parliament of Australia, Canberra, 2017.} 

^{36. Australian Institute of Health and Welfare, GEN: Aged Care Data: data improvements, Australian Government, 2021, viewed 1 February 2023.}