May 01, 2010

I recently attended a conference in Australia and had the opportunity to visit a nursing facility there and make comparisons to how we do things in the United States.

I spent some time with Mike Birrell, ChB, a general practitioner, and Joy Walsh, director of nursing at Emmaus Nursing Home, a 50-bed facility affiliated with Catholic Care of the Aged about 4 hours' driving time north of Sydney. The facility is surrounded by rolling hills where kangaroos and koalas make their home. What I discovered sheds light on our different cultures and medical systems, but also reveals remarkable similarities.

Like America, Australia is an aging society with 20% of its population over 60. The government has been proactive in developing an infrastructure that can keep elders at home for as long as possible. For example, there is a Home and Community program funded by the government that is surprising in its embrace of respite services.

In this program, the caregiver for a person with dementia is eligible for respite for up to 3 nights, during which an attendant stays at the person's home. In addition, a person with dementia can have up to 3 weeks in a nursing facility to provide the caregiver a longer respite. Alzheimer's Australia manages the program with extensive government funding.

Australia has a remarkable government-sponsored health insurance program that covers every citizen. I asked Dr. Birrell if he knew of anyone facing bankruptcy because of medical bills, and he told me that this scenario did not exist. There is also the option of private health insurance, which may allow quicker access to procedures and tests.

There is an Australian equivalent to assisted living for individuals requiring some personal assistance and supervision, but the term is “hostel” services. It seems identical to ours, just with a different name—just as Aussies call an elevator a “lift,” and a pharmacy a “chemist.”

Nursing homes come under the heading of “residential services,” and there are two levels: “normal” and “high” care, reminiscent of the days when we had the health-related facility designation in this country. High care is equivalent to our skilled care and includes specialized Alzheimer's units. The gatekeepers for high care are local multidisciplinary Age Care Assessment Teams set up by the Australian government.

I toured the 5-year-old Emmaus facility with Ms. Walsh and found it to be modern with wide halls and doors, high ceilings, and open, airy corridors. Each resident had a sun-filled, private room with large windows and a lot of shelf storage. The building was immaculate, as were the residents, and I saw several staff scrubbing floors and safety railings. I learned about the many community volunteers who assist with pastoral care and activities in the nursing home. Some residents had wide, flat computer screens and were surfing the Web. Emmaus includes high care in its services.

When I questioned Ms. Walsh regarding operations, she revealed huge differences from how things are done in the United States. For example, the facilities are not required to have an administrator or medical director—their functions are all done by the director of nursing. There is no such thing as a Minimum Data Set, and physicians are required to see patients only once every 3 months. I found no equivalent to the vigorous rehabilitation or subacute services that are part of the fabric of most American nursing homes.

Unlike America, which has been subject to stringent laws governing nursing homes since 1987, Australia has seen regulation of this industry only recently. Similar to the case in America, the push to regulate came from consumer groups and an expanding population of elders with political power.

Beginning in 2000, the Aged Care and Accreditation Standards agency enforced new standards. This agency performs unannounced inspections that focus on facilities' procedures as well as the clinical outcomes of residents.

I was surprised and impressed with the sophistication of the regulatory emphasis on safe and effective systems. The standards also address issues such as independence, privacy, dignity, the right to vote, and “security of tenure,” which ensures that a resident cannot be arbitrarily discharged.

I was impressed by Australia's emphasis on medication reviews and the mandatory, government-reimbursed participation of pharmacists in the process, even for community-dwelling elders. In nursing homes, the government pays for education of staff about medication regimens and for feedback to treating physicians. Events triggering pharmacist review include falls and behavior changes.

Half of Dr. Birrell's practice is dedicated to nursing home residents. A descendant of Quakers who immigrated to Australia 150 years ago, he spoke with enthusiasm about his work with the elderly. His father was a renowned physician in Australia who championed public health laws related to alcohol restriction and seat belts. Australian physicians spend 6 years in medical school, followed by 1 year of general practice and 2 more years of residency in a hospital. Dr. Birrell described his approach as purely holistic, fixing issues related to mobility and mentation while maximizing both the length and quality of life for elders under his care.

In a program he calls “Agings and Endings,” Dr. Birrell takes medical students from the University of New South Wales, Sydney, on nursing home rounds. In his teaching, he emphasizes the skills of chronic care and end-of-life issues.

One striking difference between long-term care in America and Australia is the litigation situation. When I inquired whether nursing homes get sued for injurious falls or pressure ulcers, Director of Nursing Walsh looked at me quizzically and remarked that these lawsuits were “unheard of.” I learned that Dr. Birrell's malpractice insurance was a fraction of what a similar physician would pay in the United States, and the concept of “defensive medicine” is virtually nonexistent. In Australia, I got the impression that quality care is indeed possible without the threat of litigation.

I had a lovely experience visiting Emmaus Nursing Home, and was impressed with the caring attitudes of the staff as well as with the facility itself. As I was leaving, I spoke with a wheelchair-bound elder with severe upper extremity contractures sitting quietly by a window. He told me that he spent part of his morning watching kangaroos out on the lawn.

Despite the vast differences, some things are very similar to nursing home practice in America. As Dr. Birrell and I were having lunch, his cell phone rang. It was the nursing home calling to inform him that his admission had arrived and that he needed to come make an initial visit. Dr. Birrell looked puzzled and said into his phone, “What admission?” His spirit, however, was undampened by the unexpected addition to his workday.

What a remarkable experience it was to travel so far to find an outstanding role model for any physician who works in long-term care.

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