Aged care system pressures affect TCP

Workforce shortages, increasingly complex care needs and gaps in care pathways are threatening the ability of the Transition Care Program to deliver the best outcomes for older people, a new white paper has warned.

The Restorative Care in Practice: Advancing the Transition Care Program white paper draws on insights from aged care providers, clinicians and sector leaders shared during a national workshop on how restorative transition care is being delivered following updated guidelines.

The TCP provides short-term care for older people as they recover from a hospital stay and can include social work, nursing support, personal care or allied health care.

But workshop participants identified workforce shortages across allied health, nursing, pharmacy and primary care as a critical barrier affecting access – limiting multidisciplinary practice and increasing reliance on brokered services.

This is creating challenges for providers across metropolitan, regional and rural areas alike.

Co-developed by Aged Care Research and Industry Innovation Australia and Flinders University’s Caring Futures Institute, the 22-page white paper also found many older people are facing barriers beyond their health needs while recovering after discharge from hospital, including:

• financial hardship
• housing instability
• long waits for support services
• low health literacy
• limited access to interpreters.

Lead author Dr Claire Gough from Flinders University’s Caring Futures Institute said that while the sector strongly supports the principles behind the updated guidelines, practical barriers make implementation increasingly difficult.

“The message from stakeholders is clear. The guidelines reinforce what good restorative care looks like, but guidelines alone will not deliver outcomes,” Dr Gough said.

“Older Australians are leaving hospital with increasingly complex needs and many services are struggling to access the workforce and resources required to support them effectively.”

Gaps in care undermining recovery

The white paper also found that wait times for home support services and shortages in community-based care are similarly contributing to gaps in support following discharge from transition care programs.

These gaps can go on to undermine recovery and increase the risk of avoidable hospital readmissions, stakeholders warned.

Researchers did identify opportunities to improve outcomes through greater use of telehealth and technology, particularly in rural and remote areas, but digital literacy, internet connectivity and clinician confidence remain barriers to wide adoption.

Dr Gough said investment in workforce capacity, system integration and better measures of restorative care outcomes will be essential to meeting the needs of Australia’s ageing population.

“Every older Australian deserves the opportunity to recover well and maintain their independence after a hospital stay,” she said.

“Our findings show that if we want transition care to fulfil its potential, we must invest in the workforce, strengthen connections across the system and ensure services are equipped to meet growing demand.”

Better connectivity across care services needed

ARIIA industry manager Joanna-lee Tan said there needs to be stronger connections between health and aged care services to ensure recovery continues beyond the transition care period.

“Transition care cannot operate in isolation,” said Ms Tan, who is also an Australian Physiotherapy Association gerontological physiotherapist.

“When people finish the programme, they still need access to ongoing supports. Without stronger links between hospitals, primary care, community services and aged care, there is a real risk that people lose the progress they have worked hard to achieve.”

The white paper outlines several recommendations on how to:

• strengthen workforce capacity
• strengthen multidisciplinary care
• support goal setting
• plan transitions beyond TCP
• manage increasing client complexity in TCP
• ensure appropriate referrals and identify patient readiness
• promote equity and service access in TCP
• integrate technology and innovation into TCP.

Read other stories for executives here
Follow Australian Ageing Agenda on LinkedIn and Facebook, sign up to our twice-weekly newsletter and subscribe to AAA magazine for the complete aged care picture