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Impact of Ageing Population on Models of Health Care Delivery

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School of Nursing and Midwifery, Edith Cowan University

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Impact of Ageing Population on Models of Health Care Delivery

Like other developed countries, Australia is experiencing an increase in older residents

aged 65 years and above. Compared to 20 years ago, the country had fewer older residents. In the

fiscal year 2015-2016, 3.4 million residents aged 65 and above resided in the country, making up

around 15% of the total population (Khadka et al., 2019). In 2031, older residents will comprise

19% of the total population. Older adults utilize a disproportionately large amount of health

services, with the cohort accounting for 41% and 48% of all hospital days and hospitalizations,

respectively (Khadka et al., 2019). As the population increases, so will the demand for healthcare

services. Moreover, the government may have to spend more on residential aged care in the

coming decades. The paper aims to discuss the impact of the ageing population on care delivery

models in the country.

Models of Health Care Deliver

Older adults in Australia rely on private and public aged care services to meet their needs.

These care services fall into home care packages, senior residential care, and transition care

(Khadka et al., 2019). Homecare packages focus on providing community-dwelling older people

with the support and maintenance they need to prevent premature placement into permanent

residential homes or hospitalizations. Since 2015, the structure of these services has changed,

and they are now run by the Commonwealth Home Support Program and Home Care Packages

Program (Khadka et al., 2019). On the other hand, residential aged care comprises both respite

and permanent residential care. Lastly, transition care provides short-term support and care for

patients transitioning from hospitals to other care or community settings (Khadka et al., 2019).

Generally, these services are funded by the government, although non-profit entities are in the

market.
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Funding of care is funded either through a hybrid two-tier system. The first tier is

Medicare, which is a universally supported tier. The second tier is voluntary private health

insurance, which covers ancillary healthcare services and private hospital care (Calder et al.,

2019). Both out-of-pocket payments and Medicare are used to finance primary care. Under the

Medicare schedule, 85% of the total fee are reimbursed to practitioners in primary care settings.

On the other hand, consumers pay for the rest of the costs (Calder et al., 2019). However, in

2012, the government introduced the Home Package system to replace the two-tier system for

aged care but continued to fund the two-tier system (True et al., 2022). The Home Package

system was in response to the failures of the two-tier system to meet the care needs of the aged

population.

In developing the home package system, the Australian government relied on the person-

centered medical home approach. The approach is built on ten principles, a template for the

future, care coordination, comprehensiveness, prompt access to care, continuity to care,

population management, patient-team partnership, team-based care, empanelment, and data-

driven improvement and engaged leadership (True et al., 2022). Under the program, an appointed

agency would stratify risk, develop team-based-care guidelines, bundle payments per enrolled

older adult, and conduct share planning. The government began to improve the new model in

June 2016 and ran the program until June 2021. by the 21st of August 2018, around 10,161

eligible individuals had been successfully placed in 131 care homes in ten primary health

network regions (True et al., 2022). However, the program did not achieve its objectives.

The Home Package program was meant to increase the role of the private sector in

improving the choice of services they could order for home-based care. The program was

introduced because most Australians prefer to spend the end of their lives at home, with survey
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data showing that 60-70% of older adults in the country would prefer to die at home. It echoes an

emerging trend among older adults to age in place (Gaans, Emy-Albrecht, & Tieman, 2022). As

such, most prefer to stay home and receive end-of-life care in their homes. However, the

program was not effective. In 2017, 47.3% of allocated packages had not been spent. The amount

had reached $350 million. Moreover, by 2019, each client had $7000 unspent funds (Rowland &

Joyce, 2020). Some factors that contributed to the problem included clients choosing temporary

leaves of the program, holding onto funds, and automatic upgrades of packages (Rowland &

Joyce, 2020). As such, the program had not met its expected goals.

Moreover, the home package program was flawed. The system had prolonged wait times,

contributing to higher mortality among older residents and increasing the risk of transition to

permanent residential homes (Visvanathan et al., 2019). Older patients who waited more than 30

days for a home health program had an excess mortality risk of 20% two years after placement

(Visvanathan et al., 2019). One of the reasons for the prolonged wait times was the development

of a centralized wait list in 2017, which provided a picture need for unmet needs. Before the

development of the waitlist, individual providers had their waitlists and prioritized placement

and provision of services depending on the needs of eligible patients. By 30th June 2018, around

121,418 consumers were on the national waitlist (Visvanathan et al., 2019). However, the process

was flawed due to the complex interaction between demand, mix, and supply of aged care

services. As such, the government began to look for alternative methods for improving the

quality of care.

In 2021, the government introduced primary health networks (PHNs) to meet the growing

demand for palliative care in response to the aging population. PHNs are independent

organizations that aim to rationalize health services and ensure older people and the general
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population have access to healthcare services (Gaans, Emy-Albrecht, & Tieman, 2022). Under

Greater Choice for Home Palliative Care, the government would provide funds for PHNS, with

the goal of; (a) improving access to the best palliative care; (b) supporting palliative care at the

community level, and provision of primary care; (c) ensure that patients receive the proper care

at the right place, and the right time to reduce unnecessary emergence department services; and

(d) leverage technology to provide responsive and flexible care to the older population (Gaans,

Emy-Albrecht, & Tieman, 2022).

Bosel and Sharp (2020) state that PHNs could potentially improve patient care delivery.

They are more robust, and PNHs are better suited for dealing with the complex care needs of

older people. For older persons, PHNs aim to ensure that they receive proper and quality care

like other Australian citizens. The critical attributes of PHNs that make them suitable include the

ability to engage community members, the ability to collaborate with other providers, including

social and healthcare providers, high distribution across the Australian state, and their ability to

undertake comprehensive population health planning. Currently, there are more than 31PNHs

across Australia that work directly with healthcare providers, aged care services, hospitals,

general practitioners, and state and commonwealth officials (Bosel & Sharp, 2020).

Australia’s 10-year plan for 20222-2023 envisions a change to the healthcare sector,

characterized by increased funding to enable PNHs and other institutions involved in providing

care to older adults to improve the quality of services and reduce frailty in the population

(Australian Government, 2022). the government will invest $17.7 billion to reform healthcare for

older adults in the country. The proposed reforms to improve the quality of life include boosting

access incentives for general practitioners and allied health service providers. Moreover, the

reforms aim to improve the quality of care in residential aged care, improve dementia care
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pathways, and provide more funding for service providers working with older adults in

community settings. These reforms are meant to enhance the quality of life of older adults,

increase support for home care, reduce unnecessary hospital visits, and provide more effective

care to the population (Australian Government, 2022). However, the extent to which these

reforms will effectively improve care is yet to be seen.

Australia could benefit from an alternative healthcare delivery model that is more

effective and less fragmented. The current system comprising profit, non-profit, and public

providers is inefficient, fragmented, unfair, and underfunded (Gaans & Dent, 2018). For

example, the waiting times for non-urgent procedures can range from 2 days to 365 days,

depending on the location (Calder et al., 2019). It comprises multiple players with no sufficient

oversight. Services for older people are often inaccessible, with long wait times, limited choice

of appointments, and low accommodation. On the other hand, there are issues of accessibility. A

good example is the time it takes for patients to be seen, which has increased from 93 minutes to

99 minutes between 2013 and 2108 (Calder et al., 2019). These inefficiencies pose a significant

threat to the welfare of patients. However, the country could benefit from new health delivery

approaches like value-based care.

Value-based care offers an alternative to the fee-for-service two-tier system. According to

the value-based approach, the quantity of care services does not determine the reimbursement

rates (Bally et al., 2022). For example, physicians would not be reimbursed for the number of

services provided but rather for the value of the services they provide in dollar terms. In a value-

based care model, outcomes are measured at different points in the continuum of care to

determine whether the services are meaningful to the welfare of users, such as their quality of

life and functional status. A value-based care model requires healthcare organizations to optimize
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quality measures so that service funders and patients can better make informed decisions (Bally

et al., 2022). As such, the value-based approach requires multidisciplinary collaboration and

integration of information technologies to facilitate sharing of data and delivery of service.

Australia has made some progress toward implementing value-based care.

In 2022, 11 programs and initiatives were based on the approach. One good example is

the NSW initiative, which comprises four programs, collaborative commissioning,

commissioning for better value, integrated care, and better value care (Dawda et al., 2022). The

collaborative commission is an initiative where PHNs and local health districts employ patient-

centered commissioning groups to improve the health outcomes of local communities. Such

models include urgent care for frail and older adults, addressing poorly managed diabetes, and

cardiology in the community (Dawda et al., 2022). Another example of value-based care is using

HealthPathways to improve care by integrating referral information and evidence-informed

clinical data at points of care. Early adopter sites can use the program across Australia. The

Australian government has also run programs such as the Health Care Homes Trial, which tests

the model in residential homes, to determine the feasibility of value-based care (Dawda et al.,

2022).

Conclusion

The Australian government recognizes that the percentage of older adults in the

Australian population is increasing. As such, it has conducted several reforms to improve

efficiency in healthcare delivery to the aging population. Some reforms include implementing the

home care program to enhance the quality of life among older Australian community residents.

However, despite being based on an evidence-based approach, the program was unsuccessful. It

was plagued with delayed enrollment, failure to effectively use funds, and long waiting times. In
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response to the collapse of the previous model, the government introduced primary health

networks to bridge the healthcare delivery gap among older people. However, the model has not

been evaluated. One of the main reasons that the healthcare delivery system has been able to

respond to the aging population is the high fragmentation of the system. The healthcare delivery

system comprises multiple players, public, private, and non-profit, with little oversight. In

response to these challenges, the government is experimenting with a value-based approach to

care. The ability of the government to improve healthcare delivery will depend mainly on its

ability to resolve problems with its earlier programs.

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References

Australian Government. (2022). Future Focused Primary Health Care: Australia's Primary

Health Care 10-Year Plan 2022-2023. Canberra ACT: Australian Government.

Bally, E., Grieken, A., Ferrando, M., Fernandez-Salido, M., Dix, R., Zanutto, O., . . . Raat, D.

(2022). 'Value-Based Methodology for Person-Centered Integrated Care Supported by

Information and Communication Technologies' (ValueCare) For Older People in Europe:

Study Protocol for a Pre-Post Controlled Trial. BMC Geriatrics, 22(680), 1-12.

Bosel, M., & Sharp, S. (2020). Primary health networks submission to the Royal Commission

into Aged Care Quality and Safety on the topic of system governance market

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