Background
Worldwide, the number of people aged 60 years and older has doubled over the past 30 years [
1]. Similar to other industrialised countries, Australia is experiencing significant population ageing, with more than one in every seven people aged 65 years and over in 2017 [
1]. Population ageing is driving a rise in Australia’s old-age dependency ratio [
1,
2], and this is largely attributable to a 3.3% increase in the population aged 65 years and over (1996–2016) [
3]. It is expected that there will be over 6.4 million older Australians by 2051; nearly triple the ~ 2.3 million in 1999 [
4].
The rate of population ageing presents many challenges for federal, state, and local planners [
5]. In Australia, population ageing is expected to result in a loss of 0.4% in revenue and add 0.3% to spending by 2028–2029, equating to a $36 billion annual cost, exceeding the anticipated total cost of Medicare in the same timeframe [
1]. These increased costs are largely associated with the greater level of assistance required for day-to-day activities in order to maintain functional independence required by approximately 10% of people aged 65 to 74 years, and over 50% of people aged over 85 years [
1]. These proportions compare with only 3% of individuals aged less than 65 years [
1].
A Community Geriatrics Service (CGS) aims to improve access to specialist geriatric healthcare for older people requiring management for complex conditions, through outreach into general practice with case review or joint consultation [
6]. CGSs provide overall support through geriatrician outreach, consultation, the promotion of multidisciplinary team care, and management plans that focus on delaying or reducing the likelihood of hospital or residential care admissions [
6,
7]. A focus on community and informal care effectively maintains the functional independence of individuals [
8]. For these reasons, CGSs have been developed globally to address both specific and generalised challenges in elderly populations [
9]. In Australia, current CGS models of care support patients at home, in residential aged care, or in an outpatient setting and may be complete services aimed at preventing acute hospital presentation [
10], or specific services such as wound or skin care [
11].
Identifying and addressing gaps in service provision can inform the strategy for local service providers, improve the healthcare of the local population, reduce the burden on local hospitals, and can lead to new and improved models of care that can be translated nationally and internationally. Providing community-based care for older individuals will improve the diagnosis, treatment, and management of chronic conditions in an appropriate manner that is tailored to the social and cultural needs of the community [
8], whilst decreasing healthcare spend [
12]. The present study aimed to gain a holistic understanding of the social and healthcare requirements of community dwelling older people in South Western Sydney (SWS), where individuals aged 65 years and over account for 11.9% of the population [
13]. A needs assessment was conducted to identify and understand gaps in current service provision, with the purpose of developing an integrated approach to aged care via a CGS.
Discussion
This project captured stakeholder insights on the barriers to geriatric service use experienced by the Macarthur community. Findings highlight the perceived importance of a novel CGS that addresses the health and social challenges of older people, facilitates access to services and resources, and addresses referral processes and health system navigation. These barriers and social challenges are well-documented in multiple settings in the literature, for instance, in diabetes care [
16].
Managing BPSD, falls, and multimorbidity is challenging in the community care setting. The development of an in-home geriatric programme in the Netherlands found that such programmes can improve the detection of symptoms and management of BPSD [
17]. The risk of falls among older adults can be mitigated through balance training programs [
18], virtual reality training [
19], and dynamic posture training [
20], which are all potential avenues for CGS service augmentation. Additionally, a world-leading BPSD service established in Australia has helped improve the management of BPSD in RACFs through multimodal psychosocial interventions, which may be adopted by CGS programmes [
21]. Multimorbidity was also reported as a concern, which is somewhat unsurprising, given that SWS is thought to be affected by significantly disproportionate health outcomes compared to greater Sydney, including higher prevalence of diabetes, cardiovascular disease (CVD), and lung, gastro-intestinal, liver, kidney, and thyroid cancers [
22‐
25]. Costs in managing multimorbidity in the community setting can be reduced through an effective CGS. For example, in the USA, the per patient cost of at-home case-managed individuals is valued at approximately 75% of the cost of institutional care [
12].
Active social challenges included non-compliance with treatment plans, which may be exacerbated by the cognitive deficits associated with dementia. Additional social challenges are also associated with BPSD [
26]. CGS development must consider early diagnosis of cognitive impairment and the interactions between cognitive deficits and treatment management [
26], as well as the effective and timely dissemination of this information to stakeholders [
6]. Gerontological social workers may also relieve communication difficulties, given that they are trained to conduct holistic geriatric assessments [
27], create conducive housing environments, and encouraging treatment-adherence [
28]. However, there are currently no gerontological educational programs available across all undergraduate fields in Australia and New Zealand, unlike the USA which offers gerontology-specific degrees at all educational levels [
29,
30]. Further, it is thought that social work curricula are missing a strong gerontology focus, despite the critical role that social workers could play in the management of older peoples’ health in the community [
31,
32].
Caregiver stress was highlighted as a major challenge within SWS, where primary caregivers often experience poor health and negative health behaviours [
33]. Caregiver stress is more prominent in CALD populations, where there are varying degrees of functional dependency such as language barriers that may attribute to high levels of caregiver stress and elder abuse [
34,
35]. This is also observed in Aboriginal and Torres Strait Islander communities, who experience higher rates of depression, coupled with economic and social disadvantage, when compared to the general population [
36]. A CGS may relieve these stressors by referring caregivers to support and respite services, whilst providing tailored advice for kinship caregiving. Moreover, elder abuse is prevalent in all cultural groups within society; one in four older adults are estimated to be vulnerable to elder abuse [
37]. Community services, including the CGS, may hence form an essential component of the strategy for preventing and stopping elder abuse, through the identification and referral of at-risk individuals to the relevant support systems.
Social isolation within SWS was of concern, and has previously been identified as an independent risk factor for low levels of self-reported health and wellbeing [
38]. Self-perceived loneliness has been linked with increased risk of chronic conditions, including dementia [
39], and all-cause mortality [
40]. Social isolation has been exacerbated by social distancing interventions during the COVID-19 pandemic [
40]. Purposeful social engagement may be an effective public health intervention for socially excluded members of the community [
38]; an area where the CGS could play a role. Age-related social stigma was described as a challenge as it can lead to marginalisation and the under-diagnosis of illnesses affecting older people, including dementia [
41]. Age-related stigma is associated with a ‘hypercognitive culture,’ which results in conditions including dementia being viewed as discreditable, ultimately isolating and marginalising older people [
41]. Social stigma is also exacerbated in CALD communities, where the challenging behaviours in dementia are thought to cause feelings of fear within the community [
42]. The lack of public awareness associated with social stigma extends to non-age related diseases, including diabetes [
16]. By providing informal and community care, CGS programmes may play an essential role in destigmatising chronic conditions prevalent amongst older adults.
Poor integration between primary and secondary care creates several issues. In some areas, 64–68% of primary and secondary care doctors believe that patient care is not well-coordinated between their two levels [
43]. In the context of diabetes management in SWSLHD, stakeholders state that traditional modes of collaboration between primary and secondary care professionals lack transparency, as communication lines are typically closed and the processes lack visibility [
44]. Australian primary care services are also thought to have poor linkages with other relevant services, and more training is required for primary healthcare providers to understand the multidisciplinary needs of specific age groups [
45]. Improving communication, information sharing, and providing a model of effective digital health using multidisciplinary healthcare teams within a CGS is considered to be one of the most effective approaches for community patients to access improved consistency of care, also known as integrated care [
43].
Advance care directives were deemed as very important due to their ability to improve individuals’ and caregivers’ quality of life, quality of dying, and drive the establishment of advance care plans [
46]. Providing targeted education and training to healthcare practitioners and RACF staff on advance care planning allows an opportunity to ameliorate the disproportionate health outcomes and high levels of caregiver stress experienced in SWS [
22]. Low levels of understanding of enduring guardianship and power of attorney have been linked with a lack of knowledge regarding medico-legal services available to older adults and their caregivers [
16,
47]. This knowledge gap can be overcome through community-directed action plans to raise awareness of the health challenges faced by older people. A CGS is well-placed to deliver such an action plan.
Limited community transport has been described elsewhere, for example, in New Zealand, where loss of existing transport options may threaten the functional independence and quality of life of older adults [
48]. In Australia, mobility and health challenges create substantial barriers to public transport usage, and driving cessation as a consequence of these challenges is often linked to a perceived reduction in independence [
49]. Through CGS development, multidisciplinary healthcare teams can travel to the patient, diminishing accessibility issues. A well-resourced CGS allowing multi-disciplinary review in the community will help to address accessibility issues.
Given the COVID-19 pandemic, virtual health or telehealth has also become increasingly utilised to deliver quality healthcare [
50]. By mainstreaming this method of care and providing the healthcare workforce with the appropriate accreditation and training, telehealth options may relieve many of the logistical and equity issues surrounding healthcare access [
50]. The inclusion of virtual health in CGS development may contribute to improved health outcomes for the local community through increasing the accessibility and reach of the programme. Virtual health, and the reimbursements provided by the Medicare Benefits Schedule (MBS), a selection of healthcare services subsidised by the Australian government, may also mitigate the financial burden of specialist geriatric services. Specifically, three MBS items allow for the comprehensive health assessment of older people to identify any health risks, as well as a broad range of factors which influence social, psychological, and physical wellbeing [
51]. Under the MBS, a rebate is payable once annually for each eligible patient [
51]. The affordability of the CGS is paramount, as participants in similar studies have expressed that specialist geriatric services should be free of cost or have minimal out-of-pocket expenses to ensure service utilisation [
52].
This project had several strengths, including data triangulation and a relatively large sample size for a qualitative study. However, the investigation was designed to inform service development; thus, data saturation was not considered crucial to this outcome, and subsequently, was not achieved, which may compromise the validity of results. Resources permitting, future work could explore a broader range of issues across a larger geographical area with a greater sample size, and indeed, such a study is underway. Potential introductions of bias, which could have affected the reliability of the data, include the use of a single researcher to conduct the interviews, varying transcription methods, and the use of a finite list of primary care providers provided by the medical marketing company. The primary outcome of this needs assessment was to inform the development of a local service; this was achieved. The results were highly informative and guided the successful development of a CGS in SWS. This paper, the methods used, and the findings may be valuable for other groups when assessing community needs, providing a scalable method to inform the development of CGS programmes relevant to local community needs. An evaluation of the CGS will be conducted in due course.
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