1. Barriers and Facilitators of Consumer-Directed Care in Residential Aged Care Facilities
Marita McCabe PhD FAPS
Director, Institute for Health & Ageing
Australian Catholic University
17th Alzhemer’s Australia Biennial National Dementia Conference
Melbourne: October 2017

2. Chief Investigators
Marita McCabe, Institute for Health and Ageing, ACU
Elizabeth Beattie, The Dementia Collaborative Research Centre, QUT
Gery Karantzas, School of Psychology, Deakin University
David Mellor, School of Psychology, Deakin University
Kerrie Sanders, Institute for Health and Ageing, ACU
Lucy Busija, Institute for Health and Ageing, ACU
Belinda Goodenough, Dementia Training Australia, University of Wollongong
Michelle Bennett, School of Allied Health, ACU
Kathryn von Treuer, Cairnmillar Institute

3. Research Staff Jess Byers, Institute for Health and Ageing, ACU
Jeretine Tan, Institute for Health and Ageing, ACU
Benjamin Fox, Queensland University of Technology
Catherine Travers, Queensland University of Technology

4. Acknowledgements
We would like to thank the following organisations for funding this project:
Dementia Collaborative Research Centre
Mercy Health Foundation
IRT
We would also like to thank residents and staff from the following organisations for participating in the study:
Mercy Health
Ozcare
Beaumont Care
Carinity

5. Background
Many residential aged care facilities (RACFs) adopt person centred care
This study was designed to implement and evaluate a training program for staff to adopt a consumer directed care model in RACFs
It focused on the development of clinical skills (e.g., communication with residents), job roles, and organisational change
Evaluation centred on the resident, staff, organisation and costs (economic evaluation)

6. What is Consumer Directed Care and Why is it Important?
Consumer Directed Care (CDC) is designed to:
Support older people to make decisions about their care and everyday routines
Have a care plan that, where possible, is directed by older people
Wrap the system around the older person, rather than have the older person fit into the system

7. Focus of the Study
Implement and evaluate a program, Resident at the Centre of Care (RCC), to deliver CDC within RACFs
The six-session program focussed on three main areas:
Improving communication between residents and staff – collaboration, respect, conversations
Fostering shared leadership so staff on the floor feel empowered to make decisions
Working towards organisational change to accommodate CDC
Talking about footy, their favourite music, gardening and establishing a relationship with the resident find out about their needs.
Rather than just showing or feeding residents actually tuning into their wellbeing, their mood-seeing if they have physical problems (e.g. pain) or mental health problems (e.g. depression)
Communicate among staff about the residents they care for – leaders sitting down with on the floor staff and all staff having an input into a decision on the well being of residents

8. Content of the program Session 1: Facility Leaders
Focus on identifying the components of CDC (as opposed to PCC)
Discussion on establishing communication and forming a working relationship with residents
Understanding of the Resident Care Form (which obtains the resident choices on care)

9. Content of the program Session 2: Facility Leaders
Discussion of the importance of transformational leadership in order to deliver CDC
Highlight importance of organisational change in order to implement CDC
Enablers and barriers to the implementation of CDC
Session 3 and 4: Leaders and “On the Floor” Staff
Coverage of material in Sessions 1 and 2 with all staff, with Facility Leaders acting as co-facilitators
Four-week break in order for staff to implement CDC

10. Content of the program Session 5: Leaders and “On the Floor” Staff
A discussion of strategies that could be used to work with the enablers and address the barriers to implement CDC
Session 6: Leaders and “On the Floor” Staff
Development of a CDC plan that works for the facility

11. Roll-out of program so far
9 facilities recruited
3 allocated to the RCC program
3 to the RCC program and additional support
3 to a control condition
Study has been implemented at 9 sites
Partnership NHMRC submitted early 2017
Launch of study findings, Canberra, June 2017

12. How have staff responded?
Initially
Apprehension
Enthusiasm
Concern
Little understanding of the nature of CDC: they think they are already doing CDC
Fear about the changes required
Resistant because of changes required
Can’t be done, too much change

13. How have residents responded?
Don’t know what it means to have choice
Don’t want to be a burden on staff
Confusion
These responses are most likely to come from long-term residents

14. Barriers Time Backfill Staff need to know residents Negativity
Staff feeling pressured (by themselves, colleagues and residents)
Confusion
Too much change
See CDC as a task rather than an improvement

15. Barriers Need to work in teams Misunderstandings Lack of agency
Permission
Assumption and expectation of others
Legislation
Funding

16. Enablers Great staff Good teamwork Leadership Communication – staff
Respect choices and decisions of direct care staff
Mutual respect – staff, residents, families
Empowerment
Management approval

17. Enablers Teams already in place
Encouragement to build healthy work relationships
Support for new ideas and nurturing
Existence of a focus for open discussion in a safe environment
Common goals and purpose
Sharing information
Focus on improving problem solving skills

18. Perceived benefits of CDC
Residents
Increased
Happiness
Choice and control
Empowerment
Dignity
Care satisfaction
Privacy
Autonomy
Home like environment
Purpose/meaning
Involvement in activities

19. Perceived benefits of CDC
Staff
Positive relationships
Understanding/knowledge of resident
Greater continuity of care
Reduced absenteeism/turnover
Greater job satisfaction (after initial adjustment)
Facility
Improved image (i.e., provider of good care)

20. Results Residents Mean scores on key outcome measures Variable
Baseline
Follow up
Difference (T3 - T1)
Quality of Life
Care as usual
42.43
42.73
0.30
Training only
44.50
48.81
4.31
Training & support
37.65
40.42
2.77
Consumer Directed Care
19.87
20.98
1.11
21.75
23.72
1.97
20.00
22.14
2.14
Working Alliance
25.16
27.78
2.62
30.95
35.15
4.20
23.90
27.98
4.08

21. Results Residents Mean scores on key outcome measures (cont’d)
Variable
Baseline
Follow up
Difference (T3 - T1)
Relatedness
Care as usual
21.38
22.80
1.42
Training only
23.29
25.50
2.21
Training & support
20.76
25.14
4.38
Competence
17.23
18.89
1.66
20.00
21.89
1.89
18.60
19.29
0.69
Autonomy
22.15
23.23
1.08
23.21
24.10
0.89
19.42
21.86
2.44

22. Results
Residents
There were improvements from the beginning of the program to three months follow up in residents’
quality of life
satisfaction with their voice being heard in directing care
relationship with staff
sense of competence
sense of being in control of their lives

23. Results
Staff
There were limited changes in their job satisfaction or practice of CDC
There were positive changes in staff relationships with residents
Senior staff were more likely to report positive changes

24. Results Organisational Changes
These factors relate to staff members perception of support, trust, workplace pressure, fairness, recognition and encouragement to drive change in the implementation group
Staff on the floor did not show improvements in these areas
Senior staff perceived that all of these areas had improved

25. Results Economic Evaluation
The main costs were the training for staff to participate in the program – these are one-off costs.
There was no increase in staff costs
There was a change in the job roles of staff – staff worked across a greater range of care tasks with a smaller number of residents

26. What do we know about CDC?
Improves residents’ lives
Supported by senior staff
More work is needed to involve staff who work on the floor
CDC leads to major change in the job role of staff as well as the organisational structure of RACFs
There are one off costs for training but staff costs do not change

27. Where do we go in the future?
Obtain funding to roll out and evaluate our Resident at the Centre of Care training program with a larger number of facilities over a longer time period
Align Government funding and associated performance frameworks with CDC
Ensure there is appropriate funding to support the training costs for staff
Need patience, collaboration and commitment to change the current system – we all need to be part of this
Ensure dignified ageing is a priority in our society