1. Sample Characteristics and Data Sources
Interviews were conducted with 49 GPs. The community forums held in Camden included 28 representatives, Wollondilly had 15, and Campbelltown 16 representatives from 4 residential aged care facilities (RACFs) and various health service providers and support organisations including Liverpool Hospital Aged Care Services, Ambulance Service, Campbelltown City Council, Wollondilly Shire Council, National Seniors Macarthur, Longevity Senior Services, Dementia Advisory Service, and Dementia Australia. Approximately 4,337 older people are cared for by these service providers each day: RACFs care for 1,476 residents; the GPs see 695 patients, and the health service providers see 2,166 patients.
2. Qualitative Data
Five overarching themes emerged from the coding of the data. Theme 1, Active Health Conditions, included four sub-themes: management of challenging behaviours in dementia, management of falls, management of multimorbidity, and other relevant conditions. Theme 2, Active Social Challenges, included six sub-themes: patient non-compliance, need for aged care social workers, caregiver stress, elder abuse, social isolation, and stigma. Theme 3, Referrals, included two sub-themes: availability of specialists and communication, and specialist input and advance care directives. Theme 4, Access, included two sub-themes: lack of transport options, and inaccessibility of local geriatrics clinics and specialists. Theme 5, Awareness, included three sub-themes: lack of awareness, lack of knowledge, and lack of resources.
Theme 1: Active Health Conditions
When asked about active health conditions, representatives of three RACFs indicated that the most common, and most difficult to manage, medical condition amongst older people is the behavioural and psychological symptoms of dementia (BPSD). Representatives of RACF1 stated that “behavioural and psychological symptoms of dementia are some of the hardest medical issues geriatric patients have, which require more staff to look after.”
Providers have also indicated that falls occur frequently amongst older people. RACF 2 reports 22 falls a month, of which 5 residents are sent to the hospital. Another provider (RACF 3) indicated that 1–6 residents are referred to secondary care as a consequence of falls, bleeding, and loss of consciousness, where they expressed that “some hard-medical issues include falls and malnutrition. Doctors [are] not available for 24 hours. For falls, review by doctors would help.”
The GPs interviewed indicated that many older patients experience multiple active chronic medical conditions. Multimorbidity amongst geriatric patients was commonly reported by RACF staff: 82% of geriatric patients managed by GPs have 2 or more active health conditions. Specifically, 41% of all geriatric patients managed by participating GPs have been diagnosed with diabetes, and 35% of all residents at RACFs.
When asked, consumers and community representatives described many relevant health conditions for which they require treatment. The lack of available podiatrists was specifically mentioned, with GP referrals to podiatrists not being seen. This demand for podiatry was linked with the high levels of diabetes diagnosed across geriatric patients and RACF residents in all three LGAs. Dental care was also of particular concern. When residents or geriatric patients presented with dental conditions, they were often directed to hospitals, rather than dentists. Within the Campbelltown LGA, people with dementia were reported to disproportionately experience dental conditions. Community representatives have indicated the need for more convenient and subsidised access to dentistry. Mental health conditions were also reported as prevalent amongst older people. Participants from Camden expressed dissatisfaction with long waiting lists, and a lack of public services within the region. Malnutrition within rural and peri-urban communities was also described.
Theme 2: Active Social Challenges
While less than 10% of RACF residents were reported to have active social challenges, GPs reported these amongst 57% of geriatric patients. Patient non-compliance was described as the most common personal barrier faced, where patients refuse placements and referrals, particularly so for patients with dementia experiencing challenging behaviours. GP 1, when asked about social challenges, stated “deconditioned, non-compliant patients and frequent attendees … refusing placement, patients refuse to go to care.”
RACF providers indicated the need for social workers who specialise in communicating with older adults. GPs also expressed that the development of an aged care social work service would prevent the referral of individuals to hospitals to access these services. For example, GP 2 expressed that the “need [for] geriatric social work leads to sending patients to hospitals to access social work.”
Consumers and community representatives have described high levels of stress amongst caregivers of older people. This was attributed to social pressures and difficulty dividing their time between work and care. However, many caregivers considered this care as their responsibility to their family members. This was particularly true within culturally and linguistically diverse (CALD) communities with strong family ties.
Elder abuse and social isolation were identified as significant social challenges that require priority attention. Participants thought that elder abuse was becoming prevalent within the Macarthur region, and that the community would benefit from the distribution of resources to raise awareness of elder abuse. Social isolation in rural and peri-urban areas of Camden and Wollondilly was thought to be a consequence of the geographic location, coupled with a lack of accessible transport options.
Consumers and community representatives reported social stigma around ageing as personal barriers to service utilisation. This was discussed as a contributing factor to the under-diagnosis of illnesses, ailments, and chronic conditions, such as dementia, particularly so for older men who have reported not seeing a physician in years. Patient and carer groups expressed the need for education within the community in order to eradicate the social stigma surrounding illnesses and remove these personal barriers to accessing care. Participants have expressed that this education is necessary to create a culture of normalcy regarding healthcare and ageing. For example, Community Representative 1 explained that “education is required for the community, including the elderly and GPs, regarding this, to break the stigma.”
Theme 3: Referrals
Participants reported that geriatric patients and residents experiencing acute illness, including falls, are often referred to secondary care. However, RACF representatives (RACF 1) expressed the view that GPs have a lower understanding of when to refer a patient to a specialist, having explained that “some GPs have a lower understanding of when to refer to the specialist and indicated there is a resistance to refer. This will significantly impact on the quality of care provided…”
Despite this, most of the GPs interviewed discussed their expectations of geriatricians in regard to the management of long-term cases, with GP 4 having expressed that “geriatricians need to help troubleshoot new or chronic problems to help aged conditions.” In particular, GPs expressed their expectation that geriatricians should help with mobility or motor and functional conditions.
Similarly, there was also a demand for the comprehensive geriatric assessment of complex cases. The GPs interviewed indicated a lack of education regarding the services offered by specialists, as well as barriers to effective communication between GPs and specialists, which have resulted in higher levels of referral to hospitals. Community Representative 2 explained that “integration is a huge part of this, between primary [care] to hospitals and back, a lot of work needs to be done… they’re not talking to each other so the result for the patient is that the information is not flowing as freely…”
When asked about the need for specialist input, many participants indicated the need for advance care directives in various environments. This included in areas that have lower socio-economic status, or in CALD patient populations, and in RACFs.
Theme 4: Access
When asked about challenges regarding access to facilities and aged care services, many consumers and representatives indicated that a lack of transport options was a significant issue, where Community Representative 3 expressed that “the issue with access is logistic[s]… with these clinics, people need a way to get to them…” Of the 695 geriatric patients managed daily by the GPs interviewed, 23% of GPs expressed concerns about older people driving. GPs reported that driving was challenging for their patients and this would be an increasing challenge into the future. This concern also extended to commuting and accessing public transport, which was expressed amongst consumers and community representatives across Campbelltown, Camden and Wollondilly, albeit was more pronounced in rural and peri-urban areas.
The inaccessibility of local geriatrics clinics and specialists was adjunct to the transport issue. Affordability was also identified as a barrier for accessing specialist services, as well as the documentation involved in the process. This concern, like a lack of transport, was heightened in rural and peri-urban areas, including Wollondilly and Camden.
Theme 5: Awareness
When asked about guardianship, consumers and community representatives from Camden and Wollondilly LGAs indicated that the larger population is unaware of the way in which enduring guardianship of older people is classified. There were similar concerns regarding power of attorney, where GP 7 expressed “more advance [care] directives are required in low socioeconomic areas.”
Consumers and representatives suggested that there is a lack of resources available to them regarding challenges faced by older people within the community. These participants suggested that education would be the driving factor in the management of the active health and social challenges facing older people within the community. Suggestions included a community outreach program as an influential action plan for the dissemination of information. Participants felt that these resources should be aimed toward the children, spouses and other caregivers of older people, and should include a specific focus on advance care planning. This concern was common to community representatives across all LGAs.