Re‐imagining health care for an ageing population

In this issue of the MJA, Reid and colleagues describe private and public hospital bed utilisation in Australia during 1993–2020, with a particular interest in use by older people.1 They report that, despite overall bed utilisation rising from 21.0 million to 29.9 million bed‐days during this period, population utilisation rates for multiple day admissions declined, by almost 40% for people aged 65 years or more and by 17% for those under 65 years of age, primarily because mean hospital stays were shorter. However, the decline in length of stay was minimal in recent years, suggesting that the potential for efficiency gains from this source is now close to exhausted. Without analysing linked data the authors could not determine to what extent administrative transfers within hospitals or same‐day transfers between co‐located hospitals contributed to reduced length of stay.1

It is projected that there will be 5.7 million Australians aged 75 years or more by 2066, a 211% increase from the 1.8 million in 2020.2 By 2027, there will be about 610000 people aged 65 years or more who are frail.3 Our health system must therefore adapt to better meet the needs of people at risk of frailty, which is frequently associated with having multiple medical conditions. Reforms with the aim of integrating and coordinating care with older people and their carers should enable general practitioners to be the primary health care providers in a home‐based model of health care.

Integrated care for older people is a World Health Organization priority for the United Nations Decade of Healthy Ageing (2021–2030).4 Screening and timely interventions for people experiencing cognitive, sensory, mood, mobility, or nutritional decline are encouraged. To achieve this aim, especially for people who are frail or at risk of frailty, we need incentives to shift the Australian general practice model of care to comprehensive and integrated care approaches that draw on the expertise of multidisciplinary teams. As demand for general practitioners already outpaces supply — a shortfall of 11392 full‐time equivalent general practitioners is expected by 20325 — the attractiveness of a career in general practice must be improved.

As our Medicare system rewards episodic transactional care and fast throughput, it is unsuited for handling the comprehensive continuous care provided by general practitioners, particularly for older and frail patients with complex health care needs. Individual episodic Medicare Benefits Schedule item numbers that could support comprehensive care when bundled are underused, particularly for people at high risk of hospitalisation. Among the more than one quarter of a million people with home care packages — which reflect their frailty risk — emergency department and hospital use rates are high.6,7 Only 30% of people aged 75 years or more with home care packages receive health assessments within six months of their aged care eligibility assessments, about one‐third receive chronic disease management plans with or without team care arrangements, and only 5.4% receive medication reviews, despite medication misadventure being a frequent reason for hospitalisation.8 Better coordination between general practice and aged care service providers, and shared care protocols with specialists in state health services, could improve health care for these people.9 Such models of care must be adequately funded, and capitation funding for GPs and targeted support for strategies that reach people with the greatest needs will probably be required, facilitated by appropriate information technology infrastructure.9

Linking data for established or new out‐of‐hospital models of care and making this information accessible to all clinicians involved in a patient's care could improve the effectiveness of integrated care. For example, the Transition Care Program, funded by both federal and state governments from 2005–06, provided short term support for older people after their discharge from hospital. The annual number of beneficiaries peaked at about 25000 in 2017–18, and the program may have contributed to the reduction in mean inpatient length of stay noted by Reid and colleagues for patients aged 80 years or more.1 However, the mean length of hospital stay in this program had plateaued at just under eight weeks during the decade to 2017–18.9 Increased medical practitioner integration into the transition care program, as in the medically focused care transition intervention in the United States, could lead to better health outcomes and improved flow through the program.10,11 Identifying health conditions, ensuring appropriate treatment, recording progress in health records accessible to patients, recognising red flags, and promptly escalating care when indicated: essentially, comprehensive geriatric health assessment is the core of a care transition intervention.11 But it must also empower people, and their carers, to manage their own health.

We must re‐imagine our existing health care system to future‐proof it. Only then can it better meet the needs of patients, many of whom are frail and will increasingly need care. As American physician Francis Peabody noted a century ago, “the secret of the care of the patient is in caring for the patient”.12 GPs are best placed to take responsibility for the continuity of integrated non‐hospital care, but GPs must be appropriately remunerated to do so in a comprehensive capitated funding model that focuses on outcomes, not transactions.