Ageing population profile

Along with many developed countries, Australia and New Zealand have a growing population over the age of 65 years. In the next 15 years, this population will nearly double as the ‘baby-boomer’ generation ages. In Australia in 2009 there were approximately 4.1 million people aged 60 years and older, and this number is expected to rise from the current 13.5% of the total population to 22% (17.1 million) in 10 years’ time (Australian Bureau of Statistics, 2010). An important consideration for health policy is the steadily increasing number of people aged over 85 years, with numbers expected to peak at 5.8 million during 2010–2015 and not expected to slow until 2020. Women are living longer than men, with the number of women aged 80 years and over predicted to be almost double that of men in 2016.

New Zealand has a younger population than Australia, but a similar rate of growth for people over the age of 65 years (13% of the total population), which is expected to grow much more rapidly by 2031 (22%) and by 2051 (25%) (Statistics New Zealand, 2009). Unlike the steady growth in the small number of older Indigenous Australians (Australian Bureau of Statistics, 2009a), increases in New Zealand’s older Māori and Pacific peoples will be particularly significant over the next 50 years (Statistics New Zealand, 2009). There is an expected 270% increase in the proportion of Māori aged 65 years and over, and a more than 400% increase in the proportion of Pasifika people aged 65 years and over. Other ethnic minority populations, while relatively young, are also projected to increase significantly.

While the ageing process is experienced and understood by older people, their families and cultural communities in many different ways, most Australians and New Zealanders aged 65 years or over are relatively fit and healthy. However, the burden of morbidity and mortality among Indigenous Australians is significantly worse than that of non-Indigenous Australians and of other ‘Anglo-settler societies’ like New Zealand (Hunter, 2007). The majority of older non-Indigenous Australians are well enough to live independently, with 80% of 60- to 79-year-olds living alone in a private dwelling, compared with 34% of those aged 80 years and over. Only a minority are frail and vulnerable and require high levels of care and disability support, usually during the last few years of their lives or as a result of chronic illness or disability that may have been present for many years. Consequently, the proportion of people, including Indigenous Australians, living in cared accommodation increases with age and illness, rising from 1.1% of all 60- to 79-year-olds to 15% of people aged 80 years and above (Australian Bureau of Statistics, 2010). Of the small number of older people living in non-private dwellings, the majority (54%) live in some sort of cared accommodation, including nursing homes or aged-care hostels (50%) and hospitals (3.0%).

The ageing of the population has impacts on different community members and systems, mainly the family. Informal care support is provided by families for approximately 80% of people over 65 years of age with a chronic illness. More than one million people over 65 years of age also receive community-based services, usually for chronic illnesses support (Department of Health and Ageing, 2010a). Access Economics (2010) has estimated that around 60% of Australians with dementia are living in the community and the majority of them are supported by 6.2 million informal carers (Australian Institute of Health and Welfare, 2011a) (Figure 43-1). Family support in Australia and in New Zealand is supplemented by a mix of government and non-government community-based services, which together help the older person to maintain connections to family and community and exercise choice of services if they require a higher level of care.

FIGURE 43-1 The level of care required by older people varies from individual to individual.

Image: iStockphoto/Guven Demir.

While people are healthier for longer than in past generations, the rapid growth of the number of chronic illnesses that tend to occur in older age will inevitably increase pressure on health funding. A New Zealand Ministry of Health paper (Johnston and Teasdale, 1999) projected that, based on 2000–01 patterns, health expenditure would need to grow by an average of 3.6% per year over the next 50 years to meet increased demand for existing services (Ministry of Social Development, 2001). The actual rate of increase is difficult to predict, however, because of the impact of other factors, such as changes in the availability of informal carers, technological advances, rising expectations for more and better services and changing rates of disability among older populations, which can work to either increase or decrease funding pressures. Australian and New Zealand governments have responded to the challenge of age-related chronic illness by establishing policies to support active, healthy ageing to reduce the prevalence of disability (Department of Health and Ageing, 2011a; Ministry for Social Development, 2001).

Policy contexts

Primary healthcare

Modern-day primary healthcare has its origins in the global primary healthcare strategy conceived by nations attending the WHO conference at Alma-Ata in South Eastern Russia in 1978, where they collectively called for ‘Health for all by the year 2000’ and vowed to embrace the principles of the Declaration of Alma-Ata:

These three principles heralded a turnaround from the view of health as a biological state, directed at individuals, experienced and modified by individuals and separated from the socioeconomic and political environment in which people reside. While the year 2000 is long gone and universal health remains an aspiration, the Declaration of Alma-Ata was a turning point for primary healthcare towards more actively addressing persistent inequity, injustice and general lack of fairness in the delivery of healthcare (Salmond, 2008).

A fundamental shift in the provision of primary healthcare was required to reach the goals agreed to at Alma-Ata, a shift that continues today (McKillop and others, 2012). Nurse leaders in New Zealand have defined primary healthcare nursing as:

Traditionally, primary healthcare has been delivered in Australia and New Zealand from general practice clinics originally set up for illness treatment rather than wellness support. When a health service is geared for treatment of sporadic, one-off illness episodes or for regular chronic illness management, health promotion and assessment of illness risk are more likely to be neglected (McKillop and others, 2012). More recently, health policy and funding have targeted healthcare along the continuum from health promotion to illness care, but changes in the way primary healthcare is organised are required to enable new approaches to primary healthcare.

An example of a new approach to primary healthcare is the program of the Australian government to help improve the health and wellbeing of Australian Aboriginal and Torres Strait Islander peoples (Australian Institute of Health and Welfare, 2011b). While comprehensive primary healthcare includes access to nurses, Aboriginal Health Workers and other healthcare professionals, it also includes access to social and emotional wellbeing services. These programs help individuals to reunite with their kinship networks, and include the ‘Bringing Them Home’ and ‘Link Up’ programs and counselling services associated with family and community reconnection. The ‘Bringing Them Home’ and ‘Link Up’ counsellors help individuals (many of whom are now over 55 years of age), families and communities affected by past practices of the forced removal of children from Aboriginal and Torres Strait Islander families to reunite with their families, culture and community, and to restore their social and emotional wellbeing. The focus of the Bringing Them Home counsellor program provides counselling and related services to individuals and families, while the Link Up services support people in tracing, locating and reuniting with their families. Access to these particular primary healthcare services is critical for preventing ill-health, effectively managing stress-related chronic disease and improving health outcomes to close the gap in life expectancy between Indigenous and non-Indigenous Australians (Australian Institute of Health and Welfare, 2011b). Comparisons between ‘old’ and ‘new’ primary healthcare are presented in Table 43-1.

TABLE 43-1 THE DIFFERENCES BETWEEN ‘OLD’ AND ‘NEW’ PRIMARY HEALTHCARE

From Ministry of Health 2001 Implementing the primary health strategy. Wellington, Ministry of Health.

Community and people-focused healthcare

Community engagement is a prerequisite for consumer and community involvement in the planning and delivery of healthcare for older people. There are various layers of healthcare governance, and each should include community representatives so that the voices of service users and/or their advocates are included in health decisions (Coney, 2004). As previously identified, the concept of ‘community’ has many meanings. Five core elements were derived from a narrative review of 154 definitions of community: its location, sharing common interests and perspectives, joint action as a source of cohesion and identity, a foundation of social ties and that some diversity is expected and accepted since all people are unique (McQueen and others, 2001).

The location of a community is not just where older people live, but also other places that they come together; for example, where they socialise. Rural people are more likely to have greater restrictions to accessing healthcare from home, especially for those living in remote and inhospitable locations. The realities of rural and remote Aboriginal health are distinguished by ‘hardship, sufferance and invisibility’ (Hunter, 2007), referring to the high levels of unrecognised and untreated illness and to the lack of understanding of the extreme difficulties that Indigenous people experience in seeking culturally sensitive healthcare in rural and remote locations. Therefore, where the older person lives and the availability of health infrastructure in that location will influence the way that nurses are able to engage with different rural communities. To provide an effective community health service, nurses will need to gain a good understanding of the shared interests and health perspectives of particular communities when planning and delivering relevant and acceptable health services (McQueen and others, 2001).

Integrated community health services

As previously discussed, the purpose and focus of primary healthcare involves not only care for individuals with health problems, but also health promotion and preventative care. In their health promotion and preventative care work, and in light of ever-increasing rationing of health resources, nurses are challenged to provide older people and their families with the most appropriate education and support to improve the social determinants of health (Sharpe and O’Sullivan, 2006). Effective primary healthcare involves expanded nursing services, community outreach and multidisciplinary team collaboration to provide healthcare across the continuum of care, as identified in the Australian and New Zealand aged care policies (Finlayson and others, 2008; Ministry of Health, 2001, 2003; Productivity Commission, 2012; Wagner and others, 2001).

Primary healthcare providers that are well integrated with each other and other social services can provide a seamless service for their clients (Sheridan, 2005). Nurses need to work with other services to improve access to support to improve the social determinants of health, including housing, education and a range of other social services. Not least, care that is integrated across primary and secondary services can avoid gaps and overlaps in health services. A recent discussion document published by the Australian Primary Health Care Advisory Council (PHCAC) suggests that future primary healthcare organisations, whatever form they take, ‘will need to define together what the glue will be that will hold them together’ (PHCAC, 2009:4). Exploring the implementation of the PHCAC guidelines may reveal the ‘glue’ that integrates services. The way that services are arranged and connected with each other is represented in the model of healthcare on which they are constructed.

Therefore, appropriate community-based nursing will be individualised to suit the client and their family, have a population health focus (Sheridan, 2005) and rely on continuing relationships with other health services (Wagner and others, 2001). This approach requires a reorienting of health services across the health continuum, not just in the primary healthcare sector (Bodenheimer and others, 2002a). Six interlinked components are essential to the effective integration of care (Wagner and others, 2001; Bodenheimer and others, 2002b):

Community-based services for older Australians and New Zealanders

The six components listed above are essential to an effective integrated healthcare system for older people and their families. For example, over one million older Australians and their family carers access government-subsidised integrated community-based services from the following programs (Figure 43-2).

FIGURE 43-2 Services to support older people across the continuum of care.

From Productivity Commission 2011 Caring for older Australians: overview. Inquiry report no. 53. Canberra: Productivity Commission, p. XXIV. © Commonwealth of Australia, Productivity Commission. Reproduced with permission.

AUSTRALIAN AGED-CARE SERVICES

The Home and Community Care (HACC) program is the largest program; it is funded by the states and territories (40%) and the Australian government (60%) under the Home and Community Care Act 1985. Funding is allocated largely based on demand and services are provided at the discretion of providers. HACC services include transport, nursing, home maintenance, counselling and personal care (Department of Health and Ageing, 2009) and the HACC program delivers services to people with a range of disabilities, regardless of whether that disability is related to an acquired condition or injury, and also supports Indigenous health by improving access to community services in rural and remote Australia (Department of Health and Ageing, 2010).

Community Aged Care Packages (CACPs) target older people living in the community with care needs equivalent to those of low-level residential care; it provides the greatest number of operational packages, estimated at around 45,654 in 2010. A range of support services is provided, such as personal care, domestic assistance and social support, transport to appointments, food services and gardening. Approval from an Aged Care Assessment Team (ACAT) is required before services can be obtained (Department of Health and Ageing, 2009).

Extended Aged Care at Home (EACH) packages target older people living at home with care needs equivalent to those of high-level residential care, estimated to provide around 5770 packages in 2010. Approval by an ACAT is also required to receive an EACH package. In addition to the services offered by CACPs, an EACH client may be able to receive nursing care, allied health care and rehabilitation services. EACH-D extends the EACH package with service approaches and strategies to meet the specific needs of care recipients with dementia. In 2010 an estimated 2901 EACH-D packages were offered (Department of Health and Ageing, 2009).

In 2010 the Australian Government trialled 1200 consumer-directed aged-care places in Australia (Department of Health and Ageing, 2011a). Service providers offer consumers the choice of consumer-directed CACPs, EACHs and EACH-Ds to individual consumers based on a needs assessment, with budgets administered on their behalf by an approved provider for an agreed percentage of the allocated budget. The care recipient has the same level of entitlements as those specified under the individual packaged care programs, but holds greater responsibility for the delivery of services. One of the most important objectives of consumer-directed community care is that care recipients have genuine flexibility in program arrangements, such that services can be tailored to the care recipient’s individual circumstances (Department of Health and Ageing, 2011a).

Under the Aged Care Act 1997, the Department of Health and Ageing (DoHA) uses planning ratios to manage the supply of residential care places and the number of packages offered under the CACP, EACH and EACH-D programs. An average of 23.1 packages per 1000 Australians aged 70 years and over was provided in 2009, with a maximum fee of $8.05 per client per day. The 2011 planning ratio is 113 places per 1000 people aged 70 years and over (Department of Health and Ageing, 2011a), allocated to 44 high-care (residential) places, 44 low-care (residential) places and 25 community-care places which comprise 21 CACPs and 4 EACH or EACH-D packages. Package costs are projected to increase from $A11.1 billion in 2010 to $A59.6 billion in 2050 (equivalent to 451% growth). Of this, the public budget will expend $A44.0 billion while the private sector will expend $A15.6 billion (Australian Institute of Health and Welfare, 2011a). Expenditure on HACC clients, community-care packages and operational residential-care places will increase to $A94.2 billion in 2050, around 749%, with public budget estimates being $A69.5 billion and private sector expenditure being $A24.7 billion (Australian Institute of Health and Welfare, 2011a).

FIGURE 43-3 Rehabilitation is crucial in maintaining the health of older people.

Image: Gabrielle Voinot/LookAt Sciences/Science Photo Library.

FIGURE 43-4 Meaningful occupational therapy is crucial in maintaining the health of older people.

Image: Gabrielle Voinot/LookAt Sciences/Science Photo Library.

NEW ZEALAND AGED-CARE SERVICES

New Zealand’s DHBs fund services that support older people to remain in their own homes for as long as they want and are able to. Home support services give older people the ability to make choices in later life about where they want to live, and to receive the support they need to do that. The Ministry of Health is responsible for the development of home and community support services for older people. A continuum-of-care approach is taken for older people’s support services, which emphasises home- and community-based services (Ministry of Social Development, 2001). All older people wishing to access publicly funded support services have their needs assessed by a Needs Assessment Service Coordination (NASC) agency contracted to each of the DHBs.

Older people are also supported through church-based services such as:

• Enliven—service offered by Presbyterian support organisations throughout New Zealand that enables older New Zealanders to stay in their own homes and to remain in control of their own destiny

• Wesley Community Action—a Methodist organisation with experience in working alongside older people in the community to help maintain their independence and quality of life

• Selwyn Centres—parish-based drop-in centres for older people hosted by the Anglican Selwyn Foundation. They offer older people in their communities a morning program which includes gentle exercise, social time and activities, for a nominal fee.

Aged residential-care services are available for older people (usually aged 65 years and over) who need more support than can be made available to them in their own homes. Options include a range of residential home-care facilities and specialist hospital facilities. In addition, a range of services and resources are provided by Age Concern, the Alzheimer’s Society, Arthritis New Zealand, the Cancer Society, Diabetes New Zealand, the Hearing Association, Hospice New Zealand, the Mental Health Foundation, the National Heart Foundation, the National Foundation for the Deaf, the Parkinsonism Society of New Zealand, the Public Health Association, the Royal New Zealand Foundation for the Blind and the Stroke Foundation.

Strengths-based approach

Both Australian and New Zealand aged-care services support a primary-health-care, strengths-based approach that strives to meet older people’s holistic needs by:

Impact of chronic illness

Age alone is not the key factor in determining the need for health-care services, but rather ill-health and/or a change in functional capacity. It is predicted that nearly two thirds of the Australian and New Zealand governments’ health expenditures will be consumed by people 65 years and older by 2050, generally peaking in the last two years of life (Access Economics, 2010; National Health Board, 2011). In acute care services alone, people aged 65 years and over accounted for 38% of all hospital admissions and for 51% of all inpatient days in 2007, with those aged over 85 years being more than five times as likely to be admitted to hospital, mainly as a result of chronic illness (Australian Bureau of Statistics, 2010).

Increasing rates of chronic disease in Australia and New Zealand are placing increasing pressure on health expenditure as well as reduced future labour force participation rates and productivity. Diabetes, for example, is projected to increase from around 5% of the total burden of disease in 2003 to 9% by 2023, primarily due to increasing obesity rates (Access Economics, 2010). Current data on the management of chronic diseases indicate that the current health system works best for individuals with specific, time-limited health needs (Australian Bureau of Statistics, 2009b). Those with more-complex needs who require ongoing services and management involving collaboration between health, community and aged-care sectors tend to fare worse. Older people with a chronic illness need access to services to maintain their independence, function and wellbeing over the longer term. This increases their chances of remaining at home longer and of avoiding premature admission to residential care and/or re-admission to hospital (Australian Bureau of Statistics, 2009b). For older people with a mental illness and/or dementia, it is essential to have access to appropriate mental health and psychogeriatric services to assist in their recovery/stability and to eliminate or minimise the need for acute health services, primarily through stronger, better-resourced community-based healthcare (Australian Institute of Health and Welfare, 2010).

The future challenges associated with community nursing care for people with chronic illness across all developed countries relate to:

Evidence-based chronic illness models

When considering the best fit of health service support for older persons with a chronic illness, Leutz (1999) divided these people into three groups:

Leutz (1999) argued that the first group would likely be served sufficiently by relatively simple systematic linkage of different systems, as long as healthcare providers are aware of and understand how to access the range of services offered by other providers. The group with moderate health support needs would also operate mainly through existing health and social systems, but require additional explicit structures and processes to maintain their health and prevent disability. This would require mechanisms for routinely sharing client information and collaborative discharge planning, case management and coordinated care across various sectors. It is the group with long-term, severe, unstable conditions that is likely to benefit most from a high level of service integration of different service domains. A fully integrated system would assume responsibility for all services, resources and funding, which might be subsumed in one managed structure (Leutz, 1999).

Kaiser Permanente, a US health-maintenance organisation for older people with chronic illnesses, is a good example of a successfully integrated primary healthcare system which successfully provides three different levels of community health services at different levels of need, such as those described by Leutz (1999) (Bodenheimer and others, 2002b). Another influential chronic illness primary healthcare model, also originating in the United States, is the Evercare model, the primary aim of which is to combine preventative and responsive healthcare for older people at high risk of health deterioration, mainly through case management (Boaden and others, 2006). The program uses risk-stratification tools to assess the level of care required and to inform the development of an individualised care plan for older people living in the community, coordinated and monitored by an advanced practice nurse acting as a case manager. The Chronic Care Model (Wagner and others, 1999, 2001) aims to provide a comprehensive framework for the organisation of healthcare for people with chronic conditions via four interacting system components: self-management support, delivery system design, decision support and clinical information systems. The cornerstone of the productive interactions between the healthcare staff and the person in effectively managing the chronic illness is having an ‘informed activated patient’ and a ‘prepared proactive health team’. The role of nurses in chronic care is pivotal to helping people navigate the health service ‘informed and activated’.

The Chronic Care Model (Wagner and others, 1999, 2001) has been influential in informing chronic-care policies in a number of countries (Glasgow and others, 2001). In Australia, the New South Wales Department of Health has embraced the model spearheaded by the Greater Metropolitan Clinical Taskforce (GMCT) Aged Care Health Network, a multi-disciplinary peak-body advisory group to the Director-General of New South Wales on matters relating to the healthcare of older people. One of the goals of the GMCT is to make illness prevention ‘everybody’s business’ by strengthening primary healthcare and continuing care in the community, building community-based health partners to improve the healthcare opportunities and experiences for older people and their families and promoting and evaluating evidence-based chronic illness care models in all health settings.

These well-coordinated, community-based health services are older-person and wellness focused and responsive to older people’s needs.

Advanced community nursing

The vignettes below identify the range of services provided by NPs, ones which rely on a great deal of initiative as well as collaboration with other healthcare providers, and culturally sensitive partnerships with health consumers and the community, to provide the very best healthcare services possible with limited resources.

Competencies for community nursing

Competencies for community nursing occur at three levels: the healthcare system; the health organisation and services; and the client and family carer/support network (Australian Nursing Federation, 2009). The dual role of providing primary healthcare (health education, disease prevention, health promotion) and providing clinical care recognises the interconnected relationship between the nurse, the person and their sociocultural and living environment. Community nursing recognises this symbiotic relationship in which the person takes ownership of a lifestyle aimed at minimising disease risk and maintaining or improving health outcomes, but is affected by the physical, political, social and cultural environment, or community, in which they live.

Promoting health behaviours can sometimes require the community nurse to help the person and their carer to overcome barriers arising from the person’s social situation, such as low social opportunities and emotional support and poor access to some health services, education, employment, income, food supplies and social services (National Ageing Research Institute, 2006). This was identified as a major issue when providing community nursing services to Australian Indigenous people. It is, therefore, essential that the community nurse is culturally sensitive to the client’s and family’s unique needs and circumstances, and is culturally competent in all dealings with individuals and groups requiring community nursing support.

Nursing competencies for integrated care

Wolff and Boult (2005) have identified nine components that constitute a comprehensive system of community care service, one that is ideally suited to the community nurse role. This system includes client and carer evaluation, individual care planning, evidence-based decision making, consumer empowerment through joint decision making, promotion of healthy lifestyles, coordination across multiple conditions, coordination across provider settings, carer support and education and facilitating consumer access to health resources. In order to fulfil this comprehensive role, community nurses must arm themselves with the right sets of knowledge and skills.

Community nurses must be able to coordinate services at the micro level (nurses, other healthcare staff and client/carer), meso level (services and organisations) and macro level (healthcare system) (Davies and others, 2006). Across these levels, the nurse must focus on processes to facilitate coordination (e.g. communication strategies, support for service providers and consumers) and focus on building structures for coordinating activities (e.g. shared information systems, referral proforma, care plans and decision support systems) (Rosenthal and others, 2006). A proven strategy for improving client and carer outcomes involves strengthening the relationships between the community service, GP services and acute care services, and employing a shared client care plan and records tools to actively support coordination (Davies and others, 2006).

Consequently, as previously identified the community nurse must recognise the broader context of health from one that focuses on the biological cause of illness, by enabling the older person and their family/support networks to become actively involved in a range of health maintenance processes. This requires the nurse to have excellent assessment skills and a high capacity for communicating knowledge across the healthcare continuum. This will be especially important when having to negotiate competing value systems in provision of professional, equitable and ethical care to members of different generations, multiple cultures and broadly ranging socioeconomic backgrounds (National Ageing Research Institute, 2006).

Having a good knowledge of the available range of community-based services and developing effective partnerships with healthcare consumers and service providers is required for a number of key community nursing roles: referral procedures; brokering services for older persons and carers; providing short- and long-term case management; and working with the older person and their carer to develop care plans aimed at self-management. Partner services will include mental health, ageing, palliative and disability services; continence, wound and stoma care services; drug, alcohol and sexual health services; carer respite and community support services; and specialist treatment services (Kralik and Van Loon, 2011).

At the individual client level, the community nurse requires a good working knowledge of the unique healthcare changes occurring in the older person and the impact of these on the person’s physical, psychological and social functioning, in order to provide safe and effective care. In the first instance the nurse must learn to recognise and pay attention to the key features of altered clinical presentation that can occur in the older person, such as the disease, multiple pathology, frailty, geriatric syndromes and cascading responses to physical, social or emotional factors that can lead to severe illness or even death (National Ageing Research Institute, 2006). Common, potentially serious and debilitating conditions in older age such as delirium, falls, pain, urinary incontinence and constipation, low body mass index and sensory impairment are examples of geriatric syndromes that lead to poor outcomes (Tolson and others, 2011). These syndromes are indicative of a change in health status but frequently do not represent the specific disease condition/s causing that change.

For this reason the community nurse requires an advanced knowledge to identify the ‘atypical’ signs of illness that are complicated by multiple pathology in the older person and even conditions that are relatively minor but debilitating, such as painful feet. Unless the community nurse pays attention to these early signs of illness, they can have a cumulative effect on the older person’s overall condition, to the extent that the person can rapidly lose functional and cognitive capacity (Australian Health Ministers Advisory Council, 2005). As well, the community nurse must acknowledge that for each separate condition the older person might be prescribed different medicines. The resulting polypharmacy can lead to toxic drug reactions and interactions, which can lead to further loss of functional and cognitive capacity (Tolson and others, 2011). Given the complex factors involved in chronic illness management, the community nurse will need to help the older person to build up their self-efficacy (confidence) for self-management (Lorig and others, 2001). This can be facilitated by providing education and supervision in self-management support and treatments, helping the person to set self-care goals and helping them to gain support from others with similar chronic illnesses through links to support and self-help groups (Bodenheimer and others, 2002a; Wertenberger and others, 2006).

In this respect the community nurse must provide strong leadership in pursuing a strengths-based approach to their practice, where the emphasis is on fostering confidence in self-management; building trust and positive relationships between the person, their support network and the nurse; facilitating the older person’s and their carer’s access to relevant services; and using evidence to inform the health consumer, rather than to control (National Ageing Research Institute, 2006). The leadership qualities of an effective community nurse cover four main domains: personal values and character traits; responses and actions befitting a respected leader; high-level tacit and applied knowledge; and client-/colleague-centred professional behaviour (Kralik and Van Loon, 2011). Such leadership qualities are values-based, visionary, creative and inspiring (Stanley, 2006).

Challenges for community nurses

The challenge for community nurses is how to support positive healthcare outcomes for older people within a resource-pressured healthcare system. Community nurses need to reconceptualise the way they provide care for older people who generally have one or more chronic illnesses and high health service needs and expectations. As previously identified, policies aimed at shorter hospital episodes of care, including an increasing number of day-surgery procedures, means that at discharge older people require greater and more-complex care from community nurses (Australian Institute of Health and Welfare, 2011a). In addition, some treatment and nursing care that has traditionally been provided in a hospital setting for people with a chronic illness is increasingly being provided in the community (e.g. dialysis and chemotherapy). Other factors over the last two decades, such as changes to mental health services, have increased the demand on community nursing services to support people with complex health needs (Commonwealth of Australia, 2009).

Growing knowledge of what constitutes best-practice care, at both the consumer and the healthcare provider level, combined with new technologies which can change the way services are provided, have meant that expectations regarding health and the healthcare system have risen. Consumer demand is having more impact than ever on the community healthcare sector (Australian Institute of Health and Welfare, 2011a; Ministry of Health, 2001). Australian and New Zealand governments are grappling with how best to address these growing consumer needs and demands.

Given the projected health expenditure trends associated with population ageing, an important goal for healthcare reform in both countries is the long-term financial sustainability of a comprehensive primary healthcare system. One noticeable impact on community healthcare services is the ageing of the healthcare workforce, including nurses, and an exponential rise in retirement numbers in recent years. The average age of people employed in healthcare occupations in 2006 was 45 years, three years older than other people in the workforce (Australian Bureau of Statistics, 2010). Combined with rising consumer need and expectations, the loss of experienced nurses from the workforce leads to growing pressure on existing services, and leaves more healthcare consumers with gaps in care.

Older people with one or more chronic illnesses can miss out on necessary community care in a complex and fragmented healthcare system where access depends on the availability of services, the geographical location of suitable services and an individual’s level of health insurance cover and ability to pay for services (Commonwealth of Australia, 2009; Ministry of Health, 2003). In some respects, fragmentation in health service provision occurs because of the variety of funding mechanisms and lack of integration, coordination and collaboration between different healthcare systems, including community nursing and acute care nursing services. As well, the traditional organisation of community-based healthcare, which separates general practice medical care and more-specialised health services, does not always meet healthcare consumer needs. Diabetes, for example, has been identified as a typical condition that requires the services of a wide range of healthcare practitioners, such as GPs, nurses, diabetes educators and specialist health staff such as podiatrists, endocrinologists, dietitians, nephrologists, neurologists, pharmacists and cardiologists. All these services are needed to ensure the best health outcomes possible for the person with diabetes; however, the person may not have access to all these services, especially in rural and remote areas, and health service providers may not be aware of the scope and range of services the person is accessing (Australian Institute of Health and Welfare, 2011a).

Similarly, effective support for people living with dementia must include a range of community-based services: healthcare, family counselling and education, home support, respite care and specialist services. This need is highlighted in people with younger-onset dementia, which occurs in an estimated 16,000 people under the age of 65 years, approximately 6.2% of the total population with dementia (Alzheimer’s Australia, 2011). Children of people with younger-onset dementia may be at greater risk as the family tries to cope with the condition and relationships come under stress. Community-based support, education, respite and psychological services therefore need to be available for children and teenagers to help them cope with the effect of dementia on their parent (Alzheimer’s Australia, 2011).

The weaknesses of the current primary healthcare system affect not only older healthcare consumers through delays in care assessments and subsequent limits on the number of care packages and community nursing services available to them, but also on the work of community nurses, especially during times of staff shortages (National Health and Hospitals Reform Commission, 2009).

Overcoming community nursing challenges

In Australia and New Zealand a number of strategies have been implemented to increase the quality of community health services, including using the healthcare workforce more effectively and broadening the current roles and responsibilities of this workforce (Commonwealth of Australia, 2009; Finlayson and others, 2009). Increasing the roles and responsibilities of the community nurse workforce, such as through NPs and practice nurses, provides opportunities for new models of care and collaborative partnerships (Australian Nursing Federation, 2009). Improved collaboration among nurses and other healthcare professionals has required a reduction/eradication of some structural barriers, such as legislating for NP-authorised medicines and repeat prescriptions. This strategy has freed up resources, enabling more-effective service delivery within the community sector. As well, community nurses have been employed in alternative primary healthcare service delivery models for older people with chronic illnesses, such as ‘hub and spoke’ arrangements and the ‘Healthdirect’ inbound/outbound call centre networks in Australia (Commonwealth of Australia, 2009) and Care Plus in New Zealand (Ministry of Health, 2004).

To address some of the challenges associated with a growing older health population, increasing numbers of people with chronic illnesses and a reduced healthcare workforce, the recently released World Health Organization (WHO) report Primary health care (now more than ever) (2010) calls for a return to primary healthcare to help align healthcare systems to deliver better performance, efficiency and equity. The report found that where countries at the same level of economic development were compared, those that were organised around the tenets of primary healthcare produced a higher level of population health for the same investment, in light of the growing burden of disease associated with chronic illness. Well-coordinated primary healthcare systems are also more efficient, have lower rates of hospitalisation and reduced lengths of hospital stay, fewer health inequalities and better health outcomes, including lower mortality, than those that do not, especially for managing chronic illness care (World Health Organization, 2010). Increasingly, there is also recognition that strengthening and improving the way in which community healthcare is provided is vital in determining how well the healthcare system responds to current and emerging pressures (National Health Priority Action Council, 2005).

However, increasing the level and scope of community-based health services will require a shift in current healthcare workforce allocations and reorientation of staff towards primary healthcare. The primary healthcare model will require greater partnerships between community nurses, healthcare consumers and other community-based services to manage the risks, symptoms and impacts of chronic disease, rather than focusing mainly on treatment of chronic conditions (Swerissen and Taylor, 2008).