‘YPIRAC is a wicked problem that can only be solved by working across sectors’

Dr Di Winkler AM, CEO and founder of the Summer Foundation, takes a look at the new Younger People in Residential Aged Care Strategy and reflects on what success will look like.

The recent release of the federal government’s comprehensive Younger People in Residential Aged Care (YPIRAC) strategy 2020-2025 is welcome after over a decade of limited government-led progress on this issue. The recent federal budget included $10.6 million to reduce the number of people aged under 65 years in, or at risk of entering, residential aged care. While previous government initiatives have sought to reduce the number of younger people in aged care with no long-term impact, this initiative has the potential to solve this issue once and for all. 

What is the problem?

Younger residents have substantially different needs from elderly residents and aged care facilities do not have the resources, expertise or culture to support them. There is growing evidence regarding the negative impact on health and welling being of placing young people into aged care. A recent review of international literature found that aged care facilities are unable to meet the basic human needs of younger people. The lives of YPIRAC are characterised by boredom, loneliness and grief. They are denied many of the everyday choices that you and I take for granted – where to live, who to live with, what to eat and when. 

Why is it still a problem?

Young people often end up in aged care because they fall through the gap between hospitals and the disability service system. The two systems operate on completely different time frames. For example, if a young person has a very severe brain injury, as soon as they are medically stable there is pressure to move them out of a hospital bed. But disability services take weeks or months to determine if a suitable housing and support option is available.

Rolled out in 2016, the National Disability Insurance Scheme (NDIS) is a significant part of the solution but it is not a silver bullet. Through the NDIS, people under 65 with a disability are eligible for funding for the support and equipment they need to live in the community. However, the issue of young people in aged care needs more than the NDIS. Previous initiatives have failed to have a long-term impact because they provided additional disability services rather than address the systems change needed to prevent new admissions. This requires changes to underlying structures and practices within hospitals, housing, primary health disability and aged care. 

The new National YPIRAC Strategy

Unlike the 2006-2011 national YPIRAC Initiative, which had virtually no long-term impact on the number of young people in aged care, the new YPIRAC strategy does not just sit with the disability sector. YPIRAC is a wicked problem that can only be solved by working across sectors and at the interface between hospitals, housing, primary health, aged care and disability.

The YPIRAC strategy is governed by a Joint Agency Taskforce that includes the Departments of Health and Social Services, alongside the NDIS. The leadership from the prime minister is welcome, with the Morrison government announcing measurable targets with explicit timeframes. These targets include:

• no people under the age of 65 entering aged care by 2022
• no people under the age of 45 living in aged care by 2022
• no people under the age of 65 living in aged care by 2025.

Shutting the gate to young people entering aged care is critical to seeing the level of systems change needed to prevent all new admissions. The disability service system needs to step up and effectively compete with the aged care system in the provision of timely housing and support for people with disability high support needs who are in hospital and ready for discharge. 

Preventing new admissions of young people to aged care will require the rapid development of a disability service system that can provide alternative housing, and disability and health supports at a national scale as quickly as the aged care sector provides a bed.

Some of the $10.6 million in the federal budget will be used to establish a network of “independent systems coordinators” to support YPIRAC and those at risk of admission. It is critical that these systems coordinators do more than just provide a “band-aid” for a broken system. Ideally, this new workforce will also routinely collect data on systemic barriers to provide an evidence base for potential solutions and changes to underlying structures and practices within hospitals, housing, primary health, disability and aged care. Without a deliberate focus on systemic change, just like previous government initiatives, young people will be admitted to aged care when funding for this three-year program ceases.This is an opportunity to correct the systems disconnect which allows young people to fall through the gaps, into aged care. 

Progress to date

New housing is being built for 6 per cent of NDIS participants with the highest level of disability including younger people in aged care. This housing is called specialist disability accommodation (SDA) and is funded by housing payments in the plans of NDIS participants. Throughout Australia, there are new dwellings either built or under construction for over 3,000 NDIS participants. The Housing Hub currently has over 1,100 listings for vacancies in both SDA and non-SDA properties for people with disability. While the SDA market has made a promising start, new housing is needed for a further 9,000 NDIS participants including YPIRAC.

While the enrolment of younger people in aged care in the NDIS was initially slow, the NDIS now has a specific YPIRAC planning team. While most (76 per cent) of the 4,860 young people in aged care are now NDIS participants, most YPIRAC do not have SDA in their plans. To date 149 (3 per cent) of YPIRAC have been deemed ineligible for the NDIS. While we know that some young people are admitted to aged care for palliative care, further research is needed to better understand the health and support needs of this cohort to inform the development of alternative health and support services.

What is needed to achieve these targets?

When young people are admitted to aged care, they lose skills, confidence and social connection. In aged care everything is done for you and people become more dependent. Many YPIRAC need capacity building, information, resources and support over an extended period of time to consider alternative housing and support options. Rather than waiting for people to enter aged care and get them out, the main focus should be on improving the interface between hospitals and the NDIS to prevent new admissions. More work is needed to understand the risk factors and pathways into aged care, so we can design effective solutions to prevent new admissions. 

What will success look like?

The successful implementation of this strategy will focus on systems change as well as improving the outcomes of the current cohort of young people in RAC or at risk of admission. We will have a disability service system that is as effective as aged care in providing timely housing and support. When a person with disability is in hospital, the health-disability interface will work seamlessly. Hospitals will systematically identify NDIS participants early who have a housing need or are at risk of a discharge delay. The NDIS will fund timely support and housing that is ready at the point of discharge. A range of housing options will be available that enable people with severe disability to live in the community like everyone else. All of these systemic changes are essential to ensuring there are no new admissions of people under 65 to RAC after 2022. A joined up approach from government and effective collaboration with the non-government sector has the potential to both solve this wicked problem and improve the health-disability interface for all NDIS participants.