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cohealth’s submission to this Victorian Parliamentary inquiry highlights the barriers to accessing services and supports created by complex systems and a lack of information and services in languages other than English. We recommend increased investment in language services – interpreting and translating – and funding to employ bi-cultural and bilingual workers to improve access to supports for older Victorians of migrant and refugee backgrounds.
cohealth welcomes the opportunity to provide a submission to the Inquiry into Support for Older People from Migrant and Refugee Backgrounds. cohealth has extensive experience providing community-based supports and services to older people. More than 25 per cent of our clients are over the age of 65, and of these over a third are from culturally and linguistically diverse backgrounds. Many also experience socio-economic disadvantage.
In addition to providing general physical and mental health care and social support programs, cohealth provides a range of services specifically for older people. These include the delivery of a range of Commonwealth Home Support Programs (allied health – physiotherapy, podiatry, occupational therapy, dietitians – Flexible Respite, Social Support Group, Centre Based Respite, Assistance with Care and Housing and Access and Support), ethno-specific supports, homelessness services, supports for older people living in high rise public housing estates, and delivery of a range of social support groups for aged and frail people and people with dementia. Increasingly, clients with Home Care Packages are accessing the allied health and social supports they need through cohealth.
cohealth recognises the strength and diversity of older people from migrant and refugee backgrounds. The majority are engaged with family, friends and their communities, and contribute substantially to their families and the community. If their support needs increase they are able to access the services they require, often with the assistance of family and friends.
However, for some older people, including some from migrant and refugee backgrounds, the complexity of systems and the lack of information and services in languages other than English can create significant barriers to accessing services and support. Greater attention needs to be paid to ensuring the needs of these communities are included in policy and planning to ensure that they too can benefit from supports that enable them to remain well and healthy and participate in civic and community life.
Recommendation 1: The Victorian Government increase investment in language services – interpreting and translating – for older people.
Recommendation 2: Develop a workforce plan to increase bi-cultural and bilingual workers in services that support older people from migrant and refugee backgrounds.
Recommendation 3: The Victorian Government improve the oral health care available to older people from migrant and refugee backgrounds by increasing public dental health funding and advocating to the Commonwealth to establish a Seniors Dental Benefits Scheme.
Recommendation 4: Invest in roles that assist older people from migrant and refugee backgrounds find and access health and social support services, such as bicultural care navigators/care finders and care coordinators.
Recommendation 5: Ensure all service information is routinely available in preferred languages, services are culturally safe, and that bi-cultural and bilingual workers who reflect the communities they work in are funded.
Recommendation 6: Provide capacity building (training and professional development) to enhance health and aged care providers understanding of diverse cultural beliefs and responses to ageing and the care of elders.
Recommendation 7: Increase investment in programs and services that provide culturally safe services, supports and activities for older people from migrant and refugee backgrounds.
Older people from migrant and refugee backgrounds are diverse. Their experiences and needs vary depending on many factors, such as the length of time they’ve been in Australia, their experiences of getting here, income and wealth, where they live, education level, English language proficiency (verbal and written), age, sexuality, health, physical abilities, natural supports ((family, friends and neighbours) and their connections with community.
Some need no or little supports and face few barriers to participating in civic and community life. Others may however face multiple barriers that directly impact on their health and wellbeing.
Everybody has the right to live with dignity and respect regardless of age or cultural background. Everyone is entitled to the enjoyment of human rights without discrimination of any kind, including discrimination on the basis of age. Human rights and freedoms that are particularly relevant to older people, include the right to:
All services and supports for older people from migrant and refugee backgrounds must be underpinned by clear human rights principles and respect and support a person’s choices, lifestyle and decision making.
cohealth developed this submission with input from older people including cohealth clients and community members, as well as cohealth staff with experience providing services to older clients.
It is clear from our consultation with consumers (including a facilitated session with cohealth’s Consumer Advisory Committee to inform this submission) that people wish to continue to lead full lives as they get older, and that many require only limited assistance to be able to do this. Key themes about what is needed to help them remain independent, well and healthy at home include:
However, cohealth consumers also identified a range of barriers, outlined in the following responses to the terms of reference. Recurring themes are the complexity of the very systems that aim to provide support and assistance, and the difficulties faced by people for whom English is not their first language when information and supports are predominantly provided in English. This can result in them delaying finding the support or health care they require and are entitled to.
Our systems assume a high level of individual agency – English language and other literacy skills, ability to navigate complex systems, understanding of available options, and capacity to confidently self-advocate to those in authority positions – that is often compromised within cohealth’s consumer base.
Terms of Reference (a) – Adequacy of services for older Victorians from migrant and refugee backgrounds.
While there are many services designed to support older Victorians, there are distinct service gaps that impact on the health and wellbeing of older Victorians in general, and those from migrant and refugee backgrounds in particular. Even when services are provided people need to know what is available and how to access them. Community members from migrant and refugee backgrounds, and those who work with them, have identified the following gaps.
Language
The gap most regularly described is a lack of services able to effectively communicate with people for whom English is not their first language, or those that understand diverse cultural norms and approaches to ageing, health and wellbeing.
Difficulties accessing services provided in first languages or via interpreters can lead to people delaying or not accessing the services they need to maintain their health, wellbeing and social connections. Difficulties identified include:
A cohealth diabetes educator has described the consequences for older people from migrant and refugee where interpreters are not used.
‘People with diabetes require various preventative health tests and screening tests to monitor the condition and provide early treatment if required to prevent complications. However, a lack of clear information in their language about tests, fees and treatments can result in people not accessing the care they need. For example, a client stopped having vital eye tests as the clinic they attended initiated a new fee. While this fee only applied if treatment was required the clinic didn’t use interpreters so the client didn’t understand this nuance. In another case, again where a service didn’t use interpreters, a client did not understand how a routine test was to be administered.’
Another worker described the experience of a Spanish born client who received a letter in English from My Aged Care (MAC) offering a home care package.
‘I rang MAC to request the information in Spanish, so the client could digest the information and then discuss with her family and relevant worker etc (given the complexity of the info and that the client was being informed she needs to seek out a Home Care Package provider). I was appalled to be told that written communication in community languages is not a possibility and the only option was to go through the interpreter service.’
For older people requiring assistance in the home there is a lack of home care workers and personal care workers who speak the language and are familiar with the culture of the older person. As a result, families can delay seeking essential supports until a point of crisis or extreme need. In the meantime, family members, particularly women, shoulder the role of caring. While currently a service gap, this presents a possible employment opportunity for communities from migrant and refugee backgrounds.
The experiences of COVID-19 emphasised the importance of providing information in community languages, including in non-written formats, and engaging and utilising community leaders. As the pandemic progressed communities and bicultural workers developed creative methods to ensure vital information reached communities in culturally relevant ways. This included by producing videos, arranging community meetings and undertaking individual conversations. Through these means information reached people who might otherwise miss out on it. Communities should be supported to communicate information to older people in culturally relevant methods that recognise different literacy levels.
Other barriers to access
Difficulties with transport can be a barrier to accessing services for older people of all cultural backgrounds, particularly as mobility declines. Locally based services that assist with transport or provide outreach to people’s homes improves access to services.
The cost of services and activities can also be a barrier. All services and supports should be affordable to ensure equitable access.
Oral health care
Older people experience higher levels of oral disease than younger people. This is associated with general health problems such as diabetes, changes in diet, increased use of medication, and the breakdown of heavily restored teeth. Poor oral health makes it difficult to eat a nutritious diet. This is a particular problem for those who are receiving home care support or who live in residential aged care facilities.
The cost of oral health care can be prohibitive for many older people, particularly those reliant on the aged pension and who cannot afford private care. They have no choice but to languish on public dental waiting lists, where the wait for care can be years.
There is an urgent need to increase funding to public dental services to reduce overall wait times. The Royal Commission into Aged Care Quality and Safety recommended establishing a Seniors Dental Benefits Scheme, to operate similarly to the existing Commonwealth Child Dental Benefits Scheme. cohealth urges the Victorian Government to advocate to the Commonwealth for the establishment of such a scheme.
Aged care nursing in primary care
cohealth employs an Aged Care Community Health Nurse at our Collingwood site. They provide a vital role to older people in the area, particularly those who face barriers to accessing services. In addition to providing on-site physical care to older people, in conjunction with general practitioners, this role assists with medications, undertakes home visits and provides a vital bridge to other health and community services such as assisting people access My Aged Care and with Justice Connect to help with elder abuse issues. Increasing funding to enable the employment of similar practitioners across community health and other primary health settings would improve the health and wellbeing of older people from migrant and refugee backgrounds.
Supporting mobility and chronic pain
Services such as physiotherapy to treat chronic pain and mobility declines often do not meet the needs of older migrant and refugee backgrounds. Despite the expansion of evidence about multidisciplinary chronic pain management strategies, this has had limited benefit for people with migrant and refugee backgrounds. Clinicians have limited knowledge about the nuances in cultural norms and beliefs related to bodily pain. At the same time cultural beliefs about the inevitability of mobility loss from ageing can result in people disengaging with exercise services that would otherwise assist them.
Improving providers knowledge about trauma informed care, cultural beliefs and working with people from diverse cultural and language groups would help ensure services respond to the needs of older people from migrant and refugee backgrounds, as would involving communities in co-design of services and ensuring access to high quality language services.
Access to home care support
While a Federal Government responsibility, the difficulties older people face obtaining the support they need to remain at home arose many times in our consultations. Time and again we heard how difficult the My Aged Care system is to navigate and access particularly for this population, and more so for new arrivals and those of refugee background. It can be quite unusual to talk about care needs with the various assessors, people they have no existing relationship with (unlike a trusted GP), or no potential relationship with (such as a care provider).
Providing early in-home support for people is vital to ensuring they can remain at home for as long as possible. Unfortunately, clients describe the processes for accessing these services as confusing and difficult to navigate, which is exacerbated for those for whom English is not their first language. Older people without natural supports to assist with the processes find it particularly challenging. From My Aged Care’s reliance on online access, to the processes associated with aged care assessments and allocation of packages (and lengthy wait times), to identifying suitable providers and understanding the financial aspects of packages and invoicing there are many points in the system that could be improved. Navigators – particularly those speaking community languages – that can assist community members understand and access services would ensure they receive necessary supports. cohealth urges the Victorian Government to advocate to the Commonwealth Government for improved processes and access.
Strong cultural norms that family members take on the care of their older members can also mean that by the time families seek formal supports the need is great. Lengthy wait times for Home Care Packages place inordinate strain on older people and their families. cohealth urges the Victorian Government to advocate to the Commonwealth for more timely allocation of Home Care Packages for this group.
Expanding the workforce of home care providers – personal care, home support, allied health and nursing – with skills in community languages and understanding of cultural needs and preferences is vital to ensuring the support needs of diverse communities are met.
Forward planning
More recently arrived communities are now ageing towards care needs and planning need to anticipate the services and skills required to provide appropriate supports, care and activities.
Recommendation 1: The Victorian Government increase investment in language services – interpreting and translating – for older people.
Recommendation 2: Develop a workforce plan to increase bi-cultural and bilingual workers in services that support older people from migrant and refugee backgrounds.
Recommendation 3: The Victorian Government improve the oral health care available to older people from migrant and refugee backgrounds by increasing public dental health funding and advocating to the Commonwealth to establish a Seniors Dental Benefits Scheme.
Recommendation 4: Invest in roles that assist older people from migrant and refugee backgrounds find and access health and social support services, such as bicultural care navigators/care finders and care coordinators.
Terms of Reference (b) – Unique challenges faced by this cohort, including, but not limited to, social isolation, civic participation, digital literacy, elder abuse and access to culturally appropriate aged care and home care services
Language barriers
Many of the challenges faced by older people from migrant and refugee backgrounds are similar to those faced by the broader older community. However, a clear theme from cohealth’s consultations for this submission was the barriers imposed by the lack of information and services in languages other than English, and the impact these have on access to care and support. To exercise choice and control we need access to information and to be empowered to make informed decisions. Systems that cannot be understood or are difficult to negotiate impose barriers to seeking care. Our consultations highlighted that people will delay seeking or obtaining care as a result.
Some of the areas identified where older people from migrant and refugee backgrounds face barriers due to systems and services provided only in English include:
Cultural differences
Cultural differences can prevent older people from migrant and refugee backgrounds from accessing and effectively using services and supports. These include attitudes to family and caring responsibilities, perceptions about ageing and particular beliefs, behaviours and preferences that are not well understood by the non-culturally and linguistically diverse population. They may have gender preferences, certain views regarding the role of women, concerns about privacy, a mistrust of authority figures, or difficulty in expressing their needs if English is not their main language.[2] Services need to be well attuned to these differences, not assume that all older people have the same beliefs about ageing, and ensure that services are culturally appropriate and safe.
Elder abuse
Everyone has the right to live with dignity and respect and free from harm, abuse and exploitation regardless of age.
However, the Australian Institute of Family Studies estimates that up to 14 per cent of older people have been victims of elder abuse[3] – a statistic that is likely to be underreported. The abuse may be physical, financial, social, emotional, psychological and can include mistreatment and neglect. Elder abuse is a serious problem across the community but is compounded for older people who are reliant on family members due to language and cultural expectations. In these circumstances adult children can take over speaking for their parents and make decisions for them that reflect the children’s preferences, rather than those of the older person. While most often this is well intentioned, it can leave older people vulnerable.
It is important that older people have support and are able to talk to someone they know and trust and seek independent legal and financial advice, particularly before signing legal documents such as contracts, so that they can make confident, informed decisions. Service providers need to be alert for the signs of elder abuse and have clear processes for identifying and responding to it. It is critical that these services are provided in community languages and support older people to speak independently of family members.
Family members are often used to interpret for older people. While many do so accurately, this does not always happen. When family members convey their views and preferences this can lead to the needs and preferences of the older person being overlooked or contradicted, a form of elder abuse. cohealth practitioners recommend ensuring professional interpreters are used, particularly for initial appointments, to ensure they can speak directly with the client, and that organisational policies clearly articulate this.
cohealth has a Senior’s Law Health Justice Partnership with Justice Connect which sees lawyers embedded into our healthcare teams to help older people experiencing elder abuse and other legal issues. A key part of this service is supporting cohealth staff to understand what abusive behaviours look like in the context of family violence or elder abuse and whether someone is being hurtful or neglectful.
Expanding services such as this that ensure older people have a voice and advocate are critical to ensuring their rights are upheld.
Isolation
Disturbingly, many older people experience isolation, and this can increase as mobility declines. This is exacerbated for people who have limited natural supports (family, friends and neighbours) and if they face language barriers. Working with older people from migrant and refugee backgrounds to develop and support appropriate, culturally sensitive options to promote social inclusion is critical.
Programs that promote social inclusion and connection, early intervention chronic disease self-management, healthy lifestyles, healthy eating, exercise, and the like are important to maintain health, wellbeing and social connections.
However, as aged care funding has moved towards a consumer directed care model of funding providers have found it difficult to provide these sorts of group programs, and with full cost recovery of participation and transport now having to be met from a person’s aged care package, some older people are finding it difficult to afford. Previous funding arrangements allowed for subsidisation that made it easier for people to participate. Investment in programs that enhance health promotion and social inclusion is required.
Reduced in-person service access and move to digital environment
The increasing use of digital methods such as websites, text messaging and telehealth for information and access to services and activities can provide valuable virtual links and access, as demonstrated during the COVID pandemic. However, for those uncomfortable using these methods, or with limited digital literacy and skills, who do not have the devices, or who cannot afford devices and/or data, the move to digital service provision creates a barrier to participation. When these resources are predominantly provided in English there is an additional barrier for older people from migrant and refugee backgrounds. During our consultation community members referred to the challenge of obtaining COVID vaccination certificates due to the complexity of navigating both technology and language.
While some older people embrace the move to technology it is important to recognise that this is not true for everyone. Ensuring continued access to in-person services is important. At the same time, providing training in community languages and access to affordable devices and data would assist those wanting to take up these options.
Recommendation 5: Ensure all service information is routinely available in preferred languages, services are culturally safe, and that bi-cultural and bilingual workers who reflect the communities they work in are funded.
Recommendation 6: Provide capacity building (training and professional development) to enhance health and aged care providers understanding of diverse cultural beliefs and responses to ageing and the care of elders.
Recommendation 7: Increase investment in programs and services that provide culturally safe services, supports and activities for older people from migrant and refugee backgrounds.
Terms of Reference (c) – Ideas to advance the physical and mental health and wellbeing of Victoria’s multicultural seniors including global best practices
All our systems and services should be improved so they better meet the diverse needs of older people as a default, such as age friendly cities[4], universally accessible communities and housing that meets the needs of people with mobility issues, neurological issues, vision and hearing issues etc, and dementia friendly communities.
Services should be co-designed with older people from migrant and refugee backgrounds to ensure they are culturally sensitive and safe, meet the needs of the community and overcome barriers to access.
The workforce should reflect the cultural backgrounds of the community they work with. This will involve expanding the cultural diversity of community GPs, nurses, and allied health and social support services. Not only will this improve communication, but a diverse workforce will be more attuned to cultural perceptions of aging, chronic pain and the like and be able to improve the clinical guidelines about managing various conditions (for example chronic pain management guidelines) so they better resonate with all communities.
Having clear information and being able to participate in conversations about health and other supports is critical for a person’s health and wellbeing. While interpreter services and translated material are important resources, ideally services would employ bi-cultural and bilingual workers who reflect the local communities and speak relevant languages. As well as being able to communicate directly with older people from migrant and refugee backgrounds, and understand their culture, these workers can be a bridge to other team members and services.
As described earlier, cohealth employs a Community Health Aged Care Nurse at our Collingwood who provides comprehensive assessment, health care and referrals to other services. Recognising the complexities of aged care work, this site has developed an Aged Care Hub to work with older clients at increased risk of deteriorating physical or mental health. The multi-disciplinary Aged Care Hub works with older clients with complex physical or psychosocial health concerns, focussing on early detection and management of significant changes to their overall wellbeing, or where significant carer burden has been identified.
The Aged Care Hub draws on the expertise of the Community Health Aged Care Nurse together with an occupational therapist, care plan nurse and physiotherapist and works closely with GPs and other allied health practitioners. The Aged Care Hub has particular knowledge of My Aged Care services which clients can be referred for reablement programs and ongoing support.
Providing early intervention and short-term care co-ordination has enabled older clients to be linked into an extensive range of services and programs, both within cohealth and external, resulting in their health stabilising and reducing risk of hospitalisation.
Feedback from cohealth community members and staff has indicated that the health, aged care and other support systems are complex and difficult to navigate. The many different providers, the separation of health and aged care systems and the various assessments and processes can be overwhelming, particularly for those for whom English is not their first language and those without natural supports (family, friends or neighbours) to assist them navigate the system. For many people their first contact with the aged care system is during a time of crisis, acute need or deteriorating health and navigating a complex system without support can be particularly daunting.
cohealth welcomes approaches that assist people to access the care they are eligible for such as Access and Support Workers and age care navigator approaches, and the future care finder program. Providing advocacy and navigation supports and assistance with care coordination is critical to improving access and reducing the stress individuals and families experience. Investment in bi-cultural and bilingual community workers to raise community awareness about various services and supports, including My Aged Care, and coordinate access to services would improve access to these services for older people from migrant and refugee backgrounds.
In our consultations, community members have suggested a range of holistic approaches to advance the physical and mental health of older people from migrant and refugee backgrounds:
While some people find digital methods useful, participants in our consultations emphasised the importance of these activities being in person.
The ongoing training and professional development of all workers involved with providing care and support to older people from migrant and refugee backgrounds about cultural needs and culturally safe practice is critically important. This should be provided by members of relevant communities, and be provided to clinicians, support workers, care coordinators. It would be valuable for interpreters to have knowledge, and ideally qualifications in, specialised areas such as health, legal, family violence and the aged care system.
[1] Australian Human Rights Commission Human Rights and Older People
[2] Drawn from Australian Department of Health (2019) Actions to support older Culturally and Linguistically Diverse people: A guide for aged care providers
[3] Kaspiew, R., Carson, R., & Rhoades, H. (2015). Elder abuse: Understanding issues, frameworks and responses (Research Report No. 35). Melbourne: Australian Institute of Family Studies.
[4] The World Health Organisation Age-friendly Cities Framework: https://extranet.who.int/agefriendlyworld/age-friendly-cities-framework/
Collingwood