Telehealth for older people – beyond the Covid 19 environment

When we think of digital technology, we tend to think of younger people using their smartphones and other digital devices. But this picture doesn’t necessarily apply to telehealth. Older people have been taking up digital technology, especially during the recent lock-downs. Through this, they are able to use telehealth to improve their access to care and this may assist ageing in place, which is the preference of most older people, who prefer at-home support to moving to residential care.

Assisting ageing in place

Even if there are informal carers who can help with in-home care, these still need the advice and support of the healthcare community. Telehealth can also reduce the burden on family members who undertake care for their older members.

Many informal caregivers will have responsibilities of their own, from raising children to holding down a job. If they can consult with the doctor in question from the comfort of their own home, they won’t have to spend as much time and money shuttling the person they care for to and from the doctor’s office or for hospital visits. At-home healthcare providers can quickly gain valuable insight and knowledge from remote consultations, improving the quality of care for the dependent person, improving satisfaction and wellbeing for both parties and probably enhancing the quality of care.

Value of telehealth

With population ageing, the number of older people with functional and cognitive impairments, who require assistance from others, will increase. Consequently, planning for their care calls for higher-quality and more cost-effective care, as well as better integration of health care and social support services. To help achieve these goals, telehealth services are increasingly included as a component of community-based care for chronic conditions, mental health, and even palliative care. These have the potential to keep older people independent longer.

Self-reporting

One example relates to diabetes sufferers. They can use tablet devices to share information on their physical, emotional, and psychological health through regular sessions with their doctors. They can track their daily food intake on a smartphone; upload their health data, such as weight, blood pressure, and glucose levels, and transmit these data to health professionals. This gives a much more complete view of health status and allows earlier, proactive care. This type of tele-messaging can help people with chronic conditions to learn self-management skills that allow them to take control of their diagnosis and monitor their condition at home.

Activity monitoring

Activity monitoring includes passive technologies—cameras, sensors, or other devices embedded in a home, and even on clothing — which allow an older person to be monitored without requiring them or another person to operate them. Such devices can monitor mobility and risk factors such as smoke and water leaks. We already have medical alert devices worn to detect falls. Alerts can be sent to caregivers if anything unusual occurs.

Barriers and Drawbacks of telehealth

If an older person feels confident using a computer or smartphone, they’ll be more likely to try telemedicine than one who feels computer anxiety. They must believe that they’ll be capable of successfully using this new technology.

Social context also affects whether or not telehealth services will be used. Older people who are surrounded by friends and family members using communication will also be more likely to adopt the practice. They’ll also be much more likely to try it if their doctor recommends it.

Telehealth must also be seen as safe and reliable. Older people must believe that their health information will be kept private and secure. If online financial transactions are viewed with suspicion, for instance, the same may go for telehealth. Reassurance from trusted people is essential.

Even though telehealth is often more convenient, some older people may prefer a traditional visit to the doctor. And, providers may insist that a face-to-face visit is the best way to diagnose and treat illnesses. So, telehealth is often best used as a supplement to in-person healthcare, rather than a replacement.

 Many critics argue that telehealth may negatively impact continuity of care built up by long-term partnerships with doctors who are familiar with life-long health histories. Receiving care from an unfamiliar doctor through a video app may not be a long-term solution for managing all chronic health problems.

Because telehealth is such a new field, there’s also limited data on its effectiveness as compared to traditional medicine. And there is still a long way to go before home telehealth is widely available, despite its use in the pandemic lock-down. As technology progresses and more care is delivered via telephone, video and other telehealth methods, more research will be needed to identify the models of care that provide the highest quality with the best consumer access, taking into account diverse needs and also demonstrating telehealth’s usefulness and cost-effectiveness.

Posted in Uncategorized | Leave a comment

Telehealth for older people in the Covid 19 environment

Since the start of the Covid 19 lock-down, which began for me on 23 March, I have had the need twice to talk to medical professionals about health matters – once to my GP and once to a specialist doctor. Both consultations took place on the phone. I realise that this was the beginning of my participation in telemedicine and it made me start to think about how this approach could be useful for older people, not only in the current pandemic, but also in the longer term.

Telehealth

This is the wider concept – it is defined by the Ministry of Health as “the use of information and communication technologies to deliver health care when patients and care providers are not in the same physical location.” Telemedicine includes telecare and telemedicine.

Telecare

This relates to technology that enables patients to maintain their independence and safety while remaining in their own homes. It includes mobile monitoring of vital signs – such as ECG or blood pressure (this may require patients to have their own recording devices but taking a pulse can be easy). Continuous remote monitoring of patients enables the tracking of fluctuation in the medical condition of an individual over time as well as highlighting alerts relating to real-time emergencies.

Telemedicine

Telemedicine, which is what I have been experiencing, involves remote doctor-patient consultations which can enable diagnoses and evaluation of patients; remotely prescribed treatments and medication (or alternations to medication). This may be done over the phone or through a video conference.

A number of different types of consultations can take place using telehealth, from initial assessments to multidisciplinary team meetings and arrangements for therapy/treatment appointments. In my case this involved referral for a radiological procedure.

Telemedicine can also mean two-way, real-time conferencing between providers. It can be used by a physician seeking a consultation from a specialist in another location; tests being forwarded between facilities for interpretation. Taken further, telemedicine could include robotic surgery occurring through remote access and physical therapy done via digital monitoring instruments with live feed.

 

What are the benefits?

  • For patients: Faster access to care and shorter wait times, making consultations more convenient and reducing travel and transfers for older patients.
  • Less time spent travelling for doctors; closer working relationship between specialists and primary care, allowing for accessible referrals and second opinions.
  • Allied health workers: Rehabilitation and physiotherapy can take place via videoconference, meaning less time and budget spent on travel.
  • As well as doctors and patients, patients’ family and whānau can be involved in a telehealth consultation. It is possible for a number of people to take part in video-conferences. For example, a consultant might be with a medical student at one site, while a patient, members of their whānau and a rural nurse specialist are at another site.

How does this relate to the Covid-19 Response?

It has been extremely important to continue to provide health services safely throughout the pandemic, especially for older people, and those who may be especially vulnerable. In the wider view this includes emphasis on the need to keep patient contact information up to date to facilitate contact tracing.   A significant amount of information has been found to be missing or out of date.

The Ministry of Health has provided advice to health professionals and also to all users of health services. Uppermost has been the need to keep physical distance from each other as much as possible. This is where telehealth can come in. It provides a way of having an appointment with a doctor, practice nurse and other health providers without seeing them in person. It may involve emailing, texting or having a phone or, where possible, video communication where you can see your health provider and talk about your condition just as you would if you were in the same room. The benefits, in the Covid 19 situation, include:

  • removing the risk of catching or spreading germs
  • reducing time and costs involved with travelling to an appointment
  • not having to leave the house when you are in lock-down or feeling unwell.

 

The main drawback is that the health professional will not be able to have a hands-on examination. But people can sometimes examine themselves or at least indicate the location of a problem. Sometimes a family member, friend or other health professional can help.

If the consultation is through a private healthcare facility, such as your family doctor/GP, you will be asked to pay for the health professional’s time. This will differ by health professional. I was charged a lesser fee than usual for the telephone consultation with my GP, and was told, in no uncertain terms, that I would be receiving a bill from the specialist.

There seems to be a lot more to say about telehealth for older people, so I will continue in my next blog post.

 

Posted in Uncategorized | Leave a comment

Social Distancing/Isolation – how are older people coping?

I am happy to admit that I am over 70 – and for the last six weeks I have been told incessantly that I am “elderly” and “vulnerable”. This is not really how I see myself, but the messages have been so pervasive that my self-image has been dented. I have been told that I should stay at home and have whatever I need brought to me. I must admit that I have been well cared for by my two daughters, for which I am very very grateful – phone calls, Facetime sessions and food drops – but I have had to obey their well-meaning admonitions not to go to the supermarket, swab and sterilise!

So, I was pleased to be able to take part in a webinar put out by Charles Sturt University and the Australian Association of Gerontology, presented by Belinda Cash and entitled “Exploring the Impact of Social Distancing on older adults”. There was apparently a large global audience, estimated at 500, showing that this is an issue which has been widely noticed.

Countries around the world have adopted similar strategies to break transmission of the Covid 19 virus – isolation, quarantine, safe distancing, no non-essential movement away from home. This is easy to accept but the timeframes for distancing have been uncertain, which certainly doesn’t help anxiety and apprehension. The extra restrictions for older people are justified on the basis that the virus presents a special danger to them and they are disproportionally affected. From data presented in the webinar (and elsewhere) it can, however, be argued that chronological age is not the best basis for recent measures.

The webinar-provided figures for Australia, at the time, were 6720 cases of Covid 19 infection: the highest numbers in the 20-29 age group and the median age for them 48. Admittedly, for deaths from the virus the age effect is clearer – the median age of deaths from Covid 19 in Australia 79, with none under 40. Recent figures from New Zealand[1] are 1474 cases, with only 8% in people aged 70 plus; deaths 17 out of 19 are of people 70 plus.

Sure, chronic health conditions and co-morbidity are risk factors, but many older people can manage with some success. And, as Belinda Cash and many others have pointed out, older people are not all the same. The determinants of their vulnerability vary by gender, socio-economic status, education and employment, location and culture. Low incomes among older people, especially older women, mean they are less able to manage when price gouging appears and when they cannot make their own decisions on the “best buys” at the supermarket.

What then are the social distancing/isolation issues which especially affect older people?

  • Their usual family and social connections are disrupted. Many do not have close family living nearby or able to provide support – how many have children and grand-children living overseas who could not get home?
  • Routine activities are also disrupted, and this can cause anxiety. The maintenance of routine activities can benefit social, physical and cognitive wellbeing.
  • Those who are caring for spouses or others at home may be especially affected when they are disconnected from support.
  • Many older people have poor digital skills and are less able to use new technology. Or they cannot afford the hardware, software and connectivity required. The webinar noted that 57% of people aged 70 plus in Australia have low or no digital literacy; 62% of those 50 plus have never made a video call. The digital divide has not been spanned.
  • Social isolation and loneliness are increased. These are already major risks. Loneliness, for all age groups has been linked to other emotional responses – depression, anger, sadness, vulnerability, suicide. Good social connections provide protection against such risks.
  • Too much information about the pandemic, which has dominated the news for weeks, heightens anxiety and can be overwhelming. (I still find if difficult not to tune in to the National Programme several times a day). It is best to limit this exposure, like screen time just before bedtime.
  • The tendency of older people wanting not to be a burden can be heightened when we hear about how overwhelmed the health services are. We do not want to make it worse. As Belinda Cash said – “Tell them it is OK to have home care.”

I heartily agree with the webinar conclusions and I suspect so would Age Concern and our Minister for Seniors: –

  • Do not underestimate the individual resilience of older people; some adjust well.
  • Looking forward, do not make ageist assumptions.
  • Do not make age the sole determining indicator for restrictions, rather look at health conditions.
  • Do not let the label “vulnerable” come to mean less valuable.

Webinar PPT slides available at:

https://csu.ap.panopto.com/Panopto/Pages/Viewer.aspx?id=ba8899a2-21e9-42e7-8d7a-abab006bf211

[1] Article by Charles Waldegrave, Dominion Post 30.3.20 https://www.stuff.co.nz/national/health/coronavirus/121309735/coronavirus-elderly-need-balance-between-protection-and-isolation)

Posted in Uncategorized | 2 Comments

Can redundancy be a silver lining?

We hear a lot about the plight of older people who are struggling to get into or return to the workforce. Only recently there was a Stuff headline – “How employers are freezing the over 50s out of the job market”.

The article reported stories about unexpected redundancy and failure to find work even after sending out dozens of applications. The people involved included many who had had successful careers and listed transferable skills. They were frustrated and embarrassed and many did not want to be identified for fear of jeopardising their situation even further.

It would be easy to share these feelings and point to this as proof of “ageism in action”. Redundancy is almost universally portrayed as a negative event. However, about the same time as reading this Stuff article I came across an academic paper – “Ageing and redundancy and the silver lining of entrepreneurship “which threw a different light on the situation.[1]

The authors found that, while redundancy and old age can have negative effects and outcomes, starting up a business enterprise can be something positive for people in later life. They concluded that both age and redundancy may be spurs to entrepreneurship that might ultimately prove positive and contribute in lifestyle terms for older workers: “a silver lining effect”.

“Entrepreneurship can be triggered by events, positive or negative, that shake an individual from their status quo to start a venture” and there are specific appeals of entrepreneurship facilitated and enhanced, not reduced, by older age”.

 Therefore, entrepreneurship may be considered as a reasonable alternative to employment. Redundancy may be a way to secure capital for business if a severance payment is involved. In a different context, I personally know of an example where a person took voluntary redundancy to acquire funds for a house purchase after a matrimonial settlement left him homeless!

As I have pointed out before, there are many advantages for older people starting up their own businesses. Entrepreneurship may be attractive in providing an opportunity to do something for interest, lifestyle and income which was not possible in previous stages of life. Where once income may have been prioritised, other rewards may be gained, such as free time, family time, and new/existing interests.

 All this comes through in some of the stories we were told when we interviewed “senior entrepreneurs” for our current research on workforce ageing. It emerged that many of our interviewees had experienced redundancy from paid work at some stage in their working lives. Many of the older ones, who had reached pension age, agreed that income from their businesses was supplementary for lifestyle rather than basic need.

 Along with the authors of the British paper, we have found a variety of motivators and drivers of entrepreneurship.

  • The desire to continue to contribute and apply skills and experience.
  • The lifestyle-based attractions of working for oneself, flexibility, being one’s own boss. independence, freedom, satisfaction and growth.
  • The opportunity to fulfil other roles too – such as caring for older relatives

From the British study the conclusion was –

“Entrepreneurship was perceived as an opportunity, but this opportunity was less about being an entrepreneur and more about the lifestyle advantages perceived of independent business in the context of older age and circumstances.”

We are thinking about this in the context of our research – would we agree that “redundancy a blessing in disguise?” Perhaps for some.

 

 

[1] Rebecca Jane Stirzaker and Laura Galloway (2017) Ageing and redundancy and the silver lining of entrepreneurship. The International Journal of Entrepreneurship and Innovation, Vol. 18(2) 105–114.

 

Posted in Uncategorized | 2 Comments

Are our older people prepared for an emergency?

Our Accredited Visiting Service is a national programme aimed to help provide social connection and support to older people who are feeling lonely or isolated.
If you need support during Covid-19, please find more information on our website and contact your local Age Concern if you need more company: https://bit.ly/2Ka01in

*This survey was sent out before the Covid-19 pandemic.

 

In consultation with WREMO (Wellington Region Emergency Management Office) and local councils, Wellington Age Concern developed a questionnaire for users of the local Accredited Visitor service. (AVS). AVS visitors were asked to complete this with their clients.  The aim was to find out how prepared isolated and vulnerable older people are for an emergency, such as a major earthquake.

Excluding people in rest homes or retirement villages – assuming that relevant emergency care would be available for them – 23 responses were included in the analysis. This coverage may not be extensive, but it does indicate areas where action could be taken to improve the preparedness of vulnerable older people in the event of emergencies. These are in bold below.

Preparedness – emergency supplies/equipment

The majority of survey respondents had basic emergency supplies of food, water, medication, equipment such as torches, candles, matches and batteries, and a first aid kit. The main deficit was lack of an alternative sanitation option, such as a portable toilet, in case the wastewater system was compromised. Some had buckets and/or plastic bags. More information on how people could manage this aspect of preparedness would be useful.

Dependence and outside help

The vast majority of respondents had someone nearby who would check on them in an emergency. Almost all said they had someone to stay with if they had to evacuate. Only a very few had anyone who relied on them.  The majority of respondents did not have a pet, but, where they did, they stated that they had food and essential supplies for them.

It was clear that the majority of people who replied to the survey had problems which would make evacuation difficult. Most of these related to mobility – having to use walkers or wheelchairs – and thus likely to be able to move only slowly and with difficulty on stairs and slopes. Another reason was blindness or poor sight. Evacuation is clearly an area where help is vital in an emergency and first responders need to know the location of the persons needing help and what is needed.

Keeping informed and in contact

Respondents were asked to rate their awareness and preparedness for a major emergency. Only one admitted that they were neither aware nor prepared. The rest were split between the “aware and prepared” category and “aware but not prepared” with slightly more saying the latter.

All the respondents had access to a telephone landline and most also had access to mobile phones, although some did not use them or keep them charged. The underuse of mobile phones was also illustrated by the fact that very few respondents received emergency alerts and none had downloaded the Red Cross Hazards app. . This group of older people clearly require more information and guidance about the use of mobile phones during emergencies.

A variety of ways were offered whereby older people could obtain information on how to prepare for an emergency. The most popular was a booklet which they could pick up from the local council; followed by newspapers, especially local papers; mailing, library displays and via the radio. Given that many are housebound or have mobility problems, access via newspapers or mail-outs might be the most acceptable. Websites were not popular.

Following on was a question about keeping up to date once an emergency has occurred. Radio and TV were clearly the most popular means of communication, followed by texts. There was little mention of websites and none of social media. Messages aimed at older people rather than younger generations should take these results into account.

Strengths and vulnerabilities

Finally, respondents were asked how they might be able to help their communities in an emergency, or if they had other ongoing concerns. Many did not add anything. Only one person suggested that they could provide accommodation and share food. Another reported that they were installing a rainwater tank in case of emergency. Several were concerned that their personal alarms depended on a power supply which might be cut off in an emergency. Many responses reiterated their vulnerability – their lack of mobility, dependence on aids and need for assistance.

Posted in Uncategorized | Leave a comment

Older Men and Suicide

We hear a lot about New Zealand’s dreadful suicide rates and what should be done about them, especially when young men are involved.  But what is rarely said is that, proportion to population, there are very high rates per 100,000 population for men aged 85 plus.

I pointed this out in the “From Birth to Death” series of books which I wrote in the 1980s and 1990s, published first by the New Zealand Planning Council and later through the Institute for Policy Studies at Victoria University. The graph below shows the 1994 figures for suicides per 100,000 population by age and sex. In this year the highest rates were for males aged 80 plus, the next highest group being males aged 20-24.[1]

Suicide graph 3 April

Yet Ministry of Health reports up to the 2000s can still state -“Adults aged 65 plus years generally had the lowest rates of suicide”. This is another example of how clumping together the whole population aged 65 plus can distort, and, in this case, cover up important trends and differences.

The comparatively high suicide rate among older men seems to have been recently rediscovered. A headline in the New Zealand Herald in February 2019 read “High suicide rate among elderly NZ men, targeted treatment needed”. This quotes a University of Auckland study published in the New Zealand Medical Journal which suggests the need for a campaign encouraging pensioners to seek help and a new face to front it, similar to the well-known John Kirwan advertisements.

Another recent publication [2] identified a rising suicide rate for very old men. Coronial Services data from 2011 to 2019 produced suicide rates by age groups per 100,000 as follows:

16-19               23.5,

20-24               29.0,

25-29               27.0,

85 plus             27.9

These trends are not confined to New Zealand. In Australia, men 85 and older have the highest suicide rate of any age or gender group – 32.8 per 100,000 in 2017 as against 12.7 for the total population – and are six times more likely to end their own lives compared to women in the same age group. In the USA older European-descent men are again overrepresented among suicide deaths.

Why is this? There are various suggestions. In all countries, bereavement, loneliness, dementia, mental and physical illness may be experienced in advanced age. But there may also be cultural and psychological influences, such as limitations brought on by age and threats to masculinity.

Economic deprivation is more likely to affect older women, but older men are not immune from poverty. Then there are questions about the definition of suicide and the reporting of such deaths. All these factors need to be examined when considering initiatives for suicide prevention aimed at older men.

If you, or anyone you know needs support with mental health or depression please call any of these help lines:

Suicide Crisis Helpline – 0508 828 865
Depression Helpline – 0800 111 757
Elder Abuse – 0800 EA NOT OK
Lifeline – 0800 543 354
Healthline – 0800 611 116

 

 

[1] Keren Skegg & Brian Cox (1991) Suicide in New Zealand 1957–1986: The Influence of Age, Period and Birth-Cohort, Australian and New Zealand Journal of Psychiatry, 25:2, 181-190

[2]  Yoram Barak, Gary Cheung, Sarah Fortune and Paul Glue (2020) No country for older men: ageing male suicide in New Zealand. Australasian Psychiatry 1-3.

Posted in Uncategorized | 2 Comments

That was then …..how about now? (Part 2)

Retirement

The Ageing New Zealanders report pre-dates the Human Rights Act 1993; age was not included as grounds for unlawful discrimination until 1999. In 1982 there was compulsory retirement at age 60 for a large proportion of the workforce, including the public sector (then accounting for 20% of the workforce). This infringement of individual liberty seems to have been accepted, but there were rumblings against compulsion in the public service.

The Third National Government’s “National Superannuation” (now NZS) was comparatively new. This scheme was universal (not means-tested), available from age 60, and it paid 80% of the average wage for a married couple and 48% for a single person. As such it was generous compared to the current level – 66% of the net average wage for a couple.

The report did, however, suggest that people should make adequate preparation for their retirement years, which continues to be a regular exhortation in Retirement Income Policy Reviews. But the only action suggested were lectures or seminars stressing the importance of sufficient finance, appropriate housing and fulfilling interests.  Exhortations to save came later, spearheaded by the Retirement Commission.

Adequacy of income

Although the incomes of older people can be calculated in different ways, it seems that, over the years NZS has been in operation, roughly 30-40% of older people have relied solely on it.  Poverty among older people is also difficult to measure, especially when trying to make comparisons over time. Again, it appears that the proportion of older people living in poverty has continued to be between 15 and 20%. The 1982 report suggested that “about one in five elderly people were experiencing some financial difficulty and only about two percent were facing serious hardship” (1973/74 survey data).

Older people identified as experiencing financial difficulty usually had little or no income additional to superannuation and few financial assets. They were likely to be in rental accommodation or still making mortgage repayments and to be in poor health. These attributes still apply today and are noted in recent policy reports.

It is clear that the universal nature of NZS and lack of a work test, applauded in 1982, still provide flexibility in income choices in retirement.

Aged care

In earlier decades families were assumed to have the major role in caring for dependent older people in New Zealand. “The major responsibility for this care usually falls on one or two family members, the daughter/daughter-in-law or the son/son-in-law.” This was expected to follow stereotypical lines with the daughter/daughter-in-law being the main supporter in terms of personal care and the son/son-in-law helping in the upkeep of the house and grounds.

However, the report noted that this was changing – “The family is no longer seen as having responsibility for supporting the elderly financially or in providing accommodation; instead, state and community bodies are turned to in these instances”. In 1974 the government introduced the Domestic Purposes Benefit, payable to those who cared on a full-time basis for an elderly person who would otherwise require institutional care. The DPB became associated mainly with sole parents and was controversial. In 2013 it was replaced either by Supported Living or Job Seekers allowances. It is difficult to tell from published sources exactly how many such benefits are being used to support older people. Starting in 2020, after considerable pressure, family members, including spouses, will be paid for caring. It remains to be seen how this will work out for dependent older people.

Housing

In 1982 the vast majority of people aged 65 and over owned their homes mortgage-free; only about 15 % rented accommodation, mainly from private owners. Since then there has been a fall in home ownership overall which has affected the older age groups and it is predicted that this will continue. A rise in renting for older people, predicted to be just over 20% by 2050, raises a range of concerns, as pointed out recently in the 2019 Retirement income Policy Review (see recent blog post).

Residential Care

Another big change since 1982 relates to residential care. The report states that about one in every three older people in such care were not disabled and a further third were only slightly disabled. This suggests, the authors continue, a serious “misplacement problem” in residential homes. Bereavement or family pressure were often important factors in the decision to enter a home, so that the “fit” entrants into residential care “had less family support, a lower level of social interaction, less optimism and had more mental apathy” than “fit” older people living in the community. In the mid-1970s New Zealand had one of the highest rates of rest-home residency in the Western world[1].

Gradually ideas about older people remaining connected with family and community have gained wider acceptance. From the 1980s older people were encouraged to continue living in their own homes, with support services such as Meals on Wheels and household help provided by District Health Boards. Private providers of home-care services also emerged.

Some who can afford it now live in retirement villages in small units or flats, with a range of optional support services. This allows many older people to be independent for longer. But, despite the policy of ‘ageing in place’, those who become unable to care for themselves are likely to move to a rest home eventually.

Since 1982, while the residential care population has increased, in line with population ageing, and it has become much older and much more highly dependent. Very few would now be accepted for “social” reasons. Recent figures show that less than 5% of the age groups under 70 are in residential care. The proportion in the 75-84 are groups is falling but a higher proportion are aged 85 plus. Overall the residential care population is itself ageing.

In 2010 the provision of rest homes became a deregulated industry. While some rest homes are still run by churches and charitable trusts, around 75% of New Zealand’s rest homes are owned by overseas companies, run on a commercial basis, under contracts with the DHBs.

[1] https://www.eldernet.co.nz/gazette/a-history-of-residential-care-in-new-zealand/

 

Posted in Uncategorized | 1 Comment