Caring for older Australians

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NEW AGED CARE MODEL OPTIONS

C.1

C New aged care model options

The Commission contracted Applied Aged Care Solutions Pty Ltd (AACS) to

provide an independent report on a new aged care and assessment model. This

appendix presents their report.

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‘New Aged Care Model

Options’

FOR THE PRODUCTIVITY COMMISSION

‘INQUIRY INTO CARING FOR OLDER AUSTRALIANS’

Dr Richard Rosewarne and Janet Opie Applied Aged Care Solutions

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Glossary

AACS Applied Aged Care Solutions

ACCNA-R Australian Community Care Assessment revised

ACFI Aged Care Funding Instrument

ADL Activities of Daily Living

AH Allied health

CACFI Community ACFI

CACP Community Aged Care Packages

Carer Primary informal carer

CDC Consumer directed care

CENA-R Carer Eligibility Needs Assessment revised

Client All persons broadly eligible for aged care programs (care recipients and carers) Consumer The general public, potential clients, others representing potential clients

CR Care Recipient

CRCC Commonwealth Respite & Carelink Centres

EACH Extended Aged Care at Home packages

EACH-D Extended Aged Care at Home for dementia packages

GP General Practitioner

HACC Home and Community Care

Hubs Regionally based sites using nationally consistent assessment tools and processes but flexible to local and broader jurisdictional issues

IADL Instrumental Activities of Daily Living

Lead Agency The leading service provider where there is more than one service provider

MDS Minimum Data Set

NRCP National Respite for Carers Program OH&S Occupational Health and Safety

PC Productivity Commission

QA Quality Assurance

RCS Resident Classification Scale RTO Registered Training Organisation

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1: New Model Considerations

There are many shared principles stated in the various submissions to the Productivity

Commission’s Inquiry ‘Caring for Older Australians’. The purpose of this report is to

describe an aged care system model that will accommodate many of the principles in a new way forward that places the client at the centre of the model and further improves the operation of the overall system that is designed to support older Australians. The suggested model reflects the principles in a practical and achievable way and is demonstrated and described in the suggested approaches for the provision of information, assessment, support and care for older Australians. The delivery of a new way forward will not only require a practical assessment and classification system but a re-configuring of the aged care programs moving from the current inflexible ‘care package’ approach where support service availability types and amounts are partitioned in a way that does not necessarily reflect the actual care need supports required for an individual. The new model reflects an approach where any required service (based on assessed care need) is available with the aged care classification the person achieves. The only restriction within the classification levels and special supplements (e.g. dementia low vs. high) is the amount of service (e.g. cost) that can be provided based on the individuals assessed care needs. This approach is more appropriate if we believe it is important to provide a fit between a person’s care needs and supports the aged care program can provide. This new model will also provide for greater consumer choice with selection of the available service providers and level and type of assistance.

The new model also proposed a structuring of a central agency responsible for the overall aged care program management with the operational and service aspects performed by a network of regional hubs that could be managed at a jurisdictional level. This approach will provide for recognizable and accessible local hubs for consumers that will also serve to promote better co-operation between the various service system providers in the region and build capacity that will be responsive to local population needs and geographic and

service system capacities.

The underlying principles in many of the submissions indicated that the purpose of the aged care system should be to assist the physical, emotional and social wellbeing of the person

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and provide the opportunity for purposeful interaction with their community and family. This clearly identifies that the new aged care system should respect the client and their role in society allowing them a degree of control and self determination in terms of service types, amounts and providers that is not always apparent in the current approach.

The proposed model intends to incorporate the commonly shared principles and ideas enunciated in the submissions and place these ideas into a new structure of regionalized hubs using a defined process with standardised assessment and classification aspects that would underpin such a model.

1.1 PRINCIPLES

Assessment Model Principles

The proposed model is based on the most common principles described in the submissions to the Productivity Commission and discussed at AACS consultations. The model should allow for a nationally consistent process and assessment approach that provides for:

 Recognition of consumer rights, delivery of consumer choice and consumer control

in their care support arrangements wherever possible and practical

 Consumer choice to be imbedded in the outcome of the assessment process that

covers service types, service providers and care settings (as appropriate)

 Transparency of the assessment process, services available and outcomes expected

for consumers and their families

 Information points that have detailed knowledge of eligibility requirements, the

supports available and how to access them in a timely manner

 The provision of a central agency responsible for the overall aged care program

management with the operational and service aspects performed by a network of regional hubs that could be managed at a jurisdictional level

 Consistency in the application of the information, assessment and classification

approach that will produce equity of outcomes for consumers

 Seamless access to aged care services for consumers provides a clear, predictable

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 An approach that assesses for health promotion needs and the ability to improve

independence, maintenance of independence and care needs that require ongoing support

 The recognition of the important role of the Carer and the need to support them in

that role with a range of services not limited by the existing aged care program service types (awareness, access to supports, education and skill training, assessment in their own right)

 Access to a wide range of services (in and out of the community setting) from the

central assessment agency hubs, covering the current HACC services and more to support consumer choice of setting of care e.g. palliative care,

rehabilitation/restorative services, technological assistive devices

 Client referrals to be based on assessed needs and not restricted by what is

available by any one service provider’s offerings

 A fit with the promotion of wellbeing, healthy ageing, prevention programs and

social inclusion activities

 A single aged care scheme that will streamline access to a wide range of aged care

services e.g. from low level through to high care services

 Processes that interconnect the health and aged care systems in all jurisdictions in a

nationally consistent way

 Electronic records that can reduce assessment burden for consumers and provide

timely information for all service providers involved in the persons care. This will allow service responses to be better targeted and more responsive to the changing care needs of clients.

 An information platform that can bring together information from various systems

and sources and builds a single client record (care recipient and carer) that is accessible to relevant service providers (as approved by the client and carer).

 A better fit with a market approach that provides incentives for providers to

improve quality and innovation

 The identification of the unique issues of special needs groups with the

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1.2 BROAD REQUIREMENTS

This section will discuss the broad requirements needed to implement the principles

described in Section 1.1. The new model would be ideally managed through the provision of a central agency responsible for the overall aged care program management with the operational and service aspects performed by a network of regional hubs that could be more directly supervised at a jurisdictional level. The broad requirements need to cover the new model aspects of:

 Information

 Assessment for identification of needs and classification

 Coordination and links to services

Consumer directed care will require access to information and other supports (coordination and independent advocacy by the regional assessment hub, case management at the service provision level) to assist the consumer to exercise their choice and control over service types, service providers and care settings. A clear and accurate information base should provide the basis for consumer decisions.

Studies have found strong evidence that service systems impact on the kind and amount of services received, producing inconsistency in the allocation of services based on resource

availability rather than client characteristics (Howe, Doyle and Wells 20061_{). While the}

assessment used for classification and identification of needs should be undertaken independent of the Service Providers, consideration also needs to be given to the flow of the process and the system bottlenecks that may be produced as an unintended

consequence. The evidence however also indicates that if the care needs assessment and classification outcome is determined in a setting independent of service provision, there are usually fewer regulations and requirements imposed on service providers by the body responsible for the funding of the services (e.g. government).

1_{Howe, A., Doyle, C., & Wells, Y. (2006) Targeting in community care: a review of recent literature}

and analysis of the Aged Care Assessment Program Minimum Data Set. Unpublished report to the Australian Department of Health and Ageing, Canberra.

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An intake assessment is considered critical in allowing the client quick access to services and in directing the flow of the client through the system. Early access to services that promote independence will benefit the overall aged and health systems by encouraging use of services that can maintain or restore functional decline and this will in turn support people to live longer in the setting of their choice (Howe, Doyle and Wells 2006). It is therefore important that the assessment tool supports early identification of both current and emerging needs and easy access to services to support client independence.

A broad based intake assessment investigating current performance, impairments, dependency and support requirements should be conducted to properly inform on client needs. This intake assessment phase should not be influenced or affected by the local or available service resources as this will be considered at the referral stage of the assessment process. A broad client profile collected at the initial assessment stage will most likely identify a range of issues that can be then attended to in order of priority together with a plan to support the client to maintain their independence.

The intake assessment should:

 Be designed to fit with the assessment setting (online, phone and face to face)

 Be flexible and support best practices in assessment e.g. conversational approach

 Support an equitable process for clients by providing a consistent manner for

identifying needs and determining supports and service selection

 Take a broad approach when looking at dependency, other care needs and unmet

needs so as to be fully informed about the appropriate response for the client

 Support early identification of emerging care need issues

 Be fit to the purpose, providing an initial shorter assessment level (including self

navigation, eligibility criteria), however with enough detail to support a classification approach and triggers to the next assessment level. The next assessment level should provide access to higher resource care packages that could be delivered in the community or residential settings

 Detail processes and tools to allow standardised input from external sources (e.g.

health programs and specialist assessors), this will reduce assessment burden and assist communication between systems

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 Be used by assessors trained in the methodology, use and assessment process

supported by the specific tool. In the suggested new model the assessors are aged care comprehensive assessors and specialist assessors.

 Deliver reliable and useful data that can be shared as appropriate by agencies and

service providers

 Provide governments with consistent information to manage and target resources

in an equitable and sustainable manner at a regional and national level

 Produce a minimum data set for activity reporting and research purposes

A nationally consistent approach to intake assessment would be achieved by the assessment hubs which would be the entry or front end of the system, and would provide:

 Access and provision of consistent assessment at all regional locations across

Australia via the regionally based assessment hubs

 The network of regionally based integrated assessment hubs would play an essential

role in coordinating client assessment information and supporting service providers in the regional network

 Client classification details and advise on any co-payment requirements

 Support for consumer directed care by including the consumer in the planning

aspects including client goal setting, priorities and desired client outcomes as an indicator of service ‘pack’ effectiveness

 An independent review of services and the service outcomes with services based in

the regional network

 An independent advocacy service for consumers receiving services from providers

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1.3 CLASSIFICATION CONSIDERATIONS

What are the features of a classification model for an aged care program providing services across community and residential settings? The determination of the features will inform on the final selection of the criteria, assessment questionnaire content and statistical model that is required to determine the classifications. The model and associated instruments will need to be flexible enough to include the required options.

Eligibility needs to be determined to ensure that objective criteria are developed for the ‘bottom end’ of the classification model. For example:

 Eligibility for care programs may be limited to people with reaching a specific level

of care need in one area or across many care domain areas. This is effectively the approach used in Australia via the Aged Care Assessment Team (ACAT) system. An ACAT determines a person as being ‘eligible’ for specific types of care based on the person’s level of care need. If determined as eligible by the ACAT for higher level community care the person is then also assigned the type and level (effectively funding) of assistance required (e.g. EACH package). In this case the ACAT

effectively determines the payment allocation ‘group’ that the client is eligible for based on the ACATs assessment of care needs. If however the ACAT recommends that the client is eligible for residential care, the persons funding allocation is not determined by the ACAT but by the ACFI assessment conducted by the residential facility. In this case the ACFI assessment provides for a number of funding levels based on the average cost of services for a person in a particular care need group

 Eligibility may be limited to people meeting a set criteria such as chronological age

 Eligibility may be limited to a set number of people that can be funded out of a

pre-set budget amount. For example domestic assistance may be provided for a fixed number of people in a geographical area for a set period of time. After this time period other people who have applied can then receive the service

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2: Report Background

2.1 METHODOLOGY

The methodology section will describe the outcomes of the background review for this project. It will describe:

• Project scope

• International and Australian perspectives on aged care programs including feedback

from consultations with some of the submission authors

2.2 PROJECT SCOPE

The scope of this paper covers the design an assessment model at the front end of the aged care system. The assessment model will determine the relative resource allocation for aged care services that could be provided in residential and community care settings. Ideally the assessment will be a single instrument that would include a set of core items (e.g. a Minimum Data Set) to be applied across all settings, perhaps with data sub-sets collected for particular settings. The MDS would be completed using various suitable assessment tool/s. The assessment tools need to have met a set of standards that provide evidence that the tool has been validated for use with the target audience by the anticipated users. The assessment tools should be validated in a broadly based trial with the target audience and actual users.

Setting

The model will cover current community and residential aged care programs and services that are funded or part funded by the Commonwealth Government:

 Home and Community Care [HACC]

 Community therapy and support services (Day Therapy Centres and the Assistance with

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 Respite services: National Respite for Carers Program – grant based for carers [NRCP]

and residential respite arrangements – for the client (high and low care)

 Community Aged Care Packages (CACPs)

 Extended Aged Care at Home Dementia Packages (EACH-D)

 Extended Aged Care at Home Packages (EACH)

 Residential Aged Care – low and high care

Participants

The model will describe the roles and activities of:

• The gateways for intake and assessment using regional hubs that interact with the

client and local service providers

• Persons eligible for aged care programs

• Carers for persons eligible for these care programs

• Service Providers of aged care services

• Other Health Systems and Agencies that interface with the system e.g. health

system, specialist assessment agencies

2.3 AGED CARE PERSPECTIVES

2.3.1 Introduction

The characteristics of international and Australian approaches used in lower level community care, higher level community care, residential care and respite care for recipients of services and their caregivers, will be briefly described in relationship to eligibility, assessment and classification approaches (refer to Table 2.1).

In particular, Table 2.1 describes:

 Aged care service models and principles, and scope of services offered

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 Assessment features - who completes the assessment, type of assessment domains,

strengths and weaknesses

 Classification features – how it is determined and used

The countries in Table 2.1 are grouped as follows:

• Austria and Germany

• Sweden, Denmark and the Netherlands

• UK and New Zealand

• USA

• Japan

• Australia

Table 2.2 then describes the Australian Community Care Programs (HACC and community care packages) in terms of:

• Purpose

• Eligibility

• Assessment

• MDS

• Services provided

• Differences between the programs

• Program Issues

• Other programs offered at these levels

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Ta b le 2. 1: A g ed C are P er sp ec ti ves Co un tri es Bro ad m od el f ea tu re s El ig ib ilit y A sse ssm en t Cla ss ific at io n A us tra lia in c omp ari so n Ge rm an y Aus tr ia Fo cus o n per m an ent c ar e. Co nsu m er c ho ic e o f se tt in g. O ff er c ash o r se rv ic es o r in st it ut io na l c ar e. O ff er li m ite d r esp ite a nd e co no m ic (p en si on ) a ssi st an ce . Fo cus o n D is ab ili ty a nd F unc tio na l ne ed s. A cc ess t o co m m uni ty a nd re si de nt ia l se rv ic es det er m ine d by si ngl e a ss essm en t. M edi ca l a nd H ea lth Pr of essi on al te am . Fa ce to fa ce a sse ssm en t. Func tio na l f oc us , no t co m pr eh en si ve . In de pe nd en t o f S er vi ce Pr ov id er s. N ot s ta nda rdi sed. N o c as e man ag eme nt . Th re e l ev el s b ase d o n ho urs o f c are o r f reque nc y of a ssi st an ce . Co ve rs m or e t ha n p er m an en t c ar e (tra ns itio na l c are , p re ve ntio n tr ea tm en ts, e ar ly int er ve nt io n, lo w in te ns ity , c oo rd in ate d lo w c are , co or di na ted hi gh c ar e) . El igi bi lit y i s a sse sse d se pa ra te ly fo r co m m un ity a nd r es id en tia l l ev el c ar e. Co mmu ni ty C ar e:  H A CC e lig ib ili ty fo r l ow in te ns ity se rv ic es  N RC P f or c ar er s uppo rt  DV A fo r v ete ra n a ff airs pro gra m s  A CA T f or DT C, re sp ite , tra ns itio na l c are , c om m un ity ca re pa ck ag es (c oo rdi na te d l ow and hi gh c ar e) Re sid en tia l C ar e:  A CA T det er m ine el ig ib ili ty fo r lo w /h igh c ar e ge ne ra l l ev el s onl y  Re si de nt ia l c ar e ha s a se pa ra te asse ssm en t ( AC FI ) f or th e fundi ng  A CF I c om pl et ed by th e re si de nt ia l p ro vi de r  Se pa ra te a ss essm en t s er vi ce s fo r di ff er ent c om m uni ty se rv ice s (HA CC , N RC P, V HC , D TC/ re sp it e/ Co m mu ni ty c ar e pa ck age s/ tr an si ti on al c ar e) .

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Pa ge | 17 Co un tri es Bro ad m od el f ea tu re s El ig ib ilit y A sse ssm en t Cla ss ific at io n A us tra lia in c omp ari so n  M ul tip le r esp it e p ro gr am s e .g. N RCP , H A CC De nm ark N et her la nds Sw ed en H ous ing a nd w el fa re a ppr oa ch. O ff er s pe ci al ly b ui lt nei ghbo ur ho ods , s hel ter ed ho us in g, ho m e m odi fic at io ns . D ec ent ra lis ed, no n-me di cal , d e ins tit ut io na lis at io n. C ons um er cho ic e. Ins tit ut io na l c ar e i s bei ng pha se d o ut in D enm ar k. In S w ed en the c om m uni ty is the pr ov ider o f se rv ic es. O ff er c ash o r se rv ic es. O ff er ec ono m ic , r es pi te, a nd per so na l sup po rt . A cc ess t o co m m uni ty a nd re si de nt ia l se rv ic es det er m ine d by si ngl e a ss essm en t. M ul ti d is ci pl in ar y t ea m . Re gi on al a ss essm en t or ga ni sa tio ns. Fa ce to fa ce a sse ssm en t. Co m pr eh en si ve asse ssm en t. In de pe nd en t o f S er vi ce Pr ov id er s. N ot s ta nda rdi sed, no t st ruc tur ed. Ca se m an age m en t f or se rv ic e t ar ge tin g, co or di na tio n a nd enha nc ed o ut co m es . N o c la ss ifi ca tio ns in D en mar k an d S w ed en . A sse ssm en t t ea m a nd co ns um er de ter m ine se rv ic es a nd s et tin g. Ca se m an age r di sc re tio n i n am ou nt s o f se rv ic es pr ov ided. N et he rl an ds b ase le ve ls o n ho ur s o f c ar e. D en mar k an d S w ed en o ff er ca sh to se le ct o w n S er vi ce Pr ov ider , t he c ons um er cr ea te s t he r el at io nsh ip w ith th e Se rv ic e P ro vid er N ot a s d ev el op ed r ega rd in g ho us in g opt io ns . N ot ful ly dec ent ra lis ed. N o de i ns tit ut io na lis at io n pr inc ipl e, ho w ev er s up po rt in g ho m e a nd co mmu ni ty s er vi ce s o pt io n. Car er P ay me nt an d C ar er A llo w an ce . Ca re r S up po rt s erv ic es t hro ug h N RC P pr ogr am s. U SA W el fa re b ase d, w ei gh te d t o in st it ut io na l c ar e ( hi gh est fu nd in g) . Fun ded pr im ar ily by fed er al subs idi es (M edi ca re a nd M ed ic ai d) and o ut o f po ck et c os ts . T he re is a lo w a m ount o f pr iv at e i ns ur anc e. Th is is a man ag ed c ar e mo de l w ith lim ite d ho m e c ar e c ov er age . Ther e ha s bee n a n i m pr ov ing re co gn iti on o f c ar egi ve r ne ed s i n th e U S se en th ro ugh gr ow in g ca re gi ve r l egi sl at io n a t f ed er al a nd st at e l ev el s. The U S Fe de ra l Go ve rn m en t pr ov ided a ss is ta nc e t o f am ily ca re gi ve rs, t hr ou gh t he O ld er A me ri can s A ct ’s N at io nal F ami ly Ca re giv er Su pp ort P ro gra m (N FC SP ) in 2 00 0, th e Fa m ily a nd M ed ic al A cc ess t o co m m uni ty a nd re si de nt ia l se rv ic es det er m ine d by m ul tipl e asse ssm en ts. RA I f or L TC (N ur si ng H om es) p ro du ce s a M D S. M ul ti d is ci pl in ar y. N ot inde pe nde nt . Fa ce to fa ce a sse ssm en t. Tr ai ne d a sse sso rs (man ual s, tr ai ni ng e tc ). A sse ssm en t p ro du ce s Ca re P la ns a nd R eso ur ce A llo ca tio n ( th e se ve n ca se m ix le ve ls) . Co m put er pr od uc ed al go ri th m le ve ls . U SA n ur si ng ho m es ha ve 7 ca se m ix le ve ls:  Reha bi lit at io n  M edi ca l  Sp ec ia l C ar e  Co m pl ex  Co gn iti on  Beha vi our  Ph ys ic al F un ct io ni ng AC FI a ss essm en t p ro du ce s t he cl as si fic at io n f un di ng le ve ls fo r l ow or hi gh c ar e i n r es ide nt ia l c ar e, b as ed on t he l ev el o f need in t hr ee c as e ty pe s ( A DL , De m en tia & B eh av io ur, Co m pl ex H eal th C ar e) . A CF I do es no t pr oduc e a co m pr eh en si ve C ar e P la n. Re ce nt A us tra lia n re po rts h av e fo cus ed a tt en tio n s qua re ly o n t he ref or m need ed i n t he c om m uni ty ca re s ec to r, to p re pa re fo r th e fu tu re . T he 2009 Co m m on w ea lth o f Au st ra lia ’s H ou se o f R ep re se nt at iv es re po rt ‘Wh o C ar es ..? ’ in to b ette r su pp ort f or c are rs o pe ra te s w ith in se ve ra l p ol ic y c on te xt s. The I nt er na tio na l a nd A us tr al ia n po lic y di rec tio ns hi ghl ig ht th e ne ed

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Pa ge | 18 Co un tri es Bro ad m od el f ea tu re s El ig ib ilit y A sse ssm en t Cla ss ific at io n A us tra lia in c omp ari so n Lea ve A ct (F M LA ) o f 1 99 3, a nd thr oug h M edi ca id H om e a nd Co m m uni ty -B ase d S er vi ce s ( H CBS ) w aiv er p ro gra m s th at in clu de re sp it e c ar e f or fa m ily c ar egi ve rs. Be tw ee n 2004 a nd 2006 t he th re e m ost c om m on st ra te gi es w er e:  Ca re gi ve r t ax in ce nt iv es  Fami ly an d m ed ic al le ave po lic ie s  Re sp ite c ar e p ro vi si on s fo r a na tio na lly c ons is te nt asse ssm en t a pp ro ac h a cr oss m ul tip le ca re r p ro gr am s ( to a ssi st c ar er a cc ess and r educ e c ar er bur den) t ha t asse sse s a b ro ad r an ge o f c ar er a nd ca re re cip ie nt n eed s t o f ul ly s upp or t ca re rs i n t he ir c ar e gi vi ng r ol e. A na tio na lly c ons is tent a nd co m pr ehen si ve da ta a ppr oa ch c an hel p t o e qui ta bl y i dent ify c ar er ne ed s, a ssi st e ff ic ie nt u se o f re so ur ce s a nd p ro vi de p ro gr am pl ann ing da ta . U SA : W is co ns in m odel In te gr at ed p ro gr am o f h eal th an d lo ng t er m c ar e d esi gn ed to im pr ov e ac ce ss a nd q ua lit y w hi le a ch ie vi ng co st sa vi ngs. Th e i nt er ve nt io n is se rv ic e co or di na tio n f or c ons um er s, in cl ud es s er vi ce c on tr ac ts w ith pro vid ers . A im is to re du ce e ntry to ho spi ta ls a nd N ur si ng H om es. Inc lude s pr ev ent at iv e c ar e. Fl ex ib ili ty to s ui t c on su m er c ho ic e, co mb in es man ag ed c ar e i n a r is k ba sed env ir onm ent .  Co ntro l h ea lth c os ts  Co m pr eh en si ve r an ge o f se rv ic es i n t he c om m un ity  Co or di na te d c ar e a cr oss sy st em s  Imp ro ve h eal th o ut co me s  Inc rea se pa rt ic ipa nt dec is io n mak in g  In cr ea se q ua lit y ( co nsu m er def in ed m ea sur es o f qua lit y) Th ey h av e t ar ge te d cl ie nt ty pe s w ho a re el igi bl e f or M edi ca id a nd m eet nur si ng ho m e l ev el of c ar e. V ol unt ar y pa rt ic ipa tio n. A cc ess t o co m m un ity se rv ic es det er m ine d by si ngl e a ss essm en t. In cl ud es Go al se tt in g to und er st an d t he c lie nt ’s ne ed s. N ee ds a ss essm en t b ase d on R A I. In te rd is ci pl in ar y t eam m odel . I nde pen de nt o f se rv ic e p ro vi de r. Co m m uni ty ba se d or ga ni sa tio ns su b co ntra ct w ith h os pita ls , cl ini cs , H M O a nd o ther pr ov ider s o f a cut e a nd LT C se rv ic es They c om bi ne f un di ng fr om M edi ca id a nd M edi ca re i nt o o ne pr og ra m . A vo ids fr ag m ent at io n a nd dupl ic at io n o f s er vi ces . T he pa ck ag e i s i ndi vi dua lis ed. Co mmu ni ty c ar e p ac kag es o ff er re si de nt ia l l ev el c ar e i n a c om m un ity se tt in g w ith c ase m an age m en t (s er vi ce c oo rdi na tio n) . C om m uni ty ca re p ac ka ge s N ot a s f le xi bl e. A sse ssm en t b y AC A T t o d et er m in e el ig ibi lit y. A no the r a ss es sm ent by se rv ic e c oo rd in at io n s er vi ce (s epa ra te t o A CA T) . Li m ited num ber o f pa ck ag es , pr ov isi on o f r esi de nt ia l p la ce s a nd co mmu ni ty c ar e p ac kag es b as ed o n re gi on al d em ogr ap hi cs. Jap an Lo ng ter m c ar e i ns ur anc e. Po si tiv e a ge in g p hi lo so ph y A cc ess t o co m m uni ty a nd N at io na lly s ta nda rdi se d co m pr eh en si ve Co m put er a lg or it hm re su lts i n a c as e m ix m od el H A CC a nd V H C a sse sso rs a re n ot inde pen de nt o f c om m uni ty c ar e

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Pa ge | 19 Co un tri es Bro ad m od el f ea tu re s El ig ib ilit y A sse ssm en t Cla ss ific at io n A us tra lia in c omp ari so n in cl ud in g p re ve nt at iv e se rv ic es. re si de nt ia l se rv ic es det er m ine d by si ngl e a ss essm en t. asse ssm en t. Q ua lif ie d a sse sso rs (s ta nda rd tr ai ni ng a nd ex ami nat io n) . N ot r equ ir ed to be inde pen de nt o f pr ov ider s. Co m pr eh en si ve asse ssm en t, m odi fied RA I. D om ai ns of A D L, IA D L, reha bi lit at io n, Beha vi our , M edi ca l Tre atm ent . of:  A D L di ff ic ul ti es  M oder at e ha ndi ca p  H eavy C ar e  H eavy c ar e w ith sp ec ia l n ee ds  Bedr id den/ dem ent ia O nl y o ne le ve l ( A D L) lim ite d t o c om m un ity se tt in g e .g. n o c ho ic e i n se tt in g p ro vi de d. pr ov ider s; t hey a ls o pr ov ide inf or m at io n t o c ons um er s. N RC P a sse sso rs a re in de pe nd en t o f pr ov ider s; t hey a ls o pr ov ide inf or m at io n t o c ons um er s. A CA T a re i ndep en dent o f a ge d c ar e pr ov ider s, t hey a lso p ro vi de inf or m at io n t o c ons um er s. AC FI a ss esso rs a re n ot in de pe nd en t of r esi de nt ia l c ar e p ro vi de rs. U K/N ew Z eal an d D ec en tr al ise in t he U K t hey ha ve re gi on al p ri mar y c ar e tru sts ; i n N ew Z ea la nd th ey h av e Di stric t H eal th B oar ds . Co ns um er c ho ic e. M ovi ng aw ay fr om f avo ur in g in st it ut io na l c ar e. Pe rso n c en tr ed . Ev id en ce b ase d gu id el in es. Th e N ew Z ea la nd go ve rn m en t ha s a Car er s’ S tr at eg y a nd F iv e-ye ar A ct io n P la n . T hi s w as pub lis hed on 28 A pr il 2008 . Th e U K l eg is la tio n a nd p ol ic ie s co nc er ni ng c ar er s i s qu it e dev el ope d. C ar er s ( Re co gn iti on an d S er vi ce s) A ct 1995 - t he c ar er ’s ri gh t t o a n a sse ssm en t o f h is/ he r ow n needs . Thi s w as ex tend ed u nd er S ta nda rd 6 o f t he N at io na l S er vi ce Fr am ew or k ( N SF ) t o a n a ss essm en t of th ei r c ar in g, p hy si cal an d me nt al hea lth nee ds , w ith a w ri tt en c ar e pl an w hi ch i nc lu des c ar er inp ut . Ca rer s ( Equa l O ppo rt uni ties ) A ct A cc ess t o co m m uni ty a nd re si de nt ia l se rv ic es det er m ine d by si ngl e a ss essm en t. N ee ds a ss essm en t and i nc om e t es ted. Co m pr eh en si ve asse ssm en t b y q ua lit y asse sso rs. Ca se m an age m en t. N at io na lly a cc redi ted tool box es , w ith a na tio na l MDS . Pr ov ide i nf or m at io n o n se rv ic es. A cc ess t o m ed ic al a dv ic e. Adm is si on t o a cut e. Pr ov id e r ev ie w s. Inc lude c ons um er s in dec is io n m ak ing . H av e c la ssi fic at io ns, b ut no t a lg or ithm ba sed, asse sso r d et er m in es l ev el s. Lo ca l a ut ho ri ty /r eg io na l bud get s, no t i ndi vi dua l fundi ng . Budg et s a re c ont ro lle d by th e r egi on s, w hi le thi s al lo w s f or in di vi du al is ed appr oa ches it is po te nt ia lly open t o i ne qui ty due t o a lac k o f s ys te mat ic appr oa ches . Sha re d pr inc ipl es  Co ns um er c ho ic e  Pe rso n c en tr ed  O ff er in g mo re c ommu ni ty c ar e Age d c ar e i s s ep ar at e to th e h ea lt h sy st em . Th er e a re s ep ar at e asse ssm en t pat hw ay s f or c ommu ni ty an d res id ent ia l c ar e. A CA T c an pr ov id e a le ve l o f i nt eg ra tio n. Fun di ng fo r H A CC se rv ic es is pr ov ided t hr oug h f un di ng agr ee m en ts b et w ee n S ta te /T er ri to ry go ve rn m en ts an d S er vi ce p ro vi de rs fo r ca re se rv ic es t o a c oh ort o f el igi bl e r ec ip ie nt s Fund in g a t r es id en tia l c ar e l ev el (c ommu ni ty c ar e p ac kag es o r ca re i n re si de nt ia l se tt in g) is c al cu la te d f or indi vi dua ls a t f ix ed le ve ls , a nd gi ve n to se rv ic e/ fa ci lit y p ro vi de rs w ho t hen pro vid e c are s erv ic es to a c oh ort o f el igi bl e r ec ip ie nt s.

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Pa ge | 20 Co un tri es Bro ad m od el f ea tu re s El ig ib ilit y A sse ssm en t Cla ss ific at io n A us tra lia in c omp ari so n 20 04 fo cu se s o n c ar er s’ h ea lth , emp lo yme nt a nd li fe –l ong lea rni ng issu es. T he B ill p la ce d re sp on si bi lit y on lo ca l a ut ho ri ty s oc ia l s er vi ce s depa rt m ent s i n in fo rm in g c ar er s of th eir r ig ht s a nd to p ro m ote c are r hea lth a nd w el fa re In J une 2 00 8 t he B ri ti sh N at io na l G ov er nm ent la unc hed t he po lic y do cum ent “C ar er s a t t he h ea rt o f 21 st C ent ur y f am ili es a nd co m m uni ties ”. A us tr al ia n g ov er nm ent re po rt o n ca re rs ‘W ho Ca re s… ?” (2009) Re po rt o n th e i nq uiry in to b ette r su pp ort f or c are rs h ad s im ila r ou tc om es a s th e UK re po rts . T he y rec om m ended ide nt ify ing a ll c ar er s, pr ov idi ng them w it h t he ir o w n co m pr eh en si ve a sse ssm en t, in a na tio na lly c ons is tent a ppr oa ch w ith a nat io nal d at a c ol le ct io n, an d ac ro ss go ve rn m en t d ep ar tm en ts – di sab ili ty , me nt al h eal th , ag ed c ar e.

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Pa ge | 21 Ta b le 2. 2: C o m m u n it y C are P ro g ra m C o m p ari so n s Pro gra m H ome a nd C ommu ni ty C are Co mmu ni ty A ge d Car e P ac kag es Ex ten ded A ged C ar e a t H om e p ac ka ges EA CH - D em en ti a A cr ony m H AC C CA CP s EAC H EAC H -D Pur po se A pr og ra m o f ba si c m ai nt ena nc e an d s up po rt s erv ic es fo r f ra il o ld er pe op le a nd th e c ar er s o f t he se peo pl e t o pr ev ent pr em at ur e ad m issi on to r esi de nt ia l c ar e a nd tha t pr om ot e i ndep end enc e a t ho m e a nd i n the c om m uni ty . A lte rn ativ e c om m un ity s etti ng fo r pe rso ns w ho m ee t e ligi bi lit y f or re si de nt ia l l ow c ar e. Indi vi dua lly pl ann ed, c oo rdi na te d a nd man ag ed p ac kag es o f c ommu ni ty ag ed ca re se rv ic es t ar ge te d t o t ho se w ith co mp le x c ar e ne eds . R ec ipi ent s w oul d ot her w ise b e e ligi bl e f or a t l ea st lo w le ve l r esi de nt ia l c ar e. A lte rn ativ e c om m un ity s etti ng fo r o ld er pe rso ns [ yo un ge r p eo pl e w ith d is ab ili ti es a re ge ne ra lly n ot c on si de re d f or E A CH P ac ka ge s] w ho m ee t e ligi bi lit y f or h igh le ve l r esi de nt ia l ca re b ut w ho h av e e xp re ss ed a p re fe re nc e t o liv e a t h om e. Indi vi dua lly pl ann ed, c oo rdi na te d a nd man ag ed p ac kag es o f c ommu ni ty ag ed c ar e se rv ic es t o p ro vi de fo r c om pl ex c ar e n ee ds o f ol de r p eo pl e. D esi gn ed to 'c om pl em en t' CA CP s A lte rn ativ e c om m un ity s etti ng fo r pe rso ns w ho m ee t e ligi bi lit y f or h igh le ve l r esi de nt ia l c ar e a nd ha ve beha vi our s o f c onc er n a ss oc ia ted w ith dem ent ia . To pr ov ide a c oo rdi na ted a nd m ana ged ca re p ac ka ge to p eo pl e w ith d em en tia w ho ha ve beha vi our s o f c onc er n. T hes e beha vi our s ha ve a s ig ni fic ant im pa ct o n thei r Q O L. W itho ut E A CH -D c lie nt w ou ld be a t r is k o f a dm is si on t o a dem ent ia sp ec ifi c h igh c ar e a ge d c ar e f ac ili ty . El ig ib ili ty Crite ria El de rl y D is ab ili ty H A CC S er vi ce p ro vi der c an de te rm in e e ligi bi lit y A CA T c an r ec om m end H A CC se rv ic es a nd r ef er c lie nt b ac k t o se rv ic e p ro vi de r A CA T ap pr ov al fo r l ow le ve l a ge d ca re and s ui ta bl e t o r em ai n i n c om m uni ty A CA T a ppr ov al fo r hi gh l ev el a ge d c ar e a nd sui ta bl e t o r em ai n in c om m uni ty A CA T a ppr ov al fo r hi gh l ev el a ge d c ar e and s ui ta bl e t o r em ai n i n c om m uni ty A sse ssm en t In di vi du al S er vi ce P ro vi der A sse ssm en ts A N at io na l a ss es sm ent ins tr um en t A CC N A -R /CE N A -R ) ha s bee n dev el ope d. Ser vi ce P ro vi der a ss es sm ent w hi ch i s no t s ta nda rdi se d, s om e i tem s r epo rt ed in A CC M IS * da ta ba se a nd po ss ibl y SP AR C ( A ge d C ar e pa ym en t sy st em ) d at ab ase . MDS H A CC MDS V ario us S ta te MD S: SC oTT; IN I; O N I A CC R MDS . A ged C ar e C lie nt R ec or d ( A CC R) c om pl et ed by A CA T, ther e i s a s m al le r s ubs et o f da ta r ec or ded i n the m ini m um da ta s et (P arts 1 -4 a nd 6 -7) . A CCM IS Se rv ic es pr ov ided • D om est ic a ssi st an ce • So ci al Su pp or t • N ur si ng Ca re • A lli ed H ea lth C ar e • Pe rso na l C ar e • Ce nt re b ase d r es pi te c ar e • Fo od se rv ic es Si m ila r t o H A CC b ut no N ur si ng C ar e o r A lli ed H ea lth a ls o h as o n c al l a cc es s. Pr inc ipa lly des ig ne d t o m eet c lie nt 's da ily ne eds inc lu di ng pe rs ona l as si st anc e w hi ch m ay inc lude: ba thi ng , sh ow er in g, p er so na l h ygi en e, to ile tin g, Si m ila r t o C A CP b ut g ener al ly inc ludes qua lif ied n ur si ng in t he de si gn a nd o ng oi ng m ana gem en t o f t he pa ck ag e a nd al lied hea lt h se rv ic es. Same as E A CH p ac kag e w it h ad di tio nal em ph as is o n d em en tia sp ec ifi c s er vi ce s asse ssm en t a nd c ar e p la n d ev el op m en t an d m on ito rin g, a nd d ire ct c are w orke rs sk ill ed i n k no w ledg e o f dem ent ia a nd appr opr ia te be ha vi our al s uppo rt int er ve nt io ns a nd pr og ra m s.

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Pa ge | 22 Pro gra m H ome a nd C ommu ni ty C are Co mmu ni ty A ge d Car e P ac kag es Ex ten ded A ged C ar e a t H om e p ac ka ges EA CH - D em en ti a • Re sp ite • A sse ssm en t • Ca se m an age m en t • H ome mai nt en an ce • Co uns el ling / s up po rt , in fo rmat io n, ad vo cac y • A ids & E qui pm ent • Tr ans po rt fo r s ho ppi ng , appo int m ent s a nd a ct iv iti es dr es si ng o r u ndr es si ng , m obi lit y, tr an sf er , p re pa ra ti on a nd e at in g m ea ls, se ns ory c om m un ic atio n, o r f ittin g sens or y c om m uni ca tio n a ids , l au ndr y, ho m e hel p, g ar de ni ng a nd sho rt t er m ill ne ss . A ls o m ay in cl ud e, c on tr ol a nd adm ini st ra tio n o f m eds , r eha b sup po rt , a dm in o f t rea tm ent s uc h a s ey e d ro ps, b ac k r ub s, d re ssi ngs, u ri ne te sts , e m otio na l s up po rt a nd d ire ct supe rv is io n, a ss is ta nc e w ith s pec ia l di et , r esp on si bl e a ge nc y/ pe rso n on c al l fo r e m erg en cy a ss is ta nc e, tra ns po rt to sh op or g o t o d oc tor , s oc ia l a ct iv iti es, te m po ra ry in h om e r esp ite , su pp or t se rv ic es t o m ai nt ai n p er so na l a ff ai rs an d t o p ro te ct th e p er so n' s i nt er est s. Ge ne ra l S er vi ce s • A dm in is tr at io n • Car e P lan ni ng man ag eme nt Clin ic al Se rv ic es (r eg is ter ed nur se pr ov ide d or su pe rv ise d di re ct ly /i nd ir ec tly ) • Cl in ic al C ar e ( e. g. pa in, c om pl ex h ea lth ca re ) • A cc ess t o H ea lth s er vi ce s Ca re Se rvic es (e xc lu de s se rv ic e i f t he c ar e re cip ie nt & c are r c ho os e a nd /o r i s a ble to pr ov id e t he se fo r s el f) • A D Ls • N ut ri ti on, hy dr at io n a nd m ea l pr epa ra ti on • Sk in in te gr ity man ag eme nt • Co nt inenc e m ana gem ent • Su pp orts fo r c og nitiv e im pa irm en t • Mo bility a nd d ex te ri ty • Le isu re a nd a ct iv iti es • Em ot io na l s uppo rt • Th er ap y se rv ic es • O n ca ll a cce ss • H om e sa fe ty • H ome mai nt en an ce • M in or H om e m od ifi ca tio n • O xy gen a nd e nt er al fe edi ng sup pl em ent s Ho w d oe s t hi s pro gra m d iff er fro m o th ers ? N ur si ng is pr ov id ed i n H A CC bu t no t in C A CP s It in cl ud es a c ase m an age m en t co m po nent . A r equi rem ent fo r co or di na tio n o f s er vi ces w itho ut w hi ch the c lie nt w oul d b e a t r is k o f a dm is si on to an ag ed c ar e f ac ili ty . EA CH is di st ing ui sha bl e f ro m C A CP s i n t er m s of c om pl ex ity a nd in te nsi ty o f se rv ic e n ee ds. W her e po ss ibl e A CA Ts s ho ul d w or k w ith E A CH pr ov ider s t o h el p dev el op a c ar e pl an i n l in e w ith th e c lie nt 's a sse sse d ne ed s. O ngo in g asse ssm en ts b y t he E A CH p ro vi de r ( at le ast 6 m ont hl y) to ident ify c ha ng es in bo th t hei r ca re n ee ds a nd in t he r ol e o f t he ir c ar er s so th at th e pa ck age c an b est r esp on d t o t ho se ne ed s. Th re e c ha ra ct er ist ic s d ist in gu ish t he se pa ck age s f ro m E A CH . 1 . H igh ly sk ill ed , de m en ti a sp ec ifi c c ase m an age m en t. 2 . Fl ex ib le , i nn ov at iv e de liv er y & m ix o f se rv ic es. 3 . L in ka ge to sp ec ia list s er vi ce s an d su pp or ts. W he re p ossi bl e A CA Ts sho ul d w or k w ith E A CH pr ov id er s t o hel p dev el op a c ar e p la n i n l in e w ith t he cl ie nt 's a ss ess ed n ee ds. O ngo in g asse ssm en ts b y t he E AC H p ro vid er ( at le ast 6 m on th ly ) t o i de nt ify c ha nge s i n bo th t he ir c ar e ne eds a nd i n t he r ol e o f

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Pa ge | 23 Pro gra m H ome a nd C ommu ni ty C are Co mmu ni ty A ge d Car e P ac kag es Ex ten ded A ged C ar e a t H om e p ac ka ges EA CH - D em en ti a th ei r c ar er s so th at t he p ac ka ge c an b est re sp on d t o t ho se n ee ds. Pr ogr am Issu es Ex cept in spec ia l pr og ra m s s uc h a s CO Ps in V ic to ri a, c as e man ag eme nt is no t se en a s be in g p ar t o f t he pr ogr am . S om et im es, c lie nt s m ov e to C A CP s, e ve n t ho ug h t he ir le ve l o f ca re d oe s n ot w arra nt it, p ure ly fo r cas e man ag eme nt / c oo rd in at io n pur po ses . A s m al l n um be r o f c lient s a re re ce iv in g a d is pro po rtio na te am ount o f t he H A CC bu dg et. A lle n r ep or t ( 2006) e st im at ed t ha t 33 % o f t he H A CC budg et is s pe nt o n 3% o f H A CC c lie nt s. T he se H A CC cl ie nt s ha ve si m ila r c ha ra ct er ist ic s to C A CP c lient s. T he D oH A su bm is si on( 20 10 ) a ls o s ta te d t ha t:  2. 1% o f a ll H A CC u se rs a ge d 65 or o lder w er e f un ded a bo ve CA CP  75 % funded bel ow C A CP Th er e a re d iff er en ce s b et w ee n pr ogr am s, fo r e xa m pl e d iff er en t am ou nt s o f r esp it e a re a va ila bl e fro m d iff ere nt pro gra m N RC P, D V A , H A CC . T he re a re d iff er en ce s w ithi n pr og ra m s a cr os s j ur is di ct io ns e. g. d iff er en t l ev el s/ ty pe s o f se rv ic es fo r c lie nt s w ith s im ila r ch ara cte ris tic s. D oes no t i nc lu de p ro vi si on f or nu rs ing . So m et im es pe op le go o nt o a C A CP fr om H A CC ev en t ho ug h t he ir c ar e do es n ot w arra nt it, p ure ly fo r c as e m an age m en t/ co or di na tio n p ur po se s. Si gn ifi ca nt n um ber s o f C AC Ps c lie nt s use H A CC s er vi ce s a lso , p ar tic ul ar ly nu rs in g se rv ic es. F ul l c ost r ec ov er y i f CA CP s p ur ch ase s se rv ic es f ro m H A CC . Th e P ac ka ge P ro vi de r m ak es t he fi na l dec is io n t o a cc ept a n a ppr ov ed per so n as a c lie nt . Th er e a re d iff er en ce s w ith in p ro gr am s ac ro ss j ur isd ic tio ns e .g. d iff er en t le ve ls/ ty pe s o f se rv ic es f or c lie nt s w ith si m ila r c ha ra ct er is tic s. O nl y r ea lly e ff ec tiv e w ith fu ll t im e l iv e i n ca re r. Dif fic ulti es w ith a pp ro pria te s ho rt te rm re si de nt ia l c ar e - r es pi te , a cce ss to se rv ic es suc h a s da y c ent re s di ff ic ul t. D iff ic ul t t o m ai nt ai n l ev el o f se rv ic es i n r ur al a re as. Dif fic ult to g et s erv ic e p ro vid ers t o ta ke o n ex tr a b ur de n o f h om e v isi ts e tc e .g. GP s. L ac k of g er ia tr ic ia ns a nd m ent al h ea lt h pr ov ider s i n man y ar eas . F und ing g aps w hen a per so n go es o ff a no ther pa ck ag e a nd o nt o E A CH , due to th e a sse ssm en t p ha se e tc , t he fu nd in g need s t o c ont inu e, pa rt ic ul ar ly fo r ex am pl e go ing to E A CH fr om C A CP s. A ddi ti ona l f und ing requi red f or tho se w itho ut a ful l t im e l iv e i n ca re r. E qui pm ent fu ndi ng ina de qua te a t beg inni ng , pa lli at iv e c ar e i na de qua tel y f unde d at end o f l ife. D iff ic ul tie s i n f und ing th e ne ce ssa ry ti m e t o a ss ess a nd p ut a pp ro pr ia te se rv ic es i n p la ce . F ul l c ost r ec ov er y i f E AC H pu rc ha se s s er vi ce s f ro m H A CC . A s f or C AC Ps , t he P ac ka ge P ro vi de r m ak es t he fina l dec is io n t o a cc ept a n a ppr ov ed per so n as a c lie nt . Th er e a re d iff er en ce s w ith in p ro gr am s a cr oss ju ri sd ic tio ns e .g. d iff er en t l ev el s/ ty pe s o f se rv ic es f or c lie nt s w ith si m ila r c ha ra ct er ist ic s. Same as E A CH , b ut mo re d iff ic ul ti es w ith sp ec ia lise d pr ac tit io ne rs i n so m e ar ea s. A s f or C A CP s a nd E A CH , t he P ac ka ge Pr ov id er m ak es t he fi na l d ec is io n t o ac cept a n a ppr ov ed per so n a s a c lient . O th er pro gra m s th at pr ov ide f or si m ila r l ev el o f ca re . D V A se rv ic es, N RC P p ro gr am s a nd DT C a re a cc esse d v ia o th er pat hw ay s. D V A h om e c ar e p ro vi de lo w le ve l se rv ic es t o v et er an s inc lu di ng ga rde ni ng , ho us e m ai nt ena nc e, do m est ic a ssi st an ce , p er so na l c ar e A ll t he se p ro gr am s a re a cc es se d vi a the A CA T pa thw ay . Resi de nt ia l L ow C ar e Tra ns itio n c are : A ged c ar e c lient in c om m uni ty e nt er s A ll t he se p ro gr am s a re a cc es se d vi a t he A CA T p at hw ay . Re si de nt ia l H ig h C ar e Tra ns itio n c are

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Pa ge | 24 Pro gra m H ome a nd C ommu ni ty C are Co mmu ni ty A ge d Car e P ac kag es Ex ten ded A ged C ar e a t H om e p ac ka ges EA CH - D em en ti a and r es pi te. D V A c om m uni ty nur si ng pr ov ide s nur si ng se rv ic es to v et er an s. D ay T he ra py C en tr es a re Co m m onw ea lth f unde d a nd pr ov ide th er ap y se rv ic es t o a ge d c ar e cl ie nt s. N RC P pr ov ides c ar er s up po rt a nd re sp it e ac ut e hea lt h ho spi ta l. A ge d c ar e c lie nt d ue fo r d isc ha rg e fr om ho spi ta l. A sse sse d b y A CA T a s m ee tin g re si de nt ia l c ar e e lig ib ili ty . Su ita ble fo r tra ns itio na l c are p ac ka ge to p ro vi de e xt ra se rv ic es i n t he s ho rt te rm to a vo id e nt er in g r esi de nt ia l c ar e fu ll t im e.

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2.3.3 Discussion

Ageing in place

There has been an increasing desire in Australia from older people and in general from the wider community for older people to remain living in a supported manner in their own home or other private accommodation settings for as long as it is feasible, affordable and safe. This is demonstrated by the demand on the Commonwealth and State funded HACC Program services and the steadily increasing allocations of Commonwealth funded community aged care places (residential

‘equivalent’ care packages provided in community settings). People now live in the community with higher care need levels than was previously the case 20 years ago in part because of the availability of these in-home support services previously confined to residential care environments.

Where living in a person’s own home is no longer possible, the emerging practice in Australia and internationally is for the congregate or residential environment to be capable of providing an ageing in place support model. In this approach the person can stay in a familiar place, build social

connections with other residents and staff while having their changing care needs met by the care model, without needing another move to, for example, a higher care facility. This approach effectively separates the accommodation and hotel aspects of support from the care provision aspects which are then tailored to individual need. This approach reflects the international trends in the development of flexible care residential environments and supports the practice of ageing in place. Australia however presently maintains for the most part a two tier approach of

predominantly lower care and higher care residential environments although the balance of this mix is changing as Commonwealth funded residential care becomes more focused on people with higher levels of care need requirements. In terms of international approaches where even people with high care needs are supported in community care type settings, Scandinavia appears to be the most advanced in offering a broad range of accommodation choices with the use of innovative community housing models that can offer an alternative to institutional high care.

Consumer decision making

Consumer choice and participation in decision making can be seen in many of the international models. Scandinavian countries have a strong principle of including the consumer in the decision making process and the lack of defined classification rules allows them to be flexible in responding to the client’s needs. However this approach can potentially be open to inequitable outcomes due to assessor bias. In Japan they have official pathways (e.g. local boards) to ensure the consumer has a

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voice in the decision making to ensure they will receive a fair hearing and say in the outcomes of the assessment.

Eligibility, Information & Assessment

The majority of international models have a single system with an independent approach to information, eligibility and assessment for care and this may reduce the difficulty for clients navigating the system. The Australian model in comparison is sometimes referred to as confusing, complex, lacks a continuum of care/ seamless experience and appearance due to the multiple number of entry points, differing levels of information provided and the multiple assessments required.

The Australian community care model relies on:

(i) ACATs to provide an independent consistent assessment approach for access to the

higher level care spectrum as well as information about the aged care system. It has a gatekeeper role in determining eligibility for residential and some ‘residential

equivalent’ community programs (community care packages) and Commonwealth funded community programs (e.g. DTC, respite, transitional care). However not all aged care clients will access services via an ACAT recommendation or referral. The actual assessments and information provided may vary between ACATs and between jurisdictions.

(ii) Community Care Service Providers determine access to the base level of community care

services (for HACC, VHC) for clients not required to have an ACAT assessment. Clients will often rely on the Community Care Service Provider to provide information about the system. In some cases Service Provider information may be limited to services they provide and not the broader aged care system options available to the client.

(iii) There are other services and organisations that can provide information about the aged

care system. Some are Commonwealth funded agencies such as the national network of Commonwealth Respite and Carelink Centres, State government agencies , local

governments, general health care providers (GPs, acute hospitals, community health centres etc) and aged care service providers. The service may be provided by telephone, face to face, or online. The consumer needs to be well informed about the options, then able to collate the information and work their best options in the current circumstances.

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(iv) The National Respite for Carers Program (NRCP) carer support program also provides

access for carers to various support programs (e.g. respite, support groups etc.) through the Commonwealth Respite and Carelink Centres.

The Australian aged care client moves between the different services and programs as their need change. Some may receive some integration assistance in the form of case management if they have a community care package. If having multiple care needs they will often be assessed by the range of service providers who service each need area unless the Service Provider is large with a full range of programs available. The consumer will often rely on these Service Providers for information unless they can navigate through the maze of possible sources of information and services. While this system has been largely effective in assisting older Australians it could be more co-ordinated. This would better assist the consumer to be properly and fully informed about their aged care options promoting their ability to make informed decisions as their needs change.

What services are important in a community aged care program delivery?

Currently there are different entry points for different service types. For example the assessment and eligibility to HACC community services is separate to assessment and service to the higher level care packages (e.g. CACP, EACH, EACH-D) provided in the community. This results in a multitude of assessments from different services that clients undergo as their needs become more dependent and complex. To incorporate integrated assessments services and access to services in the client’s setting of choice, the community aged care program client needs access to a wide range of services. The literature and the feedback from consultations would suggest that the most important elements of any home based support is that it provides services along a continuum of care, and would include HACC type services and those services that are currently found in the CACPs and EACH/D packages. Table 2.3 presents a list of services described by the World Health Organisation (WHO) organisation that should be available in a mature aged care system.

Table 2.3: Elements of Quality Long Term Care

Service Type

Preparation and mobilisation of society and the community for caring roles Development of voluntary work and provision of volunteer opportunities to clients

Health promotion, health protection, disease prevention, postponement of disability e.g. wellness approach, independence approach

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Provision of information to consumers, family, and general public Assessment, monitoring, and reassessment

Coordination services to assist clients navigate through the system Community-based restorative and rehabilitation services

Referral and linkage to community resources

Facilitation of self-care, self-help, mutual aid, and advocacy

Opportunities for productive activities, recreation, physical activities Facilitation of social interaction and development of informal networks Physical adaptation and maintenance of the home

Health care, including medical, medication, nursing care Personal care, e.g. grooming, bathing, meals

Household assistance, e.g. cleaning, laundry, shopping, nutrition

Provision of supplies (basic and specialised), assistive devices and equipment (e.g. hearing aids, walking frames), and drugs

Alternative therapies and traditional healing

Specialised support (e.g. for incontinence, dementia and other mental problems, substance abuse) Respite care (at home or in a group setting)

Palliative care provided at home or in residential setting e.g. management of pain and other symptoms

Counselling and emotional support

Education and training for clients and informal/formal caregivers Support for caregivers before, during, and after periods of care-giving

Classification for Care Needs, Program Allocation and Funding

Most countries base the classification on the basic functional needs of clients (IADLs - independent living skills and ADLs - personal care and mobility needs) often incorporating psychosocial needs (emotional, cognitive, behavioural).

There is various classification approaches reported in the international literature. Countries with non independent assessors (USA and Japan) demonstrated an objective or computer based algorithm approach to funding classification as this was believed to reduce assessor bias. Countries with independent assessors varied their classification approaches:

 Some (UK, NZ) described set levels but allowed assessors to determine which level the client

fitted into

 Others (Germany and Austria) provided objective algorithms (e.g. number of ADLs,

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 While the Scandinavian countries of Sweden and Denmark do not appear to have any formal

classification levels based on assessment tools or questionnaires

There are several elements that need to be considered in determining the purpose of the classification approach. For example:

 An objective classification based on a standardised assessment tool will provide a more

consistent approach to client resource allocation by directing similar funding to similar types of clients. The classification determines the funding and the assessment the types of

services relevant to meet the client’s needs

 While the classification and funding may be similar for some clients the assessor and the

client must be given flexibility in the final determination of service types and amounts (within the allocated budget) to allow for flexibility to meet individual situations

 An algorithm based classification system will determine the minimum data required to

determine classification for funding

 The purpose of the assessment determines the scope and depth of the domains covered in

the assessment. For example if the assessment purpose includes detailed care planning then more depth of information is required than for classification purposes. The classification for funding and program eligibility should form a natural outcome of the assessment tools

 Any classification model used in the Australian context needs to be derived as an outcome of

the assessment toolkit used to assess the care need requirements of clients

Inclusion of carers

Inclusion of the carer’s needs to provide for a holistic assessment is also gaining international recognition. The International and Australian policy directions highlight the need for a nationally consistent assessment approach across multiple carer programs (to assist carer access and reduce carer burden), assessing a broad range of carer and care recipient needs to fully support carers in their care giving role. A nationally consistent and comprehensive approach to carer assessment can identify carer needs, assist efficient use of resources when couples are being supported by multiple programs and provide program planning data.

Australian policy and reform documents have a number of recommendations for future changes or reforms which could impact on carer assessment in the future. They make recommendations for the consolidation and integration of existing programs, for example across disability, mental health and aged care.

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Common Assessment

The international literature reports that most countries have a single assessment approach that links home based care, community care and residential sector into a consolidated funding model. A common assessment approach for all clients (care recipients and carers) should be adopted for several reasons including:

• The need to clarify and then streamline eligibility for ease of access to required services

• The need to target information only as required i.e. simple (or quicker) assessment for low

levels of support at home, through to more rigorous assessment to determine eligibility for higher levels of community and residential care

• The use of a common language for defining need to allow all stakeholders to understand the

outcomes of the assessment process

• The need to reduce the requirement for people to undergo multiple assessment in order to

access services

• To enhance the flow of health information and communications among patients and health

professionals throughout the country

• To link assessment criteria to classification models

• To measure and improve health and performance outcomes

• To use the data collection and reporting from systems to help inform funding allocation,

track progress, assist in determining the relationship between care needs and the cost of services in community care and assistance with policy formation

• To enhance decision-making, drive improvements in clinical practice, guide how resources

are marshalled and deployed and provide the basis for feedback loops to promote improvement in access to, and quality and efficiency of care

Exploring New Funding Models in the Australian Community Care

Packaged care can be described as the provision of community care services to those individuals with ‘intense and/or complex care needs’. To be eligible for a care package, clients must be assessed and then approved by an Aged Care Assessment Team (ACAT). The care package, in effect, is to some extent a residential care funding ‘related adjusted subsidy’ without the accommodation and hotel services components. It is paid directly to the service provider to support an eligible client living in the community who can use all the package funding or a proportion of the funding on an individual client. Recipients of care packages would otherwise be eligible for at least low level residential care accommodation and a subsidy based on their ACFI level. Currently, the formalised care packages available are CACPs (Community Aged Care Packages), EACH (Extended Aged Care at