This Document Reflects Ongoing Discussion and Debate Regarding the Implementation of The

Commonwealth Home Support Program Advisory Group Notes of Small Group Discussions at the June 2013 Workshop

This document reflects ongoing discussion and debate regarding the implementation of the LLLB aged care reforms. It is an interim information document that represents discussion at a fixed point in time and is not reflective of either NACA or DoHA advice, position, or recommendations.

The Commonwealth Home Support Program (CHSP) Advisory Group held a workshop in Sydney on 13-14 June 2013. Small group work was used to discuss specific program design and development issues in greater details. The outcomes were then discussed and added to by the full advisory Group. This document reflects the discussions held at the June workshop and is not formal NACA advice. The issues discussed included:

• The role of reablement in the CHSP;
• Consumer Directed Care and CHSP – What will it mean in 2015 and beyond?;
• Prioritisation – How will the CHSP manage demand into the future?;
• Fees and Charges;
• CHSP Service Streams (including what’s missing);
• Supporting CHSP Volunteering with a changing demographic;
• Where and how do Day Therapy Centre services fit in the CHSP; and
• HACC Service Types that are not included the reviews.

The Role of Reablement in the CHSP

This group:

• Identified the importance of consumer direction, consumer empowerment and independence to any reablement approach;
• Acknowledged the benefits of a reablement approach for both the consumer, including improved wellbeing and independence;
• Acknowledged the benefitsfor the sustainability of both the aged care and health sectors, including reducing or delaying the need for ongoing services;
• Framed Reablement as a philosophy, approach and program, and recommended that the CHSP design needs to incorporate all three of these framings, which will require cultural change across the sector; and

-Maintaining independence;

-Physical, social, and psycho-social assessment; and

-Support by services such as allied health, home modification, assistive technology and IT, wider community, health and mainstream services.

The group also felt that reablement as a specific type of short-term intervention should be considered and identified the main elements of such a program as:

• A precursor to ongoing services;
• Designed to maximise independence and possibly minimise consumers’ ongoing care needs;
• Different to restorative or rehabilitation programs (as these imply an institutional setting and high-intensity);
• Occurring in consumers’ homes and in centres; and
• Time-limited, but would be able to be accessed more than once.

The recommendations of this group included:

• Timely interventions;
• Goal-oriented and outcome focused care planning;
• Exploration of new options;

-New money

-Reallocation of funding from existing HACC services e.g. Day Therapy Centres

-CDC & business models;

-Refocusing Centre Based Day Care;

-Use of Level 1 Home Care Packages;

• The reablement philosophy should be formalised in a document and used to check to ensure develop over time remains true to the philosophy; and
• People with dementia and cognitive impairment should have access too reablement programs and approaches as reablement has been shown to have great outcomes.

Other issues identified by the group included:

• Transport is the ultimate enabler and access to transport is very important in a reablement approach;
• Tension between CDC and reablement – need to respect the right of those consumers who may not want reablement services or where they may not be appropriate (e.g. when a consumer may only want a single service and may not want a Reablement approach);
• Evaluation of reablement approach;

-Evaluation methods will be important as it can sometimes be hard to show the benefits in long term service/cost-reduction, and has high initial costs – (e.g. one-on-one time spent training people to use public transport etc.)

-However, it is cost-effective as the upfront costs reduces the ongoing cost of service, as well as health sector money because of improved consumer wellbeing;

-In terms of evaluation in a dual cost benefit mode to value reablement projects

• CALD and reablement;

-CALD consumers need to be consideredin the program design for reablement;

-Possible resistance to reablement approaches in some cultural groups and consumers should be able to choose what services they want to engage in;

-Hesitation to seek services due to the expectations in some CALD consumers that families will take on the caring role should be acknowledged;

• Families as a ‘resource’ in reablement;

-Families as a support unit;

-Providers supporting families to help reable the clients;

-Need to include and incorporate families to prevent them becoming a resistance factor; and

-LGBTI issues to recognise with this – including the nature of families and acknowledgement of partners.

CDC and CHSP – What will it mean in 2015 and beyond?

The group felt that the aim of CDC in the CHSP should be to empower consumers and enhance consumer choices.

The Group felt that implementing CDC in the CHSP should be done in a staged manner and involved a CDC trial, as well as significant education for consumers, providers, workforce and the sector as a whole.

The top issues for CDC within the CHSP were identified as:

• The need to know more about the future streaming of the CHSP;
• Lack of knowledge of unit-costs – required as part of a move to individualised funding;
• Need to move away from the current (very prescriptive) service groupings, reporting models and artificial barriers between services in HACC, as they are the ‘antithesis’ of CDC;
• The need for trails of CDC in CHSP services – possibly commencing with respite services;
• The challenges associated with sub-contracting individual services, such as safeguards, workforce issues, and WHS;
• The low-level of funding associated with the CHSP, particularly to enable one-off costs that consumers may prefer, such as infrastructure, home modifications, or assistive technologies; and
• That a shift to CDC in only some streams of the CHSP would be inconsistent with the current state of Home Care (more flexibility and all CDC).

The Recommendations of this group included:

• More work on the CHSP and streaming to inform CDC decisions;
• Implement any CDC program in a staged manner (possibly with some streams moving to CDC first, i.e. respite), including a trail of CDC that would cover;

-Approaches to implementing CDC from individuals budgets through to ‘cashing-out’;

-How CDC will work with an understanding that change and feedback are positive in designing a new system;

-What services people are choosing;

• Education and empowerment for consumers;
• Education and cultural change for providers, workforce and the sector as a whole;
• The aim of CDC in the CHSP should be to empower consumers to continue to engage in community life; and
• The NACA Secretariat should draft a document that reflects the overarching principles of CDC for the future reference of all NACA groups.

Other issues identified included:

• How to continue the high level of cooperation in the sector in the more competitive environment of a CDC model;
• The increased importance of consumer feedback and consumer created data in a CDC model to ensure that we are measuring the consumer experience;
• The relationship between HACC and CDC;

-The nature of HACC (infrastructure, high numbers of volunteers etc.) lends it to block funding rather than individual;

-Therefore it is important to reinforce that CDC is NOT just about individual funding and purchase – it is about individual choice and control; and

-CDC in this area means putting to the consumers to see if the way the system works now matches want consumers want.

Prioritisation – How will the CHSP manage demand into the future?

This group discussed the role of the Gateway in assessment and prioritisation and recommended that:

• The training of Gateway assessment staff will be crucial;
• Access barriers and special needs need to be recognised and responded to by the Gateway;
• The Gateway priority should act as a ‘lever’ for service providers to validate and guide their service delivery;
• There should be the ability for individuals to self-advocate for their needs and supplement advocates provided for those who may face challenges in doing so;
• There should be a requirement for providers to report service provision and consumer outcomes to the Gateway within a certain time frame;
• An automated reminder should be in place at the Gateway to ensure follow up with providers if they have not heard from them after a certain period of time to prevent people getting lost in the system;
• There may be a particular role for the CHSP in providing interim services for those requiring higher-level services but who are on waitlists. However, this needs to be balanced with the need to prioritise those with low-level whose needs may dramatically escalate if not responded to in a timely way;
• There will be a need to manage consumer expectations and improve consumer understanding of the referral system; and
• Assessment and prioritisation processes should engage checklists that utilise experiential descriptors not identifiers – particularly for special needs groups – in order to adequately capture consumer needs.

The Group also discussed issues with telephone assessments, noting that phone assessments are more likely to be undertaken by family members and/or carers, rather than the consumer. Additionally, if consumers do undertake a phone assessment they are more likely to underestimate their needs and the telephone method does not provide additional cues to get a fuller picture.

Fees and Charges

This group discussed fees and charges within the CHSP and identified the need to measure the costs of service provision to ensure sustainable funding. This would incorporate consumer fees, government subsidies, other charities and activities. However, it was acknowledged that it may be difficult to determine total costs given that there is currently no central record of what fees are paid and the suite of different factors across jurisdictions and between different providers in the current system.

There should be an acknowledgement that many consumers are happy to pay fees, particularly if they can pay more for immediate access or for a specific service.

The group had considerable concerns with the long-term viability of a national fee structure, noted that fees should reflect the socio-economic factors in different areas, and felt that means-testing and taper rates will be crucial. It was also noted that locking in a fee level in federal legislation prevents indexation over time and removes the flexibility required to fairly administer fees.

It was felt that carers should not be means-tested or required to pay fees. However, the possibility of opening Day Centres during working hours and allowing carers to pay for this service so they can maintain their employment should also be considered.

Additionally, the group also identified some services that should not attract a fee, including:

• ACHA;
• Advocacy and information;
• Some social supports;

-Volunteer as surrogate friend;

-Dementia monitoring program and other services that are frequently provided to resistant consumers;

-Day Centres – particularly for those clients who attend centres with high frequency as they are very frail and need the continual supervision and meals provision.

The group also discussed the purpose of fees, noting that is a fee could be considered a vital financial contribution of service delivery or for a service, which is inconsistent with the principle that the consumer outcomes should be consistent regardless of where they are. The groups conclusion was that in reality fee levels have little relationship to the real cost of a service, however in forming fee levels, there should be consideration of labour intensity and costs.

CHSP Service Streams (including what’s missing)

This group noted that the current HACC service streams have odd combinations of services and are affecting providers and the sector negatively. Therefore, various purposes and outcomes of streaming services should be considered. Service streams should be redesigned to provide flexibility and choice, and to reflect the principles and philosophy of the new CHSP.

The group noted that a considered approach to service streaming would:

• Allow the flexibility to block fund;
• Identify services that can be individually funded;
• Simplify communication with clients;
• Give consumers the freedom to choose services that meet the same needs in different ways; and
• Streamline arrangements.

It was noted that service type streams tend to lock in specific service responses rather than being flexible to meet consumer needs and preferences.

Therefore, the group recommended that streams be structured based on the consumer outcomes to be achieved, as this would promote a person-centred focus and lead to positive reporting processes. Secondary considerations would include service types, funding approaches, and delivery mechanisms.

The proposed streams[1] included:

The Advisory Groupnoted that there were a number of changes that should be considered to the CHSP beyond that currently considered by Government. This included:

• Merging of the separate Community Visitors Program with the current social support services provided under the Commonwealth HACC Program. This could either be incorporated with the CHSP (preferred option) or current Commonwealth HACC Social Support services could be moved from CHSP into the Community Visitors Program.
• Exploration and potential inclusion of residential respite services, into a single respite/carers service stream
• Removal of advocacy services from CHSP into a new Advocacy program that incorporated the National Aged Care Advocacy Program (NACAP) with the independent, individual advocacy services provided by Commonwealth HACC along with Commonwealth HACC funded systemic advocacy services.

While the group noted that the final version of service streams should remain as an outcome focused approach, there were a number of services that did not fit into a single stream. This may mean that such items may be funded through multiple streams or that an additional “multi-outcome” stream may need to be developed. Further deliberation about the role of streams such as meals, transport and equipment is required before finalising these streams within the CHSP.

The issues identified in this approach included:

• The lack of visibility between service provision by State and Territory Governments and other organisations;
• Funding types – e.g. block funding of infrastructure; and
• The hesitation to return to rigid service type groupings.

The group also noted that a longer term move towards an exclusionary approach (as is outlined in the NACA Home Care CDC Policy Elements and Guideline Development Advisory Paper)could be utilised to be consistent with NACA’s Home Care Packages recommendations and to support the future transition to a single home care system.

Supporting CHSP Volunteering with a changing demographic

This group discussed a range of issues relating to the role of volunteers in the CHSP, including that:

• The volunteer base for the future is changing. However this depends on location and socio-economic status, and is difficult to gauge because of the mixed messages of increasing enthusiasm for volunteering, but a decrease in free time;
• More information on the role, skills and numbers of volunteers in the home support sector is needed;
• The role of volunteers on boards should be shaped in a way that supports innovation;
• There is a need for a National Volunteering Strategy;
• Increasing risks in providing services to very frail people need to be acknowledged;
• Funding needs to reflect the substantial costs of infrastructure and transport to support volunteers;
• Training requirements should be reflective of tasks undertaken and funding should be available to ensure we have a skilled workforce; and
• The formalisation of this workforce should be implemented in a way that does not needlessly increase red tape. This may involve the centralisation of arrangements for requirements such as police checks and/or the reduction of financial disincentives attached to fulfilling these requirements.

Where and How do Day Therapy Centre Services fit in the CHSP

This group indicated that Day Therapy Centres (DTC) have multiple purposes, including reablement (not maintenance), restoration, and community/social connections (particularly through group activities).

It was decided that DTCs offer something that the sector wants to keep, but that certain aspects may need to be moved into different streams.

While the inconsistency of DTCs across the country was acknowledged, it was recommended that existing data be utilised and the new role of DTCs in the CHSP be defined in the way that is considered most beneficial.

It was recommended that this new definition of DTCs should be kept together as an entire service regardless of where the funding is to be placed, with options including: