Submission to Integrated Care at Home Program Discussion … · Web view2018-03-09 · Submission to ‘Future reform – an integrated care at home program to support older Australians’

Submission templateDiscussion paper:

Future reform – an integrated care at home program to support older

AustraliansSubmissions close on 21 August 2017

Instructions: Save a copy of this template to your computer. It is recommended that you read the relevant pages in the discussion paper prior to responding. You do not need to respond to all of the questions posed in the discussion paper. The numbering of the questions in the template corresponds to the numbering in the discussion

paper. Please keep your answers concise and relevant to the topic being addressed. Upload your completed submission on the Consultation Hub. Alternatively, if you are experiencing

difficulties uploading, you can email your submission to: [email protected]

Thank you for your interest in participating in our consultation.

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https://consultations.health.gov.au/aged-care-policy-and-regulation/discussion-paper-future-care-at-home-reform/

Submission to ‘Future reform – an integrated care at home program to support older Australians’ – July 2017

Tell us about you

What is your full name?

First name Clare

Last name Hargreaves

What is your organisation’s name (if applicable)?

Municipal Association of Victoria

What stakeholder category/categories do you most identify with?

☐ Commonwealth Home Support Program1 serviceprovider

☐ Home Care Package service provider☐ Flexible care provider

☐ Residential aged care service provider ☐ Aged care worker

☐ Volunteer

☐ Regional Assessment Service

☐ Aged Care Assessment Team/Service

☐ Consumer

☐ Carer or representative ☐ Advocacy organisation

☐ Peak body – consumer☐ Peak body – carers

☒ Peak body – provider

☐ Seniors membership association

☐ Professional organisation☐ Disability support organisation

☐ Financial services organisation ☐ Union

☒ Local government☐ State government

☐ Federal government

☐ Other Click here to enter text.

Where does your organisation operate (if applicable)? Otherwise, where do you live?

☐ NSW ☐ SA☐ ACT ☐ WA

☒ Vic ☐ NT☐ Qld ☐ Tas

☐ Nationally

May we have your permission to publish parts of your response that are not personally identifiable?

☒Yes, publish all of my response

☐No, do not publish any part of my response

1 Includes Home and Community Care Providers in Western AustraliaPage | 2


Section 2. Reform context

2.3 Reforms to date

CommentsWe would welcome your views and feedback on the February 2017 (Increasing Choice) reforms.Refer to page 6 of the discussion paper

Refer to page 6 of the discussion paper

The Municipal Association of Victoria is submitting this response on behalf of the 79 councils and has legislated authority to represent Victorian local government.

The Challenge is in the Administration of Change

The discussion document includes a number of high-level aspirations for creating a more consistent, transparent and integrated aged care system and this is to be commended. While there is some detail concerning what should be achieved there is rather less information outlined in terms of how an effective, functional and better system will be delivered. To some extent this is to be expected given that the various jurisdictions are at different places in terms of the availability and quality of aged care services at present. However, this could potentially pose a challenge in terms of delivering on these high level aims. The public administration research literature clearly demonstrates that the greatest challenge of policy processes typically relates to its implementation (Moon et al, 2017). Without the provision of greater detail outlining how these broad aspirations might be delivered and how capacity will be built within the system to do this, there is a danger that these reforms are a policy implementation problem waiting to happen.

The need for Stewardship by Government

Many of the reform processes outlined within the discussion paper are contingent on effective processes of stewardship operating at various levels of government. Yet, as the recent Productivity Commission (2017) review into human services noted, there are currently a number of limitations in terms of governments’ abilities to act as system stewards. This issue is not restricted to Australia. Internationally a number of different systems are grappling with this issue. We believe this indicates a real and significant need to invest in improving the capacity and capability of government agencies to act as effective stewards if these benefits are to be realized. There are significant risks in driving greater levels of competition within public services, particularly for those who are most disadvantaged. Without significant investment in improving the stewardship capabilities of governments there is the potential for a number of these reforms to fail to achieve their aims and potentially have a detrimental impact on some parts of the population.

Victoria has a long standing intergovernmental partnership to plan and deliver a coordinated system of community care to older people – which provides a high quality platform and essential stewardship.

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Section 3. What type of care at home program do we want in the future?

3.1 Policy objectives

Question Are there any other key policy objectives that should be considered in a future care at home program? Refer to page 9 of the discussion paper

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Victorian local government and public health and community health services offer a distributed model of care across the state which provides an integrated service system built on an access and equity approach. With over 500,000 Victorians over 75 years of age in 2016 and a rapidly ageing population, the service offerings through the domestic assistance, meals, personal care and home maintenance as well as community programs and activity groups play a very important role in keeping people well and at home, out of hospital and care. Wellness promotion and reablement require a flexible and person centred approach and an appropriately qualified workforce to deliver it. Councils have invested heavily in a skilled and qualified workforce, and the quality of the service offering is well recognised. This decentralised although accessible model throughout the state plays a big part in demand management.

The following elements are based on Victorian councils’ long experience of service delivery, service and infrastructure planning and coordination, where older people are citizens in the community first who may require care and support response as needs change.

The community aged care system needs to be:

Prevention focussed: community care services play a significant role in maintaining older people in a positive state of good health and wellbeing and therefore restraining growth in more expensive health services

Person centred: support older peoples’ goals through flexible community care services that are delivered with an enabling and restorative approach to the people using them, and facilitate referrals to related services (e.g. housing, financial support, recreation, adult learning, physical activity).

Accessible at local level: good quality assessment that engages face to face with the person in their home environment is essential to achieving positive results

Designed to ensure continuity of care and certainty of service availability and provision for older people

Able to be coordinated around needs of the individual : coordinated system and range of services offered at the local level and assistance provided to older people to access services

Supportive of family and carers: aligned to the community in which older people live, including respecting carers, neighbours and family members who are intrinsic to people remaining at home and supported in their communities

Designed to facilitate service provider engagement and networking which is critical to getting a more person and family centred, responsive and restorative approach to care delivery

Designed for seamless integration and use by older person of community care services and the rest of the health and community care service system including between CHSP and packages as needs change

Enhancing quality of care in the home and community setting - thereby reducing referral to hospital settings: aged care community services can support timely hospital discharge, reduce unplanned hospital readmissions and contribute to the ongoing support of frail older people with chronic conditions. This entails consequential impacts on health services in the form of decreasing demand for services and more responsive community care services for people exiting hospitals.

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Governments perform a range of functions to help ensure service provision is effective at meeting such policy objectives. A competitive environment of itself is unable to deliver the features outlined above.

As we know context is important in terms of care services and this is highly variable across the country. The majority of these policy objectives relate to outcomes of care and are to be supported. What might need to be acknowledged further in the objectives is that different means will need to be adopted for individuals and/or areas according to the nature of those places and care arrangements- particularly for Victoria where an integrated system of community support is in place.

Section 4. Reform options

4.2 An integrated assessment model

Question What do you believe could be done to improve the current assessment arrangements, including addressing variations or different practices between programs or care types (e.g. residential care, home care and flexible care)?Refer to page 12 of the discussion paper

Any review of assessment arrangements needs to place the current client experience at the centre. Currently there are multiple agencies and people involved with an individual client. A standard access process includes contact with MAC contact centre staff, RAS or ACAS staff, and finally with service provider staff who discuss service levels for referred service types. Clients can experience varying degrees of confusion, duplication of questions, and time delays in service commencement as a result of multiple agency contact. Variations in practice are also an inevitable outcome of this structure.

There are many anecdotes of the frustrations of family members and other informal carers having difficulty in navigating systems and in particular being recognised to access the entry to the system through My Aged Care. There is a need to have processes which acknowledge the carer/authorised agency to able to act on the client’s behalf when registering the person with the MAC.

Realignment of assessment functions to achieve practice consistency needs to ensure key strengths such as knowledge of local service systems, local service and assessment relationships, and local planning and development capacity embedded in assessment functions are not lost.

Wherever possible, one locally coordinated face-to-face assessment point is preferable to meet the needs of older people, their families and carers. There is an established qualified assessment workforce in Victoria with benefits and savings in reduction of long term dependency on CHSP services as well as strong links with care coordination and the network of agencies and services.

A national assessment program consisting of geographically based assessment services with a team of assessors which completes assessments from entry level through to comprehensive assessments would address several issues. The size of geographic areas would be small enough to ensure local knowledge and relationships are optimised. (NDIS Local Area Coordination teams establishing physical presence in local communities has assisted with the development of local relationships and community sector knowledge).

With the necessary authority, this would address issues including the varying demands for assessments at the two levels. An intake process for the full assessment service could allocate assessments to an appropriate team member based on their qualifications, experience and responsibility. Improved communication between different levels of assessment will enhance the client journey through assessment processes and support consistency in practice. Registration of clients by this assessment team in their geographic catchment would reduce the number of entities contacting a client.

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4.3.1 New higher level home care package │ 4.3.2 Changing the current mix of home care packages

Questions Would you support the introduction of a new higher package level or other changes to the current package levels? If so, how might these reforms be funded within the existing aged care funding envelope?Refer to pages 12 – 14 of the discussion paper

“In discussion with local HCP providers there has been little or no movement of clients to date who are choosing to utilise the option of shifting their packages between providers in the municipality, although it should be noted that in some areas Local government is the only provider at this stage. Local providers indicate there is a concern around the transparency of allocation of packages across the region and nationally and also confusion around priority with some clients facing lengthy wait times for packages and not receiving them” (Loddon Mallee Councils)

There is clearly a need to review the structure of home care packages. In particular, the review needs to be undertaken in the context of the continuum of aged care support at home and residential aged care. As an example, Level 1 packages align closely with available CHSP support. Level 4 packages are not adequate to support all people who are capable of living in the community. Considering only one element of the “care at home program” as the question proposes, will have implications for other elements (and people) across the care at home system. The danger is that preventative upstream interventions will be overlooked in viewing the ‘system’ from the highest level of cost and care responses.

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4.4.1 Changing the current mix of individualised and block funding

Question Which types of services might be best suited to different funding models, and why?Refer to pages 14 – 15 of the discussion paper

There are a range of different funding models available to purchasers, each of which has their strengths and weaknesses. As a general guide, individualised funding could be appropriate where there is a clear sense of what is to be purchased, there is competition within the market to deliver this and the service does not depend on other purchasers of the service for it to be sustainable. Block funding may be more appropriate where this is a collective service, there is little or no competition within the market and the service is difficult to specify or an aggregated group of services is required. Levels of trust between purchaser and provider are also important to take into consideration, as are the transaction costs associated with the services.

The Productivity Commission’s (2011) report into disability services outlined a vision for the NDIS largely reliant on individualized funding but with a role for block funding within this. The Commission argued:

“While consumer payments to providers […] should become the industry norm over time, there may still be a role for some block funding where markets would otherwise not support key services. Specific areas where block funding may be required are: crisis care; rural areas; community capacity building, some individual capacity building; to support disadvantaged groups (such as indigenous Australians) and as a tool to promote innovation, experimentation and research.”

National Disability Services (2014) outline six areas that they believe block funding will be needed in disability services, namely:

The provision of information, advice and community development support Support the ongoing production of social capital Seed innovation, research and evaluation to identify and build good practice Ensure reasonable and necessary support options where markets are thin Enable informed choice and expand knowledge of community options Sustain and build service capacity during transitions

Many of these areas are designated as in need of block funding either to ensure the supply side in limited markets, to assist consumers and potential consumers to navigate the demand side of the system or to ensure that expertise and social capital will not be lost in the transition to the NDIS. These concepts apply fully to the aged care and support system.

The Negative Effects of a Shift Away from Block Funding A number of the areas highlighted by National Disability Services (NDS) are demonstrated in the literature relating to individualized funding in the English system. There is evidence from other systems to suggest that a shift away from block funding of services to those purchased on an individual level can have negative effects for the availability of collective (group-based) services. Needham (Needham 2012), for example, found that day care centres in over half of areas surveyed were closing. Shared spaces were viewed as no longer viable and many areas reported substantial increases to charges for day centre attendance, transportation and meals. The available level of budgets to individuals was reported as low, meaning that people reported being priced out of day centres or having to reduce the number of days that they attended. Needham concludes that “The commitment to choice and control within the personalization agenda is absolutely right: no one should be made to attend a day centre if that is not what they want to do. However, choice may be taken away from service users if a valued day centre is closed. The forms of empowerment that personalization advocates campaign for require collective spaces in which people can share concerns and articulate forms of personalization based on inclusion and empowerment rather than isolation and risk-transfer” (pg. 17). Similar findings have been reported in relation to a range of other collective services (e.g. Mencap 2012, Spandler 2004). Concerns

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have also been expressed around who will play a role in developing new facilities or maintaining communal spaces that are used by range of different community organisations.

What these examples illustrate is that introducing individualized funding systems can increase transaction costs within the system. It is more expensive for providers to cost services and contract for these on an individual basis, than it is to do so through a bulk contracting approach where a level of funding is assured. This has important implications for the cost and availability of collective services. If we see the loss of collective spaces such as this, and individuals spend more time at home, then we will see an associated reduction in social capital. If there is a lack of collective services within a particular locality, then people may spend longer travelling to locations where these services are and this can weaken links to local communities.

Question What would be the impact on consumers and providers of moving to more individualised funding?Refer to pages 14 – 15 of the discussion paper

When we examine the literature to identify the impacts that the individualization of services and the introduction of market forces into aged care we find somewhat of a mixed picture. While some studies report such reform processes having positive impacts (albeit with some caveats), others indicate a far less optimistic perspective.

Choice and control can be facilitated through a variety of means and not simply those where services are provided by third party agents under contract.

Starting with the more positive accounts, Ottmann et al (2013) examined satisfaction and preferences of users in consumer-directed aged care models in the UK and US. Their review found that users are satisfied with the opportunities for choice that consumer-directed models allow for, but that the administrative burden can be prohibitive. This aligns with other studies that show that the major difficulties of personalized funding schemes related to ‘bureaucracy, paperwork and administration’ (Spandler 2004). Ottman et al (Ottman, Allen, and Feldman 2013) therefore conclude that there is capacity for consumer-directed care models to improve outcomes by maximising the control afforded to individuals but limiting responsibility for administration to users. It is identified that the crucial factor for user satisfaction is the ability to exercise choice and control, but the authors are at pains to indicate that this does not necessarily mean the care services need to be marketised. Choice and control can be facilitated through a variety of means and not simply those where services are provided by third party agents under contract.

Negative Accounts of Impacts of Individualised Funding Resulting from the Reforms, particularly for older people Turning now to some of the more negative accounts of these reforms, in one of the most significant reviews of the impact of individualized funding schemes, Glendinning et al (Glendinning et al. 2008) undertook a review of individualised budgets in England and this scheme incorporates the delivery of services to older people. This study highlighted a number of concerns relating to personalization and aged care. Outcome interviews found that older people in personalization systems had lower levels of wellbeing than the comparison group in block-funded systems. The authors attribute this to anxiety and

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stress about perceived changes to their support arrangements, which moderated any potential gains from greater choice, control, transparency and flexibility offered by individualised budgets. Of all the age groups interviewed, older people were reported most resistant to the changes. Overall the review found that:

Care supports for older people are often approached at a time of crisis, or a tipping point that has made people feel vulnerable, unwell or otherwise unable to administer their own care

Older people indicated that the experience of decision making and administering individualised budgets was burdensome, rather than empowering of choice

The focus of older people’s care packages tended to be on personal care rather than social participation, employment or occupation which restricts the potential for improvements in wellbeing

What these findings indicate is that it is important how these schemes are rolled out and how people are supported to make decisions. Particularly important according to Glendinning et al (Glendinning et al. 2008) is the role of care co-ordination and planning support and they make the argument that this is a more intensive role than that required for younger adults. Another important observation from this study relates to the size of packages available. These researchers found that older people received smaller than average levels of IBs [individual budgets] compared to younger adults” (Glendinning et al. 2008: 238). Where the size of budgets is smaller this provides less opportunity for flexibility, innovation and responsiveness to the varied needs to older people and may be why we find lower levels of wellbeing in older people than younger adults in receipt of individualised funding.

An oft-reported weakness of care systems is a lack of continuity of care and gaps between services (Dickinson and Carey 2017). It is often argued that individualised systems of care reduce the likelihood of gaps in services and enhance continuity of care because they are not bound by the same demarcations of services that traditional services are (Leadbeater 2004). However, the evidence suggests that individualized systems of care do not necessarily enhance continuity of care more effectively than traditional systems (Dickinson and Carey 2017, Moran et al. 2011). Individualized systems of care still encounter challenges relating to continuity and coordination of care. Although funding for care services might be individualised, other lines of funding for mainstream services might not be included in these funding streams. Further, providers might be incentivised to compete against one another which could make services even more fragmented (Netten et al. 2012). Providers are rewarded for delivering particular services, but not necessarily funded for collaborating with other agencies.

Older People With Less Complex Needs Had Been Left With Fewer Community Based Care OptionsIn an examination of trends in individualization in Finland, England and Australia Yeandle et al (Yeandle, Kroger, and Cass 2012) concluded that ‘de-institutionalization’ efforts may have contradictory outcomes for population level health. The problem is that most services that are specific enough to cater for people with complex needs are only available in residential settings, so de-institutionalization for this group remains difficult. In all three countries de-institutionalization enabled a greater number of older people with complex needs to remain at home, with higher levels of care met by family and other unpaid carers. In some cases, this may be appropriate, but in others this can generate high levels of stress and demand on families and friends. As with the discussion above relating to the loss of collective services as a result of individualized funding, there are also implications for the availability of services here. In Finland, Kröger and Leinonen (Kröger and Leinonen 2012) observed that older people with less complex needs had been left with fewer community based care options as a result of processes of de-institutionalization efforts.

Issues of Equity – requires ‘supply’ side to be ensured Page | 9


An important point to draw from the conversation above relates to issues of equity. It is often argued that individualized systems of funding based on markets and competition will be more equitable as it allows individuals to demand what they want and need, and not simply what they are allocated by the system. However, this assumes that there is the availability of these services on the supply side and also that individuals are able to identify and to demand what they need. Yet there is evidence to suggest that for some individuals and for some areas (e.g. regional and remote) there is not the availability of services that there are in other areas. Often this is described in terms of ‘thin’ markets. In addition to a lack of options in terms of service providers, thin markets are also susceptible to market failure, where no new providers enter the market place due to high costs of entry or lack of business prospects, and existing providers are challenged by being paid retrospectively for business, gaining the necessary breadth and depth of expertise and business costs running higher than the funds collected via individuals. In the case of market failure or thin markets, individuals already disadvantaged geographically are unlikely to be able to exercise “true” choice and control. To some extent this was recognised by the Productivity Commission (Productivity Commission 2011) that argued there will be the need to continue to block fund some aged care services.

The Benefits of Individualized Systems Are Dependent on the Advocacy and Support Networks to Which Individuals Have Access Turning to the demand-side of market systems, it is often assumed that individuals will be able to clearly identify the types of services that they want and need. Yet, the evidence suggests that this is not necessarily the case and that the benefits of individualized systems are dependent on the advocacy and support networks individuals have access to (Needham 2013, Williams and Dickinson 2016). The UK evidence demonstrates that individuals with significant supports in place prior to personalization (i.e. financial and interpersonal) are more likely to experience benefits than those who do not (Needham 2013) (Needham, 2013). This suggests that those who are already marginalized or of low-socio-economic status may benefit least from individualized care systems. This is consistent with the inverse care and prevention law (Hart 1971), a problem that has plagued population health interventions. Here, individuals who need to gain the most from health interventions actually gain the least. The inverse care and prevention law can be seen in Needham’s (Needham 2013) work in disability, which has shown that there is little supporting evidence that personalization efforts have a positive effect on social inclusion or income. She argues “evidence highlights the dangers of inequity between those with financial and social resources to supplement their use of budgets and those without”. That is, those who have more resources are more likely to reap the benefits of personalization than those without.

Markets Need Significant StewardshipAs the evidence set out above indicates, there are challenges in terms of both the demand and supply sides of care markets and these can have very real implications in terms of the quality and care and outcomes of care recipients. In recent reviews the Productivity Commission has acknowledged that markets do not operate in a neo-classical economic sense (Australian Government Productivity Commission 2016a, b), and need significant stewardship in terms of ensuring an effective supply side and also helping to manage demand for services.

Individualized Care Models Present Challenges To Collaboration Most individualized care models rely upon collaboration between care service providers and mainstream service providers for co-ordination of care and supports. However, it has been shown that direct funding systems can impact upon service provider networks and communities of practice. Evaluation from a trial site of the Australian NDIS recorded descriptions of significantly changed, and in some cases diminished, networks for collaboration between service providers and organizations that traditionally worked closely with them (Meltzer, Purcal, and Fisher 2016). In this case study; the market model of the NDIS prompted an initial reframing of collaborators as ‘competitors’, a trend that was adjusted in some instances as service provider organizations found opportunities to “collaborate in new ways” (Meltzer, Purcal, and Fisher 2016: 3). Meltzer et al also observed that service providers had no way to bill for collaboration and the significant time spent rebuilding the diminished organizational networks for care co-ordination and support.

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One of the strengths of the Victorian local government aged care sector is in the sector collaborations with other community support agencies. The marketised system threatens the continuity of these valued collaborations with a resultant impact on quality of care.

Need For a Meso-Level Organization to Create an Effective System to Respond to Inevitable Market Failure

As outlined above, many of these observations suggest the need for a meso-level organization to work to make the system operate in an effective way. Without such an intervention there is a risk that individual and separate agencies work in a way that serves only their specific purpose, which has significant implications for the broader population and area-level. Market systems are based on competition, meaning that some providers of services will inevitably lose out and fail to exist. In traditional consumer markets the collapse of a provider may not have impacts that are too detrimental, but in the context of care services this can be far more significant. For example, in the UK there have been significant collapses in care home providers, which saw one provider Southern Cross close 752 care homes in 2011 impacting 33,000 residents. Following this collapse, local government worked collaboratively with national government to ensure that there were no residents of these care homes who found themselves without care. Councils had the agility, capacity and experience to step in to make alternative arrangements when this provider failed. Such an occurrence is not without precedent in Australia. The collapse of A.B.C. Learning Centres Limited which at the time was Australia’s largest child care corporation caused great uncertainty for many families as it provided care for over 100,000 children and employed approximately 16,000 staff (Sumison 2012). This company was initially bailed out by government, but in many areas Local Government was instrumental in stepping back in to deliver these services following market failure.

Market failure is a predictable component of market-based systems which use the power of competition to purportedly drive innovation up and costs down. Evidence suggests that government will be a provider of last resort in a context of market failure. However, there is an important question about the capacity of governments to do this in a context where their scope is being narrowed and the size and delivery capacity of these agencies is being stripped down. In the case of local government, the reforms that are taking place around the NDIS and aged care services have the potential to significantly reduce the ability of these organizations to respond to market failure in the community care sector.

In conclusion, regardless of the mix of funding types adopted, it is proposed that a new funding stream for care coordination support at the local level be introduced, to meet the needs of older people through coordinating the services they require.

Question Are there other ways of funding particular services or assisting consumers with lower care or support needs, e.g. a combination of individualised funding and block funding, vouchers etc.?Refer to pages 14 – 15 of the discussion paper

Much of the evidence relating to the individualisation of care funding in the UK suggests that where care packages represent as small overall cost this loses the potential benefit that might be leveraged from these forms of contracting arrangements (Glendinning et al, 2008). Where individuals have low care or support needs, the overall budget for their care package is typically low and therefore attracts disproportionate transaction fees and offers little room for the individual to be innovative with their care packages in a way that larger packages allow. Given the additional administrative burden that these approaches also generate, consumers find that they are required to do more work for little additional benefit. Block contracting for lower levels of support and operating

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access to this through effective assessment and case management processes would allow for lower transaction costs and greater engagement with the individual and their particular circumstances. Having more effective information about the needs and circumstances of an individual at this point will enable the creation of more effective care plans that should ultimately serve a preventative force, maintaining individuals at home for longer. A voucher system might be used in conjunction with this, but simply offering a voucher service without careful and locally appropriate case management will likely have less of an impact in terms of quality outcomes.

4.5.1 Refocussing assessment and referral for services

Questions Should consumers receive short-term intensive restorative/reablement interventions before the need for ongoing support is assessed? If so, what considerations need to be taken into account with this approach?Refer to page 16 of the discussion paper

“Restorative care needs to be embedded in service provision not just at the initial assessment point. Introducing another stage in the overall process only adds to the complexity of entering the aged care system. When consumers are paying for a service there is often considerable confusion as to the scope of the service, e.g. “if I’m paying for it then why am I doing it myself” this represents a paradigm shift for providers and consumers” (Golden Plains Shire)

As with many of the responses to the questions posed in this document, it is difficult to be definitive about all individuals given the very different circumstances and contexts. For some individuals this will be highly appropriate, for example, after a recent traumatic event or illness. Assessing these individuals prior to restorative/reablement interventions may lead to the inappropriate assessment of ongoing support needs. Others may be less amenable to restorative/reablement for a variety of reasons and would benefit from a timely assessment of ongoing needs. Again, what these issues point to is the importance of effective case management that engages with individuals in an informed and locally appropriate way to identify the options that are best suited to this individuals (Glendinning et al, 2008).

QuestionHow could a wellness and independence focus be better embedded throughout the various stages of the consumer journey (i.e. from initial contact with My Aged Care through to service delivery)?Refer to page 16 of the discussion paper

Victoria has had many years in developing a wellness and reablement framework which has involved a paradigm shift for providers and consumers. Expectations are clarified and opportunities for goal establishment in the assessment phases. Assessments must have this quality of engagement to achieve a wellness frame.

Wellness and independence focus can best be embedded throughout the journey by supporting a localised capacity building approach (such as transport and social support programs) which can respond to keeping people connected beyond the service system to their communities and peers. Within the formal system, expectations can be enhanced from initial assessment with knowledge and direction to a broad range of services (not just funded services). From initial assessment onward, individuals should

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have the opportunity to articulate what wellness and independence looks like for them. Navigation supports may need to be provided for complex systems to maintain this focus.

4.6.1 Ensuring that services are responsive to consumer needs and maximise independence

QuestionsHow do we ensure that funding is being used effectively to maximise a person’s ability to live in the community and to delay entry to residential care for as long as possible? For example, should funding be targeted to services or activities where there is a stronger connection with care and/or independent living? Are there examples of current services or activities that you believe should not be funded by government?Refer to pages 16 - 17 of the discussion paper

The program structure and funding needs to reflect the intent of this question – i.e. available resources are directed to a client outcome rather than a set of service inputs. Current provider funding flexibility is limited to similar service types so any adjustment focusing on better ways to support achievement of the client’s goal requires a client review. Provider funding structures and accountability relates to outputs rather than outcomes. As such providers’ responsibilities are primarily to deliver units of service and achieve their organisation’s financial objectives. There is limited funding, responsibility or discretion to facilitate goal achievement. Clarity about who is responsible for client goal achievement is required.

The recognition of the informal carers, friends, neighbours and family in contributing to people living well at home must be factored into system design.

Different individuals will have different needs and requirements in terms of living within the community and delaying entry to residential care. Careful planning with individuals as to what these precise requirements are is necessary so the most appropriate support structures are put in place. As with experiences of individualised funding systems in the UK and other jurisdictions (Dickinson, Sullivan, and Needham 2015), allowing individuals to think creatively about how their needs might be met through a supported process could lead to more targeted funding that enables this to happen. To this end, restrictions should only be made to services or supports that do not clearly meet the outcomes that agreed in care planning processes. Further, the delivery of short and episodic services, rather than carefully planned and longer term arrangements, restrict ability to support individuals to delay entry to residential care services.

QuestionHow do we maximise the flexibility of care and support so that the diverse needs of older people, including those with disability, are met?Refer to pages 16 - 17 of the discussion paper

On the demand side, care and support mechanisms are able to be flexible where they are underpinned by high quality care planning and co-ordination processes that have a good understanding of the local context and the individual and their family (Glendinning et al, 2008). On the supply side these processes are enhanced where there is stability and consistency for providers and there are not concerns over the short term nature of funding

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and/or contracts. The re-contracting or re-tendering processes for the provision of services leads to significant instability in the system and impedes the ability for providers to respond to the care needs of individuals in a flexible way.

Victoria’s experience is that block funding for price/volume community care services has been successful in managing demand as well as providing a response appropriate to all citizens.

4.6.2 Accessing services under different programs

QuestionUnder the current program arrangements, does allowing some consumers to access both programs promote inequity, particularly if other consumers have to wait for a home care package?Refer to page 17 of the discussion paper

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QuestionsUntil an integrated care at home program is introduced, is there a need to more clearly define or limit the circumstances in which a person receiving services through a home care package can access additional support through the CHSP? If so, how might this be achieved?Refer to page 17 of the discussion paper

“Social Support is one of the most effective services that enable clients to connect with their community and improve their wellbeing and health. Restrictions of access to CHSP Social Support services, for Home Care Package consumers, is impacting their ability to achieve outcomes and goals. This is especially applicable to low level services where funds are limited” (Eastern Metropolitan Region councils)

4.8.1 Supporting specific population groups

QuestionHow can we make the care at home system work better for specific population groups, particularly those whose needs are not best met through current CDC models and administrative arrangements?Refer to page 19 of the discussion paper

There is a growing volume of data from the NDIS and other international individualised funding systems to demonstrate that these can have negative impacts on some groups of individuals – typically those who are most disadvantaged or isolated on entry to these schemes. It is often assumed that individuals will be able to clearly identify the types of services that they want and need. Yet, the evidence suggests that this is not necessarily the case and that the benefits of individualized systems are dependent on the advocacy and support networks individuals have access to ADDIN EN.CITE <EndNote><Cite><Author>Needham</Author><Year>2013</Year><RecNum>2706</

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RecNum><DisplayText>(Needham 2013, Williams and Dickinson 2016)</DisplayText><record><rec-number>2706</rec-number><foreign-keys><key app="EN" db-id="pa2550peiea59iexpr8p02aw9aafadrwt9f2" timestamp="1490226978">2706</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Needham, C</author></authors></contributors><titles><title>Personalized commissioning, public spaces: the limits of the market in English social care services</title><secondary-title>BMC Health Services Research</secondary-title></titles><periodical><full-title>BMC Health Services Research</full-title></periodical><pages>S5</pages><volume>13</volume><number>Suppl 1</number><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Williams</Author><Year>2016</Year><RecNum>2598</RecNum><record><rec-number>2598</rec-number><foreign-keys><key app="EN" db-id="pa2550peiea59iexpr8p02aw9aafadrwt9f2" timestamp="1480254272">2598</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Williams, I</author><author>Dickinson, Helen</author></authors></contributors><titles><title>Going It Alone or Playing to the Crowd? A Critique of Individual Budgets and the Personalisation of Health Care in the English National Health Service: Individual Budgets and the Personalisation of Health Care</title><secondary-title>Australian Journal of Public Administration</secondary-title></titles><periodical><full-title>Australian Journal of Public Administration</full-title></periodical><pages>149-158</pages><volume>75</volume><number>2</number><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(Needham 2013, Williams and Dickinson 2016). The UK evidence demonstrates that individuals with significant supports in place prior to personalization (i.e. financial and interpersonal) are more likely to experience benefits than those who do not ADDIN EN.CITE <EndNote><Cite><Author>Needham</Author><Year>2013</Year><RecNum>2706</RecNum><DisplayText>(Needham 2013)</DisplayText><record><rec-number>2706</rec-number><foreign-keys><key app="EN" db-id="pa2550peiea59iexpr8p02aw9aafadrwt9f2" timestamp="1490226978">2706</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Needham, C</author></authors></contributors><titles><title>Personalized commissioning, public spaces: the limits of the market in English social care services</title><secondary-title>BMC Health Services Research</secondary-title></titles><periodical><full-title>BMC Health Services Research</full-title></periodical><pages>S5</pages><volume>13</volume><number>Suppl 1</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>(Needham 2013) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FXOJkHCV","properties":{"formattedCitation":"(Needham, 2013)","plainCitation":"(Needham, 2013)"},"citationItems":[{"id":4719,"uris":["http://zotero.org/users/1920306/items/KBUFT76E"],"uri":["http://zotero.org/users/1920306/items/KBUFT76E"],"itemData":{"id":4719,"type":"report","title":"The Boundaries of Budgets: why should individuals make spending choices about their health and social care?","publisher":"Centre for Health and the Public Interest","publisher-place":"London, England","source":"Google Scholar","event-place":"London, England","URL":"http://chpi.org.uk/wp-content/uploads/2013/07/Boundaries-of-Budgets-Catherine-Needham-July-31.pdf","shortTitle":"The Boundaries of Budgets","author":[{"family":"Needham","given":"Catherine"}],"issued":{"date-parts":[["2013"]]},"accessed":{"date-parts":[["2015",11,16]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Needham, 2013). This suggests that those who are already marginalized or of low-socio-economic status may benefit least from individualized care systems. This is consistent with the inverse care and prevention law ADDIN EN.CITE <EndNote><Cite><Author>Hart</Author><Year>1971</Year><RecNum>2707</RecNum><DisplayText>(Hart 1971)</DisplayText><record><rec-number>2707</rec-number><foreign-keys><key app="EN" db-id="pa2550peiea59iexpr8p02aw9aafadrwt9f2" timestamp="1490227231">2707</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hart, JT</author></authors></contributors><titles><title>The inverse care law</title><secondary-title>Lancet</secondary-title></titles><periodical><full-title>Lancet</full-title></periodical><pages>405-412</pages><volume>I</volume><dates><year>1971</year></dates><urls></urls></record></Cite></EndNote>(Hart 1971), a problem that has plagued population health interventions. Here, individuals who need to gain the most from health interventions actually gain the least. The inverse care and prevention law can be seen in Needham’s ADDIN EN.CITE

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<EndNote><Cite><Author>Needham</Author><Year>2013</Year><RecNum>2706</RecNum><DisplayText>(Needham 2013)</DisplayText><record><rec-number>2706</rec-number><foreign-keys><key app="EN" db-id="pa2550peiea59iexpr8p02aw9aafadrwt9f2" timestamp="1490226978">2706</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Needham, C</author></authors></contributors><titles><title>Personalized commissioning, public spaces: the limits of the market in English social care services</title><secondary-title>BMC Health Services Research</secondary-title></titles><periodical><full-title>BMC Health Services Research</full-title></periodical><pages>S5</pages><volume>13</volume><number>Suppl 1</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>(Needham 2013) work in disability, which has shown that there is little supporting evidence that personalization efforts have a positive effect on social inclusion or income. She argues “evidence highlights the dangers of inequity between those with financial and social resources to supplement their use of budgets and those without”. That is, those who have more resources are more likely to reap the benefits of personalization than those without. What this evidence suggests is effective systems for advocacy and support need to be in place and accessible before individuals transfer into such a system. It is not enough to simply have complaints systems in place, individuals will need effective advocacy services and/or case management if they are to benefit from individualized systems of funding.

Support to sector development in Victoria has been a long standing feature, to ensure the needs of diverse groups (multicultural, LGBTI) are met. Public sector agencies such as councils also have the mandate to respond to the needs of all their citizens and trained staff to provide tailored services.

4.8.2 Supporting informed choice for consumers who may require additional support

QuestionWhat additional supports could be considered to ensure that people with diverse needs can access services and make informed choices and exercise control over their care?Refer to page 19 of the discussion paper

As with the NDIS, in order to make the most effective use of the system’s resources it is crucial that effective information supports are provided and as the discussion paper notes, individuals will have very different information needs. The availability of effective care planning and management and advocacy services will be crucial to support individuals in navigating care systems and making informed choices.

4.10 Other suggestions for reform

QuestionDo you have other suggestions for care at home reform, or views on how changes might be progressively introduced or sequenced?Refer to page 20 of the discussion paper


Section 5. Major structural reform

5.2 What would be needed to give effect to these structural reforms?

QuestionAre there other structural reforms that could be pursued in the longer-term?Refer to page 21 of the discussion paper

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Section 6. Broader aged care reform

6.1.1 Informal carers

QuestionHow might we better recognise and support informal carers of older people through future care at home reforms? Refer to page 22 of the discussion paper

“In our experience, many consumers only approach a service provider after years of ‘making do’ or trying to sort things out.” (Eastern Metropolitan Region councils)

A key gap in the service system architecture is that there is no specific entry point for an informal carer.

Informal carers are vital to maintain the health and social care needs of older adults. Recognition that there is an adequate continuum between informal and formal care is vital. This could be through providing respite care services or peer support to ensure the wellbeing of the carer.

“The system needs to provide carers’ choice over what is going to make a difference for them and how they support the person for whom they care. For example, a carer may prefer to receive domestic assistance rather than respite even though they are capable of doing the tasks. This may alleviate stress and allow them to sustain their caring role in a way that works for them” (Eastern Metropolitan Region councils)

Informal carers currently provide a significant amount of care as the paper acknowledges. Informal carers need to be an important and considered part of care planning processes and in the case of individuals living at home with high support needs, may require their own care assessments to put in place any supports for these individuals. The availability of advocacy and support networks can also be useful in giving individuals a place to turn for social support or advice.

6.1.2 Technology and innovation

QuestionHow can we best encourage innovation and technology in supporting older Australians to remain living at home?Refer to page 22 of the discussion paper

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The Social Support Independent stream could be expanded to encourage innovation. A Victorian council engages secondary school students to train older residents to use iPads. Council can then use facetime or other means to check on wellbeing of clients and to also reduce isolation.

QuestionWhat are the existing barriers, and how could they be overcome?Refer to page 22 of the discussion paper


6.1.3 Rural and Remote areas

QuestionHow can we address the unique challenges associated with service delivery in rural and remote areas?Refer to page 22 of the discussion paper

Dispersed populations and thin or no markets, are a challenge which has only recently come to the fore as previous to the disaggregation of the HACC system and the advent of individualised funding and price controls in the NDIS, service was provided through local government and public and community health. Councils and rural health services have been the main provider of community care and support services for older people and those with a disability in the community. Councils have contributed to the cost of relative high quality service delivery through their own resources. Innovative local community models can be built upon this base of community knowledge and connectedness.

Local government is considering options for continuing service provision in this time of major change and disaggregation of the former HACC program. The viability of service provision which is already under pressure from workforce costs, travel and smaller consumer bases is further compromised as under 65s separate into NDIS eligible and those not, and older people in the CHSP. All councils are concerned that access to quality services are continued in the coming years. Rural councils in Victoria are particularly concerned should they determine to not continue in direct in-home service provision that their residents may not have equity of access to quality integrated services.

QuestionWhat other service delivery and funding models could we consider for providing care at home services to consumers living in rural and remote areas, including examples of innovative local community models?Refer to page 22 of the discussion paper

Sustainable funding models are required to secure quality providers. These models need to address additional costs and limited demand challenges to provider viability when providing services in rural and remote areas.

Transport often presents real barriers to access for people living in these communities. Funding approaches are required to support service transport continuity and sustainability.

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6.1.4 Regulation

QuestionHow can we further reduce regulation to allow for innovation while ensuring that essential safeguards remain in place?Refer to page 23 of the discussion paper

6.1.5 Aged care and health systems

QuestionWhat are some examples of current gaps or duplication across the aged care and health systems, and how could these be addressed?Refer to page 23 of the discussion paper

Transition from one system to the other, especially from health to aged care can often be held up by delays in the aged care system responding in a timely fashion. Programs such as transition care have assisted to bridge this gap but then can create other issues such as the person not being able to get the same level of support from CHSP, delays on getting into HCP or residential care and them having to adjust to another provider and new staff once they do transition. It fills a gap for the system but is not necessarily in the best interest of the person. It may be more consumer-focused to have transition support available with the provider of their choice. This could be accessed by the way of vouchers or individualised funding.

Any further comments?

Other comments

Do you have any general comments or feedback?

To replicate the localised service provision in a new national system will require a recognition of the key elements of the public sector which can support the agenda, as well as timely sector development support. To ensure that there is not divestment by councils in the meantime, there needs to be acknowledgement of the strengths of the service delivery role of local government and a willingness to work in partnership with the sector to ensure the quality, responsiveness and cost effectiveness of the service in Victoria can be continued.

The MAV looks forward to working with the Commonwealth and the State to explore opportunities to maintain the strengths of the Victorian system, possibly through the development of a bilateral agreement. While we acknowledge the desire of the Commonwealth to achieve national objectives in a reformed aged care system, there are many examples where bilateral agreements have been successfully put in place to achieve similar nationwide outcomes. For example, under the National Partnership on Universal Access to Early Childhood Education (to achieve 15 hours of kindergarten) bilateral agreements recognised the different starting point of each jurisdiction and successfully built on their existing system.

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The MAV would be pleased to work with the Commonwealth to fully unpack the consumer experience of community care in the home in Victoria. Satisfaction results at a state wide level are consistently demonstrating that the community places a very high priority on councils’ aged services and a high satisfaction with the service received (Local Government Victoria). The general community is unaware of the changes that are proposed and for most people, the first port of call is the local council. The permeability of the local system has meant that the trusted place for community care response is the council. The risk to increases in demand for residential care and acute hospital admissions is very real if the continuity of care and access at a local level is diminished. We believe that there is a need to fully appreciate the opportunities and risks of dismantling the Victorian distributed model and would be pleased to participate in further framing of the policy going forward.

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MAV RECOMMENDATIONS

1. The care at home program to support older Australians be nationally consistent whilst maintaining the benefits of the Victorian system through the development of a bilateral agreement with the following elements:

1.1 State based management of; CHSP assessment at local/regional levels Population based planning with local government to identify coordinated range of services

required

1.2 Maintenance of block funding of all service types, including community programs and social support to maximise economies of scale and contain transaction costs

1.3 Maintenance of qualified, well trained and supported workforce on fair wages

2. My Aged Care intake and assessment processes be reviewed to support the ability of families, carers and designated agencies to act on others’ behalf.

3. Create a new funding stream for care coordination support at the local level.


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Dickinson, H, H Sullivan, and Catherine Needham. 2015. "Self-directed care funding: what are the implications for accountability?" Australian Journal of Public Administration.

Dickinson, Helen, and Gemma Carey. 2017. "Managing care integration during the implementation of large-scale reforms: the case of the Australian National Disability Insurance Sheme." Journal of Integrated Care 25 (1).

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Mencap. 2012. Mencap (2012) Stuck at Home. London: Mencap.

Moran, Nicola, Caroline Glendinning, Martin Stevens, Jill Manthorpe, Sally Jacobs, M Wilberforce, M Knapp, David Challis, J.L. Fernandez, Karen Jones, and Ann Netten. 2011. "Joining up government by integrating funding streams? The experiences of the Individual Budget Pilot Porjects for older and disabled people in England." International Journal of Public Administration 34:232-243.

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Netten, Ann, Karen Jones, Martin Knapp, J.L. Fernandez, David Challis, Caroline Glendinning, Sally Jacobs, Jill Manthorpe, Nicola Moran, Martin Stevens, and M Wilberforce. 2012. "Personalisation through individual budgets: Does it work and for whom?" British Journal of Social Work 42:1556-1573.

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Sumison, J. 2012. "ABC Learning and Australian early education and care: a retrospective ethical audit of a radical experiment." In Childcare markets local and global: can they deliver an equitable service?, edited by E Lloyd and H Penn, 209-225. Bristol: Policy Press.

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Documents

Submission to Integrated Care at Home Program Discussion … · Web view2018-03-09 · Submission to ‘Future reform – an integrated care at home program to support older Australians’