Future Reform – an Integrated care at home program to support older Australians: Response to the Department of Health discussion paper

CPSA's response to the Department of Health's discussion paper. 

More information about the discussion paper can be found on the Department of Health website, along with CPSA's response. 

CPSA's Submission 

CPSA welcomes the opportunity to contribute to the development of an integrated care at home program for older Australians. The vast majority of older Australians would prefer to receive care and support in their own home as opposed to a residential aged care facility[1] and the establishment of a holistic and integrated care at home program is integral to ensuring this choice can be realised.

4.3 Better Meeting Consumer Demand

It is difficult to provide detailed comment regarding how client demand could be better met through the existing pool of resources, as there is very little public information detailing HCP approvals and allocations. In order to know how the current system could be improved, it is critical to understand how long clients are currently waiting to receive an approval for a HCP, how long between approval and service uptake, as well as how many clients are being placed on lower level packages while they wait for a higher level package to become available. CPSA urges the Department of Health to release this information to the public.

CPSA strongly supports an increase in the number of HCPs, particularly level 3 and 4 packages. CPSA conducted a survey of members, which revealed an overwhelming preference to avoid residential aged care, with 95% of respondents saying they would prefer to receive care in their own home. Given that the policy rationale behind these reforms is to increase choice for clients, it is critical that there are sufficient HCPs available for clients to exercise their choice to receive care at home. The only alternative to a high level HCP is residential aged care, which comes at a much greater cost to the individual client, their family and the public purse[2].

CPSA has recently heard from a number of clients who moved into residential aged care as they were unable to access the HCP they had been approved for. These clients described their experience as disempowering and contrary to their own preferences. Clients must be supported to make their own decisions as to whether they receive care at home or in a residential aged care setting. The Australian Government must support clients to do so by ensuring that there are a sufficient number of HCPs available to meet the needs of clients.
The long-term goal should be to significantly reduce the number of clients receiving residential aged care services by ensuring that those clients whose care needs can be met in a community setting have access to the care and support they need to continue living at home. A client should only ever move into residential aged care when it is no longer possible for their care needs to be met at home. This decision should be based solely on the client's care needs and a shortage of higher level HCPs should never be a reason for transitioning into residential aged care. CPSA notes an increase in the number of higher level HCPs will translate into reduced spending on residential aged care, although there is likely to be a delay before the full extent of the savings are evident.

Recommendation 1: That the Australian Department of Health publish data detailing waiting times for HCPs.
Recommendation 2: That the Australian Government significantly increase the number of Level 3 and Level 4 HCPs available.

4.4 Greater Consumer Choice and Flexibility

Consumer choice

Ensuring ease of access must be a policy priority with regard to entry-level services under the proposed integrated care at home program. Given the emphasis on wellness and reablement, early intervention is critical. CPSA is concerned that the complexity of individualised budgets and even the assessment process may constitute barriers to the early uptake of entry-level services. Many older people do not identify as requiring care, even if they may benefit from entry-level services. CPSA is concerned that the idea of individualised budgets may be too confronting for this cohort and thus act as a deterrent to service uptake. Accordingly, CPSA does not support individualised budgets for entry-level services.

CPSA also notes that individualised budgets require a high level of client engagement and knowledge. It takes time to acquire familiarity with the aged care sector and this generally occurs through exposure. Ensuring easy access to entry-level services provides clients with this exposure, allowing them to develop the knowledge and confidence to move on to an individualised budget when their care needs increase.

The issue of pricing, specifically client contributions for entry-level services, is significant and somewhat complex. Early intervention is critical in supporting people to maintain their independence at home, so it's critical that entry-level services are provided at minimal cost to clients. If these clients don't take up preventative entry-level services, then the risk is that the Australian Government will be required to fund a higher level of care down the track. Accordingly, CPSA supports the continued subsidisation of entry-level services. This being said, CPSA is not opposed to means-tested client contributions, whereby those who can afford to pay more do so. However, the overarching goal must be to remove barriers to the early uptake of entry-level services – financial or otherwise.

Recommendation 3: That the Australian Government prioritise ease of access to entry-level services when developing the Integrated Care at Home Program.
Recommendation 4: That the Australian Government should not introduce individualised funding for entry-level services.
Recommendation 5: That the Australian Government should continue to heavily subsidise entry-level services.

Block Funding

For the purposes of this submission, entry-level services include community transport and mobility support, social support programs, domestic assistance including meals on wheels, and case management. While the current CHSP does provide some personal care, clinical care, and allied health services, CPSA does not consider these to necessarily be entry-level services.

In order to facilitate ease of access and thus support the policy objectives of wellness and reablement, CPSA urges the Australian Government to consider providing block funding to entry-level services. This would allow for initial street level access of these services for a certain period of time, with clients then referred on for a more formal needs assessment to determine whether a higher level of support is required, whether they should continue to receive the current level of service, or whether services are no longer required. It is important that the initial period before formal assessment is sufficient to provide time-limited support with a focus on reablement in order to meet the needs of clients who require episodic support following a period of illness or injury.

CPSA is of the view that these entry level services, which must be block funded to ensure viability for providers and stability for clients, should then form the basis of all other aged care packages. This means that HCP clients would continue to receive case management, mobility support, social support, domestic assistance, and case management and would then use an individualised funding package to purchase personal care, clinical care and allied health services on top. The amount of funding available to purchase care and allied health services within an individual package must be based on clinical need and it is likely the current four level band structure could be mapped across.

CPSA is also of the view that those receiving residential aged care services should continue to have access to these entry level supports as these services would fill current gaps. In terms of entry-level supports, only case management, mobility support and social support would be required for those living in residential aged care as there would be no need for domestic assistance. CPSA notes that mobility support is a particular gap with residents required to cover their own transport costs for medical appointments, regardless of whether they can afford to do so. CPSA has heard from residents who have missed appointments as they cannot afford the cost of unsubsidised community transport or a taxi.

CPSA is particularly keen to see a more clearly defined role for case management within the aged care sector. Access to case management underpins an aged care system focussed on wellness and reablement and there are many older Australians who would benefit immensely from case management alone. CPSA urges the Australian Government introduce a government agency dedicated to providing case management to clients of the aged care system. Clients would have a single dedicated case manager who would then provide independent advice, support, coordination and advocacy spanning the transition from entry-level support services to full residential aged care. It is critical that the case management function operates separately from the delivery of care and services so as to eliminate any potential conflicts of interest. CPSA is of the view that this independent case manager could also fulfil the function of 'system wrangler' and support clients to navigate the aged care system.

Recommendation 6: That the Australian Government provides block funding to entry-level services.
Recommendation 7: That clients should be able to access entry-level services directly for a period of time before they are required to undergo an assessment.
Recommendation 8: That entry-level services should be available to all older Australians, including those receiving HCPs and those living in residential aged care.
Recommendation 9: That individualised funding packages should be available to purchase personal care, clinical care and allied health services.
Recommendation 10: That all older Australians have access to a case manager who can provide independent advice, coordination, advocacy and support to navigate the aged care system.
Recommendation 11: That the Australian Government establish a dedicated agency for aged care case managers to ensure independence.

4.7 Increasing Sustainability

Affordability for clients

CPSA is concerned that fees are not being considered as part of the development of the integrated care at home program, given the significance of affordability in shaping client behaviour. Affordability is absolutely central as older people are very reluctant to take up services they cannot afford regardless of how much they need those services.

CPSA is particularly concerned that there is a disconnect between what the Australian Government considers to be 'affordable' in terms of minimum client contributions and what clients can actually afford to spend on care and support services. The 'basic daily fee' for a HCP client is $10.10 (ie $141.40 per fortnight). A full rate single pensioner receives $888.30 per fortnight and a couple on a full rate combined pension receives $1,339.20 per fortnight. Aged care is typically required at a point in people's lives where their retirement savings are depleted or exhausted, so that their capacity-to-pay the 'basic daily fee' is limited. For a pensioner, the cost of a HCP itself constitutes a major barrier to accessing aged care services, as this cost must be fully absorbed out of a fixed low income.

Full rate Age Pensioners experience significant financial hardship, with many classified as living in poverty[3]. It is both unrealistic and unfair to expect an Age Pensioner to be able to manage the costs of an HCP. The rate of Age Pension is intended to cover the basic cost of living and the majority of pensioners spend all of their money on living expenses such as food, rent (or rates and home repairs for home owners), utilities, transport and health care. Age Pensioners who find themselves in need of care must either try to curb their spending on these basic living expenses, make do without support, or consider moving into residential care, where affordability issues persist.

Recommendation 12: That the Department of Health review the affordability of the basic daily fee of $10.10 payable by Home Care Package recipients for full-rate Age Pensioners.

Fees charged by home care providers

CPSA is concerned that home care providers are charging excessive fees for administration, case coordination and support (administration fees). Obviously, it is reasonable to expect there to be some costs involved in administering and coordinating an HCP, however the sorts of fees that have been referred to CPSA constitute blatant rorting by providers. For example, CPSA was contacted by a client who was charged 47% of their Level 2 HCP in administration fees, leaving just 53% of the package funding to cover the delivery of care and services. The itemised breakdown included over $3,000 for 'ongoing advice', for which they reportedly received two meetings, each a couple of hours long. The breakdown also included $3,000 in 'service support', with no explanation as to what this actually entailed. This client was unable to access the care and support they needed to continue living at home and had to move into residential aged care as a result.

CPSA is very concerned that some home care providers are seeking to maximise their own revenue by charging excessive administration fees, in exchange for which clients receive minimal or no services from the provider. This is a huge concern as it takes package funding away from the delivery of care and services, which in turn undermines the very sustainability of the system. Accordingly, CPSA urges the Australian Government to regulate home care fees to ensure that providers are not overcharging for administration, coordination and support activities as a strategy of revenue maximisation. This could be achieved by nominating a maximum percentage of HCP funds to be spent on administration, coordination and support activities based on an independent assessment of the overheads costs involved in the delivery of HCPs.

The introduction of pricing regulation in home care is likely to take some time, however there is a pressing need to increase transparency around HCP fees as a matter of urgency. All home care providers should be required to publish their maximum administration, coordination and support fees via MyAgedCare. This is a critical step in supporting clients to make informed choices, which they are currently unable to do as the information is not available.

Recommendation 13: That the Australian Government should regulate home care fees to ensure that providers are not overcharging.
Recommendation 14: That all home care providers should be required to publish their maximum administration fees via MyAgedCare.

References 

[1] CPSA Members’ Aged Care Survey (2014): in response to the question ‘If you needed some kind of aged care, where would you prefer to receive care?’ 95% of respondents answered ‘At home’ and 5% of respondents answered ‘In a nursing home’

[2] The discussion paper indicates that the maximum subsidy for a HCP Level 4 is $48,906 p/a while the average annual subsidy for a person in residential aged care is $63,400

[3] OCED (2015) 'Pensions at a Glance 2015' Available: http://www.oecd.org/publications/oecd-pensions-at-a-glance-19991363.html