Submission to ‘Increasing Choice in Home Care – Stage 1’ Discussion Paper

CPSA welcomes the opportunity to comment on the proposed changes to the ‘Aged Care Principles and Determinations’ as part of the ‘Increasing Choice in Home Care – Stage 1’ consultation process. CPSA has a keen interest in the delivery of home care services and has been involved in ongoing consultations regarding the introduction of consumer directed care. While CPSA strongly supports the goal to increase the choice and control of aged care recipients, there are concerns about how this plays out in reality, given the economic pressures cited by aged care providers that they claim require them to focus on minimising costs. It is thus critical that the voices of aged care recipients are both heard and valued by the Government.

The discussion paper covered a range of legislative amendments focused on demand management of Home Care Packages. CPSA notes that extensive demand management is only necessary where supply cannot sufficiently meet demand. While there is clearly a need for demand management of Home Care Packages, CPSA is of the view that these measures will do little to improve the experiences of recipients unless they are also accompanied by an increase in supply. Home Care Package providers are keen to expand their services in order to meet growing demand – in the 2015 Aged Care Approvals round, the Department of Health received around 20 applications for each available package[1] – and care recipients are keen to take up services. The missing link is a commitment from the Government to increase the number of funded Home Care Packages, thus addressing the supply side issues.

CPSA notes that the discussion paper provided was distinctly lacking in detail, particularly around the practicalities of the proposed national prioritisation process and changes to the Quality Agency Principles 2014. This has made it somewhat difficult to ensure that feedback is both appropriate and specific. CPSA is keen to provide further feedback regarding the proposed national prioritisation and changes to the Quality Agency Principles 2014, assuming that these will be made available. These are both matters of great interest to our members and constituents.

The remainder of this submission addresses the issues of relevance to CPSA in the order they were raised in the discussion paper.

National prioritisation process

CPSA is of the view that Home Care Packages should be available on the basis of eligibility, that is, if a person is assessed as requiring a Home Care Package to meet their needs then they should receive that package immediately. CPSA reiterates the position that demand management principles, such as the proposed national prioritisation process, are not necessary where there is sufficient supply.

With regard to the discussion paper, CPSA seeks further information regarding the determination of care recipient’s relative needs as it is unclear from the discussion paper how this will work in practice. The January Increasing Choice in Home Care – Stage 1 paper[1] specified availability and sustainability of other supports, barriers to access and prevention of institutionalisation or deterioration as the broad themes for determining priority of access to Home Care Packages. It goes on to specify the following factors, which were most commonly suggested as the basis for determining priority:

• Absence of carer or other informal supports
• Unsustainable carer arrangements
• Lack of available/accessible alternative supports (including due to demographic isolation)
• Risk of vulnerability or membership in special needs groups (particularly those with multiple vulnerabilities)
• Risk to safety
• Risk of admission to residential care
•  Recent hospitalisation or risk of admission
•  Risk of rapid deterioration of health
• Financial hardship or low means
• Social isolation.

CPSA views these as important factors in determining a care recipient’s level of priority. However, CPSA is concerned about the availability of an unpaid carer or other informal support being considered in the prioritisation process. Carers are individual people with needs and rights of their own that must be respected and supported through the aged care system. To allocate a lower level of priority due to the presence of a carer is to penalise that carer for the unpaid/informal work they already do, which is patently unfair. Incorporating carers into the prioritisation process is likely to intensify the demands placed on carers. This increases the risk of burn out, which in turn diminishes the health and wellbeing of carers and their capacity to continue providing care.

Recommendation 1:

That the prioritisation process does not use the presence of an unpaid carer as a reason for allocating a lower priority to a recipient.

The Approval of Care Recipient Principles 2014 (Part 2, section 7) specifies that in order to receive a Home Care Package, a person must be assessed as having needs that can only be met by a coordinated package of care services. Thus CPSA is of the view that being allocated a Home Care Package of any level in itself constitutes a significant priority, as there is a clear risk of institutionalisation should this care not be delivered. Accordingly, CPSA calls for the Australian Government to commit to funding significantly more Home Care Packages, particularly level 3 and level 4 packages. Home care is the preferred form of aged care for recipients[2], it is cheaper to deliver[3] and there are substantially fewer complaints in home care than in residential care[4]. CPSA recognises that significantly more Level 3 and Level 4 packages were funded in the latest round of allocations than in previous rounds and encourages the Government to keep this momentum up as the sector transitions to consumer directed care.

Recommendation 2:

That the Government increases the growth rate of funding for Home Care Packages.

Application of Item 5

CPSA supports recipients being able to take up a lower level care package until one at the appropriate level becomes available, as this goes some way in mitigating the risk of institutionalisation and alleviates pressure on the carer. Accordingly, CPSA supports the application of Item 5, as this ensures the equitable allocation of Home Care Packages in situations where a recipient may have already taken up a lower level care package. CPSA hopes the application of Item 5 will have the flow on effect of improving the accuracy of data collected by the Department on wait times, which can in turn be used to inform the development and review of the prioritisation process.

Cessation of prioritisation determinations

CPSA understands the importance of balancing the care needs of individuals with broader/aggregate demand for home care services when considering how long an individual should be given to activate a Home Care Package once it has been allocated to them. It has been proposed that a period of 56 days, with the option for an additional 28 day extension, is an appropriate time frame for recipients to commence services with an approved provider once a Home Care Package becomes available. While a total of 84 days may seem like a reasonable timeframe, there are many circumstances in which this period would need to be extended, or where additional support may be required. In particular, it is critical that provisions are made for further extension beyond 84 days in extenuating circumstances, for example hospitalisation, the death of a loved one or time spent in residential respite care. Circumstances such as these clearly limit the capacity for a recipient to arrange home care.

Recommendation 3:

That any days spent in hospital or residential respite care should be exempt from the total 84 day timeframe for taking up a Home Care Package.

Recommendation 4:

That if a spouse or other significant person passes away, care recipients should be eligible for an additional 28 day extension, on top of the 84 day timeframe.

The operation of consumer directed care requires recipients to make informed consumer decisions regarding their aged care. ‘Shopping around’ for the most appropriate home care provider is a time consuming process that requires a certain level of familiarity with the care sector. Finding a home care provider can be an intimidating task and it is important that recipients are able to access independent support, free of charge, in order to help them to do so. Information gaps or insufficient knowledge to navigate the aged care system constitute significant barriers to a recipient’s capacity to take up services within the proposed 84 day maximum timeframe following allocation of a Home Care Package.

Recommendation 5:

That funding is allocated to independent consumer advocacy services to support recipients in finding and taking up a Home Care Package within the proposed timeframe.

The question of whether a recipient’s Home Care Package should automatically cease when they permanently enter residential aged care is interesting. In the current environment, this seems like a reasonable suggestion. However, CPSA is concerned about how such a principle would play out, if residential care took a more rehabilitative/restorative approach. Currently, the Aged Care Funding Instrument provides a perverse incentive for providers of residential aged care, in that a higher Government subsidy is associated with higher care needs. Thus, there is a financial incentive to ensure the care needs of recipients do not decrease. CPSA is of the view that this must be resolved, so that residential aged care providers are incentivised to provide restorative care. It is likely such a change would see an increase in the number of care recipients moving from residential care back to home care. Accordingly, CPSA urges the Department to consider what permanent entry into residential care really means, particularly in the medium to long term. It may be more appropriate for Home Care Packages to be rested upon entry into residential care, with the possibility of resurrection should they return home.

Recommendation 6:

That the Department of Health considers the medium to long term implications of ceasing Home Care Packages upon permanent entry into residential care.

Approval of Care Recipient Principles 2014

CPSA supports the proposed amendments to the Approval of Care Recipient Principles 2014, that will mean consumers are allocated a specific level of Home Care Package, rather than a broadbanded package level (levels 1 to 2 for low care needs, level 3 to 4 for high care needs). This change will facilitate the efficient allocation of Home Care Packages according to the care needs of recipients. However, as specified on page 5, CPSA would like to see more detail regarding the prioritisation of recipients according to care needs. Further, it is critical that this measure is supported by an increase in the total number of Home Care Packages available, particularly at Levels 3 and 4, as measures designed to manage demand are of little value when supply is chronically lacking.

To ensure that recipients are able to make informed decisions about their care when choosing a service provider, CPSA recommends that information about the level of care included in each package is listed on the MyAgedCare website as well as in any subsequent print collateral. This information should cover the minimum level of service a recipient can expect to receive for each Home Care Package level, so that recipients are able to determine value-for-money when choosing a provider.

Recommendation 7:

That information about the number of hours and types of services generally included in each Home Care Package level be published on the MyAgedCare website as well as in any subsequent print collateral.

Approved Provider Principles 2014

CPSA has serious concerns regarding the implications of the proposed changes to the Approved Provider Principles 2014, which will reduce the prerequisites an aged care provider must fulfil before they are eligible to apply for accreditation as a Commonwealth approved provider. CPSA recognises that the changes are intended to shift the focus away from key personnel, who may change over time and on to the organisational structures facilitating the delivery of care. However, in the process of ‘streamlining’ the application process for aged care providers, the clinical care needs of recipients have taken a back seat. Given that the aged care sector exists to provide aged care services to older people, it seems counterintuitive that providers are not required to show their clinical capacity to provide this care at the point of accreditation. The provision of aged care requires a high level of clinical oversight, which must be delivered and supervised by an appropriately trained professional, such as a Registered Nurse or Nurse Practitioner. CPSA finds it perplexing that the provider’s capacity to meet the clinical needs of recipients is not the first and foremost consideration for the Government when determining approved provider status.

Recommendation 8:

That information about the capacity of an applicant to meet the clinical care needs of recipients be considered as a matter of top priority when an aged care provider applies for Commonwealth accreditation.

Quality Agency Principles 2014

There is very little detail regarding the nature and implications of changes to the Quality Agency Principles 2014, making it difficult to provide appropriate feedback. This is concerning given that the proposal would significantly reduce the regulations designed to ensure recipients receive quality care from Commonwealth approved providers. Rather than performing a full Quality Review with site visit and inspection every three years, the Quality Agency would be able to make a decision regarding the need for a Quality Review based on the level of risk identified through the provider’s self-assessment. CPSA notes that comprehensive quality reviews for all providers of aged care services – regardless of their previous experience or record of providing care – are critical for ensuring the safety and care of recipients.

CPSA is vehemently opposed to any measure that reduces the regulatory requirements faced by Commonwealth approved aged care providers, where those regulations are in place to ensure recipients receive high quality care. For CPSA, a robust quality assurance system constitutes the fence at the top of the cliff, which mitigates the need for an ambulance at the bottom of the cliff.

The accreditation of approved providers and each approved facility and/or service requires rigorous oversight and must be administered independently by an objective third party. This third party must able to ensure approved providers are delivering the care they are funded to deliver, in accordance with international best practice is quality evaluation and accreditation. The use of self-assessments introduces inherent conflicts of interest as a fundamental objective of providers is to continue operating, which could be threatened should a provider be fully transparent regarding the quality standards.

Recommendation 9:

That due to the inherent conflict of interest self-assessments by aged care providers be prohibited.

Transparency and disclosure of exit fees

CPSA is opposed to providers of home care services charging exit fees as this increases the cost to recipients of changing providers. Recipients are much less likely to change providers in the case of poor care if there are exit fees upwards of $500 associated with doing so, which in turn undermines the operation of consumer-directed care by constraining consumer choice. As exit fees are to be taken out of any unspent home care balance, this change will disproportionately affect those recipients who have elected to save a portion of their home care fees for additional support in case of an emergency.

The Home Care Agreement exit fees in the hundreds of dollars listed in the discussion paper are exorbitant. There is a shift towards casualisation among Home Care Workers, with a growing proportion working an irregular, rather than set roster[5]. The flexibility of the Home Care workforce reduces the cost to the provider of recipient turn over, as they are able to simply cut or reorganise staff shifts in response. Accordingly, CPSA finds the example exit fees listed in the discussion paper to be seriously over-inflated compared to the actual costs incurred by a provider when a recipient ceases their Home Care Agreement. Providers must be required to show real evidence of incurred costs commensurate to the proposed exit fees.

Given that aged care is a service whereby those entering the aged care system invariably do so out of necessity rather than choice, CPSA questions the appropriateness of charging exit fees. Recipients of aged care cannot control the level of care they require, or when their needs may increase to a point where they may need residential care. As a recipient does not control the circumstances of their care, they cannot take steps to actively mitigate the risk of breaking their current home care service agreement/contract as a result of changing care needs. Thus, it is unjustifiable to expect recipients to bear the cost of a risk, over which they have no control, in the form of exit fees. CPSA is of the view that this is one of the business risks associated with the provision of aged care services and thus that the cost associated with recipients moving between providers should be absorbed by providers.

In addition, CPSA opposes absolutely the retrospective introduction of exit fees into Home Care Package contracts. CPSA views the imposition of exit fees as totally unreasonable and unacceptable. Further, the retrospective introduction of exit fees is likely to be breach with the terms and conditions of contracts already in place.

Recommendation 10:

That home care providers must be prohibited from charging any exit fees, including those introduced retrospectively to home care agreements.

Under Australian Consumer Law a person has the right to cancel a service free of charge if that service was; provided with an unacceptable level of care and skill, unfit for the purpose you asked for, or not delivered within a reasonable time when there is no agreed end date. CPSA thus seeks further clarification as to how the rights of recipients, as embodied under Australian Consumer Law, would be guaranteed in light of the proposed amendments to the User Rights Principles. In particular, CPSA seeks clarification of the circumstances in which a recipient would be able to cease their home care agreement and avoid exit fees (e.g. when the agreement expires, when the recipient passes away). In particular, CPSA wants to know how cases where a recipient believes the home care provider to be in breach of their obligations under the Australian Consumer Law would be managed as such an occurrence would void the applicability of an exit fee.

Recommendation 11:

That information regarding home care recipients’ rights under Australian Consumer Law be published on MyAgedCare and communicated to the public.

Reconciliation and payment of unspent home care amounts

If the goal is for care to be consumer directed, then recipients must be able to access unspent home care amounts as soon as possible after moving to a new home care provider. Accordingly, CPSA is of the view that providers should transfer any unspent funds to the new provider within 56 days, rather than 70. A 56 day period is more appropriate for recipients as it allows for quicker access to unspent home care amounts after moving to a new provider, while also allowing the previous provider a reasonable timeframe to complete the necessary administrative work. The 56 day period should commence once the outgoing provider has been notified of the recipient’s intention to change providers, or on the cessation day, whichever comes first. The inclusion of this provision will encourage recipients to alert their outgoing provider as early as possible, so that they are able to access unspent care amounts through their new provider faster.

Recommendation 12:

That outgoing providers be required to transfer the unspent home care amount within 56 days.

Recommendation 13:

That the 56 day period commence once the provider has been notified of a recipient’s intention to change providers, or on the cessation day, whichever comes first.
________________________________________

1. Department of Health (2016) ‘Increasing Choice in Home Care – Stage 1: Discussion Paper and Feedback’ p.8 [Accessed 1 June 2016] available: https://www.dss.gov.au/sites/default/files/documents/02_2016/summary_report_of_stakeholder_feedback_on_discussion_paper.pdf
2. 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’.
3. Department of Health (2016) ‘Aged care Subsidies and Supplements New Rates of Payment from 20 March 2016’ [accessed 6 June 2016] Available: https://www.dss.gov.au/sites/default/files/documents/03_2016/attachment_c_-_aged_care_subsidies_and_supplements_aacei.pdf
4. Report on the operation of the Aged Care Act 1997 for 2014-2015: of the 3725 complaints received in 2014-15 88.1% (N=3281) related to residential aged care services, 8.5% (N=316) related to home care services.
5. King et al (2013) ‘The Aged Care Workforce, 2012 – Final Report’ p.124-5 [accessed 28 January 2016] available: https://www.dss.gov.au/ageing-and-aged-care-publications-and-articles-ageing-and-aged-care-reports/2012-national-aged-care-workforce-census-and-survey-the-aged-care-workforce-2012-final-report