KPMG
Review of Home Modification
and Home Maintenance service
types under the Commonwealth
HACC Program
Final report
16 May 2014
Final report
HACC home modification and home maintenance review
May 2014
Disclaimer
Inherent Limitations
This report has been prepared as outlined in the Scope Section. The services provided in
connection with this engagement comprise an advisory engagement which is not subject to
Australian Auditing Standards or Australian Standards on Review or Assurance Engagements, and
consequently no opinions or conclusions intended to convey assurance have been expressed.
No warranty of completeness, accuracy or reliability is given in relation to the statements and
representations made by, and the information and documentation provided by the Department of
Social Services (previously Department of Health and Ageing) and other stakeholders consulted as
part of the process.
KPMG have indicated within this report the sources of the information provided. We have not
sought to independently verify those sources unless otherwise noted within the report.
KPMG is under no obligation in any circumstance to update this report, in either oral or written
form, for events occurring after the report has been issued in final form.
The findings in this report have been formed on the above basis.
Third Party Reliance
This report has been prepared at the request of the Commonwealth of Australia as represented
by the Department of Social Services (previously Department of Health and Ageing), in
accordance with the terms of KPMG’s contract dated 19th July 2013. Other than our responsibility
to the Department, neither KPMG nor any member or employee of KPMG undertakes
responsibility arising in any way from reliance placed by a third party on this report. Any reliance
placed is that party’s sole responsibility.
i
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
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Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Executive summary
The Department of Social Services (the Department) engaged KPMG to review the
Commonwealth HACC home modification and home maintenance service types.

Home modifications are structural changes to a client’s home so that they can continue
to live and move safely about the house. Modifications can include: grab and shower rails,
appropriate tap sets, hand rails, ramps and other mobility aids, installation of emergency
alarms and other safety aids, or other minor renovations.

Home maintenance is assistance is to keep a client’s home in a safe and habitable
condition. This involves the repair and maintenance of a client’s home or yard. Repairs are
generally minor repairs such as changing light bulbs and replacing tap washers. More
major repairs can include carpentry, painting and roof repairs. Garden maintenance
includes lawn mowing and the removal of rubbish.
This review, as well as concurrent reviews of three other HACC service groups, was
undertaken in the context of the Living Longer Living Better reforms for the aged care sector,
announced in April 2012.
The review of home modification and home maintenance service types is part of the
transition of the Commonwealth HACC Program into the Commonwealth Home Support
Programme. This review aims to support the development of a more consistent and effective
approach to providing these services within the Commonwealth Home Support Programme.
1.1 Review approach
A number of activities were undertaken for the review, including:

Literature review - examination of existing literature, including scientific and grey
literature to identify evidence and good practice for home modifications and home
maintenance.

Jurisdictional mapping and data analysis - mapping of current home modifications and
maintenance service delivery types and funding models used across Australia, including
both HACC and non-HACC models, to understand the current service delivery and funding
models, any gaps and overlaps, and to detail the attributes of each model across
jurisdictions. The mapping involved a desktop review of information on programs in each
state and territory, targeted jurisdictional interviews and analysis of the HACC minimum
data set.

Consultation - comprised of a website questionnaire, jurisdictional workshops and
targeted discussions with stakeholders to gain insights from existing HACC service
providers, consumers, consumer representatives, peak bodies and other relevant
ii
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
stakeholders in relation to service delivery and funding models for home modification and
home maintenance within each jurisdiction.
Background and context
The HACC Program was established in 1985 as a joint Commonwealth, State and Territory
Governments initiative. The former HACC Program provided services for older people who
were frail and their carers, and younger people with a disability and their carers. The
Commonwealth Government funded approximately 60 per cent of the program funding, and
had a broad strategic role, with state and territories funding the remainder of the program,
and undertaking day-to-day responsibility of the HACC Program. Home modification and
home maintenance were established as service types under the HACC Program in 1986.
In July 2012, the Commonwealth Government, as part of the National Health Reforms, took
full program management and funding responsibility for basic maintenance, support and care
services in the HACC Program, including home modification and home maintenance service
types. This applied to services for people aged 65 and over, and Aboriginal and Torres Strait
Islander people aged 50 and over. People with a disability are not included in the new
Commonwealth HACC Program.
It should be noted that Western Australia and Victoria were not part of these changes, and
continue to provide HACC services under the pre-existing arrangements.
The Commonwealth Government commenced funding and managing the Commonwealth
HACC Program from 1 July 2012. This gives the Commonwealth Government funding and
policy responsibility for all national aged care services, from basic home support to home care
packages through to residential aged care, with the exception of Victoria and Western
Australia. This aims to better support older people to move seamlessly between aged care
services, as their needs change, and support better integration between services. The
Commonwealth HACC Program is currently governed by the Commonwealth HACC Program
Guidelines 2012-2015.
Literature review findings
The literature review explored several questions. The key findings are summarised below,
organised around the research questions.
Why and how should home modifications and maintenance services
be provided?
Does the literature support home modifications delivery?
Home modifications can have positive outcomes for individuals and may reduce the need for
downstream care. The likelihood of positive outcomes appears to increase where
modifications are not provided in isolation, but instead form part of a holistic, re-ablement
focussed approach.
iii
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
The evidence shows that the key benefits associated with home modifications are:

Accessibility: there is substantial evidence that targeted home modification enhances
accessibility within the home, as well as improved access to the broader community and
participation in outdoor activities.

Independence: Home modification can have a positive impact on independence and
engaging in activities of daily living, for individuals, and for the independence and
wellbeing of carers. Home modifications have been linked to a reduced rate of functional
decline in older people and can slow the impact of age related disability.

Safety: There is evidence for improved safety secondary to the installation of home
modifications, particularly as it relates to risk for falls.

Health and wellbeing: Some individuals experienced a positive impact on their physical
and mental health.
There is less evidence of home modifications supporting holistic re-ablement.1
In terms of ‘downstream’ care and support, home modifications may reduce or even
eliminate the need for home care and reduce the likelihood of entering residential aged care
by facilitating self-care practices. Combining a period of re-ablement intervention with home
modifications has been shown to reduce the subsequent use of care services.
Does the literature support home maintenance delivery?
There is very limited evidence available through literature to indicate that home maintenance
can have positive functional outcomes for individuals or reduce the need for downstream
care. However, this does not necessarily mean maintenance does not have positive outcomes
or reduce the need for downstream care, rather it indicates that insufficient research has
been undertaken in this area.
1
Re-ablement, also referred to as restorative or wellness approaches, focuses on promoting self-care and
autonomy, healthy lifestyles, and successful ageing. It can be understood as both a philosophy and a form of
service orientation contrasted to traditional ‘medical’ or ‘dependency’ models of home care. The principle is
to help people ‘to do’ what they can, rather than ‘doing to or for’ them. These approaches are typified by
comprehensive assessment, time-limited rehabilitation programs with occupational therapy supports
(including home modifications where needed) and a holistic outcomes focus.
iv
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Literature examining the impact and outcomes of home maintenance services is limited, and
the available evidence is not strong. That said, the available literature suggests the following
potential benefits:

Accessibility: there is evidence to suggest links between home maintenance and
accessibility, particularly in relation to garden maintenance.

Independence: there is no conclusive evidence regarding examination of the impact of
the provision of home maintenance services on independence over a period of time.

Safety: there is no specific evidence which examines the impact of home maintenance in
and of itself on an individual’s safety that separates it from other interventions.

Health and wellbeing: services which maintain garden and outdoor spaces can reduce
anxiety experienced by individuals, increase dignity and pride, and reduce the burden
placed on an older individual’s carer.
There was no evidence available as to whether home maintenance supported holistic reablement. There was one overseas study that found investment in home maintenance led to
avoided costs elsewhere, including residential aged care services, hospital services and home
modifications).
What does the literature say is ‘good practice’ for home modifications and home
maintenance?
The literature indicates the following good practice elements:

Person-centred: the service provider places the consumer at the centre of planning and
decision making for home modification or maintenance services.

Outcomes focused: service provision is focused on and supports improvement of
outcomes for the consumer and/or their carer, and uses a strengths-based approach.

Consistent: there is a consistent approach to assessment and prioritisation, and decision
making is transparent, equitable and fair.

Culturally appropriate: considers the needs of Aboriginal and Torres Strait Islander people
and culturally and linguistically diverse people.

Access to information: consumers have relevant information to make informed choices.

Timely: service provision is timely and avoids delay.

Partnership/collaboration: strong relationships between service providers.

Reassessment and review: there is capacity for reassessment and review of services
provided to ensure outcomes are achieved and to re-assess consumer need.
Consultation findings: Strengths, issues and challenges with the
current service system
Feedback from stakeholders suggests that the flexibility for individual services to adapt
provision to their local environment is a key strength of the system. Feedback specifically
v
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
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Final report
HACC home modification and home maintenance review
May 2014
from consumers who access home modifications and home maintenance services is generally
very positive. In particular, the well-developed home modifications classification systems used
in a number of jurisdictions was seen as a strength of the current system.
Key concerns included the lack of consistency of service and operating models used across
and within states and territories, inconsistent definitions and terminology, disparities and
inequities in service access for consumers, and a general disconnect with the broader health
and community services system which limits the capacity to provide holistic assessment and
service provision. Overall, these findings suggest a low level of alignment at the system level
to the identified good practice elements for home modifications and home maintenance
services.
An overview of how the processes associated with home modifications and home
maintenance and the key issues and challenges are outlined in the tables below.
Table 1: Approaches to access and assessment
What happens now:

Eligibility criteria for access to services are generally consistent across jurisdictions. Access
pathways are broadly similar.

In most jurisdictions, consumers directly approach service providers to seek modification
and maintenance services.

For home modifications, an occupational therapist assessment is required. For
maintenance services, assessment is generally conducted by service providers, however
this is not consistent across states and territories.

Assessment is primarily undertaken with a formalised tool, often developed by the service
provider.
Key issues and challenges:

Access to services is not consistent across, or within, all states and territories (i.e. not
everyone can access a service); there is no consistent approach to assessment processes,
except in Western Australia and Victoria; and assessments are largely completed using
non-standardised tools and templates.
vi
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Table 2: Prioritisation of service delivery
What happens now:

Organisations deploy a number of strategies to manage demand for services (where
needed), the most common being waiting lists and documented criteria-based
prioritisation assessment.
Key issues and challenges:

There is no consistent, transparent approach to prioritisation of service delivery.
Table 3: Service delivery
What happens now:

The types of services available are inconsistent and dependent on where a consumer
resides (both within and between states and territories).

Service provision is not aligned with consumer-directed care principles.
Key issues and challenges:

There is inequity in service delivery, and a low level of alignment to contemporary personcentred practice.
Table 4: Consumer co-payments and fees
What happens now:

Consumer co-payments supplement program funding. Co-payment policies are
inconsistent across and within jurisdictions. The two most commonly specified methods
of co-payment for modification are recovery of the cost of materials, or a proportion of
the overall cost. Co-payment for home maintenance was sometimes levied per hour of
service, based on a standard schedule of fees; however, this is inconsistent between
states and territories and sometimes inconsistent between providers.

There are a number of approaches to means testing and waiving/reducing fees.

All providers cap the level of co-payment, but there is no national consistency in the
calculation processes.
Key issues and challenges:

There is a lack of consistency between service providers (both within and across states
and territories) with regards to the provision of payment plans and, if provided, as to the
length of the payment plans.
vii
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Table 5: Follow-up processes
What happens now:

There is little to no formalised follow-up for modification or maintenance services.
Key issues and challenges:

Follow up does not occur comprehensively.
Table 6: Program funding
What happens now:

Organisations are funded on a triennial basis using historic block funding formulas. In the
past, there have been irregular needs-based ‘top-up’ funding rounds.
Key issues and challenges:

Travel and the increased cost of providing services in rural and remote areas are not
reflected in funding.
Table 7: Workforce and training
What happens now:

Lack of access to suitably experienced occupational therapists for modifications, and to
suitably qualified builders for modifications and maintenance can contribute to
assessment and service delays, or to lack of service provision at all.
Key issues and challenges:

There are challenges in accessing suitable occupational therapists and builders,
particularly in rural and remote areas.

Occupational therapists may not have the required experience.

There is a general lack of training and professional development opportunities for builders
and occupational therapists in relation to home modification services.
A primary area of concern is the lack of consistency in the service models used across
Australia. The service models in each state and territory, and sometimes within a
state/territory, are different, resulting in considerable disparity in how services are delivered.
This inconsistency has evolved due to the historical funding and management of the program,
through the funding split between state/territory and Commonwealth, and individual
program management occurring at a state/territory level.
viii
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
What are the future opportunities to strengthen and re-orient these
services?
Based on the review findings, a number of opportunities to strengthen and re-orient the
system were identified. These can be grouped into short term or immediate opportunities to
consider for implementation at the commencement of the Commonwealth Home Support
Programme on 1 July 2015, and long term opportunities for consideration post 1 July 2015.
The short-term opportunities focus on ensuring consistency in service delivery approach
across jurisdictions. The long term solutions focus on further developing the service model
and enhancing the capability of the system to deliver.
Opportunities to consider for implementation of the Commonwealth Home Support
Programme are:

introducing regionally based common access points and consistent assessment processes,
with capacity for a specialised occupational therapy assessment for home modifications

development of a consistent, well-defined service delivery model for home maintenance
which better targets services to consumers who have the least ability to maintain their
homes, where this is affecting their safety and/or ability to remain in their home

development of a consistent home modification service model which primarily funds
simple home modifications, and some complex modifications

grouping the service types of goods and equipment with home modifications, with a view
towards enabling more flexible use of funds across the services

implementing consistent review processes to assess the impact of modifications on
consumer independence and the need for further assistance

implementing a consistent fees policy.
Additional long term opportunities have been outlined that can be considered once the initial
reorientation of Commonwealth HACC services into the Commonwealth Home Support
Programme has occurred. These include:

an alternative service delivery model for home maintenance which would move away
from the traditional Commonwealth HACC service provider model, using new approaches,
such as a voucher system for the open market or an ‘approved private provider’ model

an alternative service model for home modifications to (a) move away from the
traditional service model towards an information and ‘approved private provider’ model,
(b) allow more flexible use of funds to support independent living (i.e. using funds to
assist consumers to relocate and downsize, ), or (c) support and advocate for universal
design principles in all new dwellings which would, over time, reduce or remove the need
for structural modifications

addressing workforce challenges through the development and delivery of systems to
provide support, supervision and mentoring of less experienced occupational therapists,
and promoting service models that incorporate joint assessment visits by the occupational
ix
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
therapist and builder as well as joint professional development events for occupational
therapists and builders

improving data collection and reporting through increasing the scope of information
collected in the HACC MDS about the range of services delivered under the banner of
home modifications and home maintenance to facilitate a better understanding of
outcomes for consumers.
x
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Table of contents
1
Executive summary
ii
2
Introduction
3
2.1
Project context
4
2.2
Project objectives
5
2.3
Project approach
5
2.4
Project activities
6
2.5
Report structure
7
3
4
5
6
Literature review findings
8
3.1
Key areas examined
8
3.2
Home modification
8
3.3
Home maintenance
12
3.4
Elements of good practice
14
The current service system
15
4.1
Consumer profile and services accessed
15
4.2
Overview of service delivery across home modifications and home
maintenance
16
4.3
Service delivery - Home modifications
16
4.4
Service delivery - Home maintenance
24
Innovative service delivery models
31
5.1
What is innovative practice and good practice?
31
5.2
Alternative service delivery models
32
Future opportunities
38
6.1
Opportunity area one - access, assessment and prioritisation
39
6.2
Opportunity area two - service provision for home maintenance
40
6.3
Opportunity area three - service provision for home modification
43
6.4
Opportunity area four - consumer co-payments and fees
47
6.5
Opportunity area five - follow up processes
48
6.6
Opportunity area six - workforce - home modifications
49
6.7
Opportunity area seven - data collection and reporting
50
6.8
Opportunity area eight - general
52
Appendix A : Review methodology
54
xi
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with
KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International
Cooperative ("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Glossary
Table 8: Glossary
Term and Definition
Assessment
The Commonwealth HACC Program Manual defines assessment as a fundamental method of
establishing the nature and extent of a consumer’s support needs and identifying services to
meet those needs. Assessment considers consumer eligibility and assessed need for assistance,
and should take into consideration the needs of the consumer’s carer where applicable. This
assessment can be undertaken by Access Points or Commonwealth HACC service providers.2
The assessment process can encompass a range of activities, including:3

screening for eligibility

determining needs and priorities

targeting resources

referral and coordination

monitoring and review

data collection.
If using an Access Point for the assessment process, such as the Aged Care Gateway Service, a
provider should refer a consumer for reassessment by the Access Point if they identify significant
increase in the care needs of the consumer. The use of the Aged Care Gateway Service, which is
to be implemented as part of the Living Better, Living Stronger Aged Care Reforms, as an Access
Point is explored as an opportunity in section 6.1.
Consumer directed care
Consumer Directed Care is both a philosophy and an orientation to service delivery where
consumers, including care recipients and their carers, can choose and control the services they
get, to the extent that they are capable and wish to do so. This offers more choice and control to
consumers than through traditional service delivery.4 5
Follow up
Refers to contact with the client, usually one off, after the modification has been completed or
maintenance service has been delivered. The intent of follow-up is to ensure quality of service
and that it met the person’s identified need.
2
Commonwealth of Australia 2012, Commonwealth HACC Program Manual, Department of Health, viewed 8
May 2014
3 Ibid.
4 Aged and Community Services Australia, Guiding principles for consumer directed care, ACSA 2010.
5
Tilly, J. & Rees, G. “Consumer Directed Care: A way to empower consumers?’ Alzheimer’s Australia 2007.
1
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Home maintenance
Assistance to keep a client’s home in a safe and habitable condition. This involves the repair and
maintenance of a client’s home or yard. Repairs are generally minor repairs such as changing
light bulbs and replacing tap washers. More major repairs can include carpentry, painting and
roof repairs. Garden maintenance includes lawn mowing and the removal of rubbish.
Home modifications
Provide structural changes to a client’s home so that they can continue to live and move safely
about the house. Modifications can include: grab and shower rails, appropriate tap sets, hand
rails, ramps and other mobility aids, installation of emergency alarms and other safety aids, or
other minor renovations. Home modifications must be conducted by a licensed tradesperson.
Prioritisation
Prioritisation refers to the process by which consumers identified to have need for HACC services
are queued to receive those services.
According to the Commonwealth HACC Program Manual, priority of access to Commonwealth
HACC services is determined by the degree to which the provision of services will support the
consumer’s ability to live independently at home. Prioritisation occurs after the consumer is
assessed at intake and assists providers in allocating resources where demand for services
exceeds the available supply.
There is no commonly agreed prioritisation guide for providers and the Commonwealth HACC
Program Manual currently recommends that service providers should prioritise consumers based
on their individual situation.
Reassessment
Reassessment refers to an assessment (as defined above) that occurs when a consumer’s needs
for Commonwealth HACC Services have changed significantly since their intake assessment.
Review
Per the Commonwealth HACC Manual, a review of a consumer’s care needs is undertaken on a
regular basis to ensure that services are appropriately matched to the consumer’s needs. These
reviews should be undertaken when there has been a change in care needs for a consumer or
their carer.6
Specialist assessment
This is an assessment undertaken by a person with skills to assess a consumer’s specific need for
HACC home modification services. This assessment is usually undertaken by an occupational
therapist assessment and may also be referred to as an “occupational therapist assessment”.
6
Commonwealth of Australia 2012, Commonwealth HACC Program Manual, Department of Health, viewed 8
May 2014
2
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
2 Introduction
The aged care system in Australia consists of organisations providing care and support services
ranging from community based services supporting those with relatively low care needs, through
to residential care facilities providing significant levels of support. The Commonwealth HACC
program assists older people with identified support needs to stay in their homes, thus
promoting independence, enabling them to remain in their familiar area and community, and
delaying the transition to higher cost care options. The program achieves this through the
provision of a range of service types, including:

domestic assistance

social support

nursing care

allied health care

personal care

centre-based day care

meals and other food services

respite care

care coordination and case management

provision of goods and equipment

formal linen services

transport

counselling/support

information and advocacy for care recipients, as well as for carers

home modifications

home maintenance.
Home modifications are structural changes to a client’s home so that they can continue to live
and move safely about the house. Modifications can include: grab and shower rails, appropriate
tap sets, hand rails, ramps and other mobility aids, installation of emergency alarms and other
safety aids, or other minor renovations.
Home maintenance refers to assistance to keep a client’s home in a safe and habitable condition.
This involves the repair and maintenance of a client’s home or yard. Repairs are generally minor
repairs such as changing light bulbs and replacing tap washers. More major repairs can include
carpentry, painting and roof repairs. Garden maintenance includes lawn mowing and the
removal of rubbish.
3
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
2.1 Project context
The Department of Social Services (the Department) engaged KPMG to review the
Commonwealth HACC home modification and home maintenance service types (noting that
HACC was previously managed by the Department of Health and Ageing). This review, as well as
concurrent reviews of three other HACC service groups, was undertaken in the context of the
Living Longer Living Better reforms for the aged care sector, announced in April 2012.
The outcomes of the Commonwealth HACC home modification and home maintenance service
types review will inform the development of the Commonwealth Home Support Programme.
This review provides information to assist with decision making in this area.
The Home and Community Care Program
The HACC Program was established in 1985 as a joint Commonwealth, State and Territory
Governments initiative. The HACC Program provided services for older people who were frail and
their carers, and younger people with a disability and their carers. The Commonwealth
Government funded approximately 60 per cent of the program funding, and had a broad
strategic role, with state and territories funding the remainder of the program, and undertaking
day-to-day responsibility of the HACC Program. Home modification and home maintenance were
established as service types under the HACC Program in 1986.
In July 2012, the Commonwealth Government, as part of the National Health Reforms, took full
program management and funding responsibility for basic maintenance, support and care
services in the HACC Program, including home modification and home maintenance service
types. This applied to services for people aged 65 and over, and Aboriginal and Torres Strait
Islander people aged 50 and over. It should be noted that Western Australia and Victoria were
not part of these changes, and continue to provide HACC services under the pre-existing
arrangements.7
The Commonwealth HACC Program
The Commonwealth Government commenced funding and managing the Commonwealth HACC
Program from 1 July 2012. This gives the Commonwealth Government funding and policy
responsibility for all national aged care services, from basic home support to home care packages
through to residential aged care, with the exception of Victoria and Western Australia. It aims to
support older people to be able to move seamlessly between aged care services, as their needs
change, and support better integration between services. The Commonwealth HACC Program is
currently governed by the Commonwealth HACC Program Guidelines 2012-2015.8
7
Department of Social Services, Request for Tender for Review of home modifications and home maintenance
services.
8 Commonwealth HACC Program Guidelines 2012-2015. Accessed February 2014.
4
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International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
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Final report
HACC home modification and home maintenance review
May 2014
Aged Care Reform Package
The Living Longer Living Better aged care reforms were announced in April 2012. These reforms
aim to change the way in which aged care services are provided to older Australians, in order to
provide a better, fairer and more nationally consistent aged care system. As part of the reforms,
the Commonwealth Home Support Programme will be introduced in July 2015. This program will
bring together a number of aged care programs that currently provide basic support, including
the Commonwealth HACC Program. In preparation, the Commonwealth Government is reviewing
a number of services within the Commonwealth HACC Program, including the home modification
and home maintenance services types.9
2.2 Project objectives
The review of home modification and home maintenance services types is part of the transition
of the Commonwealth HACC Program into the Commonwealth Home Support Programme. This
review aims to support development of a more consistent and effective approach to providing
these services within the Commonwealth Home Support Programme.
The project sought to meet the following objectives:

to develop an evidence base to better understand the performance and benefits derived
from home modification and home maintenance service types

to identify service delivery implications to inform the delivery of home modification and
home maintenance services under the Commonwealth Home Support Programme.
2.3 Project approach
The review examined a number of key program areas. These included a focus on:

current service system models and usage

evidence and good practice models

degree of integration with other systems

data and reporting

unit costs/fees

provider characteristics

consumers

workforce.
Additional information on the key areas for investigation and the methods used for each key
area, including analysis on the limitations of the review, are set out in Appendix A.
9
Australian Government Living Longer Living Better. Accessed February 2014.
5
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Final report
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May 2014
2.4 Project activities
To support the review, a number of key activities were undertaken, including:

Literature review - examination of existing literature, including scientific and grey literature
to identify evidence and good practice for home modifications and home maintenance.

Jurisdictional mapping and data analysis - mapping of current home modifications and
maintenance service delivery types and funding models used across Australia, including both
HACC and non-HACC models, to understand the current service delivery and funding models,
any gaps and overlaps, and to detail the attributes of each model across jurisdictions. The
mapping involved a desktop review of information on programs in each state and territory,
targeted jurisdictional interviews and analysis of the HACC minimum data set.

Consultation - comprised of a website questionnaire, jurisdictional workshops and targeted
discussions with stakeholders to gain insights from existing HACC service providers,
consumers, consumer representatives, peak bodies and other relevant stakeholders in
relation to service delivery and funding models for home modification and home
maintenance within each jurisdiction.

Reporting - preparation of this report, which provides a high level analysis of the findings of
this project, identification and key themes and issues, and development of potential service
delivery and funding model options for consideration.
An overview of these project stages and outputs for each stage are outlined in Figure 1.
Figure 1: Summary of project stages
Stage
Deliverable
1. Project initiation
Project Plan
2. Literature review
Literature Review Report
3. Jurisdictional mapping and data
analysis
Jurisdictional Mapping and Data
Analysis Report
4. Online questionnaire and
targeted stakeholder discussion
Consultation Report
5. Reporting
Final Report
(this document)
Source: KPMG
6
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Final report
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May 2014
2.5 Report structure
This report is structured as follows:
Section 1:
(this section) provides an introduction to this report, including the project context,
objectives, approach and structure of this report
Section 2:
sets out information on the optimal delivery of home modifications and home
maintenance, and identifies elements of good practice
Section 3:
provides an overview of the current state of home modifications and home
maintenance service delivery under the Commonwealth HACC Program, including
the strengths, issues and challenges as identified in the review
Section 4:
describes alternative approaches to service delivery, focusing on innovation and
good practice
Section 5:
outlines future opportunities for the delivery of the home modification and home
maintenance services under the Commonwealth HACC Program
Appendix A: outlines the methodological approach.
7
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Final report
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May 2014
3 Literature review findings
This section provides an overview of the literature review findings, focusing on the outcomes and
benefits of home maintenance and home modifications and the principles of good practice.
3.1 Key areas examined
The literature review looked at six areas to identify information and evidence on the outcomes
and benefits of home maintenance and home modifications services. Table 1 below summarises
the scope of information identified in relation to each of these areas.
Table 9: Overview of evidence10
Area examined
Scope of literature available:
Home modifications
Scope of literature available:
Home maintenance
Accessibility
High
Moderate
Independence
Moderate
Minimal
Safety
Moderate
Moderate
Health and wellbeing
Moderate
Minimal
Re-ablement
Minimal
None identified
Need for ongoing support
Minimal
Minimal
Source: KPMG
3.2 Home modification
There is reasonable evidence to suggest that home modification has a positive effect on an
individual’s independence and accessibility within the home, health and well being, safety and to
a lesser extent re-ablement and the need for ongoing support.
The literature and data analysis did not provide a uniform definition of either minor or major
modifications. Further, there was no consistent view as to whether aids and equipment
constituted minor home modifications or assistive technology.
10
A lack of evidence does not demonstrate that home modifications and home maintenance do not have positive
impacts, benefits and outcomes. Instead, it may simply indicate that there has not been sufficient research
undertaken to date, or that the research has not been conducted in a manner conducive to evaluate impacts,
outcomes and benefits.
8
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May 2014
Impacts, outcomes and benefits
The outcomes and benefits of home modification in Australia remains largely undocumented,
including for the current Commonwealth HACC home modification service types, in part due to
the limited rates of follow-up. The majority of research conducted overseas, particularly in the
United States (US) and the United Kingdom (UK),11 although there is emerging evidence from
Canada, Sweden and other jurisdictions.12 13 14 15 16 Variations in the definition of home
modification, including the difference between assistive technology, home adaptation and home
maintenance, make a consistent comparison between studies difficult.
The key impacts, outcomes and benefits identified through the literature and analysis associated
with home modifications in general are outlined below.
Accessibility
Accessibility relates to the degree to which an individual can freely interact and move about their
home environment.17 There is substantial evidence that targeted home modification enhances
accessibility within the home,18 19 as well as access to the broader community and participation
in outdoor activities.20 21
Independence
The concept of independence, specifically in the context of home modification, generally relates
to the capacity of an individual to undertake a wide range of tasks without assistance.22 23 Home
11
Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home Maintenance and Modification Services in Achieving
Health, Community Care and Housing Outcomes in Later Life’. AHURI Final Report No. 123. Australian Housing
and Urban Research Institute, Queensland Research Centre. 2008.
12 Ryburn, B. & Wells, Y. ‘Enabling independence: Restorative approaches to home care provision for frail older
adults’, Health and Social Care (2009), 17 (3), 225-234.
13 Stark, S. ‘Removing environmental barriers in the homes of older adults with disabilities improves occupational
performance’, Occupation, Participation and Health (2004), 24 (1), 32-40.
14 Fänge, A & Iwarsson, S. ‘Changes in accessibility and usability in housing: An exploration of the housing
adaptation process’, Occupational Therapy International (2005), 12 (1), 44-59.
15 Fänge, A & Iwarsson, S. ‘Changes in ADL dependence and aspects of usability following housing adaptation – a
longitudinal perspective’, American Journal of Occupational Therapy (2005), 12 (1), 44-59.
16 Hutchings, L. Olsen, R. & Heather, J. ‘Environmental evaluations and modifications to support aging at home
with a developmental disability’, Journal for the Elderly, 22 (4), 286-310, 2008.
17 Iwarsson, S., Isacsson, A., & Lanke Jan, ‘ADL dependence in the elderly population living in the community: the
influence of functional limitations and physical environmental demand’, Occupational Therapy International
(1998), No. 5(3), 173-193.
18 Molinuex, M., Rosenwax, L. and Harmsen, J., ‘A home without barriers’. Centre for Research into Disability and
Society, School of Occupational Therapy and Social Work, Perth, 2010, pp. 13-14.
19 Niva, B., & Skar, L., ‘A pilot study of the activity patterns of five elderly persons after a housing adaption’
Occupational Therapy International, No. 13(1), 2006, pp. 21-34.
20 Niva, B., & Skar, L., 'A pilot study of the activity of five elderly persons after a housing adaption' Occupational
Therapy International, No. 13(1), 2006, pp. 21-34.
21 Ibid.
22 Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home Maintenance and Modification Services in Achieving
Health, Community Care and Housing Outcomes in Later Life’. AHURI Final Report No. 123. Australian Housing
and Urban Research Institute, Queensland Research Centre. 2008.
9
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May 2014
modification can have a positive impact on independence and engaging in activities of daily
living, particularly in relation to self care activities such as washing, bathing, dressing and
toileting. Furthermore, improvements in independence of the care recipient can also benefit the
carer who would otherwise be more involved in assisting the individual to use showering
facilities.
Home modifications have been linked to a reduced rate of functional decline in older people and
can slow the impact of age related disability.24 This in turn is considered to reduce the risk of
admission to residential care, so older people can remain in their homes for longer.25
Safety
There is a growing body of evidence for improved safety secondary to the installation of home
modifications,26 particularly as it relates to risk for falls. The use of home modifications has been
demonstrated to:

be an effective risk management strategy to reduce the number of falls among the elderly27

can mitigate the rate of falls for those considered to be at high risk of falling, in conjunction
with hazard reduction strategies28

improve an individual’s perception of safety.29
Health and wellbeing
There is evidence to suggest that home modifications can have a positive impact on advancing
the state of health and wellbeing of people with diminished functional capacity. Some individuals
experienced a positive impact on their physical and mental health following the installation of
home modifications.30 This includes:

benefits to psychological wellbeing include improved lifestyle choices, greater self-image,
restored dignity, and greater involvements in society and improved relationships31
23
Petersson, I., Lilja, M., Hammel, J., & Kottorp, A., ‘Impact of home modification services on ability in everyday
life for people ageing with disabilities’, Journal of Rehabilitation Medicine, No. 40, 2008, pp. 253-260.
24 Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home Maintenance and Modification Services in Achieving
Health, Community Care and Housing Outcomes in Later Life’. AHURI Final Report No. 123. Australian Housing
and Urban Research Institute, Queensland Research Centre. 2008.
25 Petersson, I., Lilja, M., Hammel, J., & Kottorp, A., ‘Impact of home modification services on ability in everyday
life for people ageing with disabilities’ Journal of Rehabilitation Medicine, No. 40, 2008, pp. 253-260.
26 Ibid.
27 Gillespite, L. D., Gillespie, W. J., Cumming, R. G., Lamb, S. H. & Rower, B. H. Interventions for preventing falls in
the elderly. The Cochrane Library, Oxford 2001.
28 Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home Maintenance and Modification Services in Achieving
Health, Community Care and Housing Outcomes in Later Life’. AHURI Final Report No. 123. Australian Housing
and Urban Research Institute, Queensland Research Centre. 2008.
29 Heywood, F,. ‘Money well spent: the effectiveness and value of housing adaptations’, Policy Press, 2001,
Bristol.
30 Heywood, F., ‘Adaptation: altering the house to restore the home’, Housing Studies, No. 20(4), 2005,
pp. 531-47.
31 Heywood, F., ‘Adaptation: altering the house to restore the home’, Housing Studies, No. 20(4), 2005,
pp. 531-47.
10
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
positive impacts on an individual’s pain as a result of making self care activities less
demanding following the installation of minor home modifications32

improvements in individuals’ capacity to perform activities of daily living, which gave them
increased independence and efficacy in performing valued activities and roles, reduced stress
of their carers, and supported the continuation of social networks and relationships.33
Re-ablement
Within the literature, the provision of home modifications is usually part of a multi-component
program focussing on re-ablement, with a limited number of studies outlining the direct impact
of home modifications alone on re-ablement of consumers. A re-ablement approach provided as
an intake mechanism for all new home care consumers is cost-effective in terms of preventing
residential aged care admission and reducing the need for higher level services.34 35 In addition,
comprehensive occupational therapy interventions, including provision of modifications with
comprehensive pre- and post-intervention functional assessments, are associated with positive
impacts on the social ability and quality of life of older adults, and reduced caregiver burden.36 37
Impact on need for ongoing support
Home modifications may reduce or even eliminate the need for in home care and reduce the
likelihood of entering residential aged care by facilitating self-care practices and reducing the
disability threshold.38 39 Combining a period of re-ablement intervention with home
modifications has been shown to reduce the subsequent use of home care services.40 41
32
Clemson & Martin 1996; Edgington 1984 as cited in: Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home
Maintenance and Modification Services in Achieving Health, Community Care and Housing Outcomes in Later
Life’. AHURI Final Report No. 123. Australian Housing and Urban Research Institute, Queensland Research Centre.
2008.
33 Tanner 2005 as cited in: Jones, A., De Jonge, D. and Phillips, R., ‘The Role of Home Maintenance and
Modification Services in Achieving Health, Community Care and Housing Outcomes in Later Life’. AHURI Final
Report No. 123. Australian Housing and Urban Research Institute, Queensland Research Centre. 2008.
34 Manthorpe, J. ‘Long-term impact of home care enablement’, Community Care, 13.10.11, 2011, pp. 32-33.
35 Francis, J. Fisher, M. & Rutter, D. Reablement: A cost effective route to better outcomes, Research Briefing 36,
Social Care Institute for Excellence, London, April 2010.
36 Stark, S. ‘Removing environmental barriers in the homes of older adults with disabilities improves occupational
performance’, Occupation, Participation and Health, 24 (1), pp. 32-40.
37 Walker, M., Leonardi-Bee J., Bath, P. Et al, ‘Individual patient data meta-analysis of randomized controlled trials
of community occupational therapy for stroke patients’, Stroke, 35, 2226-2232.
38 Carnemolla, P. & Bridge, C. Home Modifications and their impact on waged care substitution, Home
Modification Information Clearinghouse, Sydney, April 2011.
39 Sheffield, C. Smith, CA. Becker, M. ‘Evaluation of an agency-based occupational therapy intervention to
facilitate aging in place’, The Gerontologist, 10.1093/geront/gns145
40 Glendinning, C. & Newbronner, E. ‘The effectiveness of home care reablement – developing the evidence
base’, Journal of Integrated Care, Social Care Institute for Excellence, 16 (4), August 2008, pp. 32-39.
41 Manthorpe, J. ‘Long-term impact of home care enablement’, Community Care, 13.10.11, 2011, pp. 32-33.
11
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May 2014
3.3 Home maintenance
Where a need for maintenance is identified, one-third of older people delay undertaking repairs
to their home. The primary reason for delaying repairs is the expense, followed by
inconvenience.42 There is no relationship between income and likelihood of maintenance
deferral. Older householders also have considerable difficulty finding an appropriate person to
carry out repairs and are concerned about the trustworthiness of repairs and maintenance
providers.43 Some older people may move into higher dependency living situations (including
retirement villages, if it is affordable to them, or residential care) as a result of the burden of
home maintenance and repairs.44
Impacts, outcomes and benefits
Examining the outcomes and benefits of home maintenance based on published literature is
challenging due to variations in how home maintenance is defined in different jurisdictions and
countries, further complicated by differences in the target audience for whom the impact of
home maintenance is examined. There is also considerable overlap between the definition of
home maintenance and other services, such as home modification and personal support services.
The outcomes and benefits of home maintenance in Australia remain largely undocumented,
including for the current Commonwealth HACC home maintenance service types, in part due to
the limited rates of follow-up. The findings from the literature and analysis for home
maintenance outside of the Commonwealth HACC program are detailed below.
Accessibility
There may be a link between home maintenance and accessibility, particularly in relation to
garden maintenance. Activities such as lawn mowing and garden maintenance can greatly
improve an individual’s accessibility to the garden, their house and other outdoor spaces.45 In
addition, supporting people to access and work in their garden can promote a sense of coping
and increase self-esteem. 46
Independence
The concept of independence, specifically in the context of home maintenance, relates to the
capacity of an individual to live independently and manage the day-to-day activities of their
lives.47 An older person’s ability to maintain their independence and age successfully is linked to
42
Ibid.
Ibid.
44 James, B. & Saville-Smith, K. Older People’s Repairs and Maintenance: Ageing Well in Place in New Zealand,
Paper to the 22nd International Housing Research Conference, 4-7 July, Istanbul, 2010.
45 Stark, S., Creating disability in the home: The role of environmental barriers in the United States. Disability &
Society, No. 16(1), 2001, pp. 37-49.
46 Molineux, M., Rosenwax, L., & Harmsen, J. A Home without Barriers: The Western Australia HACC Home
Modifications and Home Maintenance Study Perth: School of Occupational Therapy and Social Work 2010, p. 20.
47 Victorian Government Health Information, Active Service Model Project, Retrieved 20 August 2013.
43
12
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May 2014
their ability to reside in their own home.48 The burden of repairs and maintenance influences the
decision of some older people to move to residential aged care.49 However, there is no
conclusive evidence regarding examination of the impact of the provision of home maintenance
services on independence over a period of time.
Safety
The majority of literature linking home maintenance and safety is related to reducing risks and
hazards and improving older people’s safety and well-being in their homes. Removal of
environmental hazards; coupled with other interventions such as home modifications, are
effective in reducing the number of falls in individuals at risk of falling.50 51 There is however, no
specific evidence which examines the impact of home maintenance in and of itself on an
individual’s safety and that separates it from other interventions such as home modification.
Health and wellbeing
The diversity of definitions of health and wellbeing and the limited literature around home
maintenance makes it challenging to identify the links between home maintenance and the
health and wellbeing of older people. There is evidence to suggest that poor housing conditions
can lead to deterioration in health and well being, and an increased risk of premature admission
into residential aged care for older people.52 53
Home maintenance also impacts positively on psychological wellbeing. Services which maintain
garden and outdoor spaces can reduce the amount of worry experienced by individuals, increase
dignity and pride and reduce the burden placed on an older individual’s carer to undertake
maintenance themselves.54 55
Re-ablement
No evidence relating to the impact of home maintenance services on re-ablement was identified
during the review.
48
Fausset, C. B., Kelly, A. J., Rogers, W. A., & Fisk, A. D. ‘Challenges to aging in place: Understanding Home
Maintenance Difficulties’, Journal of Housing for the Elderly, No. 25(2), 2011, pp. 125-141.
49Centre for Research and Social Assessment, Projects and Publications, Retrieved 20 August 2013.
50 Cumming, R.G., Thomas, M., Szonyi, G., Frampton, G., Salkeld, G., & Clemson, L., ‘Adherence to occupational
therapist recommendations for home modifications for falls prevention’, The American Journal of Occupational
Therapy, No.55(6), 2001, pp. 641-648.
51 Molineux, M., Rosenwax, L., & Harmsen, J. A Home without Barriers: The Western Australia HACC Home
Modifications and Home Maintenance Study Perth: School of Occupational Therapy and Social Work 2010,
pp. 24.
52 Davey J. ‘Ageing in place: The views of older homeowners about housing maintenance, renovation and
adaptation’, Wellington, New Zealand: Centre for Social Research and Evaluation, Ministry of Social
Development; 2006, pp. 3.
53 Molineux, M., Rosenwax, L., & Harmsen, J. A Home without Barriers: The Western Australia HACC Home
Modifications and Home Maintenance Study Perth: School of Occupational Therapy and Social Work 2010, p. 23.
54 Heywood, F., ‘Adaption policies especially for children: Key factors for effective outcomes’, Journal of
Integrated Care, No. 11(1), 2003, pp. 22-27.
55 Bhatti, M., ‘When I’m in the garden I can create my own paradise: Home and gardens in later life’, The
Sociological Review, No. 54(2), 2005, pp. 318.
13
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Impact on need for ongoing support
The evaluation of the UK Handyperson Program found that investment in home maintenance led
to avoided costs elsewhere. The program provided a relatively high volume of preventive
activities, such as small repairs and installation of home security measures at a relatively low
cost. This avoided the incurring of larger costs, including residential aged care services, hospital
services and major high cost home modifications.56
3.4 Elements of good practice
Good practice elements identified through the literature and analysis for home modifications
and home maintenance service delivery and funding models include:

Person-centred: the service provider places the consumer at the centre of planning and
decision making for home modification or maintenance services.

Outcomes focused: service provision is focused on and supports improvement of outcomes
for the consumer and/or their carer, including where appropriate rehabilitation,
enablement/re-ablement and uses a strengths-based approach.

Consistent: there is a consistent approach to assessment (including intake and specialist
assessment) and prioritisation, and decision making is transparent, equitable and fair.

Culturally appropriate: assessment and service provision considers the needs of Aboriginal
and Torres Strait Islander populations and individuals from culturally and linguistically diverse
backgrounds.

Access to information: the consumer has access to up to date and relevant information to
make an informed choice.

Timely: service provision is timely and avoids delay.

Partnership arrangements: service provision promotes partnerships and strong relationships
between service providers.

Follow up and reassessment: there is capacity for follow up and reassessment of the services
provided to ensure outcomes are achieved and to assess/re-assess consumer needs as these
change over time.
56
Department for Communities and Local Government, National Evaluation of the Handyperson Programme,
London, 2012.
14
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Final report
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May 2014
4 The current service system
This section provides an overview of the current service system. It is based on data analysis,
consultations and the findings from the provider questionnaire. It discusses the key system
strengths, issues and challenges identified through the review. This section includes:

an overview of the consumer profile and range of services accessed

a description of approaches to service delivery (access, intake and assessment, service
provision and need, demand management and prioritisation, consumer co-payments and
fees, and follow-up processes)

considerations regarding other key areas including funding, workforce, data collection and
reporting

strengths, issues and challenges in relation to service delivery.
4.1 Consumer profile and services accessed
A secondary analysis of HACC Minimum Data Set (MDS) data was undertaken for home
modification and home maintenance services within scope of this review (that is, those services
provided for people aged over 65 and Aboriginal and Torres Strait Islander peoples aged
over 50). The analysis included data over a four-year period from 2008-09 to 2012-13.
The data analysis indicated that, overall, home modification and home maintenance services are
provided to older individuals, with the majority of services delivered to consumers aged over 80.
The typical consumer is female and lives alone.
Home modifications
The data shows that the majority of home modifications are delivered in New South Wales,
Queensland and South Australia, together accounting for 96 per cent of all reported modification
services across Australia (note that modification (minor modification services only) services in
Victoria are reported as home maintenance, therefore, Victoria was not included in this analysis).
The greatest proportion of home modifications is delivered in major cities and regional areas.
This finding was validated in the provider questionnaire and consultations as part of this review.
Providers observed that there were some access barriers to home modifications for many people
living in rural and remote areas. Providers cited the increased cost of service delivery, and delays
associated with access to licensed trades people and generic handypersons in those areas, as the
main reasons for these access barriers.
Home maintenance
Excluding Victoria (which has the greatest proportion of home maintenance instances, but which
includes modifications (minor modifications only) within home maintenance for data reporting),
Queensland has the highest number of service instances. The consultations conducted for this
review verified that there is a high level of service provision by home maintenance providers in
15
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Queensland compared to other states, with providers tending to report more frequent delivery
of repeat services, such as lawn mowing for individual consumers, and a generally wider scope of
services in comparison to other jurisdictions.
The data showed that the majority of home maintenance assistance instances occurred in major
cities and regional areas. The consultations verified this, noting the increased cost of service
delivery and the workforce pressures outside of cities and large towns as an issue.
4.2 Overview of service delivery across home modifications
and home maintenance
The most commonly identified issue throughout the review by stakeholders is the lack of
consistency in the service models in place across Australia. The service models in each state and
territory, and sometimes within a state/territory, are different, resulting in often considerable
disparity in how services are delivered. This inconsistency has evolved due to the historical
funding and program management arrangements, with funding split between state/territory and
Commonwealth governments, and program management occurring at a state/territory level.
With the exception of Western Australia and Victoria, funding and operational management
shifted to the Commonwealth from 1 July 2012. However many service providers continue to
provide services based on old state/territory policies and operational guidelines. The majority of
service providers have not altered how they provide their services since the changes in funding
and operational management, and had not undertaken any realignment of service delivery to the
Commonwealth HACC Program Guidelines 2012-2015.
There are also different operating models within which home modification and home
maintenance are delivered. Western Australia and Victoria provide their services within broader
HACC models or approaches, which are significantly different to other states and territories.
HACC service delivery for these states is approached from a holistic consumer and family view, a
focus on the role of the consumer within the community and includes re-ablement approaches,
which have different principles to the models and approaches in other states and territories.
An overview of each of the service models for home modifications and home maintenance are
outlined in Sections 4.3 and 4.4.
4.3 Service delivery - Home modifications
As outlined in Section 4.2, home modification services are delivered in vastly different ways
across each jurisdiction. Home modifications within HACC are governed by the HACC Program
Guidelines 2012 – 2015. The guidelines state:
‘Home modifications provide structural changes to a consumer’s home so that they can continue
to live and move safely about the house. Modifications can include:

grab and shower rails

appropriate tap sets

hand rails
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
ramps and other mobility aids

installation of emergency alarms and other safety aids

other minor renovations.
Home modifications must be conducted by a licensed tradesperson.’57
However, the application of these guidelines are different across each state and territory, as well
as within each state and territory, with many service providers still using old state and territory
guidelines. In New South Wales, there is a very structured approach towards delivery of home
modifications, which was strongly supported both within New South Wales and outside of New
South Wales, with the majority of home modification services being funded through HACC.
Western Australia, South Australia and Victoria also have structured systems, which are
integrated with other home modification funding and service delivery, including state funded
home modifications.
In addition to these provider perspectives, feedback from consumers of home modification
services was generally very positive.
There is no consistency in definitions and terminology across Australia (this is also noted within
literature). For example, there is no clear definition of minor or major modifications, and
terminology relating to individual home modifications also differs between states and territories.
Access and assessment
An overview of the key elements, strengths and issues related to access and assessment,
including specialist assessment for home modifications, is outlined below.
What happens now

Eligibility criteria for access to services are generally consistent across jurisdictions.

Access pathways are also broadly similar, with consumers directly approaching service
providers to seek modification services in most jurisdictions, with the exception of Western
Australia and New South Wales (Hunter and Central Coast regions) which have central
access. Assessment often occurs using a tool, developed within each organisation, which may
not be a holistic assessment.

An occupational therapist specialist assessment is required as part of the assessment process
for all major modifications and most minor modifications.
Key strengths

57
There is broad similarity in access criteria across jurisdictions.
Department of Social Services, Commonwealth HACC Program Manual 2012 – 2015. Retrieved 11 March 2014
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Key issues and challenges

There is a general lack of awareness of services across the general community, and in
particular in culturally and linguistically diverse communities.

Other than in Victoria and Western Australia there is no consistent approach to assessment,
with assessments largely completed using non-standardised tools and templates.

Assessment, including specialist assessment, does not always consider alternatives to home
modifications (e.g. goods and equipment and/or rehabilitation).

Timely access to assessments, including eligibility and needs assessment, is often
problematic, with significant waitlists at many organisations.

Central access points were identified as requiring local knowledge to be valuable for
consumers.

There are challenges in accessing appropriate and timely occupational therapist assessments,
particularly when the occupational therapist is not co-located with the service provider.

There was a relatively high incidence of consumers declining services, with the primary
reasons outlined as inability or unwillingness to pay a contribution or fee for a home
modification, a change in circumstances, or preference to rely on family and friends.
Prioritisation of service delivery
An overview of the key elements, strengths and issues related to prioritisation for home
modifications are outlined below.
What happens now

Providers deploy a number of strategies to manage demand for services (where needed), the
most common being waiting lists and documented criteria-based prioritisation.
Key strengths

Prioritisation is usually based on consumer need.

Prioritisation still allows eligible consumers to mostly or always access home modifications
that are required.

There are examples of good practice in prioritising across providers and regions.
Key issues and challenges
There is no consistent, transparent approach to prioritisation of service delivery.
18
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Service provision
An overview of the key elements, strengths and issues related to service delivery for home
modifications are outlined below.
What happens now

The types of services available are inconsistent and dependent on where a consumer resides.

The most common home modifications being provided are external grab or handrails,
internal grab rails, redesign of bathroom or kitchen, access ramps, internal wedges/doorway
ramps and hand held shower roses.

Many providers, with the exception of providers in New South Wales and to some extent
Queensland, exclude ‘major’ modifications. New South Wales also has the highest maximum
cost threshold per major modification of those jurisdictions that classify minor and major
modifications based on cost.

There are a number of state-funded and delivered home modification programs that provide
home modifications. These influence the type of home modifications services provided by
Commonwealth HACC home modification providers in each state and territory.

Service delivery is provided both in-house as well as through outsourcing, with the most
likely services to be outsourced being construction and installation of home modifications
(including minor and major modifications).

Service provision is not aligned with consumer-directed care58 principles, and is largely
directed by the service provider.

Service delivery is more difficult in rural and remote areas due to the increased cost of labour
(both builders and occupational therapists), materials and the distances required to travel to
deliver jobs.
Key strengths

There is flexibility in service delivery to allow service providers to be innovative in service
delivery and to adapt their approaches to service delivery. However, this flexibility is not
being used to support a consumer directed care approach to service delivery.

In States and Territories where there are multiple funded programs, the Commonwealth
HACC home modification service type funds low level home modifications, with more
complex modifications funded by the States and Territories.
58
Consumer Directed Care is both a philosophy and an orientation to service delivery where consumers,
including care recipients and their carers, can choose and control the services they get, to the extent that they
are capable and wish to do so.(This offers more choice and control to consumers than through traditional service
delivery.
19
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Key issues and challenges

The types of services available are inconsistent and dependent on where a consumer resides
(both within and between states and territories and particularly if a consumer resides in an
Aboriginal housing cooperative).

There is a low level of alignment to contemporary person-centred practice.

Consultations indicated that there is a disconnect between the Commonwealth HACC
program guidelines and the delivery of services, particularly in relation to major
modifications.

Service provision is often not holistic, and does not consider the interface with goods and
equipment. It relies on the individual occupational therapist and/or service provider,
particularly if goods and equipment are not provided by the service provider. They are often
not considered as an alternative to home modifications. Some goods and equipment also
appear to be funded and delivered under home modifications.

There is a disconnect between the provision of home modifications and home care package
recipients, with home care package recipients often not able to access home modifications,
either through HACC, their package or other means.

Significant issues exist across most states and territories in providing home modifications for
consumers who reside in public and private rental properties.

There is an over reliance on building regulation AS1428, with a lack of understanding of how
this regulation relates to home modifications in private dwellings.
Service delivery was hampered by the perceived need to identify future as well as current needs
of the consumer. This resulted in consumers paying and receiving modifications that they did not
end up requiring.
Consumer co-payments and fees
An overview of the key elements, strengths and issues related to consumer co-payments and
fees for home modifications are outlined below.
What happens now

Consumer co-payments supplement program funding. Co-payment policies for modifications
are inconsistent across jurisdictions. The two most commonly specified methods of copayment for modification are recovery of the cost of materials, or as a proportion of the
overall cost.

There are a number of approaches to means testing and/or waiving/reducing fees.

All providers cap the level of co-payment, but there is no national consistency in the
calculation processes.
Key strengths
20
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
There are a range of options available to support consumer co-payments, with many
providers demonstrating flexibility in order to support payment.
Key issues and challenges

Lack of a consistent approach across jurisdictions including on means testing and/or
waiving/reducing fees.

There is a lack of consistency in service providers capacity (both within and across states and
territories) to provide payment plans.
Follow up and review processes
An overview of the key elements, strengths and issues related to follow up and review processes
for home modifications are outlined below.
What happens now

Follow up does not occur comprehensively, and was most likely to occur for major works or
on a case-by-case basis.

Follow up included a combination of review and re-assessment, but was more likely to be a
review.
Key strengths

There were no particular strengths identified in the current approach to follow up. This is an
area where there are opportunities for improvement.
Key issues and challenges

Lack of consistent approaches in follow up and review processes, and lack of use of
standardised tools to undertake both follow up and reviews.
Workforce and training
An overview of the key elements, strengths and issues related to workforce and training for
home modifications are outlined below.
What happens now

The role of the occupational therapist is critical in the delivery of home modification services.

Occupational therapists determine which environmental interventions may be required. This
may include modifications, or goods and equipment.

Occupational therapists also need to ensure that they are aware of the latest home
modifications products, as well as goods and equipment, and other options that may best
meet the needs of each individual consumer.

An experienced occupational therapist is required for an effective assessment for home
modification requirements. However, access to experienced occupational therapists is not
21
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always possible. Competencies for home modifications have also been developed by
Occupational Therapy Australia, for occupational therapists which were not widely adopted
across the sector.

Occupational therapists are required to work closely with builders in the delivery of home
modifications.

There are some training and professional development opportunities for occupational
therapists through Occupational Therapy Australia and the New South Wales Home
Modifications and Home Maintenance State Council, including the 2012 ‘Home
Modifications, a National Perspective, inaugural National Conference’. There are also training
and development opportunities available to occupational therapists through other means
including private specialist occupational therapists and Independent Living Centres.

In rural and remote areas, there was identified a lack of suitability experienced occupational
therapists.
Key strengths

The inclusion of the occupational therapist within the delivery of home modifications ensures
quality and appropriate home modifications are generally provided to consumers.

With the increase in occupational therapy graduates, there should be less issue with a lack of
available occupational therapists in rural and remote areas.

There were examples of service delivery where collaboration between occupational
therapists and builders were supported (see Section 5).
Key issues and challenges

There are challenges in accessing suitable occupational therapists and builders, particularly in
rural and remote areas.

Lack of access to suitably experienced occupational therapists and/or builders for
modifications contributes to delays in specialist assessment and provision of other services,
or to lack of service provision at all.

Occupational therapists working in home modifications may not have sufficient experience
or support to be proficient in the area.

There is a lack of appropriate supervision, support and mentoring for occupational therapists
in home modifications.

Training and professional development opportunities for occupational therapists and
builders in the area of home modifications were often limited, particularly for opportunities
that target both groups.
22
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Funding
An overview of the key elements, strengths and issues related to funding for home modifications
are outlined below.
What happens now

Services are funded on a triennial basis using historic block funding formulas. In the past,
there have been irregular needs-based ‘top-up’ funding rounds.

Victoria funds minor home modifications and home maintenance service types together, as
property maintenance, with little distinction between the two service types.

There is a perception of a lack of funding to meet current needs (which often aligned with a
lack of availability of other home modification schemes) with organisations often crosssubsidising from other services or funding sources.
Key strengths

Funding of specialist services supports the delivery of high quality services, who are able to
employ a workforce who specialise, or have a desire to specialise in home modifications.
Key issues and challenges

Travel and the increased cost of provision in rural and remote areas are not reflected in
funding.

The Victorian model of joint funding for home modification and home maintenance
contributes to a lack of clarity at a national level as to what services are funded, and how
services are funded.

Funding of specialist services may limit consideration of other options, for example goods
and equipment, to meet the consumer’s needs.
Data collection and reporting
An overview of the key aspects, strengths and issues related to data collection and reporting are
outlined below.
What happens now

The current HACC MDS does not permit breakdown analysis of the range of services provided
under modifications (i.e. actual types of modifications), or the actual unit costs for particular
types of modifications.

There is no collation of consumer outcomes following home modification installation.
Key strengths

The current HACC MDS supports organisations to understand the need for, and how to
collect data.
23
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Key issues and challenges

The HACC minimum dataset does not collect sufficient information to assist understanding
areas for service improvement.

There is no national data currently collected regarding consumer outcomes – that is, what
happened to the recipient after the modification was installed and what impact / benefit did
it deliver.
4.4 Service delivery - Home maintenance
Home maintenance services are delivered in vastly different ways across each jurisdiction, as well
as within jurisdictions. Home maintenance services within HACC are governed by the HACC
Program Guidelines 2012 – 2015. The guidelines state:
‘Home maintenance is assistance to keep a client’s home in a safe and habitable condition. This
involves the repair and maintenance of a client’s home or yard. Repairs are generally minor
repairs such as changing light bulbs and replacing tap washers. More major repairs can include
carpentry, painting and roof repairs. Garden maintenance includes lawn mowing and the removal
of rubbish.’59
As with home modifications, the application of these guidelines are different across each state
and territory, as well as within each state and territory, with many service providers still using old
state and territory guidelines to deliver their services.
Home maintenance is not a clearly defined term. As a result, there are different interpretations
of the term across states and territories, as well as within organisations in each state and
territory. The approaches to home maintenance are very individual to each organisation,
dependent on their preferences, as well as the state and territory they delivery services in.
Services are often driven by the local environment, for example living in bushfire areas leads to
increased need for lawn mowing, pruning and gutter cleaning.
Overall, one of the key strengths of the current program has been the flexibility for individual
service providers to adapt provision to the local environment. When this was done well, it
enabled service delivery to grow and adapt to changing local needs, as well as developing the
internal capacity of the service provider. Feedback from consumers of home maintenance
services was generally very positive.
Access and assessment
An overview of the key elements, strengths and issues related to access and assessment for
home maintenance are outlined below.
What happens now

59
Eligibility criteria for access to services are generally consistent across jurisdictions.
Department of Social Services, Commonwealth HACC Program Manual 2012 – 2015. Retrieved 11 March 2104
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
Access pathways are broadly similar, with consumers directly approaching service providers
to seek home maintenance services in most jurisdictions, with the exception of Western
Australia and part of New South Wales (Hunter and Central Coast regions) which have central
access points. Access to services is not clear to many consumers and is not well advertised.

Assessments often occur using a formalised tool, developed within each organisation, which
was sometimes part of a broader holistic assessment. Assessment is generally conducted by
service providers.

Victoria has an assessment framework, which includes standardised tools, which form part of
a holistic assessment, however these tools are not used by all providers.

Western Australia has an independent assessment agency which undertakes assessment for
all HACC services.
Key strengths

Broad similarity in access criteria.

Central access points provide easily identified points of access for consumers (see also key
issues and challenges).

Holistic assessments which form part of the Victoria and Western Australia assessment
processes.
Key issues and challenges

Access to services is not consistent across, or within, all states and territories (i.e. there is not
equitable distribution of services to consumers with comparable needs).

There is limited awareness of the services across the general population, which is particularly
pronounced in culturally and linguistically diverse communities.

Timely access to assessments, including eligibility and needs assessments, was often
problematic, with significant waitlists at some organisations.

Other than in Victoria and Western Australia there is no consistent approach to assessment,
with assessments largely completed using non-standardised tools and templates.

Central access points were identified as requiring local knowledge to be valuable for
consumers.
Prioritisation of service delivery
An overview of the key elements, strengths and issues related to prioritisation for home
maintenance are outlined below.
What happens now

Providers deploy a number of strategies to manage demand for services (where needed).
25
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
The most common process is for prioritisation to occur on an ad-hoc basis, although other
strategies including the use of wait lists and documented criteria-based prioritisation are also
used.

When established, prioritisation criteria have been developed by service providers.
Key strengths

Most service providers endeavour to prioritise based on consumer need, although this is
often not based on criteria.

Efforts by service provider to develop criteria-based prioritisation assessment, which are
consistent and equitable, although these are usually not validated.
Key issues and challenges

There is no consistent, transparent approach to prioritisation of service delivery.
Service provision
An overview of the key elements, strengths and issues related to service delivery for home
maintenance are outlined below.
What happens now

The types of services available are inconsistent and dependent on where a consumer resides
(both within and between states and territories). Services are provided both in-house as well
as through outsourcing.

The most common home maintenance services provided are minor garden maintenance and
minor home maintenance. The range of services that fall within those categories vary
considerably across providers and across jurisdictions.

Frequency of services varies greatly from one off services to very regular (for example every
fortnight) provision. This is dependent on each service provider. Due to perceived funding
constraints, in many instances, home maintenance has become solely focused on providing
emergency or urgent safety issues.

Most service providers exclude certain services. Common excluded services are gutter
cleaning, ‘major’ home maintenance or gardening projects, services requiring licensed
tradespeople, and ‘beautification’ services such as painting.

The main reasons for excluding services are cost and/or lack of suitable contractors to
deliver, real or perceived occupational health and safety requirements (particularly relating
to work involving ladders) and, most commonly, historic agency policy.

There are commonalities between home maintenance services and domestic assistance,
particularly for one off or in frequent cleaning that is currently provided through home
maintenance.
26
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
Service provision is largely driven by the service provider and their ability to provide
particular types of maintenance services, rather than aligned to assessed needs of the
consumer. As such provision is not aligned with consumer directed care60 principles.

Service delivery is more difficult in rural and remote areas due to the increased cost of labour
(including handymen, and licensed tradespeople), materials and the distances required to
travel to deliver jobs.
Key strengths

Many providers indicated that there is flexibility in service delivery which allows providers to
decide how they can deliver services, and the types of services they can deliver. This was
particularly important in locations with specific geographical characteristics (for example at
risk of bushfires or cyclones). However, flexibility in delivery was not being used to provide
consumer-directed care.

There are some good examples of the use of funds to implement preventative measures (see
Section 5).
Key issues and challenges

The types of services available, and frequency of service provision, are inconsistent and
dependent on where a consumer resides (both within and between states and territories).

There is a low level of alignment to contemporary person-centred practice, with services
largely driven by service providers, instead of the consumer. Generally, consumers will only
have access to one provider in their area, which will have a defined list of services it is able to
provide.

Service delivery generally does not take a re-ablement approach.

There is a lack of clarity as to the funding source (home maintenance or domestic assistance)
of one off or infrequent cleaning services.

There is significant need for the provision of services for squalor/hoarding. This requires a
multi-disciplinary team approach.
Consumer co-payments and fees
An overview of the key elements, strengths and issues related to consumer co-payments and
fees for home maintenance are outlined below.
What happens now

Co-payment policies are inconsistent across and within jurisdictions. In a number of states
and territories, fees are levied based on the hours of service provided and are priced using
60
Consumer Directed Care is both a philosophy and an orientation to service delivery where consumers,
including care recipients and their carers, can choose and control the services they get, to the extent that they
are capable and wish to do so.(This offers more choice and control to consumers than through traditional service
delivery.
27
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state based schedules. . Previous state/territory guidelines were used to guide practice for
co-payments and fees.

There are a number of approaches to means testing and/or waiving/reducing fees.
Key strengths

Providers have adapted flexible approaches to support consumer co-payments, to minimise
the number of consumers that may not be able to pay for home maintenance services.
Key issues and challenges

There are inconsistent approaches to means testing and/or waiving/reducing fees across
jurisdictions, resulting in people with similar circumstances not being able to receive the
same approach to fees.
Follow up and review processes
An overview of the key elements, strengths and issues related to follow up and review processes,
for home maintenance are outlined below.
What happens now

Follow up generally occurs on a case-by-case basis, and is not supported by formal processes
or tools, or the identification of outcomes.

Follow up is most likely to occur as a review, rather than a re-assessment.
Key strengths

Providers reported that consumers value and appreciate the services, but agreed that there
are opportunities to improve the current approach to follow up.
Key issues and challenges

There is no consistent approach to follow up and review processes and no consistent use of
standardised tools to support this to occur.
28
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Workforce and training
An overview of the key elements, strengths and issues related to workforce and training for
home maintenance are outlined below.
What happens now

There are a range of people who undertake home maintenance, however there is no
consistency in the required workforce for each service (i.e. tap washer replacement may
require a licensed plumber in some service providers but a handyman in other service
providers). This is sometimes based on jurisdictional regulations, and/or cost.

There is limited opportunity for training and professional development for occupational
therapists and builders rural and remote areas. Particular challenges include the capacity to
identify a suitable and available workforce to deliver home maintenance services.
Key strengths

Examples of different approaches to providing handymen/tradespeople with professional
development including BBQ afternoons.
Key issues and challenges

Insufficient training and professional development has resulted in significant differences in
knowledge and skills within the workforce, particularly in communication with consumers
and knowledge and/or support of re-ablement approaches.

Lack of access to suitable workforce can contribute to service delays.
Funding
An overview of the key aspects, strengths and issues related to funding for home maintenance
are outlined below.
What happens now

Services are funded on a triennial basis using historic block funding formulas. In the past,
there have been irregular needs-based ‘top-up’ funding rounds.

Victoria funds minor home modifications and home maintenance service types together, as
property maintenance, with little distinction between the two service types.

Funding often limits service provision to smaller, more frequent jobs, rather than larger, oneoff jobs which may be more sustainable for the consumer (i.e. water wise gardens).

Sometimes services can cost more (from a service provider point of view) delivered through
HACC than if a consumer organises services themselves, and pays full fees for the service.
Key strengths

Some providers support the triennial block funding allocation, as it gives providers a degree
of certainty and flexibility.
29
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Key issues and challenges

Travel and the increased cost of providing services in rural and remote areas are not
reflected in funding.

The Victorian model of joint funding for home modification and home maintenance has
contributed to a lack of clarity at a national level as to what services are funded, and how
services are funded.

Some providers suggested that the current system of block funding was not fair, as it is based
on historical allocations and means that some regions get more funds, proportionately, than
others. This means some consumers have access to a better level of funded services than
others with the same needs living in a different region.
Data collection and reporting
An overview of the key elements, strengths and issues related to data collection and reporting
are outlined below.
What happens now

The current HACC MDS does not permit breakdown analysis of the range of services provided
under home maintenance.

Cost data is not available for maintenance, with activity currently reported in units of ‘hours’.

There is no collation of data on the outcomes achieved through home maintenance,
although some providers conduct their own consumer satisfaction surveys.
Key strengths

The current HACC MDS supports organisations to understand the need for, and how to
collect data.
Key issues and challenges

The HACC minimum dataset does not collect sufficient information to assist understanding
areas for service improvement.

There is no national data currently collected regarding consumer outcomes – that is, what
happened to the recipient after they receive home maintenance services.
30
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5 Innovative service delivery models
This section provides examples of innovative practice identified through the review, as well as
examples of good practice and alternative models for delivery of home modifications and home
maintenance.
5.1 What is innovative practice and good practice?
In order to determine if a service is innovative or demonstrates good practice, what constitutes
innovation or good practice needs to be defined.
Innovation
There are a number of relevant definitions for innovative practice. Innovation in the social
services sector has been defined as ‘change that creates a new dimension of performance’.61
The European Commission has described innovation in social services as ‘a dynamic and evolving
response to growing demand for services and changes in social, cultural and institutional
expectations of social services’, which will result in ‘new forms of service delivery and/or meeting
the needs of new target groups, or the development of improved mechanisms for delivering
existing services’.62 This service improvement-focussed approach to innovation is sometimes
categorised as one component of a broader ‘social innovation’ discourse, which seeks to address
service blockages and siloed thinking as a means to improving complex social, environmental and
demographic problems.63
In the context of Australian aged and community care service providers, innovation has been
described as ‘the setting of pathways that other service providers can benefit from that lead to
cost effective design and delivery of service that improve consumer choice, flexibility, quality care
and quality of life for older people’.64
Based on the definitions above, for the purposes of this review, ‘innovation’ in the context of
home modification and home maintenance service types is defined as:
New ways of structuring or delivering services that address existing barriers or
gaps, improve outcomes for consumers, are cost effective, and can be replicated by
other service providers.
61
Drucker, PF (2012) Drucker on innovation in the social sector, Drucker Institute (online), retrieved on
26 September 2013
62 Crepaldi, De Rosa and Pesce (2012) Literature review on innovation on social services in Europe (sectors of
health, education and welfare), European Commission, Brusselss.
63 Gaulier-Grice, Davies, Patrick and Norman (2012) Defining social innovation: Part 1 of the project ‘The
theoretical, empirical and policy foundations for building social innovation in Europe’, European Commission,
Brussels.
64 Aged & Community Services Association of NSW & ACT (2012) Innovation in the not-for-profit aged care sector:
Addendum to ‘Not-for-profit sector in the aged care industry: Measuring our charitable credentials (Elton
Consulting, 2012), June, ACSA NSW & ACT.
31
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Good practice principles
As outlined in Section 3, the principles identified in the literature as good practice are:

person-centred

outcomes focused, including re-ablement approach

consistent

culturally appropriate

access to information

timely

partnership arrangements

follow up and reassessment.
5.2 Alternative service delivery models
Several innovative and good practice examples in the current home modification and
maintenance service types were identified in the literature review, desktop review and
stakeholder consultations. These are discussed below and broadly relate to service access,
technology, knowledge sharing, collaboration between parties, re-ablement, volunteering, and
modifying and extending service delivery to better meet consumer need.
Access and assessment
The following example presents a model centred on improving consumer access and assessment:
Common access and assessment, Western Australia (home modification and home
maintenance)
In metropolitan Perth and some rural areas of Western Australia, a Regional Assessment Services
(RAS) has been introduced which provides common access points for consumers accessing home
modifications and home maintenance services, along with other HACC funded services. This
initiative was introduced as part of the Western Australia Assessment Framework (WAAF)
reforms. The RAS assesses a consumer’s needs, provides initial eligibility screening and makes a
referral to a home modifications and home maintenance service provider. The service provider
employs a wellness based assessment to develop a goals-based support plan, and formalises
support services in line with the consumer’s support plan. The RAS allows for monitoring and
reassessment of consumer’s needs.
Why is this innovative?
The initiative is considered innovative due to the common and consistent assessment processes
and the ‘wellness approach’ that is used within the assessment. This ensures that the consumer
has a holistic assessment, and the outcomes/services support a whole-of-person view, with
services aligned with the consumer strengths. It also reduces time and complexity of assessment
processes, as service providers are no longer required to conduct assessment for HACC eligibility.
32
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What good practice principles are evident?

Person-centred and individualised

Consistent approach

Timely

Includes follow up/re-assessment

Promotes partnership
The following example outlines a standardised assessment tool, which also supports consumers
to undertake a self assessment.
“A Way to Stay – Home Modification Assessment and Planning Tool” Scope Access (home
modifications)
The home modification assessment and planning tool was developed by Scope Access to assist
consumers with a disability in the planning, assessment and construction quoting stages for
home modifications. The tool consists of three parts for:

individual consumers to assist with their decision making in the process

occupational therapists to support holistic assessment

team section to combine the input from the individual consumer, occupational therapist and
the builder undertaking the home modification.
The tool has been used by occupational therapists and services providing funded home
modifications through HACC or NDIS, as well as consumers who are wishing to undertake home
modifications privately.
Why is it innovative?
The tool is innovative as it supports the active participation of the consumer in the home
modification process. It supports a person-centred approach as it allows the consumer to
identify areas of consideration for home modification now, as well as in to the future, and assists
them to identify why they may require home modifications.
The tool also provides a standardised approach to assessment, and supports integration of
service delivery between the consumer, occupational therapist and builder. There may also be
scope to use or amend this tool for consumers outside of the disability sector.
What good practice principles are evident?

Person-centred and individualised

Outcomes focus

Consistent approach

Sufficient consumer information

Promotes partnership
33
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Use of technology
A number of innovative practice examples involved the use of technological innovation to
improve current modifications of service delivery. These included the use of camera phones to
take photographs, new technology in drawing programs, drawing applications for smart phones,
and the use of Skype and videoconferencing. The tele-consultation model employed by LifeTec in
Queensland leverages the use of technology to assist delivery of home modification services, as
summarised below.
The tele-consultation model, LifeTec Queensland (home modifications)
The model uses mainstream and mobile device technologies to promote access and availability
of services to consumers and service providers throughout Queensland. The tele-consultation
model involves the use of iPads and mobile devices by either a local HACC home modification
coordinator, builders, other service providers or consumers and family; on consumer sites to
provide tele-health consultation. This may include taking photographs of the environment. The
tele-health services uses mainstream platforms such as Skype or WebEx which enables the
remote occupational therapist assessment of the consumer’s function and home can be made,
and appropriate home modifications designed and recommended.
Why is it innovative?
The tele-consultation model is innovative through its use of technology to offset the difficulty in
accessing occupational therapists required for home modification assessments, and reducing the
wait time for assessment for consumers as well as the time required for assessment by
occupational therapists. This was specifically beneficial in regional areas, where access to
occupational therapy was markedly difficult. The model also allows real time liaison between
consumers, occupational therapists and service providers, and reduces travel time and costs.
This approach reduces the period between consumer request for services and making an
assessment, through to completion of service delivery. There is also a significant increase in
collaboration and discussion between the occupational therapists and the builders/service
providers by using this model, as well as the obvious of enabling the service to be provided by an
experienced occupational therapist. This also enables for follow up and evaluation of the persons
in their new environment, again whilst reducing travel needs and costs.
What good practice principles are evident?

Person-centred and individualised

Outcomes focus

Consistent approach

Timely

Includes follow up/re-assessment

Promotes partnership
34
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Collaboration and partnerships
A number of good practice and innovative examples involved the collaboration of the
stakeholders in the delivery of home modification services. These included examples of
stakeholders working together, building stronger relationships with one another, and improving
information sharing to better meet consumer needs. For example, occupational therapists and
builders carrying out joint site visits, occupational therapists integrated into home modification
service provider organisations in New South Wales, and information sharing between service
providers and builders. These examples share a common theme in their purpose which is to
improve efficiency of the parties involved in delivering services in order to better meet consumer
needs.
Joint home visits, New South Wales and Victoria (home modifications)
This initiative is employed in some areas in New South Wales and Victoria. It involves joint
consumer home visits carried out by occupational therapists and builders to conduct consumer
assessments. As opposed to a model where an occupational therapist visits the consumers’
home, assesses their need(s) and forwards recommended modification works to the builder, who
then in turn separately visits the consumers home to carry out the modification works, this
initiative combines the expertise of both parties to allow for modification works to be made that
meet consumer needs and improve their independence in a timely, feasible and efficient
manner. This approach improves the likelihood that occupational therapy prescription is in line
with regulations and structural requirements. In remote areas, this project also utilises Skype via
iPad and smart phones to access more senior building or occupational therapy expertise where it
is not available on the ground.
Why is it innovative?
The initiative overcomes ‘double up of processes’ faced when these parties carry out
assessments and home visits separately and provides a more holistic approach to assessment
and builds off the concept of bundling service provision to create ‘one stop shops’ for consumers.
It also supports collaborative working between occupational therapists and builders.
Additionally, this is described as innovative due to the reduction in wait time that occurs as
result.
What good practice principles are evident?

Outcomes focus

Consistent approach

Timely

Promotes partnership
35
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The next example illustrates knowledge sharing between parties.
Information sharing, Independent Living Centre New South Wales (home modifications)
The New South Wales Independent Living Centre (ILC) is focussed on person-centred practice,
and have identified that consumers who are not funded by HACC can procure and manage their
own high quality home modifications from the open market, or, in some cases, from within their
own family and social networks. It has also been identified that there are often complex systems
around accessing minor home maintenance and modifications. The ILC holds workshops for
consumers and provides information on the ILC website to assist consumers carry out home
modifications themselves. The ILC also runs training for occupational therapists and builders and
also provides information on access and universal design principles.
Why is it innovative?
ILC received feedback and enquiries from the general public that Government-funded services
often have long waitlists, and consumers were willing and able to pay for services that they could
not access due to the waitlists. The person-centred information sharing initiatives employed by
the ILC overcame these system drawbacks, by supporting consumers to complete minor
modification services themselves.
What good practice principles are evident?

Person-centred and individualised

Re-ablement approach

Sufficient consumer information

Promotes partnership
Innovative use of workforce
Some innovative examples involved the use of employing volunteers to deliver home
maintenance services, including the use of volunteers for components of services delivered or to
extend on HACC service offerings, or as detailed in the example following where service delivery
models were fully based on a volunteer system.
Easy Care Gardening, New South Wales (home maintenance)
Easy Care Gardening is a volunteer-based organisation that delivers HACC funded home
maintenance services, namely gardening and lawn mowing services, primarily using a volunteer
workforce. As it is a volunteer gardening service, services are more cost effective than those
operating commercially. Additionally, Easy Care volunteers also share morning or afternoon tea
with consumers, adding a social aspect, including social support, to the service provided.
Why is it innovative?
The initiative is perceived as innovative and a model of good practice as it is cost effective,
scalable, and involves the collaboration of parties and encourages consumers to participate and
assist service providers with tasks, as well as promoting community development and social
capital through the use of volunteers. This cooperative service alternative to general gardening
36
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services creates good social and community bonds that are perceived to create flow-on effects
for consumers’ well being, and assist in tackling the issue of social isolation that is experienced by
many consumers.
What good practice principles are evident?

Person-centred and individualised

Re-ablement approach

Timely

Promotes partnership
Preventative approach to home maintenance
The example below shows how home maintenance service offerings can be adapted to better
meet consumers’ long-term needs.
Baw Baw Shire Low Maintenance Garden project, Victoria (home maintenance)
A service provider in a rural location has focused on determining why consumers require garden
maintenance, and which activities they are able and interested to undertake to maintain their
gardens. Based on this, the service provides a single make over of the garden, to ensure the new
garden is better suited to the consumer’s needs, and reduces the need for ongoing services.
Why is it innovative?
This initiative involves the replacement of consumers’ gardens with low maintenance gardens.
This is perceived to improve consumer function and independence, motivation and selfconfidence, and physical activity in the garden. Feedback from consumers has been positive, as it
allows them to continue with the tasks they enjoy in the garden.
What good practice principles are evident?

Person-centred and individualised

Re-ablement approach

Outcomes focus
37
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6 Future opportunities
This section outlines opportunities to both strengthen and re-orient the Commonwealth HACC
home modifications and home maintenance service types to provide a more consistent and
effective approach to service provision within the Commonwealth Home Support Programme. It
provides an overview of the opportunities, the issues it seeks to address, the timing for the
option, potential benefits and implementation considerations.
The review of Commonwealth HACC home modification and home maintenance service types
has outlined that the current service delivery system is inconsistent across and within each
Australian jurisdiction. For both service types, this has resulted in:

inequity in services that can be accessed

significant variation in the types of services that can be accessed

provision of services that do not have strong alignment to the aims of the Commonwealth
HACC Program

inequity in the payment of fees and accessing support to pay fees.
In addition there are:

no consistent access or assessment processes (with the exception of Western Australia)

variable use of standardised tools

limited follow up/re-assessment

data reporting requirements that are not meaningful or do not provide insight into the
delivery of each service type

home modification services are often provided within siloed settings, without consideration
of other solutions, or embedded within a re-ablement approach.
There are a number of opportunities to address the issues identified as part of the review. The
key opportunities that need consideration for implementation at the commencement of the
Commonwealth Home Support Programme are:

a regionally based common access point and consistent eligibility screening and initial needs
assessment, with capacity for a specialised functional home based assessment

development of a well-defined service delivery model for home maintenance which targets
services to consumers who have the least ability to maintain their homes, where this is
affecting their safety and/or ability to remain in their home

consistency within the home modification service model which primarily funds simple home
modifications, and some complex modifications

grouping the service types of goods and equipment with home modifications, with a view
towards enabling more flexible use of funds across the services

consistent review processes
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
consistent fees policy.
Additional opportunities have been outlined that can be considered once the initial re-orienting
of Commonwealth HACC services into the Commonwealth Home Support Programme has
occurred.
For the purposes of section 6, “short term” refers to opportunities for implementation from 1 July
2015. “Long term” refers to opportunities for implementation after 1 July 2015.
6.1 Opportunity area
prioritisation
one
-
access,
assessment
and
The key opportunities to improve access and assessment for home modifications and home
maintenance are to:

create consistent and visible entry point to the services through the Aged Care Gateway;

ensure consistent, evidence based assessment as part of assessment for all HACC services as
part of the Aged Care Gateway (with provision for specialist occupational therapy
assessments as needed); and

ensuring a consistent, equitable approach to prioritisation of service delivery.
The term assessment, within Opportunity area one and all other Opportunity areas indicates
assessment undertaken through the Aged Care Gateway.
Opportunity area 1) Consistent entry and assessment through the Aged
Care Gateway for home modifications and home maintenance services
Issue/s to be addressed: unclear and multiple entry points, inconsistencies, and lack of
standardised tool usage in the current assessment process.

Entry to home modification and home maintenance service types needs to occur through a
common access point, which is visible, readily identifiable by the older population and easy
to access through a range of modes (for example telephone and internet). The Aged Care
Gateway would be able to provide a common and consistent access point for these service
types to all older Australians.

Assessment (as defined in the Glossary) should also be undertaken through the Aged Care
Gateway, and is already a proposed feature. The assessment process needs to be consistent,
evidence based (where possible) for all consumers accessing Commonwealth HACC services
and be part of a holistic assessment, including consideration of consumer’s choice and
preferences, and the potential for re-ablement.

Due to the specialist nature of home modifications, an additional layer of assessment is
required which should include consideration of intersections with other service types such
as goods and equipment and rehabilitation. See Opportunity 3 for additional details on the
specialised assessment.
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
Initial prioritisation for both service types should be undertaken as part of the assessment
process.
Potential benefits

A common access point will facilitate consumer access to the most appropriate services.

A common assessment process will enable:
-
consistent approaches to assessment and prioritisation
-
consideration of a holistic approach
-
identification of best service options to meet consumer needs
-
less inequality in accessing services
-
collection of more consistent information on consumers accessing services.
Implementation considerations
Current arrangements for occupational therapy assessments could remain in place until new
arrangements for the specialised assessment can be undertaken.
6.2 Opportunity area two - service provision for home
maintenance
The key opportunities to improve service provision for home maintenance are:

consistent delivery of home maintenance services, with services delivered to those least able
to fund home maintenance themselves, and who require services to support their safety and
to allow them to remain in their own home;

cap on the provision of home maintenance services; and

development of alternative home maintenance services to support consumers including
databases for tradespeople, services to assist in downsizing/relocation, and private service
provision for home maintenance.
Opportunity area 2a) Short term service delivery model for home
maintenance
Issue/s to be addressed - inequity and inconsistency in service provision and regulatory
requirements.
For 1 July 2015, the home maintenance service type needs to be reconfigured to ensure equity of
services, and that service provision aligns with agreed good practice.

Home maintenance services should be subsidised by government to assist older people to
remain in their own homes, with services targeted to those who have the least capacity to
self fund maintenance work. If consumers have the capacity to self fund services,
consideration should be given to either providing services on a full cost-recovery model, or
40
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referring consumers with financial capacity to pay to the private market. It is noted that, in
most regions, maintenance services can be provided for competitive prices through the open
market.

The core services to be provided and funded within home maintenance must be identified
and need to be broadly consistent across Australia. There does need to be some capacity for
local flexibility (for example, yard clean ups and gutter cleaning may not be in the core suite
of services for home maintenance, but potentially should be included in areas where there is
a high bush fire risk). This would be other than in the instance of squalor and hoarding or
where there is an Occupational Health and Safety Risk for staff entering the property, where
clean ups are required.

Services provided should be those that assist with the safety of the consumer (both inside
and outside of their home) and community accessibility. Services of a regular nature (ie. lawn
mowing or regular gardening) should be limited and be part of an approach where they assist
the consumer to be able to manage these activities better themselves in the long term.
Access to these services should be subject to well-defined eligibility criteria.

Service provision should align with the concept that the Commonwealth Home Support
Programme is an entry level home support program. When the requirements of home
maintenance are more than for an entry level program (either due to the overall cost or
frequency of service or combination of both), consideration needs to be given to referring
the consumer for a re-assessment and consideration of other options (for example a home
care package or residential care).

Specialised squalor and hoarding services should be considered, with the appropriate mix of
health professional and home maintenance staff involved in the services, particularly in rural
and remote areas where these services are not readily available.

Consumers eligible to receive home maintenance services should have an annual monetary
cap on the amount of services they receive. This will allow consumers, in conjunction with
service providers, to prioritise maintenance that is essential for the consumer’s safety and
capacity to remain within their home. The cost of providing home maintenance services in
different geographical areas varies and this should be taken into consideration when defining
annual monetary caps.

In addition to the provision of home maintenance services, there was a broader need
identified in this review to support older people to access appropriate tradespeople to
maintain their homes. If the number of people able to access funded home maintenance
services is reduced, consideration could be given to developing a central online database of
tradespeople who are able to provide services to older people. These can then be accessed
independently, and funded by the consumer without the need for a CHSP assessment.

Processes for the provision of support to assist older people in downsizing from their family
home in order to reduce maintenance requirements (and need for home modifications - see
opportunity area 3b) should be established. This includes identifying how they downsize and
access support to undertake the process.
41
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
It is recommended that no additional regulatory requirements be established, other than
those currently required through individual state and territory legislation.
Potential benefits

This will provide a more equitable and sustainable home maintenance service.

The service will be targeted to those people who have the most limited means to maintain
their home, to allow them to remain safely at home for longer.

A more targeted approach to services will allow more people to access services whilst not
increasing funding.
Implementation considerations
There may be challenges in implementing the reduced number and/or type of services, and
limiting accessibility for some consumers. This may impact on the services consumers are
currently receiving, as there are many long term consumers of home maintenance. The
Department will require a detailed implementation plan and change management strategy. This
may include consideration of grandfathering current consumers and/or making small changes to
service delivery over time, instead of ceasing service delivery with the implementation of the
new model. It may also include increasing the fees charged to existing consumers to support full
cost recovery.
Opportunity area 2b) Long term service delivery model for home
maintenance
This identifies an alternative market to service delivery for home maintenance services to be
considered following 1 July 2015.

Private home maintenance services are readily available in the community, and can often be
provided at a reduced cost to home maintenance service providers. A long-term option for
home maintenance services could include the implementation of a voucher system. Please
note: this system would be for the same target cohort outlined in Opportunity area 2a above.

This would involve:

-
initial assessment through the Aged Care Gateway
-
on identification of home maintenance needs and eligibility for subsidised home
maintenance services, one or more vouchers for local providers would be issued
-
payment of vouchers would not occur until confirmation of satisfaction and completion
of the job with the consumer.
This would require the development of a database of suitable tradespeople, which could be
the same database developed as part of the short to long term service option.
Potential benefits

reduction in workforce shortages and supports consumer choice.
42
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
reduction in regulatory burden, and ensures suitably qualified people who understand the
local environment are undertaking home maintenance services.

supports competitive pricing for service delivery.
Implementation considerations:
In implementing this opportunity, consideration needs to be given to:

identification of suitable tradespeople

Departmental requirements of tradespeople

maintenance of the database.
6.3 Opportunity area three - service provision for home
modification
The key opportunities to improve service provision and need for home modifications are:

consistent delivery of home modification services, with a focus on simple modifications, but
which includes the capacity to undertake complex modifications in some circumstances

the use of a home modification service delivery model that incorporates an occupational
therapist within the team

development of alternative home modification services to support consumers, including
information services, downsizing/relocation services and which support use of universal
design principles

greater alignment of home modifications with goods and equipment.
Opportunity area 3a) Short term service delivery model for home
modifications
Issue/s to be addressed - inequity and inconsistencies in service provision including consistent
definitions and regulatory requirements.

A glossary with consistent terminology and service items needs to be considered for home
modifications, with the option of changing terminology from ‘minor’ and ‘major’
modification to ‘simple’ and ‘complex’ modification. Consistent terminology and service
items would ensure more accurate reporting of funding spent in each area across all states
and territories. Simple home modifications would include home modifications up to a low
dollar amount (for example $1,000 of the cost to the Commonwealth), which would likely
incorporate around 90 per cent of current home modifications, and complex modifications
reflecting more expensive home modifications (due to cost and/or number of home
modifications). The home modification program should aim to maintain the mix of simple to
complex modifications, and this will need to be reviewed regularly.

Service provision should align with the concept of the Commonwealth Home Support
Programme as an entry level home support program, with funding primarily for simple home
43
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modifications, and complex home modifications up to a specified amount. This amount
should be set based on current service delivery, where it would cover approximately 98 per
cent of home modifications through the current program, which is currently a
Commonwealth contribution of $10,000. Funding for the Occupational Therapy assessment
sits outside of the $10,000 cap.

The use of simple and complex terminology would drive the requirements for assessment. It
is proposed that simple home modifications may not require a specialist assessment by an
occupational therapist. Rather, a trained health professional, including assessors who are
undertaking the Gateway assessment, would be able to identify the need for home
modifications. If it is anticipated the home modification is complex, the assessment should
be undertaken by an occupational therapist who will assess need for home modification, as
well as consider alternative solutions that may be more suitable (for example assistive
technology).

The occupational therapist needs to have the capacity to undertake a face-to-face specialist
assessment (either in person or via technology) and, if possible, undertake the specialist
assessment with the builder. Where practical, the occupational therapist and builder should
be employed within the organisation that is co-ordinating the implementation of the home
modification. This should be undertaken at a service provider level.

Through holistic assessment (as outlined in opportunity 1), consideration should be given to
identifying the most appropriate and cost effective solution, which may include goods and
equipment, and incorporate a re-ablement focus for the consumer to better align with good
practice.

The use of technology needs to be encouraged, particularly where it can assist in bridging
workforce shortages, supporting less experienced staff and supporting time efficient
practices within service delivery. This does not have to be expensive technology, as the
examples in Section 5.2 demonstrate.

It is recommended that no additional regulatory requirements be established, other than
those currently required through individual state and territory legislation.
Potential benefits

This will provide a more equitable and sustainable home modification service.

Realignment of the home modification service to the principles of the Commonwealth Home
Support Programme as an entry level home support program.

Re-orientation of the program to a re-ablement approach, which is associated with better
consumer outcomes.

Reduced confusion with regard to program and jurisdictional requirements.
Implementation considerations
In implementing this opportunity consideration needs to be given to:

developing a clear communication strategy for consumers and providers
44
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
the implications of reducing funding for major home modifications (now complex
modifications)

funding for occupational therapy to service providers

the need for this approach to be supported by other service providers who are providing
ongoing services to consumers that may be diminished or negated by the prescription and
installation of goods and equipment or home modification

capacity of service providers to support and manage occupational therapists.

The implementation of the National Disability Insurance Scheme (NDIS) also needs to be
considered as part of implementation. The NDIS will fund home modifications for people
with a disability under the age of 65 years. In the pilot sites, unit prices have been allocated
to common home modifications, and occupational therapy assessments, and registered NDIS
providers can undertake home modifications. The final model for home modifications under
NDIS has not yet been developed. Consideration needs to be given to the intersection
between NDIS and Commonwealth Home Support Programme provision of home
modifications, as well as areas of overlap and potential leverage. For example, it is likely that
with the introduction of NDIS there may be increased numbers of organisations with the
skills to provide home modifications, which may broaden the number of organisations
capable of being funded through the Commonwealth Home Support Programme. In
addition, the setting of unit prices may provide opportunities for the Department to consider
unit pricing, instead of block funding as a basis for its funding in the long term. There should
be consideration of the current Commonwealth investment and a transition period will need
to be considered, given the NDIS will be fully implemented in 2018/19.
Opportunity area 3b) Long term model for service provision for home
modifications
This presents alternate services to support the provision of home modifications, for
consideration following 1 July 2015.
The three alternate models for the provision of home modifications include:

Information and support for self funded home modifications, to assist with private
modifications being undertaken that are suitable and fit for purpose.65

As with home maintenance, a need was also identified for support to assist older people to
downsize from their family home to a more suitable property that may be more fit-forpurpose (see opportunity area 2a). This includes identifying benefits in downsizing, instead of
modifications, and accessing support to undertake the process.

The Department supporting and advocating for the use of universal design principles in all
new residential buildings.
65
Asbestos management should be considered when making any attempt to support or supply private
modification information to clients and this is a compliance issue that applies in each state and territory.
45
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May 2014

Increase options and accessibility to options of regulated draw down mechanisms to assist
consumers to access equity in their homes.
Potential benefits

Improve capacity for consumers who have the funds to undertake their own home
modifications.

Reduce the need for home modifications in the future.
Implementation considerations
The key issues for implementation are:

Identification of funding sources to support the additional activities.

How best to identify the cohort that can self fund home modifications, as this is not always
linked with income.
Opportunity area 3c) Funding of related HACC service types and groups
under similar service groupings
Issue/s addressed - duplication and lack of intersection with relevant service groups.
In order to support the development of the best option and outcomes for all consumers
accessing the CHSP, the following service types and groups should be considered to be funded
together:

Home modifications and goods and equipment to ensure the most appropriate and cost
effective solution is identified for each consumer.

Grouping the service types of home maintenance and domestic assistance with a view
towards enabling more flexible use of funds across the services, as there are similarities
between these services, with many home maintenance activities involving cleaning, although
on a less regular basis than generally provided with domestic assistance.

Consideration also needs to be given as to how the grouping of current services may
limit/enhance re-ablement approaches if home modifications and/or goods and equipment
are provided by standalone providers that do not provide a suite of other CHSP services.66
Potential benefits

Identification of the most appropriate and cost effective solution for each consumer.

Increased opportunities for a holistic and/or re-ablement approach for the consumer.

Limit multiple occupational therapy assessment for each service type (for goods and
equipment/home modification).
66It
should be noted that construction services, including asbestos management, are often very different from the
suite of services provided by most aged care providers, which primarily relates to state compliance issues.
46
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
Potential for cost savings through identification of the most appropriate solution and
limitation of multiple assessments.
Implementation considerations
Some jurisdictions currently fund home modifications and goods and equipment service types
together, whilst others would require a significant reconfiguration in order to support delivery of
both service types. For example, many jurisdictions (for example New South Wales and Victoria)
have multiple home modification providers, which may require assessment in terms of feasibility
in funding these two services types together.
6.4 Opportunity area four - consumer co-payments and fees
The key opportunities to improve consumer co-payments and fees for home modifications
and home maintenance are:

consistent approaches to fees, waiver of fees and payment plans

sliding scale for contributions of fees based on capacity to pay.
Opportunity area 4) Consistent approach to consumer co-payments
and fees for home maintenance and home modifications
Issue/s addressed - inconsistent approaches to consumer co-payment, including means testing
and payment plans.

Nationally consistent guidelines for consumer co-payments and fees need to be developed.
This needs to consider:
-
A consistent approach to means testing (or proxy measure) to determine capacity to pay.
-
A sliding scale for contributions, which decreases as capacity to pay increases.
-
For home modifications, the sliding scale may be different to other services within the
Commonwealth Home Support Programme, due to nature of the service,
-
A consistent approach to payment plans when services are one-off services (ie. home
modifications) including length of plans, payment of interest.
Potential benefits

Equity and transparency in fees and payment plans across all consumers.

Ability to support consumers who can least afford services, to access the services they need,
whilst ensuring consumers who can fund/part fund services contribute appropriately to
service dependent on their individual circumstances.
47
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Implementation considerations
Service providers are keen to have detailed information on fees, co-payments and payment
plans. A change management process, including a communication plan, will need to be
developed to support the implementation of a consistent fees policy.
6.5 Opportunity area five - follow up processes
The key opportunities to improve follow up processes are:

requirements for review and re-assessment to be undertaken

identification of outcomes to be considered as part of re-assessment.
Opportunity area 5) Consistent approach to review and re-assessment
for home modifications and home maintenance services
Issue/s addressed - inconsistent follow up and review.
Follow up processes need to be developed for both home modification and home maintenance
services.

Consumers should be followed up after all one-off home maintenance services. This could
occur over the telephone. If ongoing maintenance services are provided, a re-assessment
should occur at a minimum every 12 months. The reassessment should be outcomes focused
and consider the consumer’s feedback on the home maintenance, impact on functional
ability/independence, accessibility (including internal accessibility and community access)
and ability of home maintenance to meet the goals identified by the consumer.

For simple home modifications, review could occur over the telephone. For complex
modifications, this should occur in person. In the case of complex modifications, the review
should be outcomes focused and include a component of quality assurance. It should
consider if the home modification has been installed as per prescription and to a level of
acceptable quality, the effect on safety, including risk of falling, accessibility, functional
ability/independence, community access, and ability of modification to meet the goals
identified by the consumer.

In order to support further evaluation of the impact, outcomes and benefits of both services,
the Department should consider reviewing outcomes across a longer period of time. Longer
term outcomes would include the level of independence over time, level of supports
required, rate of hospitalisation, the time to re-location and/or residential aged care, and for
home modifications, suitability of home modification over time.
Potential benefits

Ensures the service type has met the needs of each individual consumer.

Better understanding of outcomes of both service types.
48
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Implementation considerations
A reassessment tool will need to be designed, and guidelines for re-assessment incorporated into
the CHSP guidelines. The re-assessment component will need to be accompanied by education
and support tools, as this is not common practice. Consideration will also need to be given to the
perceived lack of funding, as many service providers indicated they did not undertake
reassessment due to a lack of funding.
6.6 Opportunity area six - workforce - home modifications
The key opportunities to improve workforce for home modifications are:

recognition of the role of occupational therapist in home modifications as a specialist
position

additional support for professional development, supervision and mentoring for builders and
occupational therapists.
Opportunity area 6) Appropriately skilled and supported workforce for
home modifications
Issue/s addressed - lack of skilled workforce and the disconnect between health professional
staff, service providers and builders for home modifications.

Occupational therapists need to be part of the assessment process to determine the
functional limitations of the consumer and subsequent recommendations. This may include
the use of goods and equipment or rehabilitation under the Commonwealth Home Support
Programme in order to reduce the need for home modifications. Due to the specialist nature
of home modifications and prescription of goods and equipment, this should, where
possible, be a senior position. Where this is not possible, models to provide support,
supervision and mentoring of junior occupational therapists need to be developed.

To improve the integration of occupational therapists into the provision of home
modifications, the occupational therapist should be funded and located with the service
provider where possible. If the occupational therapist is not funded through the service
provider, clear and evident links to the service provider should be demonstrated, including
consideration of co-location with the service provider or using technology and innovative
service delivery options.

Other initiatives to support skill development and integration of both occupational therapists
and builders include the development of service models that incorporate joint assessment
visits by the occupational therapist and builder (as outlined in section 5.2 Alternative service
delivery models), and joint professional development events for occupational therapists and
builders.

Specific professional development events should be established to support builders working
in home modifications to improve their knowledge and understanding. These do not have to
be formal events, but may include informal gatherings to promote knowledge sharing.
49
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Potential benefits

Ensures sufficient knowledge and understanding of occupational therapists and builders
working in home modifications.

Supports development of occupational therapists and builders.
Implementation considerations:

It will need to be introduced gradually, as current funding expires.

This option should be piloted initially to ensure a model has been developed that will work
and be sustainable in the longer term.

A range of models, including the use of technology, will need to be considered for regional
and remote services.
6.7 Opportunity area seven - data collection and reporting
The key opportunities to improve data collection and reporting for home modifications and
home maintenance are:

improve the collection of home modifications and home maintenance data

reduce red tape, as per the Federal Government commitment.
Opportunity area 7) Data collection and reporting for home
modifications and home maintenance
Issue/s addressed - inadequate quantitative data on the actual services delivered under the
broad banners of home maintenance and home modifications, and the actual unit costs of
those services.

Increasing the scope of information collected in the HACC MDS regarding the range of
services delivered under the banner of home modifications and home maintenance would
allow for more rigorous monitoring of the program (noting that this information is already
available at the provider level, but is not reported at the national level).

Amending the way in which home maintenance units are reported (from ‘hours’ to the dollar
cost per instance service), which would allow for more rigorous monitoring and provide a
clearer picture of the actual costs of service delivery, including variations in costs across
different geographic areas, range of services being provided and should have an outcomes
focus.
Potential benefits

Will allow for a more accurate understanding of the range of services provided, where they
are provided, and the actual unit costs of services.

Will allow for quantification of issues that have been qualitatively identified in this review,
such as inequity of service provision and variable costs of service delivery.
50
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
This will facilitate better monitoring of the program, which can in turn contribute to more
effective methods of review and continuous improvement.
Implementation considerations

The introduction of the central client record will, over time, assist in reducing the burden for
data collection on service providers.

Data development takes considerable time. Providers will all currently hold this information
in their own systems, but there is likely to be very little consistency in the way they record
and manage that information.

Any changes to the national data collection will also need to be considered within the
broader context of other possible changes to the HACC MDS arising from other HACC
program reviews currently underway as well as the broader aged care reforms.
51
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6.8 Opportunity area eight - general
A small number of other general opportunities were identified for both home modifications and
home maintenance. These cover:

supporting vulnerable populations

program guidelines.
Opportunity area 8a) Supporting home modification and home
maintenance service delivery to vulnerable groups including rural and
remote populations, Indigenous populations and CALD populations
Issue/s addressed - increased costs of delivery of services to rural and remote populations and
the challenges in engaging with indigenous and CALD populations.
Key options to better support vulnerable groups include:

A loading should be included in funding to reflect the increased costs associated with the
delivery of services in rural and remote areas.

Cost travel time into funding in rural and remote areas.

Support development of partnerships between ACCHO/CALD organisations and HACC service
providers to develop models that will reach these populations.
Potential benefits

Development of service models that will engage with vulnerable groups that are currently
not accessing these services.

Improve equity in accessing services.
Implementation considerations
As these groups access services at a lower rate compared to other groups in the target
population, considerable work needs to be undertaken with stakeholders to ensure that the
developed models will be accessed by vulnerable groups. Consideration of innovation funding to
develop and evaluate pilot programs may be an option to identify models that will be successful.
Opportunity area 8b) Commonwealth Home Support Programme
manual for home maintenance and home modifications
The Commonwealth Home Support Programme manual for home maintenance and home
modifications needs to contain detail to ensure that service providers can confidently deliver the
service types, within the parameters of the program.
This includes sufficient detail on:

Types of services that can and cannot be provided.

The nature of service provision.
52
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
Workforce to support service provision.

Fees and payment plans.

Requirements for adherence to jurisdictional regulations.

Re-assessment including evaluation of impact of service.

Interface with other programs including home care packages and NDIS.
Potential benefits

Support consistent implementation of the Commonwealth Home Support Programme.
Implementation considerations
This needs to be implemented with a change management and communication strategy, to
ensure that all organisations understand the existence of the new guidelines, and requirements
to adhere to these, instead of previous jurisdictional guidelines.
53
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Appendix A: Review methodology
Based on the focus areas, a range of questions were developed by DSS to guide the review.
These are outlined in the table below. Subsequently, KPMG mapped the key areas for
investigation and associated questions to an approach for the review. The mapping of
approaches is outlined included within Table A1.
Table 10: Key areas for investigation in the review of Commonwealth HACC home modification
and home maintenance service types
Key areas for investigation
Current service system models and usage
 What are the different models amongst jurisdictions and providers? Are there any guidelines,
if so, what are they?

What are the strengths, weaknesses and synergies of each model?

What common activities are undertaken in each of the service types in each jurisdiction and
where are the overlaps and differences?

What are the eligibility criteria for a consumer to access services in each jurisdiction?

How do jurisdictions prioritise access and does it work?

What are the capping arrangements in particular jurisdictions?

Are volunteers used, if so, for what?

How do service providers establish the total cost of a job and what percentage is the
consumer expected to pay?

Are there any jurisdiction specific or other issues which could act as a barrier to national
uniformity, e.g. legislation/standards etc?

Are there other jurisdictional/Commonwealth programs providing home modifications to
older people?

What quality assurance is being given to consumers on the jobs performed? How are jobs
being checked to ensure standards are met?

Who pay for jobs to be re-done if standards are not met?

What jobs are being undertaken under Commonwealth HACC Program home modifications?
What is the most common job undertaken in each jurisdiction?
What are the different levels/categories for major home modifications in each jurisdiction?
Method
Primary method
Desktop review
Jurisdictional interviews
Questionnaire
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Stakeholder consultations
Secondary method
 Data analysis
Key areas for investigation
Evidence and good practice models
 Is there evidence that provision of home modifications and maintenance allows older people
to stay in their homes longer/delays admittance to residential care?

How else are outcomes evaluated in relation to home modifications and maintenance?

What are the impacts, outcomes and benefits of home modification on older consumers
including re-ablement?

What does the literature and evidence indicate about good practice models/service systems?

What technology innovation is being used to achieve efficient and effective service delivery,
especially in rural and remote areas?
Method
Primary method
Literature review
Secondary method
Stakeholder consultations
Questionnaire
Key areas for investigation
Degree of integration with other systems
To what extent is there duplication with other programs?
Method
Primary Method
Service mapping
Questionnaire
Stakeholder consultations
Key areas for investigation
Data and Reporting
 What home modification and maintenance data is available, for example:

-
number of outputs by service providers over time
-
time taken per output
-
types of jobs being undertaken per service type.
The data analysis is to also identify any jurisdictional differences.
55
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Method
Primary method
Data analysis
Secondary method
Stakeholder consultations
Key areas for investigation
Unit Costs/Fees
 What are the costs associated with delivering the various components of the service type?

How are unit costs currently being determined? (Has the unit cost changed over time? Are
the unit costs different in each jurisdiction? Is it possible to determine a unit cost?)

How can fees be standardised while still ensuring equality to consumers?
Method
Primary method
Data analysis
Questionnaire
Stakeholder consultations
Key areas for investigation
Provider characteristics
 Who are the major providers, what mix of services is provided? (For example, who provides
only home modifications and who provides a combination of home modifications and other
service types?)

What types of organisations are operating in each of the sectors?

Who is demonstrating innovative practice?
Method
Primary method
Data analysis
Secondary method
Service mapping
Questionnaire
Stakeholder consultations
Key areas for investigation
Consumers
What is the profile of the consumers (age breakdown, gender, what jobs are being purchased)?
Method
56
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Primary method
Data analysis
Key areas for investigation
Workforce
 Strategies to attract engagement of volunteers (where appropriate)
Is there a skill shortage and/or lack of home modification training for occupational therapists
and tradespersons?

Are there any difficulties in recruiting staff to occupational therapist positions and identifying
suitably skilled tradespersons to undertake work?

How can occupational thereapists be supported?
Method
Primary method
Stakeholder consultations
Questionnaire
Source: Adapted by KPMG from Department of Health and Ageing Request for Tender for review of home modifications and
maintenance under the HACC Program
A.1 Methodological limitations and impacts
The approach to the review included a range of methods to enable the collection and
triangulation of information from a range of sources to support a comprehensive understanding
of the program. There were, however, a number of challenges through the data and information
collection process that had some impact on the review and its ability to achieve comprehensive
understanding and analysis in some areas. These limitations and associated impacts broadly
relate to:

availability of literature to support a comprehensive understanding of the benefits, impacts
and outcomes of the two programs

limited access to consumers and their direct insights

clear, quantitative information on the range of services delivered under the banners of
‘home modifications’ and ‘home maintenance’

information on actual unit costs and associated fees/co-payments for services

limitations of the MDS data set.
57
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
Table 11: A.1 Methodological limitations and impacts
Method
Literature review
Issue and impact
The purpose of the literature review was to identify evidence supporting the provision of home
modifications and home maintenance service types, including good practice models.
How well did this approach assist in answering the key areas for investigation?
There was limited literature with regard to the efficacy of service models, outcomes and benefits
of home modifications and home maintenance. Whilst there is some literature suggesting
positive outcomes and benefits relating mostly to home modifications, the small number of
articles meant that it was not possible to definitely establish a conclusive evidence base
supporting the provision of home modifications and home maintenance.
The literature was able to provide evidentiary information to support an understanding of good
practice service delivery for home modifications and home maintenance
Method
Secondary data analysis
Issue and impact
This involved the secondary analysis of information accessed from the HACC National Minimum
Dataset (MDS). The purpose of the data analysis was to identify characteristics of home
modification and home maintenance services of consumers in each jurisdiction, and to explore
patterns and trends in service delivery and costs.
How well did this approach assist in answering the key areas for investigation?
The secondary data analysis confirmed a number of assumptions about consumer characteristics,
but also raised questions about the equity of service distribution and delivery (these issues were
explored further in the desktop review, questionnaire and consultations).
The secondary data analysis was constrained by the limitations of the MDS dataset, which
prevented detailed exploration of the types of goods and services provided under the broad
banners of modification and home maintenance, inconsistencies across jurisdictions in reporting,
and a lack of data relating to costs.
Method
Desktop review for mapping report
Issue and impact
The purpose of the desktop review was to identify the range of home modification and home
maintenance services in each jurisdiction (HACC and non-HACC), and to understand elements of
the service models used in each jurisdiction.
58
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
The desktop review involved online searches of relevant grey literature and agency websites.
How well did this approach assist in answering the key areas for investigation?
The desktop review was successful in gathering preliminary information about the range of
services available, and in identifying likely gaps and overlaps within the system. This informed the
conduct of the consultations and the preparation of the questionnaire.
However, the desktop review was impacted by a lack of available online information for some
jurisdictions and outdated information for others.
Method
Jurisdictional interviews
Issue and impact
A small number of telephone interviews were conducted with HACC program officers within the
Department of Social Services state and territory offices. The purpose of these interviews was to
clarify gaps or inconsistencies in the information gathered through the data analysis and desktop
review.
How well did this approach assist in answering the key areas for investigation?
The interviews were of variable success, as many interviewees were unable to shed further light
on the identified issues and questions.
Method
Questionnaire
Issue and impact
An online questionnaire was developed with the Department and distributed to all HACC home
modification and home maintenance providers in Australia through the Department’s website.
The questionnaire was at least partially completed by 585 unique respondents (not all
respondents answered all questions within the questionnaire).
How well did this approach assist in answering the key areas for investigation?
The questionnaire proved an effective method of collecting information from providers. The
findings correlated with the information gathered through the desktop review and consultations,
which was particularly helpful in validating identified gaps and issues across the service system.
Method
Provider and peak body consultations
Issue and impact
Workshops with home modification and home maintenance providers, as well as peak bodies,
were held in each capital city and in three regional areas.
How well did this approach assist in answering the key areas for investigation?
59
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.
Final report
HACC home modification and home maintenance review
May 2014
The consultations were broadly helpful in validating information gathered through the desktop
review and questionnaire. However, the limited consultation in regional areas prevented a
comprehensive view of regional services and issues across Australia.
Method
Consumer consultations
Issue and impact
Consultations were conducted with a limited number of consumers, carers and consumer
representative groups.
How well did this approach assist in answering the key areas for investigation?
Recruitment of consumers was problematic, resulting in a very small sample. Insights from the
consumer consultations are therefore relatively limited, and it would be difficult to extrapolate
these findings to the majority of consumers accessing home modification and home maintenance
services.
Source: KPMG
60
© 2014 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG
International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name, logo and "cutting through complexity" are registered trademarks or trademarks of KPMG International Cooperative
("KPMG International").
Liability limited by a scheme approved under Professional Standards Legislation.