Department of Social Services
Formative evaluation of the Home
Care Packages Programme
Detailed findings report
April 2015
Inherent Limitations
This report has been prepared as outlined in the Introduction Section and Appendix A. The services
provided in connection with this engagement comprise an advisory engagement, which is not subject to
assurance or other standards issued by the Australian Auditing and Assurance Standards Board 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 stakeholders consulted
as part of the process.
KPMG has 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 Department of Social Services in accordance with
the terms of KPMG’s Official Order dated 7 April 2014 and the Deed of Variation dated 18 July 2014.
Other than our responsibility to the Department of Social Services, 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.
Contents
Glossary ................................................................................................................................ 6
Abbreviations ...................................................................................................................... 8
1
Introduction and purpose of this report ........................................................................... 9
1.1
Programme context and background....................................................................... 9
1.2
Evaluation framework ............................................................................................11
1. How effective has the implementation of the Home Care Packages Programme been?
......................................................................................................................................11
2. Are there any operational issues or possible adjustments needed?..........................12
1.3
Spectrum of CDC - service orientation ...................................................................12
1.4 Structure of this report...............................................................................................14
2
Implementation of the Home Care Packages Programme .............................................15
2.1
Programme implementation timing .........................................................................16
2.2
Implementation approach by the Department .........................................................16
2.3
Communication and support materials ...................................................................17
2.3.1
2.4
Effectiveness of support materials ...................................................................17
Assessment and referral processes .......................................................................21
2.5 Consumer care fees....................................................................................................23
2.6 Administration and case management fees.................................................................24
2.7 Implementing new administrative requirements ..........................................................26
Processing of subsidy claims by the Department of Human Services (Medicare) ..........26
Role of aged care advocacy services ............................................................................27
2.8
Interface with other services ...................................................................................27
2.9
Other issues relevant to the Programme implementation .......................................29
Dementia and cognition supplement .............................................................................30
2.10
3
Acceptance of programme change and commitment to CDC .................................31
Transitioning to consumer-directed care........................................................................31
Summary of key points: development of and transition to CDC .....................................32
Main considerations for providers in transition were: .....................................................32
3.1
Provider readiness for CDC....................................................................................32
3.1.1
Classifying providers’ level of CDC readiness .................................................34
3.1.2
Activities undertaken to prepare for CDC implementation ...............................35
Internally, activities included: .........................................................................................35
Strategy and approach ..................................................................................................36
Systems ........................................................................................................................37
Management and board commitment ............................................................................38
Staff commitment, skills and capabilities .......................................................................38
Culture and practice changes ........................................................................................38
3.1.3
Provider transition and readiness for CDC – key considerations .........................38
3.2
Transitioning existing consumers to CDC ...........................................................39
Process for transitioning existing consumers .................................................................41
Consumer experience of transition to CDC....................................................................42
3.3
Key transition considerations for providers .............................................................43
Transitioning ‘high cost’ consumers ...............................................................................43
Systems changes and costs ..........................................................................................44
Administrative and coordination costs ...........................................................................44
Embedding practice changes ........................................................................................46
Other considerations .....................................................................................................46
Survey results ...............................................................................................................47
4
Consumer-directed care in action ..................................................................................48
4.1
Consumer choice and control .................................................................................48
4.2
Rights .....................................................................................................................49
4.3
Respectful and balanced partnerships ...................................................................50
4.4
Participation ...........................................................................................................51
4.5
Wellness and re-enablement ..............................................................................51
4.6
Transparency .........................................................................................................53
4.7
Considerations for special needs groups ................................................................53
4.7.1
People from Aboriginal and Torres Strait Islander backgrounds ......................53
4.7.2
People from culturally and linguistically diverse backgrounds..........................54
4.7.3 People who live in rural or remote areas...............................................................55
4.7.4
People who are financially or socially disadvantaged ......................................55
4.7.5 Veterans ...............................................................................................................57
4.7.6 People who are homeless or at risk of becoming homeless..................................57
4.7.7 Care leavers .........................................................................................................57
4.7.8 Parents separated from their children by forced adoption or removal ...................58
4.7.9 Lesbian, gay, bisexual, transgender and intersex people......................................58
5
Considerations for strengthening and improving home care and CDC...........................60
5.1
Supporting providers to implement CDC ................................................................60
5.2 Strengthened focus on re-enablement and wellness ...................................................61
5.3 Clarifying the basic care interface ...............................................................................61
5.4 Increasing knowledge of CDC across key agencies and services ...............................61
5.5 Trialling new approaches for under-represented special needs groups .......................62
5.6
Improving assessment and the continuum of care ..................................................62
5.7
Increasing consumer control through self-directed funding and portability ..............63
Appendix A
Evaluation methodology ..............................................................................64
Background ...................................................................................................................64
Objectives of the Home Care Packages Programme .....................................................64
Purpose of the formative evaluation ..............................................................................66
Evaluation questions .........................................................................................................66
1. How effective has the implementation of the Home Care Packages Programme
(including CDC) been? ..................................................................................................66
2. Are there any operational issues or possible adjustments needed to strengthen the
Home Care Packages Programme’s effectiveness in meeting its objectives? ...............66
Online survey for all Home Care Packages Programme home care providers ...............67
Review of de-identified Ministerial correspondence and Departmental communications67
Template report for Home Care Packages Programme providers delivering CDC places
......................................................................................................................................67
Evaluation governance and ethics .................................................................................72
Appendix B
Provider survey – detailed tables .................................................................74
Appendix C Survey results: Implementation of the Home Care Packages Programme ........80
Appendix D Survey results: Transition to Consumer Directed Care ......................................85
Appendix E Survey results: Preparing for Consumer Directed Care .....................................89
Appendix F Summary of key service provider data: range and cost of supports delivered
under CDC ...........................................................................................................................91
Range of supports accessed.............................................................................................91
In-house and brokered services ........................................................................................92
Appendix G Summary of key themes and issues from Ministerial and Departmental
correspondence....................................................................................................................95
Analysis of Ministerial correspondence .............................................................................95
Analysis of Departmental telephone and email enquiries ..................................................96
Glossary
Aged Care Assessment
Programme
Refers to the working arrangement between the
Commonwealth and state and territory governments to
operate Aged Care Assessment Teams (ACATs) or Aged
Care Assessment Services (ACASs) across Australia. The
core objective of this Programme is to assess the care
needs of frail older people and to assist them to gain
access to the most appropriate types of care, including
approval for Commonwealth subsidised aged care services.
Carer (or informal carer)
In this report, refers to an unpaid person who helps a home
care recipient with his or her activities of daily living.
Care worker (or personal care
worker, or direct care provider)
In this report, refers to a paid person who helps a home
care recipient with his or her activities of daily living, who
may either be employed or sub-contracted (‘brokered’) by
the recipient’s home care provider.
Consumer
A person who is receiving care and services under a Home
Care Package funded by the Australian Government. In the
Aged Care Act 1997, this person is referred to as a ‘care
recipient’.
Consumer directed care
(CDC)
An approach to the planning and management of care,
which providers consumers and their carers power to
influence the design and delivery of the services they
receive, including what services are delivered, and where
and when they are delivered.
Commonwealth HACC
Programme
This Programme provides home and community care
services for frail older people aged 65 years and over and
Aboriginal and Torres Strait Islander people aged 50 years
and over. The Commonwealth HACC programme does not
currently apply in Victoria and Western Australia.
Commonwealth Home
Support Programme
A programme commencing on 1 July 2015 in all states and
territories except Victoria and Western Australia, which
amalgamates the current Commonwealth HACC
Programme with three other programmes providing basic
support services for older people and their carers.
Dementia and cognition
supplement
A supplement of 10 per cent to the daily home care subsidy
payable for eligible consumers with dementia or cognitive
impairments.
Department
Department of Social Services.
Guidelines
Refers to the Home Care Packages Programme
Guidelines, July 2014, published by the Department of
Social Services.
Home care
A type of aged care for which a home care subsidy is
payable under Part 3.2 of the Aged Care Act 1997 and
Aged Care (Transitional Provisions) Act 1997.
Home Care Agreement
An agreement entered into by a consumer and a home care
Glossary
provider outlining rights and responsibilities and what
services will be provided to the consumer.
Home Care Package
A co-ordinated package of services tailored to meet a
consumer’s specific care needs. Commonwealth subsidies
under the package are paid to the provider at a fixed
amount by care level.
Home Care Packages
Programme
The Australian Government programme that provides a
subsidy to home care providers to support people to remain
living at home.
Home care provider (or
service provider, or provider)
An organisation approved by the Department of Social
Services under Part 2.1 of the Act as suitable to provide
home care. In the Aged Care Act 1997, this person or body
is referred to as an “approved provider”.
Home Care Standards
The Home Care Standards means the ‘Home Care
Common Standards’, as set out in Schedule 4 to the
Quality of Care Principles 2014.
Home care subsidy (or
subsidy)
The subsidy payable to a home care provider by the
Australian Government under Part 3.2 of the Aged Care Act
1997 and Aged Care (Transitional Provisions) Act 1997.
Income assessment
Refers to the means-testing conducted by the Department
of Human Services (Centrelink) to determine whether an
income tested care fee is payable by a consumer.
Income tested care fee
Refers to the fee a consumer may be asked to pay for their
home care, based on an income assessment.
Non-CDC package
A Home Care Package that is not yet delivered on a CDC
basis. From 1 July 2015, all Home Care Packages will be
delivered on a CDC basis.
Package (or place)
A co-ordinated package of care and services tailored to
meet the specific care needs of a consumer.
Re-ablement (or reablement)
The use of timely assessment and targeted interventions to
assist people to maximise their independence, choice and
quality of life and minimise support required – to enable
people to actively participate and remain engaged in their
communities.
Also referred to as wellness or restorative approaches.
Suspension
Term used when a consumer takes a period of leave from
their Home Care Package, and some or all services are
suspended.
Veterans’ supplement
A supplement of 10 per cent to the daily home care subsidy
payable for eligible consumers who are veterans.
Abbreviations
AACQA
Australian Aged Care Quality Agency
ACAP
Aged Care Assessment Program
ACAT
Aged Care Assessment Team
ACAS
Aged Care Assessment Service
ACCR
Aged Care Client Record
ACFA
Aged Care Financing Authority
ACQA
Aged Care Quality Agency
CACP
Community Aged Care Packages
CHSP
Commonwealth Home Support Programme
CDC
Consumer-directed care
DHS
Department of Human Services
DSS
Department of Social Services
DVA
Department of Veterans’ Affairs
EACH
Extended Aged Care at Home
EACHD
Extended Aged Care at Home Dementia
NACAP
National Aged Care Advocacy Programme
NDIS
National Disability Insurance Scheme
NRCP
National Respite for Carers Programme
1
Introduction and purpose of this report
Aged care reform in Australia has now been underway for a decade. As part of the Living Longer,
Living Better reforms, the Australian Government announced the Commonwealth Home Care
Packages Programme (the Programme) and implementation of Consumer Directed Care (CDC) by 1
July 2015.
In April 2014, KPMG was engaged by the Department of Social Services (the Department) to conduct
a formative evaluation of the implementation of the Programme, including the transition to a CDC
model of aged care service delivery from 1 August 2013.
The focus of a formative evaluation is the effectiveness of a programme’s implementation processes
and structures (compared to a summative or outcomes evaluation, which focusses on the extent to
which intended programme benefits have been achieved). Formative evaluations are usually
conducted early in a programme’s life to assess the extent to which a programme is being
implemented as intended, and to identify any areas where the programme could be strengthened or
improved to better position it to deliver its intended outcomes and benefits.
The purpose of this formative evaluation was to identify any operational issues or possible
adjustments required to strengthen the Programme’s effectiveness, and to ensure the successful and
complete conversion of all home care packages to CDC by 1 July 2015, as well as any longer-term
policy considerations.
The evaluation was conducted between April 2014 and February 2015, with core data collection
activities occurring from November 2014 to January 2015. Data collection activities relating to
consumers and carers were reviewed and approved by the Bellberry Human Research Ethics
Committee in August 2014 in accordance with the National Statement on Ethical Conduct in Human
Research (2007). The evaluation reported to the Department and an advisory committee of the
National Aged Care Alliance (NACA).
This report provides the detailed key findings from the formative evaluation, and identifies areas for
consideration to strengthen or improve the Programme.
1.1
Programme context and background
Home-based aged care services in Australia were significantly reformed in August 2013, with the
allocation of almost 6,000 home care packages (also referred to as home care places) under the 4level Home Care Packages Programme, and the conversion of around 60,000 former Community
Aged Care Packages (CACP), Extended Aged Care at Home (EACH) packages and Extended Aged Care
at Home Dementia (EACHD) packages to the new care levels. The care level structure is as follows:
• Home Care Level 1 – to support people with basic care needs (this care level did not exist
prior to August 2013);
• Home Care Level 2 – to support people with low level care needs (equivalent to the former
CACP places);
• Home Care Level 3 – to support people with intermediate care needs (this care level did not
exist prior to August 2013);
• Home Care Level 4 – to support people with high care needs (equivalent to the former EACH
and EACHD places).
Several new supplements were also introduced (including the dementia and cognition supplement),
that can be applied at any care level.
The Programme aims to provide a tailored, co-ordinated package of services that meet an
individual’s specific care needs, thus assisting care recipients to stay living in their own home and
providing them with choice and flexibility in the way the care and support is delivered. To facilitate
choice and flexibility, all new packages allocated since August 2013 are delivered under CDC
arrangements (that is, the 5,835 packages allocated in August 2013, and an additional 6,653
packages allocated in December 2014). Around 1,000 existing CDC packages, which had formed part
of the CDC pilot in 2010-12, have also continued under the new Programme. By 1 July 2015, all
remaining home care packages must convert to CDC arrangements. Over the past 18 months most
providers have been gradually transitioning their existing consumers to CDC arrangements as part of
their regularly scheduled reviews.
Under CDC consumers have an individualised care plan and budget with providers holding and
administering the budget on the consumer’s behalf. Commonwealth subsidies for care and services
are paid to the provider at a fixed amount by care level. The consumer receives a monthly statement
from the provider that itemises income (i.e. Commonwealth subsidies and supplements, plus
consumer fees and any additional consumer contributions) against expenditure showing unexpended
funds in their individualised budget.
The introduction of CDC to all home care packages on 1 July 2015 is prompting all providers to
reorient their business and review key elements of their organisation, including the organisational
culture, staff training needs and administrative systems.
Implementation of these arrangements has coincided with other aged care reforms, including the
introduction in October 2013 of a new online system for home care providers to submit aged care
subsidy claims to Medicare/Department of Human Services, and the introduction of income tested
care fees for new home care consumers from July 2014.
A number of other social service reforms have also occurred during this period, including changes to
residential aged care; commencement of design of the Commonwealth Home Support Programme
(CHSP) ; development of the aged care gateway (My Aged Care); and implementation of the National
Disability Insurance Scheme (NDIS) at various national trial sites. Many home care providers are also
providers of residential aged care, home support and/or disability support services, and have been
involved in these other reform activities at the same time as they have been implementing home
care packages and CDC.
1.2
Evaluation framework
An evaluation framework was developed in May 2014 to guide the data collection activities and to
provide the data analysis and reporting approach for the evaluation. Figure 1 below shows the
Programme results logic developed for the evaluation.
Figure 1: Results logic for the Commonwealth Home Care Packages Programme
The framework identified the following evaluation questions:
1. How effective has the implementation of the Home Care Packages Programme
been?
This involves consideration of the following:

How well are the new arrangements working for home care providers and ACATs? This
includes processes for implementing home care places, and the development and transition
to CDC models of service delivery (including different models of CDC); effectiveness of the
new care level structure and assessment processes; effectiveness of the intended graduated
continuum of care between care levels; effectiveness of the programme guidelines and
information processes; and considerations for different types of providers.

How well are the new arrangements working for consumers? This includes understanding the
range of care and services being accessed (including use of brokered services); application
and impact of fees; consumer perceptions of choice and control; consumer engagement with
individualised budgets and financial statements; effectiveness of information and advocacy
services; and considerations for special needs groups.

How well are the new arrangements working for the aged care system? This includes the
interface with other aged care services such as the current Commonwealth HACC
Programme (Commonwealth Home Support Programme from 1 July 2015); effects of the
new arrangements on consumer demand and expectations; waiting times; and provider
capacity and capability.
2. Are there any operational issues or possible adjustments needed?
This involves consideration of the following:
•
•
Are there any specific aspects of the Programme that could be strengthened or improved to
support the conversion of all home care places to CDC by 1 July 2015?
Are there any other aspects of the overall Programme that could be strengthened or
improved to meet its objectives?
The framework also sets out the methodological considerations for the evaluation, including
principles for conduct of the evaluation, issues and challenges to be managed, and the evaluation
governance arrangements.
Further detail on the evaluation methodology and data collection methods is at Appendix A of this
report.
1.3
Spectrum of CDC - service orientation
In this report, the concept of a spectrum of CDC orientation is used to describe and differentiate the
relative position of different providers in terms of the extent to which their service delivery is more
or less consumer-directed. Figure 2 below illustrates this spectrum.
Figure 2: Spectrum of consumer-direction in home care
Source: KPMG
Where providers are less advanced in the implementation of CDC, services are primarily ‘providerdirected’, with providers acting as care coordinators who make decisions about what supports will be
delivered to consumers based on their assessment of need, and their allocation from a centralised
funding pool.
Further along the spectrum, providers are more ‘person-centred’ in their approach acting as case
managers, using individualised assessment (which may include self-assessment tools) and actively
involving consumers in the planning of supports and offering them some level of choice over which
supports they use.
This however may be limited to a menu of available options with some level of control over when,
how and by whom supports are delivered. Providers ask consumers about their preferences and seek
to coordinate service delivery in response. Where consumers are less able to clearly express their
preferences (i.e. those with dementia or cognitive impairment, and/or who are non-verbal),
providers will seek to understand and respect the consumers’ lifelong habits and preferences, often
through discussions with the person’s family or carers. This may or may not include an indivdualised
budget for which the provider is accountable to the consumer.
At the other end of the spectrum where providers are more advanced in the implementation of CDC,
providers act more as care facilitators or care partners, assisting consumers to self-identify goals and
develop a tailored package of individualised care and supports to achieve those goals. Consumers
have choice and control over all aspects of service delivery, with an individualised budget. The
provider may or may not hold the funds.
1.4 Structure of this report
This report presents the detailed findings
from the evaluation. This report is structured as follows:
• Chapter 2 considers the effectiveness of programme implementation processes.
• Chapter 3 looks at the development of and transition to a consumer-directed model of
service delivery, focussing on home care provider readiness.
• Chapter 4 examines the operation of CDC in action.
• Chapter 5 identifies considerations for strengthening and improving home care packages and
CDC.
• The appendices set out the evaluation methodology and detailed data.
2
Implementation of the Home Care Packages
Programme
This chapter considers the effectiveness of the implementation of the Programme. The chapter
articulates the implementation planning undertaken by the Department then highlights key
challenges and considerations that have impacted implementation. It is focussed on the experiences
of home care providers and the wider aged care sector, including Aged Care Assessment Teams
(ACATs), also known as Aged Care Assessment Services (ACASs).
These findings were drawn from interviews with 25 home care providers (primarily managers and
care coordinators), 13 ACATs/ACASs across 10 aged care planning regions nationally, 14 aged care
sector stakeholder groups and the results from a national online survey completed by 29 per cent of
home care providers in December 2014. This information was supplemented with interviews
conducted with 57 consumers and carers nationally.
Summary of key points: programme implementation
• Overall, the majority of providers considered that the implementation of home care
packages has gone well.
– The new care level structure is supported and providers consider that it is a simpler
system that is easier to explain to consumers. The availability of supplements is also
strongly supported as a simple, fair model of meeting additional care needs.
– The transition from CACP/EACH to Level 2 and Level 4 has been more or less seamless,
and this was confirmed in the consumer and carer interviews.
– The introduction of Level 3 is widely supported by providers, ACATs/ACASs and other
stakeholders.
• However, several factors have impeded the smooth implementation of the Programme,
notably: timeliness of advice and communications; the subsidy claiming processes; and
access to the dementia and cognition supplement.
• There have been some concerns raised regarding the interface between home care Level 1
and HACC/CHSP basic support services; this may be resolved as the CHSP implementation is
progressed.
• There are concerns regarding the potential impact of income tested care fees on occupancy
of places, as it is has been anecdotally observed that some part-pensioners and self-funded
retirees are declining subsidised home care, but this has not yet been validated by data.
• Providers report that they have experienced considerable administrative costs associated
with the implementation.
• There is some inherent reluctance to implement CDC due to concerns regarding resourcing
and costs; required changes to business models; and the perceived capacity of CDC models to
respond effectively to special needs groups.
• Stakeholders also suggested that leave (suspension) rules are too complicated, that ACAR
allocation processes do not meet the needs of some vulnerable communities, and that the
distribution of care level places may not be supporting a continuum of care for consumers.
2.1
Programme implementation timing
The timetable for implementation of the Programme was announced in November 2012.
Implementation commenced from 1 August 2013, with the new 4-level home care framework and
broadbanded ACAP assessment framework, and the allocation of all new packages on a CDC basis. A
date was set for the conversion of all existing home care places to CDC by 1 July 2015. In July 2014,
income tested fees for home care consumers were introduced (additional to the existing basic care
fee).
2.2
Implementation approach by the Department
The Department undertook a number of activities to support programme implementation. These
activities were coordinated as part of the wider Living Longer, Living Better reform processes, which
were coordinated from a centralised project management team in Canberra.
The centrepiece of these activities was a high-profile national campaign which addressed the raft of
Living Longer, Living Better reforms, including the home care changes, and which was timed to align
with the launch of MyAgedCare. The ‘Let’s talk about aged care’ campaign included mass media and
ethnic media advertisements, brochures, posters, online stories and videos.
A series of national Aged Care Reform Roadshows were also conducted between March and June
2014 held in all capital cities and several regional locations. In addition, the Department provided
regular newsletters to service providers (of which there have been 11 issues released between
September 2014 and February 2015), regular direct electronic communications with providers (of
which there have been more than 40 releases since July 2014), and access to email-based support for
providers seeking clarification of the guidelines.
The Department also provides a regular newsletter for ACATs and ACASs (of which there were two
issues in 2014), and the Aged Care Assessment Programme Guidelines were revised in January 2014.
During this period the Department consulted extensively and regularly with the sector to discuss
implementation, notably through the National Aged Care Alliance (NACA), a representative body of
peak national organisations in aged care, including consumer groups, providers, unions and health
professionals.
The 2013 programme guidelines were co-designed by NACA and the Department, with NACA leading
the development. This was the first time the Department had engaged in such a co-design process,
rather than consultation process, and flagged the Department’s intention that the move to CDC
would also align with a move away from prescriptive regulation and oversight of the sector towards a
more consumer-driven market.
2.3
Communication and support materials
A range of support materials and activities were available to support programme implementation.
The first version Home Care Packages Programme Guidelines were published by the Department on
its website in August 2013. These were revised twice in July 2014.
A series of fact sheets about the changes were also published on the Department’s website
(https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/aged-care-reform/home-carepackages), aimed at home care service providers as well as consumers and carers, and on the
MyAgedCare website (http://www.myagedcare.gov.au/help-home/) which was established as the
national aged care entry point for consumers and carers in July 2013. A multi-platform advertising
campaign was conducted advising consumers and carers about aged care reform, including but not
limited to home care. COTA (formerly known as Council on the Ageing), the national peak body for
older consumers, received Australian Government funding for its Home Care Today initiative which
supports the implementation of the Home Care Packages Programme (and specifically the transition
to CDC) with resources, advice and training for consumers and providers. The website
(http://homecaretoday.org.au/) includes a range of resources including brochures for consumers and
carers explaining CDC and templates for home care providers. The two aged care provider peak
bodies, Aged and Community Services Australia (ACSA) and Leading Age Services Australia (LASA),
also provide support services to their members. At the time of writing this report, Commonwealth
funding for Home Care Today had been extended to the 2017-2018 financial year.
2.3.1 Effectiveness of support materials
Interviews conducted for the evaluation indicated that there were variable views amongst providers
and peak bodies on the effectiveness of support materials. This variability primarily related to where
the provider is at with implementation of CDC, including their understanding of and experience with
CDC practice. This was not influenced by provider size, type or location. The interviews indicated
that:
• Those providers that were further progressed in the implementation of CDC indicated that
the materials were useful, although few made use of all of the available materials. The
Programme guidelines, and the COTA, ACSA and LASA materials, were cited as the most
useful materials.
• Those that were less advanced in the implementation of CDC were often critical of the
available material. They wanted more face-to-face support and collaboration with other
providers rather than more written support, including increased direct access to the
Department via a helpline for assistance in interpreting the guidelines (rather than via a
generic email address), with clarification and examples of what was ‘in’ and ‘out’.
It was evident that many providers – generally those that were more critical of the support materials
– wanted more direction. They suggested that the guidelines did not offer sufficient clarity and
‘leaving too much open to interpretation’. A review of Ministerial correspondence and Departmental
enquiries from providers conducted for this evaluation also found that the vast majority of enquiries
related to matters of interpretation of the guidelines. Most providers expressed qualified support for
the concept of CDC, accepting that CDC was ‘the way things are going’ but raised concerns as to their
‘duty of care’. These concerns were particularly in relation to frail or cognitively impaired consumers,
those without family carers, or where there may be elder abuse. Such instances were often cited as a
rationale for providers needing to have clear authority to restrict consumer choice and control.
Although the guidelines (and messages from the Department and government) openly support
consumer choice and control, these providers were worried as to whether the aged care regulatory
framework was aligned to the changed policy environment – the concern being that providers do not
want to be the subject of test litigation as to whether they breached a duty of care.
Similar concerns were raised as to how the Australian Aged Care Quality Agency (AACQA) would
interpret choice and flexibility during a provider’s quality review. The general consensus from the
interviews was that it would be beneficial for providers to have more information and guidance as to
how AACQA will assess performance against the Home Care Standards in the context of CDC.
Most home care providers interviewed for the evaluation considered that they had sufficient
information on the new arrangements from August 2013. This was substantiated by the results of the
online survey conducted for this evaluation, which was completed by 29 per cent of providers.
The majority of survey respondents indicated that they had sufficient information in relation to most
aspects of the implementation although they would have valued more support in some areas. This
related to income assessed care fees (47 per cent of respondents), access to the veterans’
supplement; oxygen and enteral feeding supplements (42 per cent) and broadbanded ACAT
assessments (36 per cent of respondents).
Table 1: Did this service have adequate information and support about the new arrangement prior to
the transition to Home Care Packages by August 2013?
Yes, we have
had adequate
information and
support about
this
We have had
enough
information, but
some support
would have
been helpful
No, we have not
had enough
information or
support
Total responses
to this question
Percentage
Percentage
Percentage
Number
New package levels 1 and 3
27
51
22
143
Transition of CACP to level 2
37
49
14
152
Transition of EACH to level 4
35
49
16
136
Included care and services
35
45
20
147
Excluded care and services
28
46
26
144
Broadbanded assessments
25
39
36
148
Transition between care levels
26
45
29
149
Dementia supplement
18
49
33
149
Veterans' supplement
19
39
42
147
Yes, we have
had adequate
information and
support about
this
We have had
enough
information, but
some support
would have
been helpful
No, we have not
had enough
information or
support
Total responses
to this question
Oxygen/enteral feeding supplements
20
40
40
148
Consumer fees policy
16
37
47
151
Source: KPMG analysis of provider survey data
Survey respondents identified the Programme guidelines to be the most effective resource for
implementing the Programme: 30 per cent of respondents said this resource provided effective
information and support, and 63 per cent said it provided somewhat effective information and
support but could be improved. Other resources that providers found to be somewhat effective were
Australian Government websites (56 per cent) and email circulars (55 per cent).
Table 2: How effective has this service found the resources that support the Home Care Package
Programme? Please select one response.
This resource
has provided us
with effective
information
and support
This resource
has been
somewhat
effective for us,
but it could be
improved
Percentage
Percentage
This resource
has not been
effective
for us
Percentage
We have
not used
this resource
Percentage
Total
responses
Number
Home Care Packages
Guidelines
30
63
5
2
152
Australian Government aged
care reform roadshows
11
44
27
18
148
Australian Government
reform readiness checklist
11
46
24
19
150
Australia Government fees
booklet
13
39
27
21
150
Australian Government
websites
16
56
26
2
151
Australian Government email
circulars to providers
20
55
22
3
150
Support from Aged and
Community Services
Australia
29
32
21
18
148
Support from the National
Aged Care Alliance
13
31
26
29
150
Support from Leading Age
Service Australia
16
33
19
32
148
9
23
25
43
148
21
41
19
19
150
Support From the National
Aged Care Advocacy Service
Support from Home Care
Today
Source: KPMG analysis of provider survey data
In contrast to providers, ACATs and ACASs almost universally did not feel they had sufficient
information or support on the changes, and were concerned with regard to the accuracy of the
information they received (particularly in relation to income tested care fees).
ACATs/ACASs considered that they had not been provided with sufficient information about how
CDC packages operate in practice, and how individualised budgets translate into ‘hours of care’
(which is how they are accustomed to assessing consumers’ level of need). This has resulted in
ACATs/ACASs sometimes erring on the side of caution and approving a consumer for a higher care
level where there were any doubts as to whether they might receive an adequate volume of care.
2.4
Assessment and referral processes
Most stakeholders welcomed the more streamlined assessment processes. Many suggested that
changes could go further, with a single non-lapsing eligibility assessment on entry and no
requirement for a new assessment to move between the broadbanded low and high care levels (i.e.
this could be determined by providers, in accordance with the guidelines and possibly using
mandated assessment tools if necessary). A suggested alternative was for the re-assessment to be
optional at the request of either the provider or consumer where it was unclear (or where there was
disagreement) about whether a move to high care was required.
At interview providers routinely reported no change in waiting time for ACAT assessments. There had
been a change in waiting times to commence a package in some areas: waiting times for Level 1 and
in some cases Level 2 have reduced and waiting times for Level 4 have increased. This was verified
through the provider survey, where the majority of respondents reported that waiting times had not
been affected (positively or negatively) by the new arrangements.
Issues were raised regarding the current ACAT/ACAS assessment process. Most providers were
critical, to varying extents, about what they perceive as a lack of training for and knowledge by
ACATs/ACASs in relation to the changes. There were concerns that some ACATs/ACASs were too
prescriptive in their assessments, for example specifying a Level 2 package, or providing incorrect or
inadequate information to consumers about income assessments, fees and the ‘number of hours’
that would be available to them rather than the subsidy amount of an individualised budget. Some
providers reported that ACATs/ACASs were giving opinions to consumers as to the fairness of certain
providers’ prices, and/or suggesting that consumers utilise HACC instead of home care due to its
affordability, which the providers considered to be unfair and inappropriate.
Changes to ACAT and ACAS referral processes have occurred where the implementation of the Home
Care Packages Programme has coincided with changes to internal ACAT and ACAS processes and
structures. These processes are not consistent across Australia as the guidelines specifically allow for
referral processes to be determined by local ACATs and ACASs. In some areas, particularly rural
areas, ACATs and ACASs have either referred consumers directly to a provider or given notification of
a new assessment to all providers. Some ACATs and ACASs have now changed their processes, and
either provide a list of providers to consumers or refer them to the MyAgedCare website.
Consumer and carers interviewed for the evaluation had variable experiences of assessment, with 18
of the 57 interviewees reporting that the ACAT/ACAS assessment was positive, person-centred and
comprehensive. The remaining interviewees indicated that they felt ‘over-assessed’ or that their
needs had not been sufficiently taken into account. There were no obvious response patterns with
regard to jurisdiction, region or special needs groups.
Despite a relatively high-profile media communications campaign in the months prior to the
interviews for this evaluation, few consumers or carers were aware of MyAgedCare. Several younger
carers had used the website and found it to be helpful though often an incomplete resource (in
terms of local content). Most consumers and carers tended to come into contact with home care
after a health crisis, such as hospitalisation after a fall, and were referred for ACAT/ACAS assessment
through the hospital.
Most consumers and carers indicated that they preferred to access information, particularly at the
time of initial ACAT/ACAS assessment and entry to home care (or at the time of transition from CACP,
EACH or EACHD to a CDC package), through some form of face-to-face process. Many consumers
referred to ‘paperwork’ as something they filed for safekeeping but seldom read.
Although most consumers and carers considered that the ACAT and provider assessment processes
were timely, relatively straight-forward and comprehensive, some described them as repetitive,
having to repeat their stories multiple times. Male consumers tended to find these processes more
frustrating than females (this was the only area where there were notable gender differences in the
interview responses).
Some consumers and carers, particularly those undergoing assessments during or immediately
following a health crisis, did not consider that the assessment process was person-centred and
several reported that they felt pressured into accepting a package with a particular provider before
they had time to think about what they wanted.
Some examples of consumer and carer experiences with assessment, drawn from the evaluation
interviews, are described below.
Some consumer and carer perspectives on assessment (real names not used)
Paul cares for his wife, who has dementia. She was hospitalised in early 2014 and the clinicians
suggested that they should be assessed for a home care package. Paul found the ACAT assessment to
be thorough, but on top of various geriatric and rehabilitation assessments, and assessment for
respite care, it was exhausting. Following the ACAT approval, Paul was dismayed to experience a
further assessment by the home care provider. ‘I’m bloody over it’, is how he describes it. He feels
that he has had to repeat the same information over and over, and is surprised at how poor the
communication seems to be between services. Paul is very pleased with the package now that
services have commenced, and hopes not to have another assessment process for some time to
come.
Linda is a retired nurse and looks after her mother, a war widow who lives on her own. Linda’s
mother was receiving Veterans’ Home Care services but Linda felt that these were no longer meeting
her needs. She undertook some research into the offerings of local home care providers and then
approached the ACAT. She found the ACAT to be very helpful, providing her with advice and
information. This led to an assessment, which Linda said was thorough and took account of her
mother’s wishes as well as her capacity as a carer. The ACAT provided them with written information
and advice. Linda was soon able to access a Level 2 place with her preferred provider.
Susan works full-time and cares for her invalid husband as well as her father, who has dementia and
lives with them. About 18 months ago, her father was hospitalised after a serious fall. Her husband
was in hospital at the same time and so it was a stressful time. She has little recollection of the
assessment. She was given pamphlets which she did not really understand and felt that no-one was
taking the time to talk to her, or giving her time to think. She felt ‘pressurised’ into accepting the first
available place, and ‘threatened’ that if she did not accept it she would have to put her father into
residential care. Things did not improve when the package commenced, as she felt that she was told
what services could be provided and when they would be delivered, even though it was a CDC
package. After several disputes with the home care provider, she recently cancelled the package and
is thinking about what to do next.
2.5 Consumer care fees
Introduction of income tested fees for consumers from July 2014 presented challenges for providers.
The majority of providers indicated that there had not been enough information provided prior to
the commencement of this policy (to providers, ACATs or consumers). There were concerns raised
regarding the assessment process being too complex for consumers, and taking too long – up to
three months in some cases. The retrospective application of the fees was problematic for many
providers (especially smaller providers), as it often came as a shock to consumers and in some cases
resulted in them cancelling their packages, and sometimes refusing to pay the retrospective fees for
the period that they had already received services.
A small number of providers pre-empted this issue by giving the consumer an estimate of their
income-assessed fees using the MyAgedCare calculator and/or their own ready reckoners and
charging interim care fees.
Ten of the 25 providers interviewed reported that some consumers were declining packages as a
result of the income tested fees, which was considered to be particularly problematic for Level 1
packages. It was reported that these consumers turned instead to HACC services to meet their needs,
where they could obtain similar levels of service for lower fees, or to private services (often through
the same provider as the one offering the subsidised home care package), or decided not to have any
home care services at all. This raised a number of concerns for providers, specifically:
•
Provider income flow – some providers with Level 1 and Level 2 packages reported that they
were becoming difficult to fill, and/or those located in areas with more self-funded retirees
and part-pensioners who would be more likely to have to pay income tested fees
•
The quality of care that consumers may be receiving from private providers who may not be
subject to the Home Care Standards and the scrutiny of the AACQA
•
The potential for consumers’ health to deteriorate, making them more likely to present to
hospital or required a higher level of home care or residential care.
Some not-for-profit providers (generally faith-based providers) do not have a strong history of
collecting basic care fees and have historically waived or reduced fees for many or even most of their
consumers. The providers who were interviewed for the evaluation reported that long-time
employees of these organisations often see themselves as providing a benevolent community service
to vulnerable older people and can resent having to collect user fees (these employees are also likely
to be those struggling with the move to CDC). Some of these providers were concerned that
consumers might ‘blame’ providers for the government’s policies.
On the other hand, a number of providers – including several faith based not-for-profits – had
accepted and supported the reality of means-tested contributions to care. These providers were
more likely to be delivering other forms of community services in addition to home care (thus having
prior exposure to user fees policies), and had often undertaken specific cultural change training with
their staff which included addressing attitudes to user fees and collection of fees within a valuesbased, not-for-profit service environment
Only one consumer interviewed for the evaluation was subject to income tested care fees, and they
felt that the fees were reasonable. A number of consumers interviewed indicated that they were
paying a basic care fee, and most of them considered that the fees were fair for the services they
received.
2.6 Administration and case management fees
The issue of administration and case management fees was frequently raised during the
consultations. Many providers have faced challenges in pricing these components, with some
wanting the government to provide guidance on what was a ‘fair and reasonable’ price to charge for
administration and case management. Although the guidelines clearly separate administration and
case management, a small minority of providers indicated some confusion about the difference
between the two.
The survey showed that the average proportion of a home care budget for administration and case
management combined (across all care levels) was 27 per cent of the total subsidy. The proportions
were slightly higher for the lower care levels, as demonstrated in the table below.
Table 3: Average case management and administration fees
Home
care level
Average case
management fee
(per week)
Average
administration fee
(per week
Maximum baseline
subsidy (per week)
Proportion
of subsidy
spent on case
management &
administration
Level 1
$23.81
$20.14
$150.01
29%
Level 2
$40.72
$36.55
$272.93
28%
Level 3
$96.41
$79.81
$600.11
29%
Level 4
$90.08
$99.00
$912.24
21%
Source: KPMG analysis of survey results
Note average case management and administration fees are based on the median fees reported by
providers completing the data collection template (n=77) and exclude any additional supplements
and consumer fees received.
The way in which providers structured their administration and case management fees differed
considerably, with most charging between 20 and 30 per cent for administration, usually with a ‘built
in’ amount for required case management (care planning, reviews, an allowance for monthly
contacts) and then an hourly fee for additional case management services. Some providers
incorporated these built in costs to their administration fee rather than charging additional case
management fees. Approximately half of the providers interviewed reported that they had
undertaken some form of detailed cost modelling to develop these structures; whilst others (usually
those charging at the lower end) set the fees based on what they thought was ‘fair’. A snapshot of
different administration and case management pricing structures is set out over the page.
Snapshot of some administration and case management pricing structures
Provider 1 (rural, medium not-for-profit): Charges 15 per cent administration fee and no additional case
management charges.
Provider 2 (metro, large for-profit): Charges a 30 per cent administration and case management fee across
all care levels (this can be reduced to a 20 per cent for administration only where consumer takes on
responsibility for scheduling).
Provider 3 (metro and rural, large not-for-profit): Charges a 10 per cent administration fee, plus a $50
invoicing and statement fee per month, plus case management charged at an hourly rate on a case-by-case
basis.
Provider 4 (metro, small for-profit): Charges a 20 per cent administration fee, plus case management
charged at an hourly rate on a case-by-case basis.
Provider 5 (metro, large not-for-profit): Charges a 25 per cent administration fee, plus case management
and an hourly rate.
Provider 6 (rural, small not-for-profit): Charges a 19 per cent administration fee, plus an 8 per cent case
management fee across all care levels.
Provider 7 (metro and rural, medium not-for-profit): Charges a 30 per cent administration fee, plus a tiered
case management fee: the first tier varies between 5 per cent and 17 per cent depending on the care level
and incorporates initial assessment and planning, six monthly reviews, and up to one hour of monthly
contacts; the second tier is an hourly rate for any additional case management and advisory services in
excess of the allowed number of contacts.
Provider 8 (rural, small not-for-profit): Charges a 25 per cent administration fee, plus an initial flat fee for
setup/establishment case management, plus additional case management charged at an hourly rate on a
Snapshot of some administration and case management pricing structures
case-by-case basis.
A number of consumers and carers indicated that they were confused about how these fees were
calculated. A few felt that the fees were excessive for what they understood the fees covered. Where
consumers (and especially carers) took particular exception to these fees was where they had taken on
what they considered was a significant degree of self-management and felt that the fees should have
been reduced accordingly.
2.7 Implementing new administrative requirements
Results of the online survey suggest that providers believe they have experienced a considerable
increase in administrative activity through the introduction of the Home Care Packages Programme (61
per cent of respondents strongly agreed with the statement that ‘The Home Care Packages
Programme has increased the administrative burden on providers’, with 23 per cent agreeing).
At interview all providers indicated that there had been a substantial financial and administrative
burden associated with the implementation, which exceeded their anticipated costs. This included
the expected transitional costs of information technology upgrades, staff training, development of
new processes and materials, and consumer education and information. This was compounded by
the additional administrative burden associated with the Medicare claims processing problems
(discussed further below), a reported high error rate with income assessments, lost revenue as a
result of consumers refusing to pay backdated income assessed fees, and two revisions to the
guidelines in July 2014.
Furthermore, most providers have found that more staff time is required to deliver packages under a
CDC model due to the consumer-driven planning process, which can take longer. Many providers
explained that they were investing significant time undertaking initial discussions with consumers –
sometimes to the point of developing an initial care plan and budget – only to have the consumer
take up a place with another provider.
Processing of subsidy claims by the Department of Human Services (Medicare)
The inability for Home Care Package providers to utilise the Aged Care online claiming system
following the introduction of the new Aged Care Management Payment System (ACMPS) and
subsequent errors and delays in payments of Commonwealth subsidies created financial and
administrative problems for providers, especially smaller providers. The concurrency of these issues
with the implementation of the Home Care Packages Programme was cited as a key challenge. More
than a year after the claiming issues commenced, eight of the 25 providers interviewed in November
2014 reported that the issues still had not been fully resolved and that their subsidy payments are
significantly in arrears and/or incorrect, and that they are still required to submit time-consuming
manual claims. Peak bodies interviewed in February 2015 also reported that this remained an issue
for many of their members. DHS introduced case management support for providers in response to
these concerns.
Role of aged care advocacy services
A small number of stakeholders suggested that there was a need for an independent third party to
assist new consumers to understand fees and service pricing. When it was suggested that the
National Aged Care Advocacy Programme (NACAP) might fulfil this role, they indicated that the
existing advocacy services do not understand how CDC and individualised budgets operate, and that
they are not sufficiently equipped to assist consumers with these issues. A number of examples were
provided of instances where providers considered the advocacy services had misunderstood the
intention of home care and CDC, usually by insisting that providers should not reduce ‘hours of care’
when existing consumers were transitioned to CDC (even where their expenditure was beyond the
individualised budget).
The evaluation consulted with one of the nine services currently funded to deliver NACAP services.
This service confirmed that there had been a lack of training and education for advocates on CDC.
However, they also provided a number of examples where they considered providers had either not
understood or failed to implement CDC, including examples of telling consumers their ‘hours of care’
would reduce but not giving the consumers any say over how to restructure the package, refusing to
provide financial statements, and severely limiting consumer choice and control.
The Department is currently identifying resources and training for advocates so they can better
support home care clients in making decisions around CDC.
Additionally, a review of the Commonwealth Aged Care Advocacy Services is currently underway and
will examine how advocacy services can support aged care clients within a CDC focussed
environment. The findings of the review will be used to inform the Department on design of a new
aged care advocacy programme that can provide a strong platform to support aged care clients
across the spectrum of aged care services.
2.8
Interface with other services
The evaluation was tasked with specifically considering the interface of home care packages with a
number of other services, specifically:
•
•
•
•
•
•
Commonwealth HACC Programme / Commonwealth Home Support Programme (CHSP);
National Respite for Carers Programme;
Department of Veteran’s Affairs Programmes;
Community Visitors Scheme;
Continence Aids Payment Scheme; and
National Disability Insurance Scheme.
Overall, the interface with these programmes appears to be operating as intended (as per Part J of
the Programme guidelines), with relatively clear funding boundaries whilst still providing flexibility
for consumers to access a range of available services. The key exception relates to the interface with
HACC/CHSP. Of the 25 providers interviewed, 24 raised concerns regarding unclear boundaries
between home care Level 1 and HACC / CHSP services, which currently provide similar services at a
similar or higher level for a much lower consumer contribution. All of the ACATs/ACASs interviewed
expressed similar concerns, as did most of the other stakeholder groups. The subsidy for a Level 1
place is $7,822 per annum (almost half that of Level 2), limiting the level of supports that can be
offered. Consumers may also be required to pay an additional income assessed fee up to the full
value of that subsidy. Providers and ACATs suggested that many consumers do not see this as good
value for money when in most regions they can access similar services through HACC/CHSP. In some
regions consumers can reportedly access up to $12,000 in annual HACC/CHSP services, without
having to pay an income assessed fee and sometimes without having to pay a basic care fee or
equivalent.
It is noted that the policy intention of introducing Level 1 was to allow a low care bridge between
HACC/CHSP services for those consumers whose level of service need is not high, but who would
benefit from some case management and coordination of supports. Case management and
coordination of supports will not be available under CHSP from 1 July 2015. It is also noted that the
CHSP National Fees Policy may reduce some of the financial disincentives for consumers to access a
Level 1 package. Sector understanding of the potential of Level 1 places may therefore change after
the implementation of CHSP later this year, but at this time Level 1 is not seen as a useful addition to
the suite of packaged care.
Some providers reported a positive interface with HACC/CHSP in relation to accessing ‘top up’
services in cases of emergencies, or where consumers were eligible for a high care package but were
on a low care package due to waiting lists. However, for this to occur home care providers needed to
have a good relationship with local HACC/CHSP providers (or be the same provider), which was not
always the case and so the level of collaboration was considered to be lower than desirable.
Few issues were raised about the interface between home care packages and the NRCP, although
some stakeholders raised concerns that the consumer contribution component of respite services
could not be paid from home care budgets. This was a particular issue for special needs groups,
including Aboriginal and Torres Strait Islanders, people living in rural and remote areas (who may
incur additional transports costs for respite), and people who are financially and socially
disadvantaged.
Similarly, a small number of providers were concerned about what they considered to be a lack of
access to the Continence Aids Payment Scheme (CAPS) for high care home care recipients (although
it is noted that the Home Care Packages Programme Guidelines 2014 specifically address access to
CAPS). The guidelines state that ‘a person receiving a Home Care Package may be able to receive a
payment under the Continence Aids Payment Scheme. However, if the provision of continence aids is
identified in the home care consumer’s care plan, they will not be eligible for the Scheme’.
There were some examples given at interview of the capacity for positive collaboration between DVA
and home care packages. Specifically, these related to the pooling of resources for consumers
without ‘double dipping’ (i.e. where a consumer is entitled to a Level 4 package but is on a Level 2
due to no Level 4 places being available, the home care provider funds the clinical services and DVA
funds the domestic assistance). This flexibility was seen as being beneficial for eligible consumers,
although there is a question of equity for those consumers in similar circumstances but who not
eligible for DVA and who live in an area where there may not be HACC top up funds available.
The interface between home care and the NDIS is yet to be fully understood given the early stages of
scheme implementation is focused on trial sites.
A number of consumers indicated that one of the aspects they valued most about their home care
services was the companionship and social contact with care workers. Receiving personal care can be
very intimate, particularly for consumers who have been on packages for many years, and some of
them describe their regular care workers as being ‘part of the family’. These consumers were often
frustrated that care workers were now much more time-conscious and being forced to ‘hurry’ and
did not have time to ‘stop for a chat’ as much as the consumer desired. This may suggest that there is
potential for a closer interface between home care and the Community Visitors Scheme (CVS), which
is not prohibited under the guidelines but which does not appear to be particularly strong at this
time.
In 2013-14 as part of aged care reform, the CVS expanded to include one-on-one volunteer visits to
recipients of Home Care Packages who have been identified as socially isolated or at risk of social
isolation. At the time of this report, the Department of Social Services was developing
communication activities to promote awareness of CVS with Home Care Package providers.
2.9
Other issues relevant to the Programme implementation
Some providers and ACATs/ACASs indicated that the leave (suspension) requirements for home care
places are overly complicated. The guidelines currently differentiate between cumulative days and
consecutive days for different types of suspension which determines when the subsidy payment is
reduced.
Many stakeholders suggested that the current mix of care levels did not seem to be well-matched to
demand, with a surplus of Level 1 places (and, in some regions, Level 2 places) and insufficient Level
4 places. Stakeholders suggest that an analysis of actual occupancy rates since the commencement
of the new arrangements would verify this. It is noted that the Aged Care Financing Authority (ACFA)
will be monitoring occupancy rates as part of its regular reports on Impact of the 1 July 2014
Financial Reforms on the Aged Care Sector; these data were not available to the evaluation at the
time of this report was written).
Many stakeholders expressed concerns that the new arrangements may not offer a streamlined
continuum of care for consumers as (a) there is still a need for a new ACAT assessment before
moving between the low and high care levels; and (b) not all providers are allocated places at all care
levels in a region, meaning that consumers may need to change provider if a place is not available
with their current/preferred provider at that level. This was particularly pertinent in the context of
rural providers, or providers who specialised in provision for special needs groups. Two potential
solutions were suggested:
•
that all providers are allocated a minimum ‘set’ of all care levels; or
•
that no specific care level are allocated to providers, meaning that consumers could take
an assessment for any level of care to any provider of their choice.
The second suggestion was seen as more aligned to the values of consumer-direction, although it
may present allocation and budgeting challenges to the Department (as well as requiring changes to
the current aged care regulations). It may also necessitate changes in providers’ business models, as
they would no longer be ‘assured’ of a certain number of places at a certain subsidy level, and this
could potentially drive an increase in ‘cherry picking’ behaviour with providers giving preference to
higher care consumers over lower care consumers. At least three of the ACATs/ACASs interviewed
suggested that ‘cherry picking’ is already an issue in some areas, as consumers with dementia or
from certain special needs groups can often wait much longer for a package than other consumers
assessed as eligible for the same care level, even where there are known to be vacancies at that care
level in the region.
Several stakeholders also suggested that ACAR allocation processes should be reviewed. Three
smaller providers, and a number of other stakeholders representing the interests of various special
needs groups, indicated frustration with the ACAR allocation processes suggesting that not enough
high care places were allocated to rural areas, and that there was little if any feedback given to
unsuccessful ACAR applicants for special needs places (Aboriginal and Torres Strait Islander, and
culturally and linguistically diverse).
Two of the ACATs/ACASs expressed concern that whilst recent ACAR rounds appeared to have
focussed on increasing the number of providers operating in rural areas rather than allocating
addition places to existing providers to increase consumer choice and competition, this often did not
occur in practice. In some areas it was reported that providers refused to fill places in difficult-toaccess areas, and that having a large number of providers with only a small number of packages each
was not conducive to offering a continuum of care for consumers (because they would likely need to
change provider to change care level).
Dementia and cognition supplement
Stakeholders were very supportive of the concept of supplements. However, smaller providers
expressed concern regarding the processes for accessing the dementia and cognition supplement,
specifically the requirement for a Registered Nurse to undertake the assessment. This means they
must broker a nurse if they do not have one on staff, incurring costs that may not be recoverable.
The need to undertake an assessment for consumers that already have a dementia diagnosis was
also seen as duplicative.
The effectiveness of the mandated assessment tool was questioned. The Psychogeriatric Assessment
Scale (PAS) assessment is seen as too narrow as it focusses on memory not behaviours. The
alternative Rowland Universal Dementia Assessment Scale (RUDAS, which is the mandated tool for
assessing CALD consumers for the dementia and cognition supplement), was suggested as better tool
for use with all consumers
2.10 Acceptance of programme change and commitment to CDC
Thirty two per cent of providers in the survey strongly agreed or agreed that the Home Care
Packages Programme has improved home care and services for consumers and carers, with 31 per
cent either strongly agreeing or agreeing that most consumers are getting the level of supports they
need.
However, both the survey responses and the interviews found there is still some reluctance about
implementing CDC amongst providers. This is primarily due to the perceived workload and resources
required to implement CDC, as well as some concerns about the implications of change on provider
business models and viability.
There is also considerable concern regarding CDC amongst ACATs/ACASs. Of the 13 ACATs/ACASs
interviewed, all said that they were supportive in-principle of the new care level structure and
supplements, however only one indicated unqualified support for CDC. Many ACTS/ACASs were
particularly concerned as to the appropriateness of a CDC approach for vulnerable consumers (such
as those with dementia or cognitive impairment, the frail elderly without carers, consumers from
special needs groups). They were concerned as to the lack of clarity around the ‘hours of care’
available under packages, and whether case management could be ‘traded off’ by consumers. Many
of the interviewed ACATs/ACASs were looking for some persuasive clinical evidence that a CDC
approach could work for different types of consumers. It was commented that the available
information focussed more on theory and policy rationale rather than clinical evidence, particularly
for vulnerable cohorts.
In addition, a number of ACATs/ACASs expressed concern that income tested care fees would lead to
consumers declining home care places which would see their health condition deteriorate. Several
providers also raised this concern. It is noted, however, that when consumers do decline packages
and cite the fees as a reason, anecdotally they often decide to purchase at least some unsubsidised
supports – and often from the same provider. There are currently no data available to quantify the
extent to which this is occurring.
3
Transitioning to consumer-directed care
This chapter considers provider readiness for CDC and providers’ transition to a consumer-directed
approach. It is focussed on the experiences of home care providers, consumers and carers, as well as
the wider aged care sector (including ACATs/ACASs).
The findings in this chapter were drawn from the interviews with 25 home care providers, 57
consumers and carers, other aged care sector stakeholder groups; and an online survey completed
by 29 per cent of home care providers.
Summary of key points: development of and transition to CDC
•
Transition to CDC is ongoing, with many providers working towards full implementation
of CDC by July 2015. Most providers had developed their ‘approach’ to CDC, having
either developed or were developing revised policies and procedure documents, and
new or revised templates and tools (such as care planning templates and budgeting
tools).
•
Most consumers on existing packages (approximately 80 per cent as at December 2014)
have not yet transitioned to CDC. However, almost all providers had implementation
plans in place to gradually transition existing consumers by July 2015, with most using
the care plan review as the trigger for transition.
•
There are a small number of ‘early adopters’ who had fully embraced CDC and had
reoriented their organisations to be more consumer directed (about 5 of the 25
providers in the interview sample fell into this category). These organisations had largely
completed their transition to a CDC approach, and all or most of their packages were
being delivered on a CDC basis.
•
There were also a small number of organisations who were resistant to or not supportive
of the CDC philosophy or CDC principles, and who not made significant progress in terms
of implementing CDC arrangements in their organisations. About 6 of the 25 providers in
the interview sample fell into this category.
•
Most organisations were placed somewhere between these two perspectives:
committed to CDC and making progress to implementing CDC in their organisation,
though at different stages of ‘readiness’ and with some wide variations in their CDC
approaches.
Main considerations for providers in transition were:
•
Transitioning ‘high cost’ consumers. Transitioning higher cost consumers involved some
‘difficult conversations” with consumers, reductions in services, examining alternative
sources of support and in some case considering residential care.
•
Systems changes and costs, including the scale of changes and integration to fully
support CDC (and to automate many processes which were being done manually), and
the cost of these changes.
•
Reorienting their service delivery model, including time spent on planning, coordinating
and administering CDC packages, which is incurring higher costs.
•
Embedding cultural and practice changes, which will occur over time.
3.1
Provider readiness for CDC
Despite there being a lead-in period of more than two years (from November 2012), readiness for
CDC transition in July 2015 varies significantly across providers. Based on the interviews, there
appeared to be a small number of ‘early adopters’ who had fully embraced CDC and had reoriented
their organisations to be more consumer directed. At the opposite end of the spectrum, there were
also a small number of organisations who were resistant to or not supportive of the CDC philosophy
or CDC principles, and who had not made progress implementing CDC arrangements in their
organisations. Most organisations were placed somewhere between these two spectrums:
committed to CDC and making progress to implementing CDC in their organisation, though at
different stages of ‘readiness’.
This is supported by survey data, which indicated that as at December 2014, 78 per cent of providers
were ‘still preparing for the implementation of CDC’, and 20 per cent considered themselves ‘wellprepared’ – as illustrated in the figure over the page.
Figure 3: Provider responses to the survey question ‘How would you describe this service’s current
state of preparation for the transition of all places to CDC from 1 July 2015’
3.1.1 Classifying providers’ level of CDC readiness
The providers interviewed as part of the evaluation were categorised into three broad categories
reflecting their state of readiness for CDC:
•
Early adopters or leaders – fully embraced CDC and have largely completed the transition
to CDC
•
Proactive – implementation of CDC is a work-in-progress, wide variations in different
aspects of approach and transition
•
Reactive or resistant – not supportive of CDC, little or no progress in terms of
implementing CDC, CDC approach is similar to approach for usual care.
These are briefly described in the table below
Strategy and
approach
Systems
Management
Staffing
Culture and
practice
Early adopters or leaders
Proactive
Reactive or resistant
clear, goal-based approach to
CDC; significantly different
from usual care approach
approach to CDC is
developing/evolving
do not have a CDC approach or
approach little different from
usual care approach
have organisation-wide CDC
implementation plans, and
have reviewed strategic plans
to ensure alignment with CDC
have organisation-wide CDC
implementation plans
typically have not examined
organisational-wide strategy
may or may not have
implementation plans;
transitioned few if any
consumers to CDC
have invested in finance/IT
systems changes and
integration; systems already in
place
have made some changes to
finance/IT systems, or at
planning stage
Little investment in finance/IT
systems; CDC processes still
manual
can demonstrate strong
management/CEO support for
CDC and willingness to invest in
CDC transition
varying levels of understanding
of CDC and varying levels of
commitment
management support unclear
or resistant; concerns about
business viability
have invested in staff training
and development, including
coordinators and care workers
have invested in staff training
and development for
managers, though rarely for
care workers
some staff training undertaken
(general training available to all
organisations); limited to
managers
talk about the potential and
possibilities of CDC more
than they do about the
challenges
some practice changes,
though variable; though
some practices not
significantly different from
usual care
very few practice changes;
practices not significantly
different from usual care
Figure 4: Classification of providers
Source: KPMG
3.1.2 Activities undertaken to prepare for CDC implementation
Providers undertook or participated in a number of internal and external activities to prepare for the
CDC transition.
Internally, activities included:
• their own research on consumer-directed approaches (a small number of providers)
• development of their CDC model or approach based on research, the guidelines, external
training and information sessions, and their own experiences of CDC and other individualised
planning and funding (most providers, though noting variable levels of effort)
• revision of policies and procedures and development of new care planning templates,
budgeting and expenditure reporting template, and care planning tools (some providers)
• staff training sessions, including for coordinators (most providers), and care staff (a small
number of providers).
• Providers participated in a range of external information and training activities, as illustrated
in the following figure.
Figure 5: Provider responses to the survey question ‘What activities (if any) has this service
undertaken, or does this service plan to undertake, to prepare for the implementation of CDC from 1
July?’
Source: KPMG analysis of survey responses Aspects of provider readiness
In examining provider readiness for CDC, the following aspects were considered:
•
•
•
•
•
Strategy and approach – whether providers had developed an organisational approach to
consumer-directed care, and whether providers had an overarching corporate or
organisational strategy which was consistent with CDC principles.
Systems – whether providers had in place appropriate and integrated systems to support
a consumer-directed care approach, including finance, client management and other
systems.
Management commitment – whether provider management, including the chief
executive and senior management team, were committed to the principles and intent of
CDC, and were driving organisational and practice change as part of implementing CDC.
Staff commitment, skills and capabilities – whether providers had staff committed to the
principles and intent of CDC, and had invested in education, training and development to
ensure staff had the skills and capabilities to work in a consumer-directed way. This
included investment in care managers and coordinators, as well as direct care workers.
Culture and practice changes – whether providers had an overarching philosophy which
reflected CDC principles and were embedding practice changes in the organisation.
Strategy and approach
Most providers interviewed as part of the evaluation had developed, or were developing, an
organisational approach to CDC, including an approach to planning and goal setting. In reviewing
materials provided by these providers, it was clear that some providers had developed a range of
innovative tools and approaches to CDC which were fully consistent with the philosophy of CDC and
CDC principles. This included care planning tools and guidance, materials for consumers to prompt
thinking and discussion, user-friendly and easy to understand care planning templates, and
supporting tools and guidance for staff (such as simple, online budgeting tools). However for some
providers, their CDC approach and underlying materials, tools and guidance were similar to usual
care – that is they were providing some (but limited) choice, they were focussed on services rather
than goals or needs or saw CDC as usual care with an individual budget component.
There were few examples of providers reorienting or revising their overarching corporate or
organisational strategy to be consistent with CDC principles, though this was evident for a small
number of providers who had clearly embraced the CDC approach and were well advanced in
implementing CDC.
Most providers stated that their approach to CDC was in development and/or evolving and changing
over time as they gain more experience with working with consumers in a consumer-directed way.
This was reflected in provider survey responses – as illustrated in the figure below.
Figure 6: Provider responses to the survey questions relating to the evolution of their CDC approach
Source: KPMG analysis of survey responses
Systems
Providers are at varying levels of progress with developing or upgrading their client management and
finance systems and integrating these systems. Larger providers reported that they were closer to
having the necessary system changes in place, whereas medium or smaller providers were less
prepared. In some cases (about a quarter of the providers interviewed), providers have adopted a
‘wait and see’ approach, intending to maintain their current systems post-July 2015 and undertake
specific CDC processes manually (for example, preparation of individual expenditure statements).
A number of providers noted that systems/software vendors were not adequately prepared for the
changes or the timeframes, and were not capitalising on the opportunities that the move to CDC was
providing in terms of off-the-shelf or easily-adapted software and systems solutions.
Management and board commitment
Executive commitment to CDC was one of the key driving factors in providers developing a CDC
approach and in successfully and seamlessly transitioning to CDC. Again, there was a notable level of
variation, with some providers highlighting the high-level of engagement from their boards, CEO and
senior management and a high level of commitment to CDC (and willingness to invest in CDC).
However, there were providers for whom CDC was more of a business change rather than a strategic
change, and for whom transition was being driven by line managers and coordinators. There were
some providers who had CEOs/senior managers who were not engaged or were unsupportive, and
were concerned as to the cost of CDC on the business and the impact of CDC on business viability.
A simple indicator of executive commitment to CDC was whether or not the board received regular
reports on CDC implementation.
Staff commitment, skills and capabilities
All providers interviewed had delivered some training to staff on CDC, and/or had facilitated staff
attending external training and information sessions. There were differences in the level and depth
of training provided, and the coverage of training, with some providers seeking to ensure that all
staff (managers, coordinators, care workers) had the required knowledge and understanding of CDC
and the skills to work in a CDC frame, and were (or will be) supported to change practice, and others
who had limited training for package managers and coordinators. A small number of providers
highlighted difficulties in gaining sufficient commitment to CDC from some coordinators (typically
those who had been a coordinator for a number of years), which affected their ability to implement a
true CDC approach.
Culture and practice changes
Cultural and practice change involves management and staff reorienting their way of thinking and
approaching package care to be consumer-focussed, and changing their behaviours and practices to
be consistent with this new way of thinking. Often, culture and practice changes are only observed
in the longer-term – as people and organisations start to see the benefits of the new approach or
change and evolve their behaviours and practices as a result.
There was evidence of culture and practice changes emerging in some organisations interviewed for
the evaluation, though it is too early to observe wide-scale practice changes at this stage of
transition. Organisations that had fully embraced CDC (early adopters) highlighted the importance of
embedding change throughout the organisation – from managers through to direct care workers –
and had started to see changes in practice. This included coordinators having a different mindset
and approach to care planning, and care workers being more flexible and responsive to consumers’
day-to-day preferences. However, many providers interviewed had yet to see any significant change
in practice, with some providers not driving or supporting cultural and practice change in their
organisations, instead focussing on administrative aspects of CDC such as individualised budgets and
expenditure statements.
3.1.3 Provider transition and readiness for CDC – key considerations
Providers raised a number of concerns with regard to the CDC philosophy and overall approach, as
well as the implementation and transition to CDC. Main concerns included:
•
•
•
•
•
Questions as to whether consumers wanted more choice and to be more involved in
their care planning, and concerns about over-burdening already vulnerable people (note
that this was largely discounted by consumers themselves)
The level of time, effort and investment required to implement CDC, in the absence of
any additional funding or one-on-one support. Providers highlighted changes to IT
systems as a particular concern
Lack of standardised information resources for consumers and planning guidance and
tools for providers
The tension between service pricing to enable cost recovery whilst being competitive
The viability of organisations in the face of increasing competition and flexibility to
choose brokered services rather than use in-house services.
The provider survey sought information regarding key provider concerns. These are illustrated in the
following table.
Figure 7: Top 5 concerns of providers regarding the implementation of CDC from 1 July 2015
Source: KPMG analysis of survey responses
3.2
Transitioning existing consumers to CDC
Extent to which existing consumers had been transitioned to CDC arrangements
Providers varied in the extent to which they had transitioned existing consumers to CDC
arrangements:
•
A small number of providers had transitioned all of their existing consumers and were
delivering all packages on a consumer-directed basis.
•
•
•
•
•
The majority of providers had commenced the transition, and were expecting to
complete the transition by June 2015. However many had not made significant progress
at the time of interview and were expecting most consumers to transition during the first
half of 2015.
A small number of providers had yet to commence transition, and had not developed a
plan to manage the transition.
The provider data indicated that as at December 2014, 11 per cent of packages allocated
before 2013-14 had been transitioned to CDC arrangements. There were minor
differences across care levels, though there were notable variations by size of provider
and level of remoteness:
Small providers (those with less than 50 packages) had transitioned fewer packages to
CDC arrangements than larger providers (those with more than 100 packages) – 7 per
cent compared with 12 per cent for large providers
Providers in outer regional areas had transitioned fewer packages to CDC arrangements
than providers in inner regional and metropolitan locations – 7 per cent compared with
13 per cent (inner regional) and 11 per cent (major cities) .
This is illustrated in the figure below:
Figure 8: Proportion of existing packages (allocated before 2013-14) transitioned to CDC
arrangements, December 2014
Source: KPMG analysis of survey responses
Overall, including new home care packages allocated from 2013-14 and packages allocated in the
CDC pilot period, 31 per cent of packages were being delivered on a CDC basis as at December
2014. There were some variations across care levels, provider size and remoteness, as illustrated
in the figure over the page.
Figure 9: Proportion of all home care packages delivered on a CDC basis, December 2014
Source: KPMG analysis of survey responses
Process for transitioning existing consumers
The majority of providers had a CDC transition plan and were transitioning consumers to CDC
arrangements gradually – either at the point of each consumer’s annual care plan review, or
based on another schedule developed by the provider. This enabled providers to manage the
transition workload over time, and enabled coordinators to develop the skills required to
effectively develop a consumer directed care plan.
A smaller number of providers (generally those that had completed the transition process), had
transitioned consumers over a short period of time (e.g. a 2-3 month period).
The process for transitioning existing consumers varied across providers, and largely reflected
their overall CDC approach:
•
•
Some providers were transitioning consumers as if they were new CDC package
consumers, fully explaining CDC to each consumer (including written information and
resources), using their new approach to planning and goal setting, helping consumers
identify changes to their support arrangements and new supports, and working through
an individual budget
Many providers explained CDC in a general sense to consumers who were transitioning,
and undertook a more in-depth review than they generally would have otherwise –
discussing and reviewing current support arrangements with consumers to determine
whether they were still meeting need, helping them to identify changes and new
supports (and explaining what is possible under CDC), and providing them with an
individual budget
•
Some providers were transitioning consumers as per a regular ‘review’, reviewing
current support arrangements, making minor changes and providing them with an
individual budget, often with minimal reference or explanation of CDC or what is possible
under CDC.
Consumer experience of transition to CDC
Consumer and carer experience of the transition to CDC from existing packages was highly
variable, with consumers tending to fall into three groups:
•
•
•
those that said that there was ‘no change’;
those that said they received ‘reduced hours’ and a decline in the amount of services
available. This tended to be slightly more likely in rural areas; and
those that said that the transition had improved their package by making it easier to get
additional services or equipment, and especially through improved flexibility.
The difference in consumer perception of CDC and whether transition was positive or negative
appears to be related to whether the provider presented it as a government imposed change, or
as a change to allow more flexibility for consumers. The majority of consumers who had
transitioned to CDC understood at a broad level what the change meant and the reasons for it
(often described by the providers as being ‘government regulations’), and they were given
written materials. These were the consumers that were more likely to say that there had either
been no fundamental changes to their package or a reduction in services as a result of CDC.
A minority of consumers described having one-on-one discussions with their providers and,
sometimes, attending information sessions about CDC where providers explained that there was
more flexibility in how packages could be used. Overall, these consumers tended to be more
positive about CDC. Some examples of consumer and carer experiences with the transition to a
CDC packages are provided below.
Some consumer and carer perspectives on transition to CDC (real names not used)
John has been a widower for six years. Not long after his wife died, his daughter, who is a social worker,
convinced him that he needed help around the home and arranged for an ACAT assessment. He has been on
a CACP package ever since. About 9 months ago he was transitioned onto a CDC Level 2 package. He was
given a letter and some brochures explaining the changes but he ‘never bothers with that stuff’. The
coordinator explained to him that the services would be the same but he would now have an individual
budget. He receives domestic assistance and help with meals preparation. He used to receive services twice
a week, but this was recently changed so that he received more visits each week. This change was made
after his daughter suggested that it would be better to have someone visit more often. He likes most of the
care workers and gets annoyed when the provider sends ‘new faces’. He does not think the he has much
scope to influence who the provider will send on any given day.
Louise cares for her mother, who is deaf and blind and has been receiving an EACH package for some years.
At the time of the interview, Louise’s mother was being transitioned to a CDC Level 4 package, which she
described as a very traumatic experience because the provider said there would be less funding available
and that the services would need to be reduced to only the essential care (personal care, medication
Some consumer and carer perspectives on transition to CDC (real names not used)
management and meals assistance three times daily). They had to cancel domestic assistance, continence
pads, social activities and some of the meal services. The provider told them they would have to pay an
additional $700 per month to maintain those services. Louise feels that there should be additional
supplements for people who are deaf and blind. Louise also feels that they have little if any control over the
times of day services are delivered: sometimes they provide breakfast at 9.30am and then the lunch person
will arrive at 11.00am. Although Louise thinks that her mother usually receives good quality care, she has
found some of the provider’s care workers unreliable, particularly with medication management. They have
not considered changing providers, however, even with these problems.
Dwayne has been receiving a home care package for about 4 years. He transitioned to CDC a few months
ago. A lady from the home care provider came to his house and explained what the changes would mean,
mostly emphasising that there would now be an individualised budget and that he would receive an
itemised monthly statement The provider sat down with him to explain how the statement works using a
‘dummy sheet’. Although he has not changed any of his services, he knows that he has the ‘freedom’ to say
what he would like and to change his care plan if he wishes to. He also says when he wants them to come
and knows that he can request certain workers if he would like to. He is very satisfied with his arrangements.
Wanda lives in a regional area and has been on a CACP for about four years. She recently transitioned to a
CDC Level 2 package. Her case manager visited her to explain the changes and was very thorough. She has
noticed a few changes since she moved to CDC: she now has to pay a fee for transport to medical
appointments (previously this was paid by the provider, but there is not enough funding in her budget to
cover these costs). She also has to make arrangements to book the transport herself, whereas before the
case manager did that for her. She receives meals assistance which was fully covered before, but for which
she now has to pay an additional fee from her own pocket. She finds it more difficult to contact her case
manager. Wanda thinks that things have become a lot more complicated with CDC. Before if she wanted
extra help, in the garden for example, she would just ask her case manager and it would get done; now the
case manager needs to ‘consult the paperwork’ and see if there is enough money in the budget. It seems
very bureaucratic. She preferred it the way it was before.
3.3
Key transition considerations for providers
Transitioning ‘high cost’ consumers
Providers highlighted that under existing package arrangements, some consumers were receiving
more support, and some were receiving fewer supports, than would be possible under a CDC
package.. This was due to providers’ flexibility under current arrangements to vary the level of
support provided in each package to reflect individual needs, something which is not possible under
CDC arrangements.
Transitioning those who were receiving more supports than would be possible under a CDC package
was identified as particularly challenging. Providers highlighted a number of strategies for managing
this:
• moving the consumer to a higher-level package if there was one available and they had
been assessed for a higher package level – this was only possible where a person was on
a Level 2 package (CACP), and there was a Level 3 or Level 4 package available;
• discussing the need to reduce the levels of support at the care plan review point, and
working with consumers and families to identify alternatives – for example, reducing
higher costs services (such as support on weekends) and replacing with informal
supports;
• for some consumers on Level 4 packages and high levels of support, discussing the
possibility of the person moving to residential care; and
• some providers had committed to covering the additional cost of supports themselves,
thereby ensuring that no consumer was worse off in the transition to CDC.
• It was noted that, at the time of the provider interviews in November 2014, a third of the
sampled providers had yet to address this issue in their transition process.
Systems changes and costs
Most providers had or were planning to upgrade or replace their client management systems,
and establish interfaces with their financial management systems, to support CDC
implementation. However, a number of providers noted that:
• the cost of systems and software development was a significant one-off cost which is not
able to be recouped; and
• they were delaying implementation of systems changes until the detailed requirements
of CDC were fully understood internally and their CDC approach had been embedded –
this meant that processes around current CDC packages were being conducted manually
for example, preparation of individual expenditure statements.
Administrative and coordination costs
Providers reported that they were spending more time on planning, coordinating and administering
CDC packages than is required for other care packages, thus increasing a range of costs. Providers
stated that higher costs were attributed to a number of features of CDC:
•
•
•
•
providers are spending more time on planning with consumers at the commencement of
a package;
consumers are taking more time to consider their options and the costs, often delaying
when the package commences;
in supporting greater choice some providers were brokering additional services, which
added administration time when establishing the service arrangements (however, most
recognised the additional upfront costs were relatively minor, compared to ongoing
coordination and administration costs); and
providers are spending time tracking expenditure at an individual level and reporting
package expenditure to consumers, which resulted in additional administrative costs
(which were in turn being driven by the level of automation of the expenditure recording
processes and the sophistication of their financial systems).
Providers stated that these costs were being passed on to consumers through administration fees
and coordination charges. Some consumers were raising concerns regarding the level of
administration and case management fees, particularly where they were impacting on the amount
available to be spent on supports. It was also noted by providers that the administration and case
management fees were being disclosed to consumers for the first time, and that this transparency
was prompting questions and concerns from consumers.
Figure 10: Provider responses to the survey questions relating to the administration of CDC
Source: KPMG analysis of survey responses
Embedding practice changes
Many providers highlighted that CDC was a different way of working with consumers, and that it will
take some time to embed the new approach into their organisation. Some providers noted that they
understood the theory and principles of CDC, though were challenged in changing their practices and
behaviours. Providers who had CDC packages from the pilot period were much further advanced
than providers who had recently been allocated CDC packages.
Other considerations
Other considerations raised by providers included:
•
•
•
•
Workforce – including lack of staff skills and capabilities to work in a CDC context,
including a lack of commitment to CDC by some staff (mainly those involved in care
planning), which affected providers’ ability to implement a true CDC approach. Large
providers noted the challenge of rolling out training and sustaining change across
multiple areas of operation.
The need for coordinators to develop finance and budgeting skills with the ability to have
discussions with consumers about the cost of care (including fees and contributions). The
‘values’ of the organisation influenced this.
Individual budgets and monthly expenditure statements – there was wide variation in
providers approach to budgeting and developing monthly expenditure statements,
significant variation in the systems available to support budgeting and expenditure
reporting, and in some cases considerable time and effort in undertaking these processes
manually. Some providers suggested a sample budget and sample expenditure
statement would have been useful.
Pricing services and overheads – some providers are still developing unit prices for their
services, or have implemented price structures that may not be reflective of the actual
costs incurred (in the not-for-profit sector, these are usually under-estimated).
Survey results
The provider survey conducted as part of the evaluation sought information on the key issues or
challenges faced by providers in implementing CDC arrangements. The figure below illustrates the
key challenges reported by providers:
Figure 11: Provider responses to the survey question ‘Has this service encountered any significant
problems during the implementation of CDC?’
Source: KPMG analysis of survey responses
4
Consumer-directed care in action
This chapter considers the operation of CDC in practice. It is focussed on the experiences of
consumers, carers and home care providers. Specifically it considers how CDC is operating in practice
at this relatively early stage, using the CDC principles set out in section 2.2 of the Home Care
Packages Programme Guidelines 2014 as a framework for good practice and the intended policy
outcomes of CDC in home care.
The findings in this chapter were drawn from the interviews with home care providers,
ACATs/ACASs, consumers and carers and other aged care sector stakeholder groups; the online
survey of providers; and the provider service data collection.
Summary of key points: CDC in action
•
•
•
•
•
4.1
The transition to CDC is still in its early stages and will take some time to be embedded in
practice.
Assessing the current state of CDC against the framework of the CDC principles, it
appears that some steps have been made towards increasing consumer choice and
control, acknowledging the right to individualised care and support, and respectful and
balanced care partnerships. The extent to which these steps have been made varies
depending on a provider’s current position on the CDC spectrum.
Limited progress has been made towards the use of CDC to support community and civic
participation, and wellness and re-enablement.
The most notable accomplishment of CDC to date relates to the principle of
transparency, due to the implementation of individualised budgets and reporting. There
is still some work to be done around the transparency of administration and case
management pricing.
Some special needs groups may not be benefiting from CDC to the same extent as the
wider population.
Consumer choice and control
Principle: Consumers have managed their own lives for a long time. They should be empowered to
continue to manage their own life by having control over the aged care services and support they
receive. This requires the provision of, and assistance to access, information about service options
that enable a consumer to build a package that supports them to live the life they want.
Many providers reported that consumers were not making significant changes to their support
arrangements when they transitioned to CDC arrangements, and new consumers were not accessing
substantially different services from usual care consumers. They reported that in the main, CDC
consumers were continuing to access ‘core services’ such as personal care, assistance with household
tasks, and clinical (nursing) care, with some variation and new services at the margins. Notable
differences between consumer preferences for CDC and non-CDC consumers were observed for
supports to access social and community-based activities, transport, and in some cases specific
equipment designed to increase independence (and not available through other programmes). Data
relating to the range of supports accessed by CDC consumers is presented in Appendix C
It should be noted that the extent to which consumers were able to choose different services was
driven by the opportunities and information that providers gave them, and the support provided to
make choices – in effect the quality of the CDC transition (for existing consumers) or planning
process and the planning approach (for new consumers). A number of consumers stated that they
“don’t know what they don’t know” – they did not know what was possible or even what was
available, and they relied on their package provider to explain this to them, give them information,
and help them to develop a care plan which met their needs and goals. There were some providers
whose planning approach fully supported people to make choices based on their identified needs
and goals, whereas others provided more limited information and support and hence much more
limited choices to consumers.
Commonly, consumers expressed a lack of understanding about what else might be available and a
reluctance to ask for it unless the provider made an effort to start a discussion about what else might
be possible. A small number of consumers and some carers suggested that they had to take the
initiative in educating providers about the potential flexibility under a CDC package (which often
arose when requests were made for different kinds of services or equipment that were not part of
the ‘standard’ care and services highlighted in the guidelines).
Most consumers do exercise some limited control over their package, which is mostly around the
times that home care services are delivered and, to a lesser extent, by whom those services are
delivered. A few consumers and some younger carers indicated that they exercised more control
over the package, although this sometimes led to disputes with providers over appropriate
reductions in administrative fees to offset the self-management (generally settled through
negotiations). There appeared to be frequent disagreement with providers relating to the use of
package funds for equipment purchases, and the policies for return of equipment purchased from
package funds.
Overall, however, the vast majority of consumers and carers interviewed for the evaluation rated
their satisfaction with home care 4 or 5 out of 5 (satisfied or very satisfied). Scores were high even
where they expressed concern about having limited choice or control, or as to the quality of services.
Male consumers were most likely to rate their satisfaction higher.
4.2
Rights
Principle: CDC should acknowledge an older person’s right (based on their assessed needs and goals)
to individualised aged care services and support.
Although most providers appear committed to this principle, they are at different stages. This can be
related to their current position on the CDC spectrum. At the more advanced end of the CDC
spectrum, providers often use self-assessment tools and there is a strong focus on unhurried,
individualised assessment and planning. Providers spoke of the need to encourage consumers to
think more creatively about how packages might be individualised, acknowledging that sometimes
this had to be a gradual process. A consumer might need to get initial supports in place and feel safe
at home before they can think more about community and civic participation, for example,
particularly if they have entered the home care system after a health crisis.
At the other end of the spectrum are providers who continue to focus on a relatively standard set of
care and services, with preoccupation on the inclusions and exclusions in the guidelines. Some
consumers expressed frustration about having to ‘fight’ for certain equipment purchases or other
one-off expenditure.
4.3
Respectful and balanced partnerships
Principle: The development of respectful and balanced partnerships between consumers and home
care providers, which reflect the consumer and provider rights and responsibilities, is crucial to
consumer control and empowerment. Part of creating such a partnership is to determine the level of
control the consumer wants to exercise. This will be different for every individual, with some people
requiring or wanting assistance to manage their package and others choosing to manage on their
own.
Consumers should have the opportunity to work with the home care provider in the design,
implementation and monitoring of a CDC approach. Home care providers should be encouraged to
include consumers in their CDC redesigns.
As with the rights principle, the respectful and balanced partnerships principle is still evolving at this
stage of maturity within the Programme’s life. This is particularly so when it comes to determining
the level of control that the consumer wants to exercise over their package. Some providers candidly
reported that some of their staff were struggling with the concept – and the practice – of shifting
authority to the consumer. The importance of CDC champions and mentors for staff was emphasised,
and this was an area where providers who had participated in the CDC pilots had a significant
advantage. The overall message is that it takes time for staff to change their practice, just as it takes
time for many consumers to be comfortable in asserting and exercising some control. The transition
from a service provider/care recipient relationship, to a more partnership-based approach to care,
will also take time.
The second part of this principle envisages a level of co-production between providers and
consumers in the development of CDC approaches. Arguably, this is an ‘aspirational’ principle and a
relatively mature indicator that would not be expected to be evident so early in the implementation
of a new programme.
As such, it is not surprising that there was not any evidence of co-production occurring in any
meaningful way at this time.
Several providers spoke of seeking feedback from consumers through satisfaction surveys or similar
exercises, although only 3 of the 25 providers in the interview sample spoke about actively involving
consumers in the design and development of their service delivery models. At this time, many
providers appear to be more focussed on complying with the required timeframes for CDC
implementation.
4.4
Participation
Principle: Community and civic participation are important aspects for wellbeing. CDC in aged care
should support the removal of barriers to community and civic participation for older people, if they
want to be involved.
Some providers spoke about the importance of community and civic participation and it was clear
that, where possible, this was considered as part of CDC. The evaluation interviews suggest that for
most providers this does not appear to be a priority. That said, there were a few of examples of CDC
enabling consumers to participate in community and civic activities, as well as simply maintaining
social connections or interests of importance to them. For example:
•
An online home delivery grocery order was established for a woman with dementia living
in a rural town, so that instead of having a care worker accompany her on a weekly trip
to the supermarket, package funds could be used for a monthly visit to a nearby larger
town where the woman enjoyed browsing, window shopping and watching the passing
parade at a café as she had enjoyed doing for much of her adult life.
A man from a culturally and linguistically diverse background with limited mobility, in
consultation with his provider and doctor, decided that he was capable of managing his
medication and did not need that service provided through his home care packages once
it converted to CDC. Instead, he used funds for transport to regular club meetings in his
native language and some cultural events.
•
4.5
Wellness and re-enablement
Principle: CDC packages should be offered within a restorative or re-enablement framework to
enable the consumer to be as independent as practical, potentially reducing the need for ongoing
and/or higher levels of service delivery.
Many people enter the aged care system at a point of crisis. Such situations may require the initial
provision of services designed to address the immediate crisis. However, there should always be an
assumption that the older person can regain their previous level of function and independence with
re-enablement services being offered at a time that suits/supports the individual circumstances.
Although there was a great deal of interest in the concepts of wellness and re-enablement by the
majority of providers and other stakeholders, as well a very high level of support for the idea that
packages could support wellness and re-enablement, there was little evidence that it currently
occurs.
•
One for-profit provider – that also has strong links to the acute care sector as a provider
of post-acute services – gave a very salient description of a planned re-enablement
strategy for new consumers, which would often involve ‘frontloading’ the package with
higher levels of supports in the first few months, tapering off as the consumer’s reenablement goals were met. This meant that, contrary to the common practice of
spreading package funds more or less evenly across a year in the initial planning, they
•
planned to spend a greater proportion of it earlier with the objective being that the
consumer’s care needs would then decrease.
Only one provider spoke about moving consumers down care levels with the consumer’s
agreement once their re-enablement goals were met and ‘celebrated’, including from a
Level 4 back to a Level 2 in one case.
These were isolated examples, however, and the concept of moving consumers to lower care levels
in particular seemed a foreign concept to many providers.
4.6
Transparency
Principle: Under a CDC package, older people have the right to use their budgets to purchase the
aged care services they choose. To make informed decisions about their care, older people need to
have access to budgeting information, including the cost of services, the contents of their
individualised budgets and how their package funding is spent.
Of all the CDC principles, this is closest to being achieved as a result of the mandated individualised
budgets and monthly statements.
The majority of consumers and carers interviewed indicated some level of engagement and interest
in their individualised budget and expressed an appreciation for the monthly statements.
Approximately half of the consumers and carers read these statements thoroughly and indicated that
they valued the information, while others appreciated the transparency of the statements but felt
they were too complex or confusing or simply were not interested in the details. Younger carers were
all very engaged with the budget statements.
There were variable views expressed regarding contingency funds. The majority of consumers and
carers thought it was good to have a contingency, and some described how they worked with their
provider to plan the use of the contingency over time (i.e. for large equipment purchases or buying
blocks of respite time for weekend services for special occasions), whilst others indicated that the
contingency sat in their budgets accumulating and they had little understanding of what it was for or
even whether it was capped.
4.7
Considerations for special needs groups
A number of issues were identified relating to the aged care special needs groups. These are
considered below.
4.7.1 People from Aboriginal and Torres Strait Islander backgrounds
Stakeholders identified a number of issues relating to home care and CDC for people
from Aboriginal and Torres Strait Islander backgrounds. Many of these issues are similar to those
identified in the evaluation of the CDC pilots.
Many stakeholders consider that the guidelines do not allow sufficient flexibility to meet the diverse
needs of Indigenous communities, particularly in terms of the inclusions and exclusions. It is
suggested that the relatively low take-up of home care by Indigenous communities is a result of this
inflexibility. More specifically, some providers are hesitant of individual budgets for Indigenous
consumers because of their long-standing practice of pooling funds for community use. There is
disagreement as to whether individualised budgets are suitable for Indigenous consumers, with
some suggesting it can be stressful for the recipient to have an individualised budget that others in
the community think should be shared. This is however not a consensus view. Additionally some
providers are concerned that identifying and pricing case management as a discrete service in an
individual budget will disadvantage Indigenous consumers who need case management but may not
want to pay for that service from their individual budget.
The general exclusion of using home care funds to pay consumer fees or contributions for other
Australian Government services, particularly ‘gaps’ for Medicate Benefits Scheme and
Pharmaceutical Benefits Scheme rebated services, and co-payments for Australian Government
funded respite services was contentious. Some stakeholders suggest that package funds should be
available to cover these costs given the very low incomes of many Indigenous consumers.
Some stakeholders are concerned that guidelines are too inflexible for Indigenous communities. It
was suggested that Part E of the guidelines should make specific reference to meeting the cultural
needs of Indigenous peoples, which would allow clarity that package funds could be used for travel
to funerals and return to country. They argue that if there are specific sections on aids and
equipment and digital technology in the guidelines, there could also be something about cultural
wellbeing.
Some Indigenous-specific providers are concerned as to the fairness of ACAR allocation processes,
indicating a low success rate in ACAR allocation rounds and a lack of feedback to help them improve
their applications.
It is noted that the Department does provide generalised feedback for all applicants on its website
and, on request, provides written feedback to individual applicants. At the time of writing this
report, Outcomes Plus and the Australian Government were finalising an Overview document and
Guide to assist culturally and linguistically diverse (CALD) communities and other stakeholders to
understand the Aged Care Approvals Round (ACAR) process. It is anticipated that this document will
be published prior to launching the next ACAR.
4.7.2 People from culturally and linguistically diverse backgrounds
A key concern raised by stakeholders in relation to people from CALD backgrounds was the cost of
interpreting services. TIS National provides on-site and phone interpreting services to Australian
Government subsidised home care and residential aged care providers at no cost to the approved
provider or consumer to negotiate the Home Care Agreement, co-design the care plan and
individualised budget, and when discussing the consumer’s monthly income and expenses
statement. This ensures consumers can fully participate in the assessment, care planning and review
of their Home Care Package.
Consumers are, however, charged for interpreters when receiving personal care and other services
that have been agreed through the development of the care plan. Some stakeholders considered
that it was inequitable for CALD consumers to have the value of their package reduced to pay for
these services.
The relatively low number of home care places with a condition of allocation for priority of access for
people of CALD background was raised. Similarly to Aboriginal and Torres Strait Islander services,
stakeholders suggested that CALD services should be provided with better feedback on unsuccessful
ACAR applications to help increase their success in future competitive application rounds, and to
increase the number of home care places with a condition of allocation for priority of access for
people of CALD background.
It is noted that the Department does provide generalised feedback for all applicants on its website
and, on request, provides written feedback to individual applicants.
The National Ageing and Aged Care Strategy for People from CALD Backgrounds was released in
20121. The strategy will inform the way the Australian Government supports the aged care sector to
deliver care that is appropriate and sensitive to the needs of older people from CALD backgrounds. It
includes a number of activities that aim to address the areas of concerns raised by stakeholders,
including enhancing the capacity of existing and emerging CALD communities as potential aged care
service providers and developing relevant service models and partnerships, addressing any existing
‘stigma’ in CALD communities that inhibits aged care service access, and encouraging members of
CALD communities to consider employment, volunteering and training in the aged care sector.
The Partners in Culturally Appropriate Care (PICAC) initiative is one such initiative that aims to
address CALD barriers to aged care access. It was developed by the Australian Government to
improve the capacity of aged care services to respond to the differing needs of older people from
CALD communities. Organisations are funded in each state and territory to provide PICAC projects.
4.7.3 People who live in rural or remote areas
Two key considerations were raised for people who live in rural and remote areas. The first related to
access to sufficient care levels, with stakeholders reporting that there were not enough high care
packages available in rural and remote areas. Further there was a perception that some providers
‘cherry picked’ the location of consumers they offered a package to, prioritising those living closer to
town.
The second issue related to the additional costs involved in delivering services to rural and remote
areas. Most providers charged travel costs to the consumer (in some cases, they allowed a ‘free’
kilometre allowance based on the distance from the provider’s office, with consumers paying a perkilometre cost for travel outside of the free radius). There were concerns that this effectively
lowered the value of the package for rural and remote consumers compared to those living in urban
areas, raising equity concerns. Previously these additional costs would have been cross-subsidised by
other packages
4.7.4 People who are financially or socially disadvantaged
There was limited information in relation to this group. However, some stakeholders raised similar
issues as for Aboriginal and Torres Strait Islanders regarding the use of package funds to pay
consumer fees or contributions for other Australian Government services, particularly ‘gaps’ for
Medicare Benefits Scheme and Pharmaceutical Benefits Scheme rebated services, and co-payments
for Australian Government funded respite services. Some stakeholders suggest that package funds
should be available (or, more appropriately, cashed out) to cover accommodation costs and food
purchase costs in emergency circumstances.
1
https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/older-people-their-families-andcarers/people-from-diverse-backgrounds/national-ageing-and-aged-care-strategy-for-people-from-culturally-andlinguistically-diverse-cald-backgrounds
Comments relating to people who are homeless or at risk of becoming homeless are also broadly
applicable to the financially and socially disadvantaged group.
4.7.5 Veterans
There was insufficient information available to make any specific comment in relation to this group.
4.7.6 People who are homeless or at risk of becoming homeless
A peak body representing providers that specialise in providing services to consumers who are
homeless or at risk of homelessness, and consumers who are socially and financially disadvantaged,
reported that, despite the removal of age-based entry criteria for aged care eligibility, further work is
required to ensure that ACATs/ACASs and other stakeholders understand the early ageing effects of
chronic homelessness. It was noted that many consumers from this group experience assessment
delays because they are aged under 65 years. It was suggested that consumers identified as being
members of the homeless special needs group – as well as care leavers – should be generally
classified as ‘aged’ from 50 years plus, as per the current situation with consumers in the Aboriginal
and Torres Strait Islander special needs group.
Concerns were raised regarding potentially reduced case management hours under CDC packages.
Providers reported that care coordinators accustomed to working with homeless consumers were in
the habit of regularly ‘dropping in’ on their clients. Some providers said they were able to less of this
activity under the new arrangements. These changes were reported to be negatively impacting on
some consumers as well as staff, who were having to adjust their practice. This is consistent with the
CDC pilot evaluation, which found that homeless consumers particularly valued case management
and face-to-face contact with care coordinators more than they valued having choice and control or
services, and considerably more than they valued budget transparency.
One consumer from the homeless special needs group was interviewed. She had been receiving a
home care package for about three years, having settled in a public housing property after many
years of housing instability and homelessness complicated by financial difficulty, family conflict and
severe health problems. She reported being generally satisfied with her care and services, and
appreciates receiving the regular financial statements since she was transitioned onto a CDC
package. However, she is dismayed by what she considers considerably reduced case management
hours under the new arrangements. She has had the same care manager for many years and trusts
her, but now feels that she is unable to access the same level of support and assistance that she
previously did.
Providers also referred to the time needed to establish relationships and build trust with homeless
consumers (an issue that was also identified in the pilot evaluation), indicating that there is currently
no financial provision for the ‘pre-planning’ time needed with consumers.
Despite these concerns, providers report that the transparency provisions of CDC work very well for
most consumers in this group and, similarly to mainstream consumers, care coordinators have
adopted the budgeting tool as part of the care planning process. Overall, it is reported to have
increased consumer participation and involvement in care planning.
4.7.7 Care leavers
Care leavers includes the Stolen Generations of Indigenous people forcibly separated from their
parents, the Forgotten Australians of people raised in institutional care settings during the 20th
century, and former child migrants. Stakeholders interviewed for the evaluation indicated that there
has been little substantive action to recognise and address the needs of this group in home care to
date (what action there has been has focussed on the residential care sector). Unlike the CALD and
LGBTI special needs groups, there is no national aged care strategy for care leavers.
Often wary of authority, institutions and bureaucracy, care leavers may choose not to participate in
traditional assessment processes. They often do not actively seek out services. They can experience
early ageing as a result of long-term trauma and social isolation, and may require a trusted advocate
to help them access aged care services.
Since 2010, a number of community organisations, including a small number of aged care providers,
have worked with the government to develop care leaver education and resources for the aged care
sector. At the time of writing this report, the Department was working towards making the
resources available to the aged care sector. Stakeholders suggest that there is a need for care leaver
training, similar to what has occurred with the LGBTI special needs group, as well as allocating some
dedicated care leaver packages.
Comments relating to people who are homeless or at risk of becoming homeless are also broadly
applicable to the care leavers group.
4.7.8 Parents separated from their children by forced adoption or removal
There was insufficient information available to make any specific comment in relation to this group.
4.7.9 Lesbian, gay, bisexual, transgender and intersex people
A minority of providers referred to the LGBTI special needs group at interview. Of those that did, one
provider was working with a local LGBTI health organisation to obtain accreditation as an ‘LGBTI
friendly’ aged care provider, and another was reviewing their promotional and information materials
to ensure that they did not exclude LGBTI people. A third provider had several home care packages
dedicated to LGBTI consumers, and spoke of the particular needs for this group including wariness of
receiving services in their home, reluctance to disclose relationship status or personal circumstances,
and early ageing issues due to long-term HIV treatment.
Stakeholders indicated that the implementation of home care packages and CDC had only marginally
addressed ongoing concerns for LGBTI older people. Consumer representative groups reported that
many providers are still struggling to provide relevant information to LGBTI people. Although training
and support projects such as the LGBTI Health Alliance’s Silver Rainbow are widely available and have
been well-received, these are yet to reach the critical mass of providers necessary for them to have a
discernible impact at this time. Stakeholders report that LGBTI consumers and carers often find the
aged care assessments does not adequately consider or address their needs, and that it is a particular
problem for people who do not use identity labels, those with disclosure and privacy concerns,
people with intersex characteristics, men of trans experience (assigned 'female' at birth), women of
trans experience (assigned 'male' at birth), and people with non-binary genders.
LGBTI consumers commented that most providers are generally unfamiliar with LGBTI support
organisations and activities, and do not know how to connect LGBTI people with their community. In
addition, many mainstream support organisations for older people are not structured to cater for
LGBTI people. For example, the Community Visitors Scheme has not, until recently, had any LGBTI
community visitors. There is currently only one LGBTI visiting service (which operates in the same
region as the only currently designated LGBT home care places). It is based in a metropolitan area
and was established in 2012.
•
One consumer from this region was interviewed for the evaluation. He was connected to
the visiting service through his home care provider, and he reported that the service had
made an immense difference to his quality of life. Although he was very satisfied with
the quality of care offered by his home care provider, and with the level of choice and
control he had over his package, he still did not feel entirely free to be himself around his
care workers. The volunteers from the LGBTI visiting service made him feel less isolated
and this, he reported, had reduced the severity of depression he regularly experienced.
He considered that the home care package and the visiting service complemented each
other and that together they provided him with an improved quality of life.
Stakeholders suggest that further training is needed for ACATs and providers, particularly on issues
for people of trans experience, people with non-binary genders, and people with intersex variations.
5
Considerations for strengthening and improving home
care and CDC
This chapter draws on the findings from the evaluation to identify opportunities to strengthen and
improve the Programme. This includes areas to support the conversion of all home care places
to CDC by 1 July 2015, as well as longer-term considerations. Key areas identified include:
•
•
•
•
•
•
•
5.1
supporting providers to implement CDC;
strengthening the focus on re-enablement and wellness;
clarifying the basic care interface;
increasing knowledge of CDC across key agencies and services;
trialing new approaches for underrepresented special need groups;
improving the continuum of care; and
increasing consumer control through self-directed funding and portability.
Supporting providers to implement CDC
Providers continue to require support to effectively implement CDC from both an administrative and
practice perspective.
From an administrative perspective there are two key areas that need resolution and / or support:
• the Medicare claims process and the time taken for income assessments
– it is noted that DHS established a specialist team to address the timeliness of
income assessments, however complex assessments involving complicated
financial structures do take more time to process
– now that the processes are established, it may be helpful for DHS to disseminate
some general information about processing times, as providers may not be
aware of the degree of complexity in individual cases
• the Information Technology (IT) upgrades required to link their client and financial
management systems which are required to establish client-level cost centres and
generate the individual monthly statements required for CDC. This is a costly and timeconsuming process, particularly for smaller providers.
There is opportunity for providers to examine the feasibility of shared service arrangements for
financial and IT management activity. This could be particularly beneficial for smaller providers,
allowing them to focus on their service provision rather than financial and IT management.
There a number of other areas where assistance could be provided to support more timely and
effective transition to CDC. Such efforts could be targeted towards specific special needs groups
whose needs may not be being met under current arrangements, or to regions where there are thin
markets or potential market failure, for example in rural and remote environments. Support could
include:
• IT system adaption;
• understanding cost of delivery and associated unit pricing of services;
• service reorientation to enable more contemporary models of delivery within a CDC
framework; and
• practice development and support for care coordinators and care workers in CDC
practice.
Existing and developing practice could be leveraged more broadly to enable sharing of experience
and practical support for application of CDC. This may include expanding the current repository of
tools and mechanisms, as well as collating and sharing information and other relevant materials
across the sector. Ideally, responsibility for leading this should come from within the sector itself.
5.2 Strengthened focus on re-enablement and wellness
Re-enablement and wellness has yet to be embedded as a core objective of care and support with
many providers unclear as to how to reorientate practice to do this. At this early stage of
implementation, it is not unexpected that substantive progress has not been made in this area.
However, there is a clear desire amongst providers to strengthen the focus on re-enablement and
wellness for consumers, and this presents an opportunity to further the implementation of this policy
objective.
Documenting and disseminating good practice examples of re-enablement and wellness support
could assist providers to examine their own practice and consider new ways of working with
consumers and health providers to achieve this.
At the time of report writing, a good practice guide for re-enablement and wellness in the context of
the CHSP was being developed, with a focus on maximising consumer independence to prevent or
reduce the need for ongoing care where possible (i.e. applying re-enablement and wellness
approaches to basic support services, with the objective of preventing or delaying a need for ongoing
home care and/or residential care). A similar guide could be developed for home care, highlighting
and explaining exemplars, to show how re-enablement and wellness approaches can be applied to
home care to prevent or delay the need for higher levels of care.
5.3 Clarifying the basic care interface
The current service boundaries between home care Level 1 and the CHSP should be resolved as soon
as possible, including addressing the perceived financial disincentive for eligible consumers to take
up a lower level home care package.
Demand (occupancy) of Level 1 places should be monitored over time to assess whether there is any
change in demand once the CHSP boundary issues are resolved. Some providers already successfully
utilise Level 1 places. Supporting material should be made available to the sector showing how Level
1 places can provide be a viable option for their service, and an attractive option for consumers.
5.4 Increasing knowledge of CDC across key agencies and services
ACATs/ACASs, the AACQA, NACAP service providers and the Aged Care Complaints Scheme all
require detailed knowledge and understanding of CDC policy and programme objectives. These
agencies and services are key players in supporting decision making and access to packages and the
effective implementation of CDC. A tailored package of information and education to uplift
understanding of CDC amongst these agencies would help embed CDC within the aged care system.
Any education activities aimed at ACATs/ACASs should include a particular focus on the benefits of
CDC from a clinical perspective, explaining how individualised budgets translate into a package of
care and supporting consumer-led decision making regarding health and wellbeing.
5.5 Trialling new approaches for under-represented special needs
groups
Many stakeholders consider that some special needs groups are under-represented in home care,
and/or that their specific needs are not currently being met. Consideration should be given to
trialling and evaluating new approaches for delivering home care in a CDC framework to these
groups, with an objective of documenting and disseminating evidence on what works to meet their
needs. From the evaluation findings there are three special needs groups that would benefit from
this:
•
•
•
5.6
People from Aboriginal and Torres Strait Islander backgrounds – there was consistent
feedback from stakeholders that alternative models of CDC need to be developed for
many, if not most, consumers who fall within this group, and that these models may
include options for some communal use of package funds;
Lesbian, gay, bisexual, transgendered and intersex people – although there has been
considerable activity to address the specific needs of this group, it appears that the
majority providers are still uncertain how to identify and address those needs, with many
LGBTI consumers uncertain as to how they can safely articulate their individual needs to
mainstream service providers; and
Care leavers –this particular group have yet to be properly explored in the context of
home care, and the anecdotal information suggests that they are not accessing services
to the extent that might be expected.
Improving assessment and the continuum of care
The future potential for a single ACAT entry assessment should be explored, with an optional reassessment for moves between low and high care at the request of a provider or consumer.
Stakeholders indicate there is limited clinical benefit in requiring a re-assessment for consumers to
move from Level 2 to Level 3. The intended policy objective of requiring an ACAT/ACAS reassessment to move between low and high care relates more to the perceived need for an
independent ‘gatekeeper’ than it does to the need for a clinical assessment. There are options for
managing this gatekeeping objective without requiring an ACAT/ACAS re-assessment. For example,
providers could be required to assess and document the need for a low care recipient to move to
high care with a mandated tool (linked to the ACCR), and a regime of random audits could be put in
place to ensure the quality and integrity of the assessments. Such an approach could potentially be
trialled in a sample of aged care regions.
Consideration should be given to adjusting the allocation process to better promote the continuum
of care. In a fully operational CDC environment consumers would be able to access any assessed
level of care through any provider of their choice. To facilitate this all providers could be allocated a
minimum mix of all care levels. A consumers’ care level would then be able to increase without
changing provider (i.e. an ageing in place policy, and places would be portable. This would require
some adjustment and reconsideration of current policy and processes.
5.7 Increasing consumer control through self-directed funding and
portability
Consumers now have more choice of services and control of their budget, however they still have
limited choice and control over the provider who holds their funds – and who, therefore, still holds
authority in an entry-controlled market with minimal competition.
Establishing portability by allocating subsidy funds directly to the consumer rather than the provider
would significantly increase consumer control and give effect to the key objectives envisaged in the
CDC policy discourse. This would require safeguards and consumer protections, together with
fundamental change to the current operating environment and business models of home care
providers. Providers would need to more actively identify and promote their service offerings and
their value proposition to the marketplace, responding to consumer demand and preferences as part
of a competitive and dynamic market.
Consumer feedback to this evaluation suggests that they still feel somewhat disempowered through
the lack of capacity to easily change provider, whether it be for poor performance or that they are no
longer suitable to meet their changing needs or simply because they want a change. Portability of
home care places would enable greater self-direction for consumers and support competitive market
dynamics.
Self-directed funding and portability are two key policy areas for consideration once CDC has reached
a relative point of implementation maturity where this would be seen as the natural next steps in
practice and market capacity. Learnings could be taken from the implementation of the NDIS where
self-directed funding and portability are key policy objectives, and the provider market is undergoing
significant reorientation.
Appendix A
Evaluation methodology
This appendix sets out the evaluation methodology.
Background
The Home Care Packages Programme commenced in August 2013, with the commencement of a new
4-level care structure for home care places that replaced for former Community Aged Care Packages
(CACP), Extended Aged Care at Home (EACH) places and Extended Aged Care at Home Dementia
(EACHD) places to the new care levels. The care level structure is as follows:
•
•
•
•
Home Care Level 1 – an individualised and coordinated package to support people with
basic care needs with a Commonwealth subsidy of $21.43 per day or $7,822 per annum
using 2014-15 rates (this care level did not exist prior to August 2013);
Home Care Level 2 – an individualised and coordinated package to support people with
low level care needs with a Commonwealth subsidy of $38.99 per day or $14,231 per
annum using 2014-15 rates (this care level is equivalent to the former CACP places);
Home Care Level 3 – an individualised and coordinated package to support people with
intermediate care needs with a Commonwealth subsidy of $85.73 per day or $31,291 per
annum using 2014-15 rates (this care level did not exist prior to August 2013);
Home Care Level 4 – an individualised and coordinated package to support people with
high care needs with a Commonwealth subsidy of $130.32 per day or $47,567 per annum
using 2014-15 rates (this care level is equivalent to the former EACH and EACHD places).
A number of new supplements were also introduced (including the dementia and cognition
supplement and the veteran’s supplement, which each provide for an additional daily payment of 10
per cent of the daily care subsidy), that can be applied at any care level.
The 2013-14 Report on the Operation of the Aged Care Act 1997 states that, as at 30 June 2014,
there were 66,149 home care places nationally. Of these, 1,303 were Level 1; 50,157 were Level 2;
1,010 were Level 3; and 13,679 were Level 4. The Australian Government is gradually increasing the
number of home care packages to 100,000 by 2017, with 40,000 additional packages over the
following five year period to 2021-2. The aged care provision ratio for home care places (that is, the
target number of places available for the number of people aged over 70 years) will increase to
45:1,000 from the current actual national ratio of 28.7: 1,000.
Objectives of the Home Care Packages Programme
The objectives of the Programme, as outlined in the Home Care Packages Programme Guidelines July
2014, are:
• To assist people remain living at home; and
• To enable consumers to have choice and flexibility in the way that their aged care and
support is provided at home.
The target population for home care packages is older Australians, particularly frail older people
(although there are no minimum age eligibility requirements). A number of special needs groups are
specified in the aged care legislation, specifically:
•
•
•
•
•
•
•
•
•
People from Aboriginal and Torres Strait Islander communities;
People from culturally and linguistically diverse backgrounds;
People who live in rural and remote areas;
People who are financially or socially disadvantaged;
Veterans;
People who are homeless or at risk of becoming homeless;
People who identify as lesbian, gay, bisexual, transgender or intersex;
People who are care leavers; and
Parents separated from their children by forced adoption or removal.
In some cases, home care places may be specifically allocated to provide priority of access to
particular special needs groups, however all home care providers are expected to ensure that their
internal policies and practice ensures that services are accessible to people with special needs.
Consumer-directed care (CDC)
To facilitate choice and flexibility, all new home care places allocated since August 2013 are delivered
within a consumer-directed care framework. At the time of the evaluation, there were around 1,000
existing CDC places from the 2010-12 CDC pilot, plus 5,835 places that were allocated in August
2013, and an additional 6,653 places that were allocated in December 2014 (during the evaluation
period). All future places will be allocated on a CDC basis. By 1 July 2015, all existing home care
places must convert to CDC arrangements. Many providers have been gradually transitioning their
existing consumers to CDC arrangements since August 2013 as part of regularly scheduled home care
reviews.
The Home Care Packages Programme Guidelines July 2014 define CDC as follows:
A way of delivering services that allows consumers to have greater control over their own lives by
allowing them to make choices about the types of aged care and services they access, including who
will deliver the services and when. Under a CDC approach, consumers are encouraged to identify
goals, which could include independence, wellness and reablement. These will form the basis of the
Home Care Agreement and care plan.
Under CDC consumers have an individualised budget to give effect to their care plan, with providers
holding and administering the budget on the consumer’s behalf. Commonwealth subsidies for
supports are paid to the provider at a fixed amount by care level (which is the same for all consumers
at the same care level, plus any additional supplements the consumer is eligible for). The consumer
receives a monthly statement from the provider that reconciles income (i.e. Commonwealth
subsidies and supplements, plus consumer fees and any additional consumer contributions) against
expenditure and showing accumulated unspent funds in their individualised budget.
Purpose of the formative evaluation
The purpose of this formative evaluation was to identify any operational issues or possible
adjustments required to strengthen the Home Care Packages Programme’s effectiveness, and to
ensure the successful and complete conversion of all home care packages to CDC by 1 July 2015, as
well as any areas requiring longer-term policy consideration.
Evaluation questions
An evaluation framework was developed in May 2014 to guide the data collection activities and to
provide the data analysis and reporting approach for the evaluation. The framework identified the
following evaluation questions:
1. How effective has the implementation of the Home Care Packages Programme
(including CDC) been?
1.1 How well are the new arrangements working for home care providers and ACATs? This includes
processes for implementing home care places, and the development and transition to CDC models of
service delivery (including different models of CDC); effectiveness of the new care level structure and
assessment processes; effectiveness of the intended graduated continuum of care between care
levels; effectiveness of the Programme guidelines and information processes; and considerations for
different types of providers.
1.2 How well are the new arrangements working for consumers? This includes understanding the
range of care and services being accessed (including use of brokered services); application and
impact of fees; consumer perceptions of choice and control; consumer engagement with
individualised budgets and financial statements; effectiveness of information and advocacy services;
and considerations for special needs groups
1.3 How well are the new arrangements working for the aged care system? This includes the
interface with other aged care services such as the current Commonwealth HACC Programme
(Commonwealth Home Support Programme from 1 July 2015); effects of the new arrangements on
consumer demand and expectation; effects of the new arrangements on waiting times; and effects of
the new arrangements on provider capacity and capability.
2. Are there any operational issues or possible adjustments needed to strengthen the
Home Care Packages Programme’s effectiveness in meeting its objectives?
Data collection methods
There were three levels of data collection to gather the information needed to address the
evaluation questions:
• National data collection
• Sample regions analysis
• Targeted supplementary stakeholder consultations.
National data collection
This involved collection of information from home care providers. There were three methods of data
collection:
• Online survey for all 504 home care providers
• Review of a sample of de-identified Ministerial correspondence and Departmental
communications
• Template report for home care providers delivering CDC places.
These methods are described in more detail below.
Online survey for all Home Care Packages Programme home care providers
This method was used to collect information to address questions 1.2 and 1.3. The survey explored
service provider experiences, views and insights with the Home Care Packages Programme
implementation. This included:
• Experience with the transition to and implementation of the new Home Care Packages
Programme care levels
• Perceived effectiveness of the new ACAT assessment arrangements
• Information on the nature and extent of interface with other aged care services
• Experience with the transition to and implementation of CDC (for those providers
delivering CDC places).
A link to the external online platform hosting the survey was distributed to all 504 home care
providers by the Department.
In the results analysis, home care providers were stratified by their sub-group (new CDC provider,
ongoing CDC provider, non-CDC provider).
Review of de-identified Ministerial correspondence and Departmental communications
This method was used to collect information to address questions 1.1, 1.2 and 1.3. A qualitative
coding analysis was conducted on a sample of de-identified Ministerial correspondence and
Departmental communication logs from providers, consumers and carers.
Template report for Home Care Packages Programme providers delivering CDC places
The Excel template report sought six months of retrospective data from providers with home care
places (up to and including places allocated in the 2013 ACAR round) to understand the range of
supports provided under CDC places, the extent of brokered services, the level of care fees and
consumer funding top-ups, and general information about the range of CDC tools and processes used
by providers. The purpose of this request was to collect information that would demonstrate how
CDC consumers are using their places, and thereby providing data to address components of
evaluation question 1.1.
Sample regions analysis
This level of data collection involved a more in-depth focus in 10 aged care planning regions across all
mainland states and territories except the Australian Capital Territory. The focus regions were
selected with assistance from the Department based on identified characteristics of interest
including a mix of different types of providers, regions and jurisdictions, and different mixes of
consumers (including a proportion of consumers from special needs groups).
The sample included a mix of:
• Different types of provider (size, organisation type)
• Different locations (jurisdiction, metropolitan, regional, rural/remote)
• Providers specialising in or having notable proportion of consumers from special needs
groups
• Providers with experience of the CDC pilot as well as those that were new to CDC from
August 2013
• Representation of all four care levels.
There were four methods in this data collection tier:
• Interviews with a sample of home care providers (25 in total across the 10 aged care
planning regions)
• Review of de-identified home care and CDC documentation from a sample of home care
providers
• Interviews with a sample of ACATs (13 in total, covering the 10 aged care planning
regions – noting that ACAT catchments do not align to planning regions)
• Interviews with a sample of consumers and carers/families from the sample of home
care providers (roughly 2 per provider, or 55 in total).
These methods are described in more detail below.
Interviews with a sample of 25 home care providers
This method was used to collect information to address questions 1.2, 1.3 and 2. The interviews
explored provider experiences and insights concerning the transition to and implementation of the
arrangements, key successes and challenges, lessons learnt and opportunities for improvement. The
service providers were sampled from the following 10 aged care planning regions:
•
•
•
•
•
•
•
•
•
•
Cabool (Queensland)
Darwin (Northern Territory)
Hume (Victoria)
Metro East (South Australia)
Metro North (Western Australia)
Northern Metro (Victoria)
Riverina Murray (New South Wales)
Southern (Tasmania)
Sunshine Coast (Queensland)
Western Sydney (New South Wales).
At least two and generally three service providers were sampled from each of the 10 regions. They
were purposively sampled to ensure a mix of different provider sizes and type, different types of
geographical regions, different levels of experience with CDC, and a mix of providers with notable
proportions of clients from special needs groups.
Review of documentation from a sample of providers
This method was used to collect information to address question 1.2 and question 2. The selected
providers were asked to provide a sample of de-identified Home Care Agreements (including
consumer goals and care plans) and individual budget statements, copies of CDC and special needs
group’s policies and procedures, and copies of information materials for consumers and carers.
Interviews with a sample of ACATs
This method was used to collect information to address questions 1.2, 1.3 and 2. The interviews
explored ACAT experiences with and insights about the new arrangements, including the new
assessment processes, the new care levels and supplements, and CDC arrangements.
All ACATs and ACASs operating in the 10 aged care planning regions from which the providers,
consumers and carers were drawn were invited to participate in an interview. As ACAT and ACAS
catchments do not align to aged care planning regions, there were more ACATs and ACASs (n=13)
than aged care planning regions (n=10)
Interviews with consumers and carers/families
This method was used to collect information to address question 1.1 and 2. The interviews explored
consumer and carer experiences with the transition to new places and with CDC. The sample was
drawn from a pool of expression of interest voluntarily submitted by consumers of the 25 home care
providers (the providers distributed a general information sheet about the evaluation with an
expression of interest form and Reply Paid envelope directly addressed to KPMG to their home care
consumers; expressions of interest were collated confidentially by KPMG). Providers were not
informed whether or not their consumers either submitted an expression of interest, or participated
in an interview.
In selecting the interview sample, the evaluation sought to include the following broad mix of
characteristics:
•
•
•
Consumers/carers with experience of CDC places prior to August 2013 (i.e. continued
from the CDC trial)
Consumers/carers new to CDC from August 2013
Consumers/carers from a range of special needs groups, as well as people with dementia
or their carers.
The evaluation sought to establish a total sample of 75 consumers and carers (aiming for
approximately half of each), however a number of consumers and carers who had initially expressed
interest either declined when they were contacted for interview (due to changed circumstances,
inconvenience of the proposed interview timing, or simply having forgotten or changed their mind),
leaving a total final sample of 55.
Selected service providers were asked to distribute an expression of interest for participating in an
interview to all of their consumers (carers were also able to submit an expression of interest). The 55
consumers and carers were drawn from the pool of those that returned their expressions of interest
to KPMG in a Reply Paid envelope (i.e. their providers were unaware of whether they had submitted
an expression of interest or not). Selected consumers and carers were provided with an information
sheet and consent form, in a format approved by a Human Research Ethics Committee specifically for
this evaluation.
Expressions of interest to participate in an interview were received from 125 consumers or carers
(from a total pool of 1,342 home care packages administered to the 25 home care providers included
in the evaluation interview sample; this is a response rate of about 9 per cent – not making
allowances for places there were unoccupied at the time expressions of interest were distributed,
and assuming that all providers distributed the expressions of interest).
From the pool of 125 expressions of interest, a total of 55 telephone interviews were conducted with
consumers and carers across Australia. Of these, 56 per cent were consumers (care recipients) and
44 per cent were carers. A breakdown of demographic details for the consumer and carer interviews
is set out in the table below.
Table 5: Demographic details of consumer and carer interviewees
Aboriginal
& Torres
Strait Is.
CALD
Rural /
remote
Veteran
Homeless
Care
leaver
LGBTI
Dementia
Number
1
12
8
7
1
0
1
15
Percentage
2
22
15
13
2
0
2
27
Source: KPMG (note: there is no total column as some people fall into multiple categories).
A number of critical special needs groups were under-represented in the expressions of interest pool
(specifically, consumers and carers from the LGBTI, Aboriginal and Torres Strait Islander, care leavers,
and homelessness special needs groups). The following actions were undertaken to redress this lack
of representation:
•
•
•
•
•
•
Interviews were conducted with several peak bodies and consumer reference groups
(including the LGBTI Health Alliance and the Alliance for Forgotten Australians auspiced
by Families Australia).
A round table of metropolitan Indigenous stakeholders was held in Victoria which
included several service providers, two consumers and one carer representative.
An interview was conducted with an additional service provider servicing remote
Australia including remote Indigenous communities.
Interviews were conducted with 2 home care consumers and carers – one of whom was
a client of one of the 25 service providers included in the evaluation sample and one of
whom was not; both were recruited through the consumer outreach networks of the
LGBTI Health Alliance.
Additional written information on the experiences of LGBTI consumers and carers was
provided from care coordinators at a service provider with dedicated LGBTI home care
places (this provider was included in the evaluation sample).
Additional written information on the experiences of consumers and carers at risk of
homelessness or who have experienced homelessness was provided by service providers
with dedicated homelessness home care places (this information was coordinated by
LASA).
•
Additional written information on the experiences of consumers and carers from
culturally and linguistically diverse consumers was provided by service providers with
dedicated CALD home care places (this information was coordinated by FECCA).
Attempts were also made to directly recruit additional consumers and carers from Aboriginal and
Torres Strait Islander backgrounds for interview or participation in an informal focus group via direct
approaches to two home care providers with significant proportions of Indigenous consumers, and a
direct approach to one of the NACAP service providers. These attempts were not successful.
Supplementary interviews with other stakeholder groups
The final level of data collection involved conducting supplementary interviews with a targeted
sample of other key stakeholder groups. These stakeholders are detailed below.
Table 6: Schedule of evaluation consultations
Organisation / agency
Date(s) of consultation
Leading Age Services Australia (LASA)
February 2015
Aged and Community Services Australia (ACSA)
February 2015
COTA Australia (formerly known as Council on the Ageing)
February 2015
Carers Australia
February 2015
Alzheimer’s Australia
February 2015
Federation of Ethnic Community Councils of Australia –
for comment on CALD perspectives
February 2015
Families Australia (Alliance for Forgotten Australians) –
for comment on care leavers perspectives
February 2015
Australian Regional and Remote Community Services (ARRCS) –
for comment on rural/remote and remote Indigenous perspectives
February 2015
Focus group of Indigenous stakeholders from Victoria
(3 service providers, two consumers, one carer, and Victorian Aboriginal Community
Controlled Health Organisation) – for comment on metropolitan Indigenous
perspectives
November 2014
LGBTI Health Alliance – for comment on Lesbian, Gay, Bisexual, Trans-gender and
Intersex perspectives
February 2015
ACT Disability and Aged Care Advocacy Service – for comment on aged care advocacy
perspectives
February 2015
National Home Care IT Group – for comment on assistive technologies and digital
solutions under CDC
February 2015
Department of Social Services
February 2015
Source: KPMG
Evaluation governance and ethics
The evaluation reported to the Home Care Packages Programme Section, Department of Social
Services. KPMG met with the Department approximately every three weeks during the data
collection and report writing phases of the evaluation. The Department approved the evaluation
framework and data collection tools.
The Department was advised by the National Aged Care Alliance (NACA) home care packages
working group during the evaluation. KPMG presented to the NACA working group and the
Department on two occasions during the evaluation period: prior to finalisation of the evaluation
framework; and to present preliminary findings arising from the evaluation data collection.
The consumer and carer consultation component of the evaluation, including the participant
information sheets, consent forms and interview questions, received ethical approval from the
Bellberry human research ethics committee (reference number 2014-05-271).
The online provider survey was approved by the Australian Government Statistical Clearing House
(Approval Number: 02408-01)
Appendix B
Provider survey – detailed tables
This appendix sets out the detailed results from the online survey of home care providers conducted
in December 2014 – January 2015. The survey was approved by the Australian Government Statistical
Clearing House (Approval Number: 02408-01).
The survey was comprised of 17 questions. To minimise the burden of responding to the survey,
several filter questions were added into the structure of the survey. This ensured that only relevant
questions were presented to respondents.
The survey opened on 28 November 2014 and closed on 9 January 2015. It was distributed by the
Department to providers via an email containing a link to an external secure online survey platform.
Participation in the survey was voluntary and open to all home care providers. One reminder email
was distributed by the Department during the survey period.
A free call 1800 phone line and email address was established to respond to technical enquires about
the survey. In total, only 5 emails and 4 phone calls were received in relation to the survey.
In total, the survey was started by 410 respondents and data was submitted by 402. In 140 instances
surveys were submitted without any answers being provided. These responses were not used in the
analysis.
Of the remaining 262, a further 96 were not used as they did not provide any data beyond the initial
demographic questions. This left 166 valid responses to the survey that provided at least one
response to the substantive questions in the main sections of the survey.
Respondents were not required to answer every question. As such the responses to each question do
not total 166. Accordingly, responses are presented in total numbers (as well as percentages where
relevant).
Respondent demographics
Table 7. What is the aged care planning region where this service is located? (State)
State or Territory
Number of respondents
Percentage of respondents
New South Wales
48
32
Victoria
37
25
Queensland
31
21
Western Australia
14
9
South Australia
8
5
Tasmania
8
5
Australian Capital Territory
1
1
Northern Territory
1
1
148
100
Total responses
Source: KPMG analysis of survey data
Table 8. What is the aged care planning region where this service is located?
Aged care planning region
Number of
respondents
Aged care planning region
Number of
respondents
Brisbane South
7
Southern Highlands
2
Eastern Metro
7
Wide Bay
2
Southern
6
Australian Capital Territory
1
Southern Metro
6
Cabool
1
Northern Metro
5
Darling Downs
1
South East Sydney
5
Darwin
1
Brisbane North
4
Eyre Peninsula
1
Central Coast
4
Great Southern
1
Gippsland
4
Kimberley
1
Hume
4
Mackay
1
Hunter
4
Mid North
1
Illawarra
4
Mid West
1
New England
4
North West
1
South West Sydney
4
West Moreton
1
Western Metro
4
Wheat Belt
1
Inner West
3
Yorke Lower North & Barossa
1
Metropolitan East
3
Total responses
Northern
3
Source: KPMG analysis of survey data
South West
3
Sunshine Coast
3
Western Sydney
3
Barwon South Western
2
Central West
2
Far North
2
Far North Coast
2
Fitzroy
2
Grampians
2
Loddon-Mallee
2
Metropolitan North
2
Metropolitan South
2
Metropolitan South West
2
Metropolitan West
2
Mid North Coast
2
Nepean
2
Northern Sydney
2
Riverina Murray
2
South Coast
2
140
TABLE 9. HOW MANY HOME CARE PLACES ARE ALLOCATED TO THIS SERVICE?
Number of respondents
Number of packages
Level 1
Level 2
Level 3
Level 4
1 to 10
24
9
25
23
11 to 25
5
30
3
21
26 to 50
1
39
0
19
51 to 75
1
15
0
5
76 to 100
0
13
0
2
100+
0
30
0
1
166
166
165
165
Total responses
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 10. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE ABORIGINAL AND
TORRES STRAIGHT ISLANDERS?
Percentage of consumers
Number of respondents
Less than 1%
106
1% to 10%
36
11% to 25%
1
26% to 50%
1
51% to 75%
0
76% to 90%
0
91% to 100%
1
Total responses
145
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 11. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE FROM
CULTURALLY AND LINGUISTICALLY DIVERSE BACKGROUNDS?
Percentage of consumers
Number of respondents
Less than 1%
62
1% to 10%
36
11% to 25%
22
26% to 50%
10
51% to 75%
2
76% to 90%
0
91% to 100%
10
Total responses
SOURCE: KPMG ANALYSIS OF SURVEY DATA
142
TABLE 12. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE LIVING IN RURAL
AND REMOTE AREAS?
Percentage of consumers
Number of respondents
Less than 1%
91
1% to 10%
15
11% to 25%
9
26% to 50%
7
51% to 75%
3
76% to 90%
1
91% to 100%
16
Total responses
142
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 13. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE WHO ARE
FINANCIALLY OR SOCIALLY DISADVANTAGED?
Percentage of consumers
Number of respondents
Less than 1%
53
1% to 10%
23
11% to 25%
20
26% to 50%
13
51% to 75%
14
76% to 90%
11
91% to 100%
6
Total responses
140
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 14. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE WHO ARE
VETERANS OF THE AUSTRALIAN DEFENCE FORCES, WAR WIDOWS OR WIDOWERS?
Percentage of consumers
Number of respondents
Less than 1%
64
1% to 10%
60
11% to 25%
10
26% to 50%
2
51% to 75%
0
76% to 90%
0
91% to 100%
1
Total responses
SOURCE: KPMG ANALYSIS OF SURVEY DATA
137
TABLE 15. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE WHO ARE
HOMELESS OR AT RISK OF BECOMING HOMELESS?
Percentage of consumers
Number of respondents
Less than 1%
104
1% to 10%
31
11% to 25%
4
26% to 50%
3
51% to 75%
0
76% to 90%
1
90% to 100%
1
Total responses
144
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 16. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE PEOPLE WHO IDENTIFY
AS LESBIAN, GAY, BISEXUAL, TRANSGENDER OR INTERSEX?
Percentage of consumers
Number of respondents
Less than 1%
114
1% to 10%
21
11% to 25%
0
26% to 50%
0
51% to 75%
0
76% to 90%
0
90% to 100%
0
Total responses
135
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 17. APPROXIMATELY WHAT PERCENTAGE OF THIS SERVICE’S CONSUMERS ARE CARE LEAVERS OR
PARENTS SEPARATED FROM THEIR CHILDREN BY FORCED ADOPTION?
Percentage of consumers
Less than 1%
Number of respondents
121
1% to 10%
15
11% to 25%
0
26% to 50%
0
51% to 75%
0
76% to 90%
0
90% to 100%
0
Total responses
SOURCE: KPMG ANALYSIS OF SURVEY DATA
136
TABLE 18. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR ORGANISATION?
Organisation type
Number of respondents
Percentage of responses
12
5
126
54
Religious
21
9
Charity
23
10
Mutual
1
0
51
22
234
100
For profit
Not for profit
Community based
Total
SOURCE: KPMG SURVEY DATA ANALYSIS. NOTE MULTIPLE RESPONSES WERE ALLOWED MEANING TOTAL
EXCEEDS 166
TABLE 19. WHICH OF THE FOLLOWING BEST DESCRIBES THE SIZE OF YOUR ORGANISATION? PLEASE SELECT
ONLY ONE OPTION.
Organisation size
Number of respondents
Percentage of responses
Large (multiple sites across multiple
states/territories)
39
26
Medium (multiple sites within 1 or more regions)
59
39
Small (single site service)
52
35
150
100
Total responses
SOURCE: KPMG SURVEY ANALYSIS.
These definitions of organisation size were developed specifically for this evaluation, based on
descriptors used in previous data collection activities with aged care providers. It should be noted
that they are not based on any formal or validated definition used by the Department of Social
Services, the Australian Bureau of Statistics, the Australian Institute of Health and Welfare or any
other Australian Government agency. There is currently no such formal or commonly used
classification of provider size.
Appendix C Survey results: Implementation of the Home
Care Packages Programme
TABLE 1. DID THIS SERVICE HAVE ADEQUATE INFORMATION AND SUPPORT ABOUT THE NEW ARRANGEMENT
PRIOR TO THE TRANSITION TO HOME CARE PACKAGES BY AUGUST 2013? PLEASE SELECT ONE RESPONSE
WHICH BEST DESCRIBES YOUR EXPERIENCE FOR EACH ELEMENT IN THE LIST.
Yes, we have
had adequate information and
support about this
We have had
enough information,
but some support/ guidance
would have been helpful
No, we have
not had enough
information or support
Total
responses to
this question
No.
%
No.
%
No.
%
No
New package levels
1 and 3
38
27
73
51
32
22
143
Transition of CACP to
package level 2
56
37
74
49
22
14
152
Transition of EACH to
package level 4
48
35
66
49
22
16
136
Included care and
services
51
35
67
45
29
20
147
Excluded care and
services
41
28
67
46
36
26
144
New broad-banded
ACAT assessments
36
25
58
39
54
36
148
Processes for
consumers to
transition between
package levels
39
26
67
45
43
29
149
New dementia and
cognition supplement
26
18
73
49
50
33
149
New veterans'
supplement
28
19
58
39
61
42
147
Process for consumers
to access oxygen and
enteral feeding
supplements between
package levels
30
20
59
40
59
40
148
Consumer fees policy
(from July 2014)
24
16
56
37
71
47
151
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 2. WHAT OTHER INFORMATION OR SUPPORT WOULD HAVE BEEN HELPFUL FOR YOU? PLEASE SELECT
ONE RESPONSE WHICH BEST DESCRIBES YOUR OPINION FOR EACH OF THE ELEMENTS IN THE LIST.
Written
information
packs and
newsletters
Information
sessions and
seminars
Training sessions,
workshops or
conferences
One-on-one
support for
providers
Total
responses
No.
%
No.
%
No.
%
No.
%
No
New package levels
1 and 3
29
28
33
31
29
28
14
13
105
Transition of CACP to package
level 2
29
31
25
26
22
23
19
20
95
Transition of EACH to package
level 4
29
33
26
30
18
21
14
16
87
Include care and services
30
32
28
30
23
24
13
14
94
Excluded care and services
36
35
30
29
26
25
11
11
103
New broad-banded ACAT
assessments
40
36
38
34
27
24
6
5
111
Processes for consumers to
transition between package levels
38
34
26
23
34
30
15
13
113
New dementia and cognition
supplement
40
34
32
27
35
29
12
11
119
New veterans' supplement
45
38
31
26
34
29
9
7
119
Process for consumers to access
oxygen and enteral feeding
supplements between package
levels
43
38
27
23
33
29
11
10
114
Consumer fees policy (from July
2014)
25
20
29
23
42
33
30
24
126
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 3. HOW EFFECTIVE HAS THIS SERVICE FOUND THE RESOURCES THAT SUPPORT THE HOME CARE
PACKAGE PROGRAMME? PLEASE SELECT ONE RESPONSE.
This resource has
provided us with
effective
information and
support
This resource
has been
somewhat
effective for us,
but it could be
improved
This resource
has not been
effective
for us
We have
not used
this resource
Total
responses
No.
%
No.
%
No.
%
No.
%
No
Home Care Packages
Guidelines
45
30
96
63
8
5
3
2
152
Australian Government aged
care reform roadshows
16
11
65
44
40
27
27
18
148
Australian Government
reform readiness checklist
17
11
69
46
36
24
28
19
150
Australia Government fees
booklet
20
13
58
39
40
27
32
21
150
Australian Government
websites
24
16
84
56
40
26
3
2
151
Australian Government
email circulars to providers
30
20
82
55
33
22
5
3
150
Support from Aged and
Community Services
Australia
43
29
47
32
31
21
27
18
148
Support from the National
Aged Care Alliance
20
13
47
31
39
26
44
29
150
Support from Leading Age
Services Australia
24
16
49
33
28
19
47
32
148
Support from the National
Aged Care Advocacy Service
14
9
34
23
37
25
63
43
148
21
62
41
28
19
28
19
150
Support from Home Care
32
Today (COTA)
Source: KPMG analysis of survey data
TABLE 4. PLEASE INDICATE YOUR LEVEL OF AGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT THE HOME
CARE PACKAGES PROGRAMME. PLEASE SELECT ONE RESPONSE WHICH BEST DESCRIBES YOUR EXPERIENCE
FOR EACH ELEMENTS IN THE LIST.
Strongly agree
Agree
Neither agree or
disagree
Disagree
Strongly disagree
Total
responses
No.
%
No.
%
No.
%
No.
%
No.
%
No.
Staff at this service
have a good
understanding of the
Home Care Packages
Programme
30
21
80
55
23
16
7
5
5
3
145
Consumers and
carers/families have a
good understanding
of the Home Care
Packages Programme
4
3
31
21
39
27
47
32
24
17
145
ACATs/ACASs have a
good understanding
of the Home Care
Packages Programme
6
4
33
23
54
37
37
26
15
10
145
The Guidelines
provide a good
balance between
guidance and
flexibility for providers
6
4
54
37
58
40
22
15
6
4
146
The Australian
Government gives
enough support and
advice for providers
on the Home Care
Packages Programme
4
3
20
14
35
24
52
36
35
24
146
The Home Care
Packages Programme
has improved home
care services for
consumers
13
9
32
22
47
32
30
21
23
16
145
Most consumers are
getting the right level
of care and services
they need under the
Home Care Packages
Programme
9
6
36
25
33
23
44
30
23
16
145
The Home Care
Packages Programme
has improved home
care services for
carers/families
13
9
33
23
48
33
28
19
23
16
145
The Home Care
Packages Programme
has increased the
administrative burden
on providers
88
61
33
23
12
8
4
3
8
6
145
Waiting times for
ACAT/ACAS
assessments have
reduced with the new
Home Care Packages
Programme
arrangements
3
2
16
11
62
43
28
20
34
24
143
Waiting times for
consumers to access a
package have reduced
with the new Home
Care Packages
Programme
arrangements
6
4
9
6
42
29
52
36
36
25
145
The Home Care
Packages Programme
offers more choice
and flexibility for
consumers
21
14
55
38
37
25
19
13
14
10
146
It is easier now for
consumers to move
between package
levels
9
6
27
19
49
34
39
27
20
14
144
The Home Care
Packages Programme
providers a graduated
continuum of care
8
5
64
44
40
27
20
14
14
10
146
Source: KPMG analysis of survey data
Appendix D Survey results: Transition to Consumer
Directed Care
This section asked questions about providers experience in administering CDC packages. The
subsequent questions were filtered based on respondent’s answer to this question.
TABLE 5. DOES YOUR SERVICE PROVIDE ANY CDC PLACES?
No
%
Yes
71
48
No
77
52
Total
148
100
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 6. WHEN DID THIS SERVICE FIRST PROVIDE CDC PLACES?
Number of
respondents
Percentage of
respondents
Prior to 1 August 2013
15
21
After August 1 2013
36
51
Unanswered
20
SOURCE: KPMG ANALYSIS OF SURVEY DATA
28
TABLE 7: HOW DIFFERENT WOULD YOU SAY YOUR CDC MODEL IS FROM YOUR USUAL APPROACH TO HOME
CARE (I.E THE APPROACH FOR NON-CDC PLACES)? PLEASE SELECT ONE RESPONSE WHICH BEST DESCRIBES
YOUR EXPERIENCE FOR EACH OF THE ELEMENTS ON THE LIST.
The CDC approach is very
different to the usual
approach
The CDC approach is
somewhat different to the
usual approach
The CDC approach is the
same as the usual
approach
Total
responses
No
%
No
%
No
%
No
Assessment process
29
43
19
28
20
29
68
Care planning process
31
46
20
29
17
25
68
Involvement of
carers/families in care
planning process
26
38
21
31
21
31
68
Cost of care and service
delivery
41
59
16
23
12
17
69
Consumer choice of care
and service delivery
34
50
21
31
13
19
68
Provider approach to
administration of the
places
46
68
14
21
8
12
68
Provider approach to case
management
40
59
20
29
8
12
68
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 8. HAS THIS SERVICE ENCOUNTERED ANY SIGNIFICANT PROBLEMS DURING THE IMPLEMENTATION OF
CDC? PLEASE SELECT ONE RESPONSE WHICH BEST DESCRIBES YOUR EXPERIENCE FOR EACH OF THE
ELEMENTS IN THE LIST.
This has been a
significant problem
for us
This has been
somewhat of a
problem for us
This has not been a
problem for us
Total
responses
No
%
No
%
No
%
No
Unanticipated extra administrative
burden or overheads
41
62
21
32
4
6
66
Training staff to a CDC approach
13
20
28
42
25
38
66
Explaining CDC to consumers
17
26
38
58
11
17
66
Explaining CDC to carers/families
15
23
35
53
16
24
66
Insufficient package budget to meet consumer
needs
24
36
26
39
16
24
66
Consumer unable or unwilling to engage with CDC
11
17
33
50
22
33
66
Insufficient choice of care and services available in
the area to meet consumers' need and
preferences
5
8
14
21
47
71
66
Insufficient choice of providers in the area to meet
consumers' need and preferences
4
6
15
23
47
71
66
Providers in the area increasing their prices for
care and services
7
11
32
49
26
40
65
Consumers declining care services assessed as
being essential for their health and well-being
15
22
36
54
16
24
67
Consumers wanting to access excluded or
inappropriate services
7
11
28
42
31
47
66
Consumers wanting to 'save' funds or a
contingency higher than 10% of their budget
3
5
23
35
40
61
66
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 9. PLEASE INDICATE YOUR LEVEL OF AGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT CDC.
PLEASE SELECT ONE RESPONSE WHICH BEST DESCRIBES YOUR EXPERIENCE FOR EACH OF THE ELEMENTS IN
THE LIST.
Strongly agree
Agree
Neither agree nor
disagree
Disagree
Strongly
disagree
Total
responses
%
No
%
No
%
No
9
13
2
3
0
0
70
32
27
39
15
22
4
6
69
12
17
40
57
9
13
7
10
70
3
22
32
36
53
5
7
3
4
68
4
6
27
39
31
45
5
7
2
3
69
CDC places have
increased
administrative
burden on
providers
44
64
19
28
6
9
0
0
0
0
69
The increased
administrative
requirements
have been a
significant
challenge for us
33
48
26
38
8
12
2
3
0
0
69
Most consumers
benefit from a
CDC approach
compared to a
non-CDC
approach
11
16
31
45
19
28
3
4
5
7
69
CDC makes
providers more
accountable to
consumers
32
47
22
32
9
13
2
3
3
4
68
The benefits to
consumers
outweigh the
challenges of
CDC
20
29
18
26
21
30
5
7
5
7
69
No
%
No
%
Staff at
this service have
a good
understanding of
CDC
15
21
44
63
Consumers and
carer
have a good
understanding of
CDC
1
1
22
ACATs/ACASs
have a good
understanding of
CDC
2
3
The broadbanded
assessment
process work
well
2
The Guidelines
provide a good
balance between
guidance and
flexibility in
relation to CDC
No
Strongly agree
Agree
No
%
No
%
Our approach to
CDC has
changed over
time as we have
learned more
20
30
30
45
Our approach to
CDC is still
evolving as we
learn more
25
37
31
The approach to
CDC needs to be
26
38
23
different for
some special
needs groups
SOURCE: KPMG ANALYSIS OF SURVEY DATA
Neither agree nor
disagree
No
Disagree
Strongly
disagree
Total
responses
%
No
1
1
67
1
0
0
68
1
1
1
68
%
No
%
15
22
1
1
46
11
16
1
34
17
25
1
No
Appendix E Survey results: Preparing for Consumer
Directed Care
The 77 respondents that answered ‘No’ to question 10. (Does your service provide any CDC places?) were
directed to the following section which asked about providers preparedness, sources of information and
concerns regarding the transition of all packages to CDC arrangement on July 2015. The denominator used to
derive percentages for this section is 77 unless otherwise stated.
TABLE 10. HOW WOULD YOU DESCRIBE THIS SERVICE’S CURRENT STATE OF PREPARATION FOR THE
TRANSITION OF ALL PLACES TO CDC FROM 1 JULY 2015? PLEASE SELECT ONE RESPONSE WHICH BEST
DESCRIBES YOUR EXPERIENCE.
Statement
Number of
respondents
Percentage of
respondents
We are still preparing for the implementation of CDC
56
73
We are well prepared for the implementation of CDC: our tools and processes are developed,
managers and staff are trained and systems are in place
14
18
We have not commenced preparing
for the implementation of CDC
4
5
Unanswered
3
4
Total
77
100
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 11. WHAT ACTIVITIES (IF ANY) HAS THIS SERVICE UNDERTAKEN, OR DOES THIS SERVICE PLAN TO
UNDERTAKE, TO PREPARE FOR THE IMPLEMENTATION OF CDC FROM 1 JULY?
Activity
Number of
respondents
Percentage of
respondents
Attendance at non-government workshops, seminars or conferences
65
84
Reading Department of Social Services website information and email circulars
65
84
Internal training or change management activities for managers
56
73
Support/advice from provider peak bodies or advocacy groups
56
73
Attendance at Australian Government information sessions or roadshows
55
71
External training or change management activities for managers
51
66
Use of Home Care Today Home Care Provider web portal and/or phoneline
39
51
External training or change management activities for staff
39
51
Use of Home Care Today Home Care Consumer web portal and/or phoneline
27
35
Other
16
21
SOURCE: KPMG ANALYSIS OF SURVEY DATA
TABLE 12. WHAT CONCERNS DOES THIS SERVICE HAVE ABOUT THE IMPLEMENTATION OF CDC FROM 1 JULY
2015?
Number of respondents
We are very
concerned
about this
We are somewhat
concerned
about this
We are not
concerned
about this
Total
responses
Problem or issue
No.
%
No.
%
No.
%
No.
Lack of shared understanding about CDC
across the home care sector
34
46
34
46
6
8
74
Lack of information and support for providers
about CDC
38
51
30
40
7
9
75
Lack of clarity in the Guidelines about CDC
28
37
34
45
13
17
75
Concern about how to manage consumers
who want 'trade off' required care and
services2
41
55
27
36
7
9
75
Concern for our business model viability under
a CDC approach
52
69
17
23
6
8
75
Need for more training and mentoring about
CDC for our managers
34
45
25
33
16
21
75
Need for more training and mentoring about
CDC for our staff
36
48
32
43
7
9
75
Concern about capacity of consumers and
nominated representatives to engage with
CDC
49
65
25
33
1
1
75
New administrative and reporting
requirements may be too onerous
57
77
16
22
1
1
74
Concerns about the provider payments system
60
81
13
18
1
1
74
Difficulty in pricing our services
43
57
29
39
3
4
75
Difficulty in brokering other services
28
37
27
36
20
27
75
Uncertainty about whether CDC really is better
for consumers
40
55
26
36
7
10
73
Concern about how to deliver CDC approaches
for special needs groups
34
46
31
42
9
12
74
37
52
26
37
8
11
71
Not enough 'good practice' examples to draw
on
Source: KPMG analysis of survey data
2
This refers to the provider’s perceptions around balancing their duty of care with principles of consumer choice and control (i.e. how to manage a situation
where a consumer does not want to use the package funds to purchase care and services that the provider considers are important to maintain their health and
wellbeing)
Appendix F Summary of key service provider data: range
and cost of supports delivered under CDC
This appendix provides a summary of the information obtained from data provided to the
evaluation by 163 CDC service providers using an Excel-based template. Providers were asked
to report data for a retrospective six month period (January 2014 to June 2014).
Range of supports accessed
Providers reported that consumers on CDC or transitioning to CDC packages were not making significant
changes to their support arrangements, and were still accessing ‘core services’ such as personal care, help with
household tasks, and clinical (nursing) care. Similarly, consumers accessing a package for the first time were
also choosing to use their package on core services. Differences between consumer preferences for CDC and
non-CDC consumers were observed for supports to access social and community-based activities, transport,
and in some cases specific equipment designed to increase independence (and not available through other
programs).
The table below indicates that the most common support types accessed by CDC consumers. The table
illustrates that for level 1 and 2 consumers the most common support types accessed are personal care
services, support services (help with household tasks), and support with leisure, interests and activities. Level 3
and 4 consumers are using their package budget for similar services, though a higher proportion of support
expenditure is used for client-related transport. This is unlikely to be significantly different for non CDC
package care consumers.
TABLE 13: MOST COMMON SUPPORT TYPES ACCESSED (PROPORTION OF SUPPORT EXPENDITURE)
Services
Level 1
Level 2
Level 3
Level 4
Personal care services
26%
29%
40%
37%
Support services
48%
40%
31%
25%
2%
6%
3%
10%
10%
8%
5%
7%
Nutrition, hydration, meal preparation & dietary
services
1%
3%
5%
4%
Activities of daily living
8%
8%
5%
4%
Clinical care
1%
1%
4%
4%
Client-related transport
Leisure, interests and activities
SOURCE: KPMG ANALYSIS OF PROVIDER SERVICE DATA
Note that some providers reported data for all package care consumers, rather than for CDC consumers, hence
this data does not fully reflect the supports accessed by CDC consumers
The figure below illustrates the proportion of support expenditure by different categories of support (care
services, support services, clinical services and other). Again, these proportions are unlikely to be significantly
different for non CDC package care consumers. The figure shows that a greater proportion of a CDC level 3 or 4
package is spent on clinical and other services compared with a level 1 or 2 package, and a higher proportion
spent on care services such as personal care and assistance with activities of daily living.
FIGURE 12: EXPENDITURE ON SUPPORTS, BY SUPPORT CATEGORY AND CARE LEVEL
SOURCE: KPMG ANALYSIS OF PROVIDER SERVICE DATA
Note excludes expenditure on administration and case management/coordination
Note that some providers reported data for all package care consumers, rather than for CDC consumers, hence
this data does not fully reflect the supports accessed by CDC consumers
In-house and brokered services
Providers reported that there was a tendency for consumers to choose in-house services (services provided by
the CDC package provider). Providers stated that in the main consumers chose their services as they were
often cheaper than brokered services which meant that the consumer was not incurring additional
administrative and coordination fees which would be charged for arranging brokered services. They also stated
that consumers chose in-house services due to their level of trust and confidence in the package provider, and
the convenience of having all services provided by one organisation.
Providers stated that consumers had the option of using their package for services provided by other
organisations (for example, if they preferred a care worker from another organisation, or they wanted to
access a service not provided by the package care provider).
However the extent to which providers gave consumers information about brokered service options varied. In
many cases providers stated that they explained to consumers ‘in a general sense’ the options to broker
services at the planning stage, though they did not always present information on the services available from
other organisations or the prices of these services (whereas they would present this type of information for
their own in-house services). Further, it was noted that there is an incentive for CDC providers to encourage
consumers to use their own in-house services – to ensure that their organisations had a steady revenue stream
and remained viable.
Based on expenditure data reported by providers, 60 per cent of CDC support expenditure is for services
provided by the package care provider (that is, in-house services). This varies across care levels: a higher
proportion of support expenditure was used for in-house services for consumers on a level 1 or 2 package,
compared with consumers on a level 3 or 4 package – overall and for individual service categories. In-house
service provision varies across support categories, with higher rates of in-house service provision for care
services (personal care, assistance with activities of daily living) – as illustrated in the figure below.
FIGURE 13: PROPORTION OF SUPPORT EXPENDITURE ON IN-HOUSE SERVICES, BY SUPPORT CATEGORY AND
CARE LEVEL
SOURCE: KPMG ANALYSIS OF PROVIDER SERVICE DATA
Note excludes expenditure on administration and case management/coordination
Note that some providers reported data for all package care consumers, rather than for CDC consumers, hence
this data does not fully reflect the supports accessed by CDC consumers
The table below illustrates the proportion of support expenditure used for in-house services, by individual
support type (as reported by providers).
TABLE 14: PROPORTION OF SUPPORT EXPENDITURE ON IN-HOUSE SERVICES, BY SUPPORT TYPE
Support type
Management of skin integrity
% of expenditure in-house
100%
Activities of daily living
86%
Leisure, interests and activities
80%
Nutrition, hydration, meal preparation & dietary services
79%
Personal services
62%
Support services
56%
Access to other health and related services
51%
Clinical care
46%
Continence management
40%
Client related transport
33%
SOURCE: KPMG ANALYSIS OF PROVIDER SERVICE DATA
Note excludes expenditure on administration and case management/coordination
Note that some providers reported data for all package care consumers, rather than for CDC consumers, hence
this data does not fully reflect the supports accessed by CDC consumers
Costs per unit (hour) of service were calculated based on data reported by providers – for both in-house and
brokered services, and these are reflected in the table below. The data does not fully support claims that
brokered services are more expensive than in-house services, and for a number of different support types,
brokered services are less expensive.
TABLE 15: UNIT COSTS REPORTED BY PROVIDERS – IN-HOUSE AND BROKERED SERVICES, BY CARE LEVEL AND
SUPPORT TYPE
Level 1/2
Level 3/4
In-house
Brokered
In-house
Brokered
Personal services
$41.23
$53.88
$47.93
$45.65
Activities of daily living
$48.38
$51.41
$47.85
$65.01
Nutrition, hydration, meal preparation
& dietary services
$33.09
$20.16
$36.90
$34.57
Management of skin integrity
$50.84
na
$49.96
na
Continence management
$69.53
$20.86
$72.85
$21.48
Support services
$38.50
$39.45
$41.29
$40.46
Leisure, interests and activities
$37.99
$30.15
$42.99
$36.48
Clinical care
$75.18
$32.27
$63.33
$75.36
Access to other health and related
services
$68.89
$90.83
$56.22
$80.36
$2.04
$4.70
$2.71
$8.54
Average cost per hour
Care services
Support services
Clinical services
Other
Client-related transport (cost per trip)
SOURCE: KPMG ANALYSIS OF PROVIDER SERVICE DATA
Appendix G Summary of key themes and issues from
Ministerial and Departmental correspondence
This appendix summarises the key themes and issues arising from an analysis of de-identified
Ministerial and Departmental correspondence and communications relevant to the Home
Care Packages Programme and CDC, which was provided by the Department.
Analysis of Ministerial correspondence
KPMG also undertook a review of a sample of de-identified responses to Ministerial correspondence relating to
home care and CDC.
Much of this correspondence (n=13) related to waiting times to receive a home care package. In most cases,
the Minister or his delegate responded by clarifying the availability of, and release schedule for, packages in the
person’s area. The Minister or his delegate also recommended that the consumer/carer stay in close contact
with their provider, as well as to accept a lower level package (level 1 or 2) as an interim measure. Waiting
times was not a significant issue for the majority of consumers and carers interviewed for the evaluation
(although it was a concern in some cases), however the issue was raised by providers and ACATs in some areas.
Some of the Ministerial correspondence related to concerns by consumers or their carers in relation to the
quality of supports they were receiving (n=4), the cost of supports (n=4), or the ability to access particular
supports (n=4). In all cases of service quality concerns, the Minister or his delegate responded to by referring
consumers to the Aged Care Complaints Scheme. This range of concerns is broadly similar to the range of issues
identified in the consumer and carer interviews for the evaluation.
A number of people wrote to the Minister with concerns regarding becoming ineligible for state-based support
programmes as a result of taking up a home care package. The Minister usually replied by indicating that this
was a matter for their own state government. This issue was not directly identified in the consumer and carer
interviews conducted for the evaluation, although it was identified (usually in relation to aids and equipment)
in discussions with some other stakeholders, including an aged care advocacy service provider.
The following figure provides an indication of the range of issues identified in the correspondence, and their
frequency.
FIGURE 14: THEMES OF MINISTERIAL RESPONSES TO LETTERS REGARDING THE COMMONWEALTH HOME CARE
PACKAGES PROGRAMME
Waiting time for HCPs
Access to services
Cost of services
Service quality concerns
Resulting ineligibility for state-based programs
Carers support
Charged for services while away from home
Enquiry topic
Cost of interpreting services
Aged care funding
Aids and equipment
Insufficient package size
Medication management
OHS restrictions on care providers
Oxygen supplement
Payment system issues
Red tape
Reduced services
Respite fees
Specific subsidy for macular degeneration
Tax queries
0
2
4
6
8
10
12
14
Frequency
SOURCE: KPMG ANALYSIS OF DE-IDENTIFIED MINISTERIAL CORRESPONDENCE (DSS)
Analysis of Departmental telephone and email enquiries
The Department received a considerable number of enquiries by telephone, email and letter in 2014. An
analysis of a de-identified sample 197 enquiries was undertaken, which is summarised in the following figure.
The qualitative themes have been arranged in order of highest frequency, and then by alphabetical order.
FIGURE 15: HOME CARE PACKAGES PROGRAMME TELEPHONE AND EMAIL ENQUIRIES BY ENQUIRY TOPIC AND
SENDER TYPE
Care and service provision
Financial report
Care fees query
Miscellaneous and general
Home Care Packages availability
Leave queries
CDC issues
Administration costs enquiry
Unders and overs/funding level cuts
Aids and equipment
Enquiry topic
Legislative clarification
Guidelines issues
Formative home care evaluation
Supplements
Input to briefing/coord
Aged care reform clarification
Respite
Quality of care principles
Interface with other programmes
Software issues
Security of tenure
Provider number queries
Financial management query
Combining Home Care Packages
Clarification of effect of changes
CDC reforms
ACAT assessment queries
0
5
10
Key to enquirer type:
Aged Care Complaints Scheme
Departmental
Minister's office
Other
Service provider
SOURCE: KPMG ANALYSIS OF DE-IDENTIFIED DSS ENQUIRY LOGS
15
20
25
Frequency
Consumer
Dr
MP/Senator's Office
Other Commonwealth Department
State Government body
30
The most frequent enquiry topic was in relation to care and service provision (n=30), followed by financial
reporting f (n=26), care fees (n=25) and miscellaneous or general enquiries relating to the administration of
the Programme (n=23). Enquiries in relation to care and service provision were mostly generated by service
providers (n=11) and consumers (n=8) and sought to clarify whether certain supports could be provided under
the guidelines.
Examples of questions are set out below.
Can a client’s daughter be the sole contractor for the provision of his home care services?
(Service provider)
Is dental care covered under the package?
(Service provider)
Can people on any level of package access Centre Based Day Respite care services?
(Service provider)
Is the list of care services in the guideline a suggested list only and not a comprehensive list, so that as
long as we don't fund any services from the excluded list we can tailor the package to the individual?
(Service provider)
I would like clarification regarding what I am and what I am not able to use home package funds for.
(Consumer)
Can service providers refuse to lift the care recipient because they have a ‘no lift’ policy?
(Carer)
As can be seen from these examples, the majority of these enquiries sought clarification of
information that was already available in the programme guidelines (or assistance in interpreting
that information).
Enquiries in relation to the financial reporting topic were mostly from service providers (n=23). Most
of these related to specific acquittal processes, changes to their financial accountability
requirements and the availability of acquittal templates for financial reports to clients (it is noted
that such templates are available from the COTA website).
Enquiries about care fees were predominantly from service providers (n=14), with some
correspondence from consumers (n=5). These queries varied in nature, with service providers
enquiring about the status of income assessments and technical funding questions, and consumers
raising concerns about the cost of their care or enquiring about the rules of their package. These
issues were also regularly raised in the provider and consumer and carer interviews conducted for
the evaluation