“Aged care should not be seen as a commodity”: Commissioners propose separating care and accommodation in first consultation paper on future design of the aged care system

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The Interim Report identified that Australia’s aged care system needed a “fundamental re-design”. Now the Commissioners have gone some way to outlining that vision, releasing their first Consultation Paper – issued in their names – proposing a major reform of the way services are provided to older Australians and calling for submissions from individuals and organisations for their ideas.

The 31-page paper, released by Commissioners, the Honourable Tony Pagone QC and Lynelle Briggs AO (pictured above) late on the Friday afternoon before the final hearings for the year, outlines a model designed to offer both care and (Commissioner Briggs’ new catchcry) “joy” for older people in both residential care and living at home.

You can download the paper HERE.

It is worth taking the time to read the full paper for the insights into the Commissioners’ thinking but see my thoughts below.

So, what is the new model that the Commissioners are putting forward?

Check out the diagram above.

As you can see, the focus of the model is not on ‘aged care’, but on ‘healthy ageing and prevention’.

The Commissioners argue there should be a single entry point to the aged care system and two forms of assessment for services: a basic assessment and a comprehensive assessment – which both would result in a referral to a single care finder, to help older people link to services and oversee their own care.

This assistance would be provided mainly through face-to-face support, with the current MyAgedCare model of a website and contact centre relegated to second fiddle.

The Commissioners say this website and contact centre would offer “meaningful information about quality and cost, and a search function that helps people compare and select providers”.

To me, this spells a star rating system, a measure the Royal Commission already explored in its first research paper ‘How Australian residential aged care staffing levels compare with international and national benchmarks’ by Professor Kathy Eagar’s team at the Australian Health Services Research Institute (AHSRI).

The Commissioners also note that these two assessments will require a “clinically qualified and multi-disciplinary skill set” – suggesting they will recommend the current assessor workforce be overhauled to include nurses and other allied health professionals such as physiotherapists and occupational therapists.

This ‘finder’ would then see aged care recipients referred to one (or more) of three separate streams:

A ‘entry-level support stream’:

This would include lower level services i.e. home care services such as assistance with meals, cleaning and laundry, domestic assistance and home maintenance plus minor home modifications and assistive technologies to help people in staying living independently at home.

It’s not too different from the current model – however, this would be extended by more support for community engagement, for example, social supports, transport, day centres and other services to prevent people becoming isolated as they get older (providing the “joy”).

Access to services would also be determined by a simple screening instead of a full assessment – saving older people and their carers added stress.

An ‘investment stream’:

This stream would focus on keeping older people from declining further and needing more intensive care (and their carers from burning out) by providing restorative and respite care.

Under the model proposed by the Commissioners, respite would also be expanded from the current nine week (63 days) and improved with more regular and flexible respite options including in-home respite, day respite and cottage respite.

In terms of the current restorative care programs i.e. the Transition Care Program and the more recent Short term Restorative care program funded by the Government, the Commissioners maintain that these should also be expanded, not limited to the short-term and most importantly, made available to people in residential care (they are currently not).

“This will include exercise programs and other services to maintain and improve function,” the Commissioners state.

Assistive technologies and major home modifications would also be included under this stream – again, assisting people to stay at home.

A ‘care and health stream’:

The final stream covers the higher-care services like personal and clinical care and allied health, like help with showering, toileting and grooming, wound management, medication management and physiotherapy.

“Community nursing and allied health services should be available across the entire support and care continuum to those who need them (even for people receiving entry level supports),” the paper states. “Care services could be separately funded even for people in the higher-level care stream, although one provider may deliver the services in that case.”

Critically, the Commissioners say older people should have the choice to receive care in their own home or in “more flexible and less institutional forms” of residential care.

In short, care would be separated from accommodation – with funding assigned to individuals within the care stream, regardless of whether they live at home or in residential care.

“We expect many more people will opt to have that care provided in their homes,” the Commissioners say. “The basis of the funding assessment would be to assign an entitlement to the efficient cost of care that is both reasonable and necessary and of high quality and safety.”

The Commissioners do acknowledge separating nursing and allied health funding would be a challenge for older people in residential care, as one provider would need to provide different services under different funding streams but say this would ensure the “appropriate accountability” of the provider.

“Another option would be for separate funding for nursing and allied health to only be for those receiving support and care in their own home,” they put forward. “In contrast, those people receiving care in a residential setting would have nursing and allied health costs built into their care funding.”

The Commissioner also pledge there will be a transition in residential care over time to a “less institutional and more home-like physical environment which provides high-end care focused on dementia and end of life needs”.

This implies more ‘family-style’ care services – no more wide corridors or clinical smells.

This idea harks back to the Commission’s second background paper ‘Medium- and long-term pressures on the system: the changing demographics and dynamics of aged care’ by NDIS Chief Economist Dr David Cullen which forecast a division in aged care with a majority of people clustered at the low-care level, a smaller group in the mid-level and a large number of people in residential care with complex needs requiring high care.

Forming part of this higher care stream would be access to specialist care including primary care and palliative care – both issues highlighted last week in the Commission’s hearings into the interface between aged care and health care.

This support would be provided by multi-disciplinary teams through in reach services; Severe Behaviour Response Teams and Dementia Behaviour Management Advisory Services; and more specialist units for older people with extreme behavioural and psychological symptoms of dementia.

Too much faith in the “market”

It’s a significant change from the current system. Why have the Commissioners taken this approach?

They say the market disadvantages older people, especially those in regional and rural areas and from diverse groups.

“The aged care sector is not, and is unlikely to ever be, a fully efficient market,” the Commissioners conclude bluntly.

“The direction of current reforms puts too much faith in market forces and consumer choice as the primary driver of improvement in the aged care system. It gives insufficient attention to constraints on the availability of choice in many parts of Australia and to the supports required for people to exercise informed choice. Giving people more information to make decisions about their aged care will give them greater control, but it will only address some of the existing market imbalances. Providers will continue to know more about the aged care system than the older person or their family. People with limited financial means or decision-making capacity face particular challenges in exercising choice. Market forces have an important role to play but are not delivering equitable outcomes in all parts of the country or for all groups.”

Like in the Interim Report, the Commissioners point to the ‘transactional’ nature of aged care – rather than a focus on relationships and care.

They single out both MyAgedCare and the Government for failing to meet the needs of older people and provide ‘quality’.

“Giving older people and their families real choices requires more meaningful information and face-to-face support than is currently available,” they say. “We have heard strong messages that people trying to navigate the aged care system feel unsupported and are floundering. The system is complex, and people are making decisions about aged care when they are emotionally vulnerable. The system needs to encourage people to plan ahead for their ageing and put older people at the centre, with a focus on their needs, their identity and their right to make choices about their care. The Commonwealth has key responsibility for aged care, needs to do much more in guiding the system to deliver better outcomes for older people. We have heard that the Commonwealth should play a more active role in system planning and monitoring, including intervening in the market as necessary.”

Instead, the Commissioners advocate for a system based on trust, respect and communication between residents, families, staff and management – and for funding to be tied to the individual.

“Aged care should not be seen as a commodity, and success should not be measured by the mere completion of tasks,” they emphasise.

“We want a system that would allow older people to enter any stream and be supported to build their own bundle of supports and care. For example, where an older person starts with a social support service that they enjoy, and their needs increase, they would be supported to add personal care, nursing care and/or allied health to their bundle, and to access regular respite services. They could continue that original social support service (or a variation of that service) along the way, including if they choose to enter residential care permanently.”

Reforms to be part of ongoing discussion

The Commissioners do add that any reforms will need to be monitored by an independent party to assess whether they are delivering a better system to older Australians.

“This will need to be reassessed at defined intervals,” they stress. “Any major redesign of the aged care system will involve complex and interdependent change affecting older people, providers, the aged care workforce, different levels of government and the broader community.”

The Commissioners also underscore this proposed model is not the ‘be all and end all’, saying they will continue to test these ideas throughout 2020 – which means they are open to suggestions for improvements.

If you have thoughts on whether this new model would work – and where the challenges will be – now is your chance to have your say.

The Commissioners have provided a list of 10 questions in the paper from pages 23 to 27 around which to guide submissions, which can be made via email to: ACRCProgramDesign@royalcommission.gov.au.

The authors of select submissions (i.e. the submissions the Commissioners like) will also be given the chance to contribute to further discussions next year – with the Royal Commission to hold workshops in early 2020 as the next step in this process.

You will need to start working on your response now however – the closing date for submissions is COB Friday, 24 January 2020.

What are your thoughts on the changes being put forward by the Commissioners? Do you support them?