**Committee Draft**

NACA Advice Paper

Provision of community transport
in the Commonwealth Home Support Program

February 2014

Contents

Introduction

HSP Transport Guidelines

Purpose

Interface with non-emergency medical patient transport services

Program Streams

Eligibility

Assessment & Referral

Interface with Residential Aged Care & Home Care packages

Demand Management

Prioritisation

Funding and Delivery models

Delivery Models

Capital

Volunteers

Data and Reporting

HSP Transport Regulations

Recommendations

Conclusion

Introduction

This paper provides recommendations to the Government on the design of the Commonwealth Home Support Program’s (HSP) provision of community transport. This paper should be read as an addendum to NACA Advice Papers on the overall CHSP Design Paper.[1] The HSP will commence on 1 July 2015, combining the work of the existing Home and Community Care (HACC) program, National Respite for Carers Program (NRCP), Assistance for Care and Housing for the Aged (ACHA) and the Day Therapy Centre (DTC) Program – all of which contribute some form of funding towards community transport either specific or embedded within delivered services.

The paper builds on the work of the Commonwealth Home and Community Care (HACC) Review into Service Group Seven - community transport by Verso Consulting[2] and has been compiled with input from the NACA Transport Review Sub-Group convened to support the work of that review.

community transportrefers to all types of transport that isn’t private (driving in one’s own vehicle or by family or friends) or public (trains, trams, planes, buses etc). NACA recognises that community transport funded through the HSP, and the existing programs that will form the CHSP, form only one small part of a broader community transport system. In addition to the different community transport programs funded by state and territory governments, there are also local variations in services due to the additional services provided by local governments and community organisations or clubs in a particular area. A lack of accessible public transport in an area may also result in an increase in other community transport options for older Australians[3].

In recognition that the CHSP funded community transport forms only one part of the community transport landscape, NACA proposes the use of the term ‘HSP Transport’ and will use this term throughout this paper. NACA notes this distinction will also reaffirm the State and Territories as the primary regulators of community transport generally.

Recommendation #: That the HSP Program Guidelines use the term “HSP Transport” to signify the reference to the narrow segment of community transport being funded and regulated under the CHSP program.

HSP Transport Guidelines

Purpose

The purpose of the broader Commonwealth Home Support Program should be to “support an older person to live as independently as possible, in their own home and community, for as long as they can and wish to do so.”[4]Transport services funded via the CHSP should continue to support this wellness and reablement approach and will fall into two broad types of transport services:

  1. HSP Transport - are funded trips for the specific purpose of assisting HSP clients to maintain their independence and should focus on the following activities:
  2. Social Contact & Support
  3. Routine health appointments within the local area
  4. Shopping Banking and other activities of daily living (ADL’s)

Service providers should continue to provide a mix of planned/scheduled services (e.g. weekly shopping trips) as well as ensuring capacity for on demand / booked trips. The HSP transport program guidelines should continue to recognise the continuum of care needs amongst CHSP clients, including unassisted, client plus carer and client needing provider assistance. NACA reaffirms its preference for guidelines that provide clear indications of what is not allowed, rather than what is allowed. This will provide maximum flexibility in program delivery design by providers, enabling them to respond to the evolving needs of HSP clients.

As discussed below, HSP Transport should be funded via a social participation and access funding stream. A definition of HSP transport should be included within the HSP program guidelines along the lines of ‘HSP Transport provides services to eligible CHSP clients and their carers to enable social participation and access within their community’. Increased reporting about HSP transport trips should be developed progressively as part of the introduction of the HSP.

  1. Other transport, embedded within HSP services- Transport may also be an enabler of other CHSP funded programs– e.g. Transport to a local day therapy centre or being transported to a pre-planned social activity. Embedded transport within the HSP service may occur across any and all funding streams. While not specifically funded for transport services, it is necessary for transport activities to be reported in order to determine a holistic understand of transport services funded by the CHSP.

Recommendation: The HSP program should fund and report on specificHSP transport serviceswithin asocial participation and access stream. Transport embedded within other service types should identified and reported upon

Recommendation: HSP Transport should adopt an exclusion approach to program guidelines and focus on delivering services for:

  1. Social Contact & Support
  2. Routine health appointments within the local area
  3. Shopping Banking and other activities of daily living (ADL’s)

Interface with non-emergency medical patient transport services

NACA recognises the primary responsibility of the state and territory governments over the health and community services sectors. This includes responsibility for transport services outside of the aged care system, in particular responsibility for non-emergency medical patient transport. NACA notes the distinction between the Commonwealth’s responsibility for ‘aged care services’ and state/territory responsibilities for other services to ‘older Australians’. The HACC program has historically supplemented transportation services for older Australians that would have otherwise been delivered under state and territory non-emergency medical transport services (e.g. Trips relating to Oncology, Specialist Appointments, Dialysis, Outpatients, etc)[5]. NACA believes that this is no longer sustainable moving forward for the HSP program. With an increasingly ageing population, demand on the CHSP program necessitates that its focus remains on its primary purpose of continuing to keep older Australians in their home.

NACA notes however anecdotal reports of service reductions (or at least a lack of increased services to support increased demand) by state and territory governments in relation to non-emergency medical transport. This continues to put pressure on the Commonwealth transport programs, in particular today’s HACC program, which will continue and therefore place pressure on the HSP program. NACA believes the Commonwealth has a responsibility to play a leadership role in ensuring the state and territories provide sufficient non-emergency medical patient transport. NACA notes that future discussions about transport services flagged under the Health and Hospitals Reform process appear to have not yet occurred.[6] It is important therefore that existing services continue during the transition from HACC to CHSP while these discussions are finalised.

Recommendation: That HSP transport and its program guidelines fund support for activities of daily living for general medical transport in a person’s local area.

Recommendation: That the Commonwealth Department of Health conclude their discussions with states and territories to clearly identify program responsibility and funding for non-aged care transport services (e.g. non-emergency medical transport for the aged) as a matter of priority

Recommendation: That the HSP program guidelines restrict any new non-emergency medical transport services, while allowing existing non-emergency medical transport services to continue during a transitionary period of no more than 5 years.

Program Streams

Given the above discussion identifying state and territory government’s primacy over non-emergency medical patient transport, NACA is of the view that the future placement of HSP transport should be within a ‘social participation and access’ stream. In doing so, NACA recognises adhoc transportation to medical appointments in the local area as falling within a definition of “access”. However ongoing non-emergency medical transport (particularly those for dialysis, chemo and other chronic health issues requiring regular medical visitations) would fall within some other health funded program.

Currently it is often unclear to older Australians that there are other transport services outside of the HACC program. Where alternative programs exist, clients and service providers have little resources to identify the most appropriate provider in their area for their transport needs. This makes it challenging for providers when trying to balance referrals to a more appropriate provider along with ensuring the clients who approach them have their transport needs met. To enable effective referral between providers of different programs a single location with community transport providers under different programs is required. The Department of Social Services should create a portal of community transport providers delivering services to Australians over 65 years and the programs they deliver (both Commonwealth and state/territory funded). It should be noted that such information will be needed by Gateway staff when assessing for eligibility in order to appropriately refer clients who are deemed ineligible of alternative programs and providers they should consider. In maintaining this information in a publicily accessible manner, it will enable CHSP providers and consumers to easily identify the most appropriate program for their needs.

Recommendation #: Include HSP transport as a service within a ‘social participation and access’ stream.

Recommendation #: Develop a single portal of informationfor use by Gateway staff and CHSP providers or consumers, to identify the most appropriate Commonwealth or State/Territory funded community transport program, find theirlocal provider/s and easily identify the services they offer to older Australians.

Eligibility

NACA notes that the existing programs forming the CHSP largely have the same generic eligibility requirements (aside from ACHA which has the additional homelessness/special need requirement). However as outlined in NACA’s advice paper on the CHSP design, a number of changes should be considered compared to today’s eligibilities.[7] Of particular relevance to transportation is ensuring both clients and their carers are recognised and that restrictions for residential care clients are removed.

  • When identifying eligibility for transport services, it may be necessary to consider a series of statements to ensure: Eligibility is dependent on the client not being eligible under an alternative program (e.g. state funded non-emergency medical transport or Department of Veterans Affairs Gold Card services);
  • Eligibility for residents of residential facilities should be able to access HSP services on a separate fee recovery basis with a hardship provision; and
  • Eligibility for people living in the community with a HomeCare package are eligible on a separate fee recovery basis with a hardship provision.

NACA notes that existing clients of the programs that will become the CHSP program (i.e. HACC, NRCP, ACHA & DTC) should continue to be eligible under future CHSP programs in a grandfathered arrangement.

Recommendation #: That the Department develop eligibility criteria for the CHSP holistically and where necessary include additional criteria for the provision of HSP transport services.

Recommendation #: That clients of existing programs be grandfathered to ensure continued eligibility within the CHSP program.

Assessment & Referral

NACA notes that it has made comprehensive comments on assessment within the CHSP elsewhere[8]. In line with these recommendations NACA notes the importance of potential clients receiving community transport, being able to immediately access 6-12 weeks of HSP transport.While it may be necessary for a basic eligibility assessment to occur, a comprehensive assessment may not be immediately necessary during this initial period, particularly where only one or two services are being provided on an episodic basis.

It is noted that in many existing referral situations, the existence of a carer is not identified during eligibility assessments and in the case of the HACC program it may not be until the service provider has been working with a client for some time that a carer may be identified. Eligibility assessments and referrals to HSP transport providers must include questions to better identify carers, while also providing an easy pathway for providers or clients/carers to refer themselves for assessment following the initial assessment. In addition, it is important that during assessment it is made clear to approved clients and their representatives that eligibility does not guarantee immediate service provision and that a basic introduction to prioritisation and availabilities is explained with any notification of service eligibility approval.

Of particular importance for HSP transport providers is that referrals from the Gateway (who will conduct the eligibility assessment), occur in a timely fashion. Importantly, where client are assessed as ineligible for the HSP (or other aged care program), or there may be a more appropriate program for their transport needs, the Gateway should refer clients to other community transport programs and transport providers as appropriate for the individual’s circumstances.

Referrals from may also be received direct to Service providers, who will facilitate an eligibility assessment by the Gateway. If the client requires services for longer than 6-12 weeks, a comprehensive assessment will be required. Service providers may also request reassessments or provide further feedback on the original assessment if they feel it is incorrect.

Recommendation #: That eligibility assessment process:

a)Builds in a process to identify if a carer is involved

b)Ensures approved clients are explained that that eligibility does not guarantee immediate service provision.

Recommendation #: That ineligible clients are provided with referral to other transportation programs and providers if deemed ineligible for CHSP.

Interface with Residential Aged Care & Home Care packages

Currently access to community transport for clients receiving a home care package is very limited.Accessfor clients living in a Commonwealth supported residential aged care place is limited to the transport provided under DTC or the pre-organised trips provided by their service provider. As a principle, NACA believes that clients in these situations should have access to community transport to enable their full community participation . Of particular concern are the challenges currently faced by residential clients in accessing local medical appointments and social activities involving family and friends.

From 1 July 2015 all Home Care packages will be delivered on a consumer directed basis. This may result in some clients electing to spend a portion of their budget on transport activities. It is necessary therefore that the HSP guidelines provide guidance to transport providers on how to handle these arrangements. Keeping in mind the principle of equity of access for all clients, it may be inappropriate for consumers in receipt of a Home Care package to “top up” their package with HSP transport. This is expected to be complicated by situations where a client who may require a higher level of Home Care package is unable to access it due to appropriate level packages being unavailable. Finally, it is complicated by the fact that HSP fees are not included in the annual or lifetime caps applied to Home Care co-contributions. NACA suggests that an appropriate balance of these complexities may be to provide ‘guidance’ to providers about how to manage these complexities - without restricting their ability to tailor appropriate solutions to individual cases.

In situations where assessed levels of care need are unable to be provided to package shortages, clients should not be penalised by being required to pay more than the CHSP co-contribution and HSP transport providers should be able to utilise their funds. Importantly, NACA notes the move towards increasing co-contribution levels to those equitable to Home Care packages. Where additional transport services are being requested by the client, beyond the level of care needs assessed, HSP transport should be charged back to the client or their packaged care administrator a full cost recovery level without any funding from the CHSP.

The current HACC guidelines currently restrict HACC transport services forclients in residential facilities The only individual trip transport options for clients are therefore taxis or private cars as very few residential facilities provide transport beyond pre-planned excursions. This limits residential clients in maintaining social contact and should be addressed in some way within the aged care system. NACA feels that the HSP program should support people remain in their community, including communities of residential care. in the absence of any other aged care transport service the HSP guidelines should permit the patronage of residential clients.

Recommendation #: That the CHSP permit use of HSP transport for Home Care and Residential Care Clients.

Demand Management

Over the first 10 years of the CHSP there will be an 80% increase in over 65 population and over 50% increase in the over 85 population in Australia.[9]While the Government has committed to XX% growth in HACC funding[10], such funding is not anticipated to match the population growth. This will result in the need for a renewed focus on demand management to both delay older Australians from needing to access HSP transport, while also managing clients who have been assessed and approved for HSP transport services.

NACA supports the Australian Government funding preventative programs to minimise the HSP transport needs such as public transport training programs and driver re-education/ driver assessment services[11]. Such an approach supports the CHSP reablement objectives by providing a time-limited service that enables clients to work towards returning to their activities of daily living and prevent dependency upon the program for basic support needs.