DISCUSSION PAPER
HOME CARE PACKAGES AND CONSUMER DIRECTED CARE
1. POLICY CONTEXT
The Australian Government currently provides subsidies for home care packages in the form of Community Aged Care Packages (CACP), Extended Aged Care at Home (EACH) packages, and Extended Aged Care at Home Dementia (EACHD) packages.
As part of the Living Longer Living Better aged care reforms, the Australian Government has announced a significant expansion of the Home Care program to assist people to remain living in their own homes for as long as possible, and to introduce more choice for people receiving care at home.
The Government will provide $880.1 million over five years to increase the total number of home care packages from around 60,000 to 100,000. More than 40,000 additional packages are expected to be available over the following five year period, from 2017-18 to 2021-22.
From July 2013, there will be four levels of home care packages, including two new levels:
· Level D – equivalent to the existing EACH package
· Level C – a new package to support people with intermediate care needs
· Level B – equivalent to the existing CACP
· Level A – a new package to support people with basic care needs.
The new package levels (A and C) will be trialled and evaluated over the next two years (2013-14 and 2014-15).
From July 2013, it will no longer be necessary to have a separate EACHD level, as a new Behavioural Supplement will be available to eligible clients in all home care packages (10% of the base subsidy) and in residential care, to support people with dementia. There will also be a new funding supplement for veterans with an accepted mental health condition. The new home care packages (across all four levels) will be allocated through the 2012-13 Aged Care Approvals Round (ACAR), which is expected to be advertised before the end of the 2012 calendar year.
From July 2013, all new home care packages allocated to providers must be offered to clients on a Consumer Directed Care (CDC) basis.
In the longer term, the Government has announced that all existing home care packages, including those in operation before 1 July 2013, will need to be offered on a CDC basis. This is expected to apply from July 2015.
The Government has also announced that CDC will be trialled in a limited number of residential care settings, commencing in 2012-13. This will not be part of the ACAR.
D / High level care package / $45,534[1] / Extended Aged Care at Home (EACH)
C / Intermediate care package / $30,000 / None
B / Low level care package / $13,622[2] / Community Aged Care Package (CACP)
A / Basic care package / $7,500 / None
Actual subsidy levels for 2013-14 are yet to be determined and will depend on a range of factors including annual indexation.
2. PURPOSE OF THE PAPER
This paper has been prepared by the Department of Health and Ageing as a discussion paper for the National Aged Care Alliance Home Care Packages Working Group, which is expected to convene in mid-August 2012.
In some cases, specific questions are asked or possible approaches have been suggested in the paper. This is to facilitate discussion within the Working Group and does not necessarily represent a preferred or settled approach to implementation.
3. TERMINOLOGY
What will each of the home care package levels be called?
· Home care packages - Level A, B, C and D.
· CACP, EACH and EACHD terminology to be no longer used.
4. CARE AND SERVICES
What types of care and services should be covered in each level of package, and what does this mean in the context of CDC and non-CDC packages?
Issues
· There is a potential tension between having a specified list of care and services for home care package levels and the provision of care on a more flexible CDC basis.
· Under the current packaged care arrangements, there is a specified list of care and services for the CACP, EACH and EACHD levels. This forms part of the legal framework for the operation of the packages – as set out in the relevant Principles, payment agreements and program guidelines.
· At the same time, CDC provides an opportunity to be less prescriptive about the range of care and services at each level, to provide greater flexibility in the way that clients may use the package subsidy.
· While all new home care packages will be allocated to providers on a CDC basis, initially, this will form a relatively small proportion of the total number of home care packages. Therefore, the impact of any changes to the current CACP and EACH arrangements (for non-CDC packages) also needs to be considered.
· By July 2013, around 6,000[3] packages will need to be offered to clients on a CDC basis (out of approximately 65,000 operational home care packages). The remaining 60,000 packages will not need to be offered to clients on a CDC basis until July 2015.
Questions
· Do the current specified care and services for the CACP and EACH packages prevent or restrict providers from providing packages on a CDC basis, or is there sufficient flexibility to introduce CDC more broadly, building on the current specified care and services - perhaps with some modifications?
· Should the new home care packages (Levels A to D) be defined by reference to specified care and services, at least for the introduction of the new packages in July 2013?
· If so, does there need to be further work in the longer-term to look at the appropriateness of the specified care and services across all home care package levels?
Possible approaches:
a. Specify a list of care and services for each level of package (different across all four levels).
- Is this desirable or would it lead to less flexibility?
- In practice, it may be difficult to distinguish between care and services across four levels.
b. Specify a list of care and services across different groupings of packages.
- Level A andB as one group – largely based on the current CACP.
- Level C and D as another group – largely based on the current EACH package.
- See Attachment A.
c. Specify a list of care and services that would be common across all four levels.
- This could be broadly defined, eg to allow clinical care to be provided at each level.
- What would be the implications of extending clinical care to Levels A and B?
What types of care and services should not be covered within a package (even on a CDC basis)?
Possible exclusions
· Services or items that would reasonably be regarded as normal domestic or household expenditure (ie not directly related to the care or safety of the client).
· Payment for care and services provided by family members or friends, unless they are employees or contracted service providers of the approved provider.
Questions
· Is it appropriate to exclude these types of care and services (including purchases of normal domestic or household items)?
· Are there other types of expenditure that should be also excluded?
· How should the first category (normal domestic or household expenditure) be described in program guidelines, eg a list of examples; would not be an exhaustive list.
· At present, custom-made aids and motorised wheelchairs are specifically excluded from CACP, EACH and EACHD packages. Should these restrictions be removed in all future home care packages?
5. CONSUMER DIRECTED CARE (CDC)
Future requirements
· Commencing in the 2012-13 ACAR, all new home care packages allocated to providers must be offered to care recipients on a CDC basis.
· From 1 July 2015, it is expected that all home care packages (including those in operation before 1 July 2013) must be offered to care recipients on a CDC basis.
What is CDC?
· CDC or self-directed care is a philosophy or approach to service delivery that allows older people and their carers to make choices and exercise greater control over the types of care services they receive and the delivery of those services, including who will deliver the services and when.
CDC pilot program
· CDC has been trialled in 1,000 home care packages over the last two years.
· These packages have been converted to mainstream home care packages (CACP, EACH and EACHD packages) from 1 July 2012, with conditions of allocation to ensure that care and services continue to be provided to clients on a CDC basis.
· The evaluation report for the CDC pilot highlighted that there is considerable variation in the way that providers have offered CDC to clients.
· The evaluation identified four main broad models.
a. a progressive or tiered model
- Administration fee, but the proportion of the budget which was divided between case management and care delivery varied depending on the level of participant or care control. A client could choose to spend less on case management in order to free up more budget for direct care services.
- The evaluation found that that this appeared to be the most sophisticated and transparent model, providing a clear pathway for clients through the increasing levels of control.
b. a capacity building or mentoring model
- Under this model, the initial care assessment and planning phase included a period of intensive case management focused on putting services in place and building the capacity of the client to self-manage. Over a period of time (usually a few months), the case management would taper off, and the client would take on co-ordination responsibilities.
c. an “enhanced choice of supports” model
- Providers maintained responsibility for co-ordinating and managing packages, but clients had some increased level of choice, including more flexibility in service delivery.
- The evaluation found that the actual level of control a participant could exercise under this model was often limited in practice.
d. a ‘DIY’ optional model
- Clients could either take on all co-ordination and case management responsibilities, or else use their package to purchase some case management.
- The evaluation found that this model was not widely used, but where it was used it particularly appealed to clients with younger carers who wanted to take an active role in care co-ordination.
Individualised budget
· A key component of the CDC pilot (for all packages) was the requirement for providers to provide clients with an individualised budget that clearly identified administrative fees charged by the provider, plus a monthly statement of how the budget was spent.
Potential key features of CDC in future home care packages (for discussion)
· The approved provider remains responsible for the overall delivery of care to the client, even if services are sub-contracted/delivered by other service providers.
· The client may choose to take-on an active role in the co-ordination of services (which could result in lower co-ordination or case management fees), but the subsidy would continue to be paid to the approved provider, not cashed-out or paid directly to the client. The provider would manage the budget on behalf of the client.
· The type and amount of care and services to be provided need to be discussed between the client and the provider and agreed in a care recipient agreement.
· CDC does not mean that the provider is obliged to provide care and services exactly as directed by the client, but it is expected that there would be more flexibility for the client about when services are scheduled, who provides the services (not just restricted to workers or service providers identified by the provider), and more scope to use the budget for a range of care related activities.
· An individualised budget must be provided to the client that clearly identifies administrative fees charged by the provider, plus a monthly statement of how the budget was spent.
- This will help to empower the client to make choices by providing greater transparency about the total budget available, including the costs of particular care and services.
- Makes administrative fees/costs charged by the provider more visible to the client.
- Likely to increase the client’s expectations to utilise the full budget each year, including an expectation that “unspent” funds can be carried forward from yeartoyear.
- May reduce opportunities for cross-subsidisation between clients.
Questions
· Are these key features appropriate as a starting point for the broader implementation of CDC in home care packages, from July 2013?
· What other factors need to be considered in providing care on a CDC basis for clients - without a carer, for people with dementia, and for people from special needs groups?
· What types of resources and information need to be provided to assist providers, workers, consumers and carers in understanding these issues, and CDC more broadly?
· Who should develop these resources – industry, consumer and carer groups and/or the Department?
How to ensure that clients receive an appropriate amount of care and services under a package?