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cohealth’s submission recommends that more attention needs to be paid to the needs of vulnerable groups to enable them to remain well and healthy in the community for as long as possible. In particular we recommend that: skilled navigators or advocates are available to support vulnerable customers access the system and obtain the supports they need; block funding is retained to meet the inclusion and health promotion needs of these groups; and there are improvements in language services and cultural safety.
cohealth welcomes the opportunity to provide a submission to the Royal Commission into Aged Care Quality and Safety. cohealth has extensive experience providing community-based supports and services to older people. More than 25% of our clients are over the age of 65, and over a third are from culturally and linguistically diverse backgrounds. Many also experience socio-economic disadvantage.
cohealth is not a provider of residential aged care services. Our primary engagement with the aged care sector is through the delivery of a range of Commonwealth Home Support Programs (including physiotherapy, podiatry, occupational therapy, dietitians and other allied health practitioners), ethno-specific supports, homelessness services (including the Assistance with Care and Housing for the Aged program), supports for older people residing in public housing, and delivery of a range of social support groups for aged and frail people and people with dementia. Increasingly, clients with Home Care packages are accessing the allied health and social supports they need through us.
cohealth is strongly supportive of the principle of individual choice and control that underlies the aged care system. However, it is our experience that the needs of more vulnerable groups in the community are not as well served by the shift towards individualised packages of care. These groups include: Aboriginal and Torres Strait Islander people, people of culturally and linguistically diverse backgrounds, LGBTIQ communities, people of low socio-economic status, people who are homeless and those who have a disability. Greater attention needs to be paid to ensuring the needs of these communities are met to ensure that they too can benefit from supports to enable them to remain well and healthy at home for as long as possible.
Recommendation 1
Improve language services for all My Aged Care communications, including providing letters in preferred language, employing bi-lingual Contact Centre staff and improving cultural training.
Recommendation 2
Improve the experience of engaging with the My Aged Care Contact Centre by enhancing staff skills and knowledge and reducing wait times.
Recommendation 3
Expedite assessment and referral processes for consumers seeking a single or low-level service.
Recommendation 4
Ensure skilled navigators or advocates are available to support vulnerable consumers access the system and the home care supports they require.
Recommendation 5
Retain Commonwealth Home Support Program funding.
Recommendation 6
Retain block funding to:
cohealth developed this submission with input from consumers and carers with experience of community-based aged care services, and staff and managers with experience in providing these services.
It is clear from our consultation with consumers that people wish to be able to continue to lead full lives as they get older, and that many require only limited assistance to be able to do this. Key themes about what is needed to help them remain independent, well and healthy at home include:
However, cohealth consumers had a range of reservations about aspects of the community-based aged care system that mean it does not provide the optimal level of support:
Reforms to the Australian aged care system since 2012 aim to ‘create a sustainable, consumer driven and market-based aged care system’.[1] They include:
In addition, the Commonwealth Home Support Program (CHSP) provides entry-level care to independent older people to assist them to remain at home by providing services such as meals, community transport, allied health and therapy services, personal care, nursing, domestic assistance and respite. It commenced on 1 July 2015 and replaced several programs, including Commonwealth Home and Community Care (HACC). Providers are block funded to deliver specific support servicers, user contribution arrangements are principles based and some older people are charged little or no fees.[2]
The focus of CHSP is on wellness, reablement, and restorative care. The wellness approach seeks to identify client abilities rather than difficulties and build the capacity for self-management and autonomy. In other words, what the client might be able to do with the right support. Reablement focuses on client goals and offers time-limited interventions to support the client to resume activities and adapt to functional loss. It can include re-training, re-learning of lost skills, home modification and increased access to equipment and technology. Restorative care delivers early-stage intervention to facilitate health improvement after setback and the prevention of injury. It is multi-disciplinary in approach, using allied health therapies and services.[3]
In contrast, Home Care Packages are designed for people with more complex care needs, particularly for those who need a coordinated approach to the delivery of help at home – such as help with a number of everyday tasks, or more complex or intensive care.
As reported in the Royal Commission into Aged Care Quality and Safety Background Paper 1, in 2016 770,000 people used Home Support Services (predominantly CHSP); 100,000 used Home Care Packages; and 170,000 were in residential care.[4]
cohealth is a provider of community-based aged care services. As such this submission will focus on the areas of our expertise – the accessibility and availability of the systems and supports designed to enable older people to receive the support they need to remain at home, including My Aged Care. With our specific focus on working with people who experience disadvantage, our comments will particularly address the needs and concerns of these groups. While we recognise that matters relating to residential aged care touch many of the people we work with, we believe other organisations and individuals are better placed to comment on the many issues relating to this part of the sector.
Our experience has demonstrated that people want to remain at home as long as possible, and value the availability of services that enable them to do so. However, many express concerns about the difficulty accessing these services and that waiting for services can contribute to a deterioration in mental and physical health, too often to the point that residential care is required or even early death.
Vulnerable clients, in particular, face a number of significant challenges with the system, which on occasion results in them not receiving the care and supports they require and are entitled to.
cohealth supports the intent of promoting consumer choice and control and is committed to consumer-driven models of care. However, we have concerns that many aspects of the current system design inhibit consumer choice and control, especially for the vulnerable and marginalised communities with whom cohealth works.
The current model assumes a level of individual agency – language and other literacy skills, ability to navigate complex systems, understanding of available options, and capacity to self-advocate – that is often compromised within cohealth’s consumer base.
Resources to support individuals’ access and system navigation are very limited and many elements of system design inhibit organisational attempts to support vulnerable consumers’ engagement with it.
As such, the current system does not always provide the best outcomes for clients, particularly those experiencing disadvantage and marginalisation. We recommend that greater attention be paid to supporting and proactively responding to the needs of these clients, through retaining block funding and increasing access to system navigators or advocates.
The My Aged Care website and Contact Centre are intended to be the main source of information about, and access to, aged care services and the gateway into the aged care system.
However, cohealth consumers and those who work with them have identified a range of shortcomings and challenges that mean that My Aged Care hinders rather than assists access, particularly for the more vulnerable community members who we work with.
Language
Most of the information on the My Aged Care (MAC) website is in English. Clients from non-English speaking backgrounds can find it difficult to understand the system and find the information they need.
cohealth consumers have observed that when calling the Contact Centre they cannot reliably speak to someone in their own language. As a result, people do not feel supported by MAC staff, and may feel misunderstood. In addition, arranging interpreters to assist with calls to MAC can be difficult and require lengthy wait times. To ensure the needs of people from culturally and linguistically diverse backgrounds are met MAC needs to employ bi-lingual staff, improve cultural training for all call centre and assessment staff and improve the use of interpreters.
Similarly, letters to clients are sent out in English, resulting in difficulties for people of non-English speaking backgrounds. In addition, the information and wording in letters can be complex and hard to understand, even for people whose first language is English and are well educated. People of CALD background, or who are vulnerable, can struggle to understand these communications, with the result that they miss out on the supports they are entitled to. cohealth practitioners have heard all too often of people not realising the importance of the letters and missing critical information, such as dates for accepting offers of Home Care Packages.
Online system
‘The MAC information on the computer is difficult to understand and I can’t use the computer without help.” – cohealth consumer
cohealth consumers have described how many of those eligible for aged care services have less familiarity using online systems than the broader population. In addition, the digital divide means that some people – particularly those on low incomes and experiencing disadvantage – have limited or lower access to the internet, lower digital literacy and face cost barriers to technology.
As such, the reliance on the My Aged Care website as the main source of information is for many a barrier to accessing the information and services they need. Funding case management, advocacy and/or system navigation positions (as described below) is one way to improve access for vulnerable older people with lower levels of digital literacy.
Contact Centre
The Contact Centre can have lengthy wait times making it difficult to access at times. Once speaking with an operator, the level of information they can provide may be limited to repeating material from the website. Receiving accurate responses to more complex questions can be difficult. Callers should be able to receive the information they need, in a timely manner, when they use the Contact Centre.
Recommendation 1
Improve language services for all My Aged Care communications, including providing letters in preferred language, employing bi-lingual Contact Centre staff and improving cultural training.
Recommendation 2
Improve the experience of engaging with the My Aged Care Contact Centre by enhancing staff skills and knowledge and reducing wait times.
‘Why do I need to have all these questions asked and have someone in my house if I just need my toe nails cut as I can’t reach them anymore?’ – cohealth consumer
The number of assessments people must take part in to access even a small amount of assistance can be intimidating and create a barrier to seeking supports. Initial screening and information gathering occurs with the My Aged Care Contact Centre, followed by more detailed in-person assessments from a Regional Assessment Service (RAS) or Aged Care Assessment Team (ACAT). These formal processes often follow an identification of functional changes and discussions about support needs with medical or allied health professionals. For people seeking a single or short-term service this level of assessment can be a source of frustration or a barrier to receiving supports early to help them maintain their health and wellbeing. On occasion it can also result in people disengaging with the system as they have been required to tell their story multiple times.
As such, cohealth supports the development of expedited access to single and time limited services. This will have significant benefits for consumers, assessment services and referrers. For simple health needs where intervention is short term and health promoting, and where a quick healthcare response prevents an issue becoming chronic and more serious, being able to provide a service quickly promotes reablement and should be prioritised.
The level of assessment provided to consumers should be directed by them. The best practice approach to assessment for vulnerable groups and those with complex needs to occur over time. If clients are seeking a single service and not wishing to undertake a full assessment they should not have to have the full assessment. Support plan reviews can be requested if needs change or when the client is ready to engage more fully. For groups who are likely to disengage in the assessment process the capacity for health care professionals to support and be present at assessment needs to be considered. The current system is overwhelming and excessive for clients seeking a single time-limited service and deters many from engaging at all.
cohealth would like to see referrals from health professionals and GPs who have an existing relationship with a client be expedited without requiring further approval from non-health professionals. Through trusting and long-standing relationships with consumers health professionals are more than capable of determining the degree of assessment and services their clients require to live an independent life. Such referrals and services would be documented in the portal to ensure services are not duplicated and all stakeholders have access to the client’s full-service support program.
Recommendation 3
Expedite assessment and referral processes for consumers seeking a single or low-level service.
‘The system is confusing, there is not enough information available to help us get access to services’ – cohealth consumer
cohealth consumers observed that they found the system confusing and difficult to navigate. The processes of registering with My Aged Care, various assessments, the need to accept an offered care package in a particular time frame, and the challenge of identifying and engaging care providers can be overwhelming. This was particularly marked for those for whom English was not their first language and those without natural supports – family, friends or neighbours – to assist them navigate the system. For many people their first contact with the aged care system is during a time of crisis, acute need or deteriorating health and navigating a complex system without support can be particularly daunting.
cohealth welcomes the recent trials of various age care navigator approaches. Providing advocacy or navigation supports for people is critical to improving access and reducing the stress experienced. However, we have some concerns that most trials are based on the use of volunteers, when people with complex needs, no natural supports and who experience other forms of disadvantage require assistance from people with greater training and experience.
cohealth believes that funding is required to provide services to reach out to vulnerable groups to support them through the assessment process. Too often people are dropping out of the process for having no fixed address or missing phone calls. This disproportionately impacts people with complex needs, and sometimes chaotic lives, including people who are homeless, escaping family violence or who have a mental illness.
Particular investment is also needed in engaging vulnerable communities that have historically been traumatised by the system, including: Aboriginal and Torres Strait Islander people, including members of the stolen generation; care leavers; people who have been incarcerated; and LGBTIQ+ communities. Without this investment these groups are likely to avoid engaging with the system, with the cost being deterioration of health, greater use of emergency department presentations, and premature death.
In cohealth’s experience vulnerable consumers frequently do not have the capacity to enact their care plan and package. In many cases they are unaware they have received one. In these situations it is often up to GPs, nurses and other health professionals to support the consumer through the package process. This process is difficult as GPs and nurses are not CHSP funded and are working outside the MAC portal. Approaches to address this include:
Outreach is particularly important to engage vulnerable consumers. However, under individualised funding model, organisations have limited capacity to seek out vulnerable consumers and support them to follow through their assessment, plan progress and implementation. cohealth urges the continuation, diversification and expansion of the Access and Support Program that undertakes the assertive outreach that identifies, reaches and supports isolated people who would otherwise not engage in the aged care system.
Recommendation 4
Ensure skilled navigators or advocates are available to support vulnerable consumers access the system and the home care supports they require.
‘The waiting list for services and packages needs to be reduced so we can get the services we need when we need them. My mother got a level 3 package 3 months after she was in a nursing home. My husband needed bathroom modifications, but it was only accepted after he had died.’ – cohealth consumer
Timely provision of services
Too many people have to wait too long to receive the home-based support they need. For Home Care Packages, many people wait weeks or even months for their assessment to take place, before being placed on an even longer waiting list. Waiting times are particularly marked for those seeking the higher level 3 or 4 packages. Once a package does come through, the complex system for identifying a service provider and arranging supports through them can then create a barrier for people to receive the care they need. Even the CHSP, a program aimed at providing early support for people to remain at home, is unable to respond quickly as registration and assessment processes and arranging services can take weeks.
These barriers are particular marked for people who experience disadvantage, such as people who are homeless or from culturally and linguistically diverse backgrounds.
When responses to care requests are not prompt, are delayed, or not received at all the consequences can be significant. People may disengage from seeking services and supports, their health can deteriorate and there can be a premature need for either a higher-level home care package, or a move into residential care.
Many people require only a small amount of timely services to remain healthy and well at home, and every effort should be made to ensure that the assessment process is sensitive to this, services are easily identified and in place quickly. This is particularly important for people who are without natural supports or who are experiencing disadvantage. To date CHSP funded services have been able to respond more quickly, providing the required low level and/or short-term services.
The proposed discontinuation of CHSP in favour of moving to individualised home care packages places this timely provision of care in jeopardy. More complex and detailed assessment processes are likely to create a barrier to access and take longer for services to be in place. As a result, some people will go without services rather than engage in these lengthy processes for a specific type of care.
Recommendation 5
Retain Commonwealth Home Support Program funding
Preventative and group programs
Preventative programs such as those that promote social inclusion, early intervention chronic disease self-management, healthy lifestyles, healthy eating, exercise and the like are not readily provided in the consumer directed care model of funding.
Similarly, group programs that support particular groups in the community, such as cohealth’s Horn of Africa Women’s group, will not be supported under an individualised package of care model. These groups are critical for the social connection of individuals and are also key settings to help new arrivals learn about the systems available to support people as they age in Australia.
The introduction of individualised packages of care has also reduced participation in group and social inclusion programs that reduce loneliness, despite the growing awareness that loneliness and social isolation are significant health and mental health risks for older people. With the full cost recovery of participation and transport now having to be met from a person’s package, some older people are finding it difficult to afford. Previous funding arrangements allowed for subsidisation that made it easier for people to participate.
Block funding should be maintained to ensure the continuation of programs that meet the inclusion needs of groups that experience marginalisation and enhance health promotion approaches.
Recommendation 6
Retain block funding to:
[1] Jorgensen, M & Haddock, R (2018) The Impact of the home care reforms on the older person, the aged care workforce and the wider Health System Deeble Institute Issues Brief no. 27. Australian Healthcare & Hospitals Association. https://ahha.asn.au/sites/default/files/docs/policy-issue/deeble_issues_brief_no._27_home_care_reforms.pdf
[2] Royal Commission into Aged Care Quality and Safety (2019) Navigating the Maze: An Overview of Australia’s Current Aged Care System. Background Paper 1 https://agedcare.royalcommission.gov.au/publications/Pages/default.aspx
[3] McCallum, J. & Rees, K. (2017). Consumer Directed Care in Australia: Early stage analysis
and future directions. Brisbane: National Seniors. https://agedcare.royalcommission.gov.au/publications/Documents/related-publications/08172617PAR-Consumer-Directed-Care-Research-Report-FNEmail.pdf
[4] Royal Commission into Aged Care Quality and Safety (2019) Navigating the Maze: An Overview of Australia’s Current Aged Care System. Background Paper 1 https://agedcare.royalcommission.gov.au/publications/Pages/default.aspx
Collingwood